Every finding on record at Westover Hills Rehabilitation and Healthcare

Based on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 2 of 11 Residents (Resident #118 and Resident #162) and 1 of 5 medication carts (100 Hall Medication Aide Cart) reviewed for medication storage:1. The facility failed to ensure Resident #162 did not have a prescription medication of Mupirocin Ointment 2% at the bedside.2. The facility failed to ensure the 100 Hall Medication Aide Cart was not unlocked and unattended. 3. The facility failed to ensure Resident #118 did not have medication in their room.These failures could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion. The findings included: 1. Record review of Resident #162's face sheet dated 6/11/26 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis (infection and inflammation of the bone caused by bacteria) of left foot and ankle, diabetes (chronic disease in which the body cannot properly regulate sugar levels), kidney transplant status, and peripheral vascular disease (condition in which the blood vessels outside the heart and brain become narrowed, blocked, or damaged, reducing blood flow). Record review of Resident #162's Order Summary Report dated 6/9/26 reflected the resident did not have a physician's order for Mupirocin Ointment 2%. During an observation on 6/9/26 at 9:41 a.m., Resident #162 was observed sleeping in bed and a prescription medication of Mupirocin Ointment 2% with a pharmacy label that had the resident's name on it was observed on the bedside table on the left side of the resident's bed. During an observation on 6/9/26 at 10:52 a.m., Resident #162 was not in the room and a prescription medication of Mupirocin Ointment 2% with a pharmacy label that had the resident's name on it was observed on the bedside table on the left side of the resident's bed. During an observation and interview on 6/9/26 at 3:26 p.m., Resident #162 stated she had been admitted into the facility from the hospital maybe 5 or 6 days ago and any medications she had when she was admitted to the facility were held by the facility nursing staff. Resident #162 stated she had been told by the facility nursing staff that she was not supposed to have medications at the bedside and if she had, she would have to give them up to the nurses. Resident #162 stated, the prescription medication of Mupirocin Ointment 2% observed on the bedside table was given to her by the hospital and had been on the bedside table since she admitted . Resident #162 stated she did not know what the prescription medication of Mupirocin Ointment 2% was for, and nobody's ever said anything about it and it had always remained on the bedside table. During an interview on 6/9/26 at 3:34 p.m., LVN I stated there were no residents in the unit where Resident #162 resided who were allowed to self-administer medication. LVN I stated, a resident in the facility who was allowed to self-administer medication first had to be observed to ensure the resident was able to self-administer medications, and a physician's order was required. During an observation and interview on 6/9/26 at 3:40 p.m., LVN I, after she observed the Mupirocin Ointment 2% prescription medication on Resident #162's bedside stated the resident was not allowed to have the medication at the bedside and only nursing staff were supposed to administer the resident her medications. LVN I stated, Resident #162 would need an assessment and a physician's order to be allowed to self-administer medications. LVN I stated, medications at the bedside could potentially lead to the medication being obtained by a person who was not alert and oriented and could ingest it or use the medication improperly. LVN I stated, nursing staff and CNA staff monitored items such as medications left at the bedside during rounds. During an interview on 6/11/26 at 2:06 p.m., the DON stated there were no residents in the facility who were allowed to keep medications at the bedside. The DON stated, residents who wanted to self-administer medications had to have their BIMS score checked, obtain permission from the physician to allow the resident to self-administer medications, and if the physician approved, then the resident would require an assessment to safely self-administer medications. The DON stated, if the resident was deemed capable of self-administering medications, then the physician orders would have to be updated and then it would be care-planned. The DON stated, without following the process, the resident could not keep medications at the bedside, regardless of whether the medication was over the counter or had a pharmacy label. The DON stated that medications left at the bedside not prescribed by the doctor could result in the resident having an adverse reaction. The DON stated the nurse managers or administrative team made rounds daily, multiple times looking for objects that should not be at the bedside such as medications, sharps, and aerosol air fresheners. 2. During an observation on 6/9/26 at 12:50 p.m. revealed the 100 Hall Medication Aide cart was unlocked and unattended next to the medication room facing the walkway in front of the nurse's station. During an interview on 6/9/26 at 12:55 p.m., RN G, who was sitting behind the nurse's station with her back to the 100 Hall Medication Aide Cart stated the medication cart was assigned to Medication Aide H. RN G stated the problem with an unattended and unlocked medication cart was that anybody could get into it and take a medication that did not belong to them and could have an adverse reaction. RN G stated, if a person ingested a medication taken from the unattended, unlocked medication cart and had an adverse reaction, we would not even be able to tell the doctor what the person took if medications were taken from the cart. During an interview on 6/9/26 at 12:59 p.m., Medication Aide H stated she had been assigned the 100 Hall Medication Cart since the beginning of her shift beginning at 6:00 a.m., and stated she last used the 100 Hall Medication cart about 7 minutes ago. Medication Aide H stated she had forgotten to lock the 100 Hall Medication cart and stated she had the key with her. Medication Aide H stated, when a medication cart was left unattended and unlocked anybody could come and take or steal a medication not prescribed for them and could result in an adverse reaction. During an interview on 6/11/26 at 2:14 p.m., the DON stated it was her expectation that the medication carts should always be locked when unattended because residents who wander can get into the cart which could result in ingesting a medication that did not belong to them and they could have an adverse reaction. 3.Record review of Resident #118's face sheet dated 06/12/2026 revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 04/04/2015, with diagnoses that include major depressive disorder, recurrent, mild (repeated episodes of depression that are currently mild in severity) and memory deficit following nontraumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain which can lead to neurological deficits) . Record review of Resident #118's MDS dated [DATE] revealed a BIMS of 14 out of 15 indicating no cognitive impairment. Record review of Resident #118's care plan provided on 06/12/2026 revealed a focus area for the following: Is at risk for adverse reaction r/t medications, revised on 03/03/2021, with interventions including discuss with resident and family the number and type of medications resident is taking and the potential for drug interactions and side effects from over-medication, with an initiation date of 03/03/2021. During an observation and interview on 06/10/2026 at 9:10 a.m., revealed Resident #118 had 1 container of Vapor Rub in an open storage container on their bedside table. Resident #118 stated staff knew he had the Vapor Rub and if he was not allowed to have it, they would have taken it away because staff take away things residents cannot have. Resident #118 stated he used the Vapor rub for allergies and would put it under his nose. Resident #118 stated they occasionally have had other residents come visit him in his room. During an interview on 06/11/2026 at 9:05 a.m., CNA B stated residents were not allowed to have medication in their room and if they did, CNA B would have to let a nurse know. CNA B stated they were not sure if Resident #118 should not have Vapor Rub in their room. CNA B stated they did not know Vapor Rub and/or Chest Rub were medications but instead thought they were just creams. CNA B stated they had not seen residents wander into other residents' rooms or visit other residents in their rooms. CNA B stated the risk to residents that had Vapor Rub in their room could be ingestion but thought that Resident #118 would not do that. During an interview on 06/11/2026 at 9:15 a.m., LVN C stated residents could not have medication in their rooms unless they had a signed consent. LVN C stated they were not sure if Resident #118 should not have Vapor Rub in their room. LVN C stated they had seen residents go in and out of other residents' rooms to visit but not wander. LVN C stated the danger of having Vapor Rub in the resident's room could be the medication side effects or risk of ingestion. During an interview on 06/11/2026 at 11:19 a.m., the DON stated residents should not have medication in their room. The DON stated if residents could have medication in their room, they would have a physician's order for it as well as a safe administration of drug assessment completed. The DON stated if staff saw prohibited items in residents' rooms, they were to remove them and let the nurse know. The DON stated rotating staff were assigned rounds daily that were used to look for items residents should not have in their rooms. The DON stated they did not see safe administration drug assessments completed for Resident #118. The DON stated they were not aware Resident #118 had Vapor Rub in their room. The DON stated the risks could be that other residents could get into it or a resident with dementia could get ahold of it. Record review of the facility document titled Medication Access and Storage with revision date 8/2020 reflected in part, .It is the policy of this facility to store all drugs and biological (sic) in locked compartments under proper temperature controls. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.Only licensed nurses, the consultant pharmacist and those lawfully authorized to administer medications (e.g., medication aides) are allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access.

Based on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for service safety for 1 of 1 kitchen. The facility stored one food item without the manufacturer's use-by date and one food item beyond the manufacturer's use-by date. 2. The facility failed to ensure pureed bread and baked beans were maintained at the required holding temperature of 135 degrees on the steam table. These deficient practices had the potential to place residents at risk for consuming unsafe food and developing foodborne illness.Findings included: 1.Observation on 06/09/2026 at 9:15 a.m. during the initial kitchen tour revealed a box of taco shells stored in the facility's dry storage area with a manufacturer's use-by date of 03/19/2026. During the same observation, a box of frozen cookie dough was observed in the freezer and labeled with a handwritten date of 02/03/2026. The manufacturer's use-by date had been removed from the packaging and was not available for review. During an interview on 06/09/2026 at 9:30 a.m., the Dietary Manager stated he was responsible for monitoring food inventory and routinely checking food dates. The Dietary Manager stated he had not realized the expired taco shells remained in storage. The Dietary Manager stated the handwritten date on the cookie dough represented the date staff opened the product. The Dietary Manager confirmed the manufacturer's use-by date had been removed from the cookie dough packaging and stated he was unable to determine the manufacturer's use-by date, when the product should be discarded, when it was last used, or whether the product remained suitable for use. The Dietary Manager stated expired or unsuitable food products could place residents at risk for foodborne illness.A review of the Texas Health and Human Services Retail Food Code, Chapter 228, on 06/09/2026 revealed food items maintained in inventory must be properly identified and maintained in a manner that allows determination of appropriate use and discard dates.A review of dietary staff training records on 06/09/2026 revealed the Dietary Manager maintained current ServSafe Food Safety Certification and [NAME] A had completed ServSafe Food Safety training. 2.Observation and interview on 06/10/2026 at 11:45 a.m. during meal service revealed [NAME] A conducting temperature checks of food items held on the steam table. Temperature checks revealed Pureed bread measured 118 F and baked beans measured 121 F. [NAME] A was unable to identify the correct temperature. The Dietary Manager stated the required hot-holding temperature was 135 F or higher. The Dietary Manager stated the food items would be reheated prior to service. The pureed bread and baked beans were removed from the steam table and reheated. Follow-up temperature checks revealed the pureed bread measured 136 F and the baked beans measured 144 F, after which the food items were returned to service. During an interview on 06/10/2026 at 11:50a.m., the Dietary Manager stated hot food items should be maintained at 135 F or above while being held for service. The Dietary Manager stated serving food below the required holding temperature could place residents at risk for foodborne illness. Review of the facility Policy from Texas Food Establishment Rules, Texas Administrative Code, Title 25, Part 1, Chapter 228 revealed hot-held food must be maintained at 135 F or above during holding and service. Review of dietary staff training records revealed the Dietary Manager completed SERV Safe food safety certification on 02/12/2025 and [NAME] A completed SERV Safe food safety training on 08/22/2024.

Based on interview and record review, the facility failed to ensure residents have the right to formulate an advance directive for 2 of 3 residents (Residents #153 and #162) reviewed for advanced directives:The facility failed to determine upon admission whether Resident #153 and Resident #162 had an advanced directive, and if not, determined whether the Resident or Resident Representative wished to formulate an advanced directive.This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive medical treatment according to their rights.The findings included:1. Record review of Resident #153's face sheet dated [DATE] reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included acute osteomyelitis (infection and inflammation of the bone caused by bacteria) of left foot and ankle, diabetes (chronic disease in which the body cannot properly regulate sugar levels), kidney transplant status, and peripheral vascular disease (condition in which the blood vessels outside the heart and brain become narrowed, blocked, or damaged, reducing blood flow).Record review of Resident #153's Order Summary Report dated [DATE] reflected the resident had an order for CPR/Full Code with order date [DATE] and no end date.Record review of Resident #153's comprehensive care plan dated [DATE] reflected the resident had elected Full Code status with interventions that included to update the resident's clinical record to reflect elected code status.Record review of Resident #153's clinical record reflected there was no Advance Directive Acknowledgement document in the resident's record.2. Record review of Resident #162's face sheet dated [DATE] reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes, chronic obstructive pulmonary disease (progressive lung disease that causes airflow blockage and makes it difficult to breathe), congestive heart failure (chronic condition in which the heart cannot pump blood effectively enough to meet the body's needs), peripheral vascular disease, and acquired absence of right leg above the knee.Record review of Resident #162's Order Summary Report dated [DATE] reflected the resident had an order for CPR/Full Code with order date [DATE] and no end date.Record review of Resident #162's comprehensive care plan dated [DATE] reflected the resident had elected Full Code status with interventions that included to update the resident's clinical record to reflect elected code status.Record review of Resident #162's clinical record reflected there was no Advance Directive Acknowledgement document in the resident's record.During an interview on [DATE] at 1:20 p.m., the DON stated that the opportunity for a resident to formulate an advanced directive was provided by the SW at the time of admission and was reviewed during care plan meetings. The DON stated the Advance Directive Acknowledgement document was found in the resident's electronic record, but the SW oversaw that.During an interview on [DATE] at 1:39 p.m., Resident #162 stated she recalled a discussion about an advance directive but was not sure with whom she had the discussion and stated she did not sign a document referencing advance directives. Resident #162 stated she was currently on Full Code status and wanted to continue Full Code status.During an interview on [DATE] at 1:43 p.m., Resident #153 stated he recalled a discussion with his family member regarding an advanced directive. Resident #153 stated he wanted to remain on Full Code status but discussed with his family member the possibility of a DNR status if he should become brain dead. Resident #153 stated he was not sure if his family member had signed a document related to an advanced directive.During a telephone interview on [DATE] at 2:39 p.m., Resident #153's family member stated she recalled possibly having discussed an advanced directive with the SW but was not sure about signing a document referencing an advanced directive. During an interview on [DATE] at 3:47 p.m., the SW stated that code status and power of attorney discussions were held with the residents and/or family members at time of admission. The SW stated, the Advance Directive Acknowledgement document should be signed a few days after admission and then the document was supposed to be scanned into the residents' clinical record and could be found in the Documents section of the record. The SW stated she was responsible for providing newly admitted residents or their families with the Advance Directive Acknowledgement document and she was also responsible for uploading the document into the resident record. The SW stated she did not generate the Advance Directive Acknowledgement document for Resident #153 and Resident #162 because she had been busy. The SW stated, the Advance Directive Acknowledgement document was a big deal because the acknowledgement proved that the discussion to formulate an advance directive took place and it showed what the resident or family's preference was. During a follow up interview on [DATE] at 7:48 a.m., the DON stated residents on full code status were identified in the clinical record, and the Advance Directive Acknowledgement was important to ensure the correct information was in the clinical record and the resident's wishes were carried out.During an interview on [DATE] at 8:08 a.m., the Administrator stated the Advance Directive Acknowledgement was an important document and efforts needed to be made to ensure it was completed. The Administrator stated the Advance Directive Acknowledgement determined how to care for the residents.Record review of the facility document titled Advance Directives and Associated Documentation with revision dated 12/2023 reflected in part, .It is the policy of this facility that a resident's choice about advance directives will be recognized and respected. Further, it is the policy of this facility to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive.Procedure.Prior to, upon, or immediately after admission, a facility staff member shall: a. Provide the resident/family or responsible agent written information.regarding the right to accept or refuse medical or surgical treatment and the right to formulate Advance Directives.b. Document in the resident health record that, at the time of admission, the resident and/or resident representative have been provided with written information regarding advance directives.Record review of the facility document titled Medical Record, Content of with revision date 8/2007 reflected in part, .The resident's medical record shall contain at least the following information .Consents/Authorizations/Acknowledgments. Appropriate consent forms, authorizations and acknowledgments are signed by the resident or legal representative and entered in the medical record .These include, but are not limited to, the following .Acknowledgement of receipt of advance directive information .List of contents of the medical record .Advance Directive Acknowledgment .

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 disease and infection for 2 of 6 residents (Residents #10 and #31) reviewed for infection control:The facility failed to ensure Resident #10's indwelling urinary catheter tube and urine bag were not resting on the floor and Medication Aide E used appropriate hand hygiene when moving from a clean area to a dirty area when administering medications to Resident #31.These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.The findings included:1. Record review of Resident #10's face sheet dated 6/9/26 reflected an [AGE] year-old female admitted into the facility on 4/16/26 with diagnoses that included sepsis (a life-threatening emergency that occurs when the body's response to an infection causes widespread inflammation and organ dysfunction), kidney failure (a condition in which the kidneys can no longer adequately filter waste products, excess fluid, and toxins from the blood), urinary tract infection (an infection that can occur anywhere in the urinary system), uterovaginal prolapse (a condition where the uterus [womb] slips down from its normal position into or through the vaginal wall causing difficulty with urination), and need for assistance with personal care.Record review of Resident #10's most recent comprehensive MDS assessment dated [DATE] reflected the resident was severely cognitively impaired for daily decision-making skills and utilized an indwelling urinary catheter.Record review of Resident #10's Order Summary Report dated 6/9/26 reflected the following:- Secure (urinary) catheter with a leg strap/leg band or anchor to minimize catheter related injury and accidental removal or obstruction or urine outflow, check placement every shift with order dated 4/16/26 and no end dateRecord review of Resident #10's comprehensive care plan with revision date 4/17/26 reflected the resident utilized an indwelling urinary catheter related to retention due to a prolapsed uterus with interventions that included to secure the catheter to facilitate flow of urine, prevent kinking of tubing, and accidental removal. During an observation on 6/9/26 at 12:06 p.m., Resident #10 was observed sitting up in the wheelchair while eating lunch in the dining room and the indwelling urinary tube and urine bag were resting on the floor.During an observation and interview on 6/9/26 at 12:10 p.m., ADON F observed Resident #10's indwelling urinary tube and urine bag were resting on the floor. ADON F stated, the indwelling urinary tube and urine bag should not be resting on the floor because they could have leaks, or it could cause injury if dislodged. ADON F stated, the indwelling urinary tube and urine bag resting on the floor was considered an infection control issue and cross contamination and could result in the resident having trauma or put the resident at risk for infection, such as a urinary tract infection. ADON F stated, the nurses and medical staff were responsible for ensuring the indwelling urinary tube and urine bag were kept off the floor, and other staff such as therapy staff could make the nursing staff aware that it was occurring. ADON F stated, it's an easy fix. 2. Record review of Resident #31's face sheet dated 6/10/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included diabetes with diabetic cataract (a clouding of the eye's natural lens that develops as a result of diabetes), bilateral myopia (a vision condition in which near objects can be seen clearly, but distant objects appear blurry), and need for assistance with personal care.Record review of Resident #31's most recent quarterly MDS assessment dated [DATE] reflected the resident was cognitively intact for daily decision-making skills and had impaired vision that required corrective lenses.Record review of Resident #31's Order Summary Report dated 6/10/26 reflected the following:- Systane Solution 0.4-0.3%, instill 1 drop in both eyes four times a day for dry eyes with order dated 3/12/26 and no end dateObservation on 6/10/26 at 8:22 a.m. during the medication pass revealed Medication Aide E, after administering oral medications to Resident #31, returned to the medication cart, did not wash or sanitize his hands, and put on a pair of gloves. Medication Aide E then took the keys and unlocked the medication cart, retrieved the Systane Solution from the medication cart, and placed the keys in his right pocket. Medication Aide E, while still wearing the gloves, returned to Resident #31's bedside and instilled the Systane drops into the resident's eyes. During an interview on 6/10/26 at 8:27 a.m., Medication Aide E stated he had not realized he did not perform hand hygiene before putting on a pair of gloves or when moving from a clean area to a dirty area. Medication Aide E stated, hand hygiene must be utilized before and after glove changes. Medication Aide E stated, when administering eye drops, your hands need to be clean, as clean as possible, and was considered basic infection control practices. Medication Aide E stated, not using proper hand hygiene practices was considered cross contamination and the resident could get an infection, including an eye infection.During an interview on 6/11/26 at 2:14 p.m., the DON stated, Medication Aide E should have sanitized his hands before putting on a pair of gloves. The DON stated, if gloves were worn while preparing medications, then the gloves should have been removed, and hand hygiene should have been utilized before putting on a new pair of gloves and before administering eye drops which would help to prevent spread of infection.During a follow-up interview on 6/12/26 at 8:32 a.m., the DON stated, it was not ok for a resident's indwelling urinary tube and urine bag to be touching the floor because it could possibly spread infection, and the indwelling urinary tube and urine bag could dislodge if stepped on accidently. The DON stated it was her expectation that the indwelling urinary tube and urine bag be kept from touching the floor to prevent cross contamination. Record review of the facility document titled Catheter Drainage Bag with revision date 4/2025 reflected in part, .It is the policy of the facility to maintain continuously closed urinary drainage system whenever possible and provide a receptacle for urine.Catheter Drainage Bag.14. Position the drainage bag below the level of the resident's bladder and without resting on the floor. Ensure tubing allowed for unobstructed drainage of urine.Record review of the facility document titled Infection Prevention and Control Program with revision dated 4/2025 reflected in part, .The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of the quality assurance and performance improvement program.the elements of the infection prevention and control program consist of.prevention of infection.Process Surveillance is the review of practices by staff directly related to resident care. Some considerations for this process may include, but are not limited to.Hand hygiene.Infection control practices during the provision of resident care and treatments.

Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Residents #11) reviewed for accuracy of records: The facility failed to ensure Resident #11 had the correct order for their DNR code status. The failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.The findings include: Record review of Resident #11's face sheet dated 06/10/2026 revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 09/14/2023, with diagnoses that include chronic respiratory failure, unspecified whether with hypoxia or hypercapnia (the lungs cannot adequately exchange gases, leading to insufficient oxygen or excess carbon dioxide in the blood) and heart failure (heart muscle unable to pump enough blood to meet the body's needs for blood and oxygen). Record review of Resident #11's MDS dated [DATE] revealed a BIMS of 14 out of 15 indicating no cognitive impairment. Record review of Resident #11's care plan provided on 06/10/2026 revealed a focus area for the following: [Resident #11] . has elected to change his full code status (the patient wishes to receive all possible life-saving interventions if their heart or breathing stops) on 1/11/24 to DNR code status and has initiated OOHDNR, OOHDNR has been scanned into record revised on 01/12/2024, with interventions including Do Not Resuscitate in the event of cardiac arrest initiated on 01/12/2024. Record review of Resident #11's order summary, dated 06/10/2026, revealed an active full code order with an order date of 04/02/2026. Record review of Resident #11's out-of-hospital do-not-resuscitate (OOH-DNR) order form revealed it had been signed by Resident #11 and the physician on 1/11/2024 and notarized on 1/11/2024. Record review of Resident #11's acknowledgement of advance care planning signed by Resident #11 on 1/11/2024 revealed Resident #11 checked off the following section I/Family have executed an out of hospital do not resuscitate (OOHDNR) form and expect my wishes will be honored and respected. During an interview on 06/11/2026 at 11:19 a.m., the DON stated either themselves or the social worker were in charge of ensuring the code status for residents was changed if the resident decided they would like it changed. The DON confirmed that Resident #11 had an order to be a full code and Resident #11's care plan reflected that Resident #11 was a DNR. The DON stated they would have to verify with the social worker regarding what Resident #11's code status was. The DON stated the risk of an incorrect code status order could be that the facility could not have honored the residents' wishes. During an interview on 06/11/2026 at 11:38 a.m., the SW stated if a resident changed their mind about their code status the SW would let the nurse know and then the nurse would put in an order and the physician would sign off on the order which would change the resident's code status. The SW stated Resident #11 previously discharged from the facility and that the nurse may not have changed it back when Resident #11 readmitted to the facility again. The SW stated when Resident #11 readmitted the nurse readmitted Resident #11 as a full code and Resident #11 should have been a DNR. During an interview on 06/11/2026 at 11:46 a.m., Resident #11 confirmed he had changed his code status to a DNR and that during every care plan meeting had, the nursing staff would go over their code status to ensure the residents knew. During an interview on 06/11/2026 at 2:51 p.m., ADON D stated they were covering as nurse for the hall Resident #11 was on. ADON D stated that when a resident's code status changed typically the doctor will inform the SW. ADON D stated that usually the nurse submits the order of the resident's code status when the resident is admitted to the facility. ADON D stated the incorrect code status order could lead to harm to the resident. During an interview on 06/12/2026 at 9:04 a.m., the DON stated once the SW receives the resident's DNR, complete and verified, the SW would have either let the DON or someone in upper management know and if not present then the SW would the nurse know so they could put in the order. During an interview on 6/12/2026 at 9:06 a.m., the SW stated when a resident wanted to change from a full code to DNR the SW would notify the doctor and get the paperwork signed and then would notify the nurse who would discontinue the full code order and submit a new DNR order to the physician. The SW stated the risk of an incorrect code status order could be a big issue legally and for the facility and family. Record review of facility's policy titled, Medical Record, Content of, revised on 08/2007, revealed the following: All physicians, nursing staff and other health professionals involved in the resident's care will be responsible for making prompt, appropriate entries in the record. Record review of the facility's policy titled, Advance Directives and Associate Documentation, revised on 12/2023, revealed the following: It is the policy of this facility that a resident's choice about advance directives will be recognized and respected.

Based on observation, interview and record review the facility failed to ensure the resident's environment remains as free of accident hazards as is possible, for 1 of 6 residents (Resident #118), reviewed for accidents. The facility failed to ensure Resident #118 did not have a pair of nails clippers in their room. This failure could place the resident at risk of injury and contribute to avoidable accidents and a decline in health.The findings include: Record review of Resident #118's face sheet dated 06/12/2026 revealed a [AGE] year-old male readmitted to the facility on [DATE], with an original admission date of 04/04/2015, with diagnoses that include major depressive disorder, recurrent, mild (repeated episodes of depression that are currently mild in severity) and memory deficit following nontraumatic subarachnoid hemorrhage (bleeding in the space surrounding the brain which can lead to neurological deficits) . Record review of Resident #118's MDS dated [DATE] revealed a BIMS of 14 out of 15 indicating no cognitive impairment and recorded the needed use of substantial/maximal assistance with personal hygiene. Record review of Resident #118's care plan provided on 06/12/2026 revealed a focus area for the following: ADL self-care performance deficit r/t UTI revised on 02/17/2026, with interventions including Personal hygiene: Set Up initiated on 02/17/2026. During an observation and interview on 06/09/2026 at 10:16 a.m., revealed Resident #118 had 1 pair of nail clippers in their clear storage container on their dresser. Resident #118 stated staff knew he had the nail clippers and if he was not allowed to have them, they would have taken them away because staff take away things residents cannot have. During an observation and interview on 06/10/2026 at 9:10 a.m., revealed Resident #118 had 1 pair of nail clippers in their clear storage container on their dresser. Resident #118 stated he could not cut his nails and that his family comes and does it. Resident #118 stated they had not cut themselves with nail clippers. Resident #118 stated they occasionally have had other residents come visit him in his room. During an interview on 06/11/2026 at 9:05 a.m., CNA B stated residents were not allowed to have harmful items such as nail clippers in their rooms and if they did, CNA B would have to let a nurse know. CNA B stated they were not sure if Resident #118 should not have nail clippers in their room. CNA B stated they had not seen residents wander into other residents' rooms or visit other residents in their rooms. CNA B stated the risk to residents that had nail clippers in their room would be residents could have cut themselves or the item could be harmful. During an interview on 06/11/2026 at 9:15 a.m., LVN C stated residents could not have anything they could use to harm themselves. LVN C stated Resident #118 should not have nail clippers in their room. LVN C stated they had seen residents go in and out of other residents' rooms to visit but not wander. LVN C stated the danger of having nail clippers in the resident's room could be cutting themselves or using it as a weapon. During an interview on 06/11/2026 at 11:19 a.m., the DON stated residents should not have nail clippers in their room. The DON stated if residents could have nail clippers in their room, they would have to have a safety assessment completed to ensure they were safe to have and use the items. The DON stated if staff saw prohibited items in residents' rooms, they were to remove them and let the nurse know. The DON stated rotating staff were assigned rounds daily that were used to look for items residents should not have in their rooms. The DON stated they did not see safety assessments completed for Resident #118. The DON stated they were unaware that Resident #118 had nail clippers in their room. The DON stated the risks could be residents could cut themselves, infection and a safety risk. Record review of the facility's policy titled, Resident Rights, no date, revealed: The resident has the right: 16.To keep and use personal clothing and possessions in the nursing center as space permits unless doing so would infringe upon the rights or safety of other residents. Record review of facility's policy titled, Hazardous Items, revised 05/2024, revealed: It is policy of this facility to ensure that hazardous items get disposed of properly.

Based on interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation, or mistreatment, the facility had evidence that all alleged violations were thoroughly investigated for 1 of 3 residents (Resident #1) reviewed for investigation of alleged ANE. The facility failed to investigate an allegation of ANE when Resident #1's family member alleged Resident #1 was neglected and caused a skin ulcer. This failure could place residents at risk of being neglected.The findings include: A record review of Resident #1's admission record dated 5/23/2026 revealed an admission date of 5/10/2026 and a discharge date of 5/18/2026 with diagnoses which included laceration . left knee (wound to knee), urinary tract infection (bladder infection), and personal history of other infectious . diseases (bladder infections, lung infections). A record review of Resident #1's admission MDS assessment dated [DATE] revealed Resident #1 was a [AGE] year-old female admitted for rehabilitation for a post hospitalization with a left knee wound. A record review of Resident #1's care plan dated 5/23/2026 revealed Resident #1 was dependent on staff assistance for all ADLs. A record review of Resident #1'a skin assessment dated [DATE] revealed LVN C assessed Resident #1 was admitted with skin breakdown to her right big toe and left knee surgical wound. A record review of Resident #1's Nursing Progress noted revealed Resident #1 was administered an enema on the evening of 5/17/2026 at 8:00 PM by LVN A and LVN B. A record review of Resident #1's Nursing Progress noted revealed Resident #1 was discharged to the hospital on 5/18/2026 related to lethargy. During an interview on 5/23/2026 at 2:54 PM Resident #1's family member stated Resident #1 was admitted to the facility after surgery to her leg and hospitalization. Resident #1's family member stated Resident #1 was discharged from the hospital and admitted to the nursing home and lived there for maybe a week. Resident #1's family member stated he and Resident #1's family visited often and had observed no one would assist Resident #1 reposition and or provide incontinent care and many times the family would intervene and insist the staff provide care. Resident #1's family member stated he learned that on 5/18/2026 Resident #1 was sent to the hospital for an infection. Resident #1's family member stated he was given a report on 5/21/2026, by the hospital nurses that Resident #1 had an ulcer to her backside / buttocks and neck areas and may have contributed to her diagnosis of systemic infection. Resident #1's family member stated he grew upset and recalled there were days when he and Resident #1's family visited Resident #1, and no one had provided care. Resident #1's family member stated he called the nursing home to complain. Resident #1's famiy member stated he reached the DON and she heard his complain but he felt she was defensive and indifferent. During an interview on 5/23/2026 at 11:40 AM DON stated Resident #1 was admitted on [DATE] for LTC rehabilitation with ADL supports complicated by a left knee surgery after a fall she had at home. The DON stated Resident #1 was assessed with a change of condition on the morning of 5/18/2026 by the NP, the facility supported the NP's orders for Resident #1 to be sent to the hospital for evaluation and treatment. The DON stated she had received a phone call from Resident #1's Representative on or about 5/21/2026 who was upset that Resident #1 had pressure ulcers to her back / buttocks. The DON stated she had discussed the complaint with the Administrator, and they concluded the allegation was without merit as the interviews and record reviews revealed LVN A and LVN B had administered an enema on the evening of 5/17/2026 and neither nurse observed any skin breakdown. The DON stated the Administrator and herself decided the allegation did not rise to the level of a self-report to the state agency since the allegation had no evidence. A record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2001, revealed . policy interpretation and implementation: . Identify and investigate all possible incidents of abuse, neglect, mistreatment, poor misappropriation of resident property. Investigate and report any allegations within time frames required by federal requirements.

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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 3 residents (Resident #1) reviewed for reporting allegations of ANE. The facility failed to report an allegation of ANE when Resident #1's family member alleged Resident #1 was neglected and caused a skin ulcer. This failure could place residents at risk of being neglected.The findings include:A record review of Resident #1's admission record, dated 5/23/2026, revealed an admission date of 5/10/2026 and a discharge date of 5/18/2026. Resident #1 had diagnoses which included laceration of the left knee (a wound to the knee), urinary tract infection (an infection of the bladder), and personal history of other infectious and diseases 9bladder infections, lung infections). A record review of Resident #1's admission MDS assessment, dated 5/10/2026, revealed Resident #1 was a [AGE] year-old female who was admitted to the facility for rehabilitation for a post hospitalization with a left knee wound. A record review of Resident #1's care plan, dated 5/23/2026, revealed Resident #1 was dependent on staff assistance for all ADLs. A record review of Resident #1'a skin assessment, dated 5/11/2026, revealed LVN C assessed Resident #1 was admitted with skin breakdown to her right big toe and left knee surgical wound. A record review of Resident #1's Nursing Progress note revealed Resident #1 was administered an enema on the evening of 5/17/2026 at 8:00 PM by LVN A and LVN B. A record review of Resident #1's Nursing Progress note revealed Resident #1 was discharged to the hospital on 5/18/2026 related to lethargy. During an interview on 5/23/2026 at 2:54 PM Resident #1's family member stated Resident #1 was admitted to the facility after surgery to her leg and hospitalization. Resident #1's family member stated Resident #1 was discharged from the hospital and admitted to the nursing home and lived there for maybe a week. Resident #1's family member stated he and Resident #1's family visited often and had observed no one would assist Resident #1 with reposition or provide incontinent care, and many times the family would intervene and insist the staff provide care. Resident #1's family member stated he learned on 5/18/2026 that Resident #1 was sent to the hospital for an infection. Resident #1's family member stated he was given a report on 5/21/2026, by the hospital nurses that Resident #1 had an ulcer to her backside / buttocks and neck areas and may have contributed to her diagnosis of systemic infection (an infection throughout the body). Resident #1's family member stated he grew upset and recalled there were days when he and Resident #1's family visited Resident #1, and no one provided care. Resident #1's family member stated he called the nursing home to complain. Resident #1's family member stated he reached the DON and she heard his complain but he felt she was defensive and indifferent. During an interview on 5/23/2026 at 11:40 AM, the DON stated Resident #1 was admitted to the facility on [DATE] for LTC rehabilitation with ADL supports complicated by a left knee surgery after a fall she had at home. The DON stated Resident #1 was assessed with a change of condition on the morning of 5/18/2026 by the NP. The facility supported the NP's orders for Resident #1 to be sent to the hospital for evaluation and treatment. The DON stated she received a phone call from Resident #1's Representative on or about 5/21/2026, who was upset that Resident #1 had pressure ulcers to her back / buttocks. The DON stated she discussed the complaint with the Administrator, and they concluded the allegation was without merit as the interviews and record reviews revealed LVN A and LVN B had administered an enema on the evening of 5/17/2026 and neither nurse observed any skin breakdown. The DON stated the facility would report allegations of ANE with injury within 2 hours and without injury within 24 hrs. The DON stated the Administrator and herself decided the allegation did not rise to the level of a self-report to the state agency since the allegation had no evidence. A record review of the facility's Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2001, revealed Presidents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. policy interpretation and implementation: . Identify and investigate all possible incidents of abuse, neglect, mistreatment, poor misappropriation of resident property. Investigate and report any allegations within time frames required by federal requirements.

Based on observation, interview, and record review, the facility failed to ensure that it was free of a medication error rate below 5 percent (%) or greater. The facility had a medication error rate of 16.12% based on 5 out of 31 opportunities which involved 1 of 5 residents (Resident #1) and 1 of 1 staff (LPN B) observed for medication administration errors. LPN B administered Docusate Sodium (a stool softener used to relieve constipation), Fluoxetine HCl (a drug used to treat depression), Meloxicam (an analgesic, a drug used to reduce pain and swelling), Methenamine Hippurate (a drug used to prevent recurrent urinary tract infections), and Polyethylene Glycol (a drug used as a laxative to relieve constipation) to Resident #1 at 12:12 p.m., one (1) hour and twelve (12) minutes after the scheduled administration window, 07:00 a.m. to 11:00 a.m. This failure could place residents at risk of not receiving therapeutic effects of the medications and possible adverse reactions.The findings included: Record review of Resident #1's Face Sheet, dated 03/08/2026, reflected an [AGE] year-old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed on 03/08/2026 at 02:01 p.m., reflected diagnoses included fracture of unspecified carpal bone (one of the eight small bones that make up the wrist), left wrist; constipation (a problem with passing fewer than three stools a week or difficulty passing a stool), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and urinary tract infection (an infection in any part of the urinary system). Record review of Resident #1's 5-Day MDS Assessment, dated 02/22/2026, reflected the resident had a BIMS score of 11, which indicated she was moderately cognitively intact. She normally used a walker and required substantial/maximal assistance to roll left and right on the bed, to move from sitting to lying, from sitting to standing, and to transfer from the chair/bed-to-chair. She was noted to have an active urinary tract infection, fracture, and depression. She received scheduled and as needed pain medication and experienced pain frequently at a scale of five (5) out of ten (10). Record review of Resident #1's Care Plan Report, undated and accessed 03/08/2026 at 02:03 p.m., reflected the following focus and interventions: - Focus: Has constipation r/t Decreased [sic] mobility, date initiated 02/20/2026. - Intervention: Administer medications as ordered., date initiated 02/20/2026.- Focus: Is on Antibiotic Therapy r/t UTI, date initiated and revised 02/20/2026. - Intervention: Administer medication as ordered - Methenamine Hippurate, date initiated and revised 02/20/2026.- Focus: Alteration in musculoskeletal status r/t Fracture [sic] of the (left wrist), date initiated and revised 02/20/2026. - Intervention: Give analgesics (a drug that is used to relieve pain) as ordered by the physician. Monitor and document for side effects and effectiveness., date initiated 02/20/2026. - Focus: At risk for depression, date initiated and revised 02/20/2026. - Intervention: Administer medications as ordered. Monitor/document for side effects and effectiveness., date initiated 02/20/2026. - Focus: Antidepressant medication use r/t (Fluoxetine) Depression, date initiated and revised 02/20/2026. - Intervention: Give antidepressant medications ordered by physician., date initiated 02/20/2026. Record review of Resident #1's Order Summary Report, dated active orders as of 03/08/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 100 mg by mouth two times a day for bowel maintenance [the process of managing and maintaining regular bowel movements], order status Active, order date and start date 02/26/2026, and no end date. - Fluoxetine HCl Oral Capsule 10 MG (Fluoxetine HCl) Give 100 mg by mouth one time a day related to depression, unspecified, order status Active, order date 02/19/2026, start date 02/20/2026, and no end date. - Meloxicam Oral Tablet 7.5 MG (Meloxicam) Give 7.5 mg by mouth one time a day for pain for 14 Days after breakfast to avoid GI upset or take with snack, order status Active, order date 02/24/2026, start date 02/25/2026, and end date 03/11/2026.- Methenamine Hippurate Oral Tablet 1 GM (Methenamine Hippurate) Give 1 tablet by mouth two times a day for chronic UTI, order status Active, order date 02/19/2026, start date 02/20/2026, and no end date. - Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 1 scoop by mouth two times a day for constipation, order status Active, order date and start date 03/06/2026, and no end date. Record review of Resident #1's CMA Administration Record, dated 03/01/2026 - 03/31/2026, reflected the orders:- Docusate Sodium Oral Tablet 100 MG (Docusate Sodium) Give 100 mg by mouth two times a day for bowel maintenance. The order was noted as scheduled for administration at AM 07. - Fluoxetine HCl Oral Capsule 10 MG (Fluoxetine HCl) Give 100 mg by mouth one time a day related to depression, unspecified. The order was noted as scheduled for administration at AM 07. - Meloxicam Oral Tablet 7.5 MG (Meloxicam) Give 7.5 mg by mouth one time a day for pain for 14 Days after breakfast to avoid GI upset or take with snack. The order was noted as scheduled at AM 07. - Methenamine Hippurate Oral Tablet 1 GM (Methenamine Hippurate) Give 1 tablet by mouth two times a day for chronic UTI. The order was noted as scheduled at AM 07.- Polyethylene Glycol 3350 Powder (Polyethylene Glycol 3350 (Bulk)) Give 1 scoop by mouth two times a day for constipation. The order was noted as scheduled at AM 07. During an observation and interview of medication administration on 03/08/2026 from 12:02 p.m. to 12:12 p.m., LPN B was observed to start preparing Resident #1's medication administration at 12:02 p.m. On LPN B's electronic medication administration record screen, Resident #1's Docusate Sodium, Fluoxetine HCl, Meloxicam, Methenamine Hippurate, and Polyethylene Glycol were observed to be scheduled for administration from 07:00 a.m. to 11:00 a.m. LPN B was observed to administer Resident #1's medications at 12:12 p.m. LPN B stated the medications for Resident #1 were late due to her having not been frequently assigned to administer medications on Resident #1's hall and was therefore not very familiar with their medications. She stated she would often assist residents in repositioning and other requested tasks while in the residents' rooms, which also resulted in her having been delayed this morning, 03/08/2026, in medication administration. She stated the impact of late medication administration was that it could result in some medications that were scheduled more than once a day having been administered too closely together. During an interview on 03/09/2026 at 06:52 p.m., the DON stated it was the responsibility of the medication aides and nurses to administer the medications on time. She stated the impact of late medication administration would depend on the medication. While reviewing the medications that were administered late for Resident #1, the DON stated the late medication administration would not have impacted the resident and she stated she had notified Resident #1's provider regarding the late medication administration and they did not have any concerns. During an interview on 03/09/2026 at 07:20 p.m., the ADMIN stated his expectation was for staff to administer the medications when they were supposed to. He stated it was the responsibility of the medication aide or nurse. He stated the impact of late medication administration would depend on the medication, such that a late pain medication might result in the resident experiencing pain. He stated it would depend on what the medication was prescribed for. Record review of Policy / Procedure - Nursing Clinical Section: Medication Administration Subject: Administration of Drugs, dated revised 08/2020, reflected: Policy:It is the policy of this facility that medications shall be administered as prescribed by the attending physician.Procedures: .2. Medications must be administered in accordance with the written orders of the attending physician.7. Medications may not be set up in advance and must be administered within one (1) hour before or after their prescribed time.8. Medications may be administered within the liberalized time frame if [facility name] have transitioned to liberalized medication time frames with the approval of the resident's physicians and after consulting with pharmacy.9. Unless otherwise specified by the resident's attending physician, routine medications should be administered as scheduled.

Based on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services. 1. MA A failed to remove Resident #1's Lidoderm Patch (an analgesic, a patch containing numbing medication for pain) according to physicians' orders and manufacturer's instructions on 03/07/2026. 2. MA A incorrectly dated and did not initial Resident #1's Lidoderm Patch 03/06/2026 when administering the patch on 03/07/2026. This failure could place residents at risk for not receiving the intended therapeutic effects of prescribed medications or receiving potentially harmful side effects from prescribed medications. The findings included: Record review of Resident #1's Face Sheet, dated 03/08/2026, reflected an [AGE] year-old female. She was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #1's Medical Diagnosis tab, undated and accessed on 03/08/2026 at 02:01 p.m., reflected diagnoses included fracture of unspecified carpal bone (one of the eight small bones that make up the wrist), left wrist; constipation (a problem with passing fewer than three stools a week or difficulty passing a stool), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest in activities), and urinary tract infection (an infection in any part of the urinary system). Record review of Resident #1's 5-Day MDS Assessment, dated 02/22/2026, reflected the resident had a BIMS score of 11, which indicated she was moderately cognitively intact. She normally used a walker and required substantial/maximal assistance to roll left and right on the bed, to move from sitting to lying, from sitting to standing, and to transfer from the chair/bed-to-chair. She was noted to have an active urinary tract infection, fracture, and depression. She received scheduled and as needed pain medication and experienced pain frequently at a scale of 5 out of 10. Record review of Resident #1's Care Plan Report, undated and accessed 03/08/2026 at 02:03 p.m., reflected the following focus and interventions: - Focus: Alteration in musculoskeletal status r/t Fracture [sic] of the (left wrist), date initiated and revised 02/20/2026. - Intervention: Give analgesics (a drug that is used to relieve pain) as ordered by the physician. Monitor and document for side effects and effectiveness., date initiated 02/20/2026. Record review of Resident #1's Order Summary Report, dated active orders as of 03/08/2026, reflected the following order summaries with order status, order date, start date, and end date if available: - Lidoderm Patch 5% (Lidocaine) Apply to lower back topically one time a day for back pain remove every evening before bedtime, order status Active, order date 03/04/2026, start date 03/05/2026, and no end date. Record review of Resident #1's MA Administration Record, dated 03/01/2026 - 03/31/2026, reflected the order Lidoderm Patch 5% (Lidocaine) Apply to lower back topically one time a day for back pain remove every evening before bedtime. The order was documented as administered on 03/07/2026 by MA A. During an observation and interviews of medication administration on 03/08/2026 at 12:43 p.m., LPN B was observed to enter Resident #1's room to administer her scheduled Lidoderm Patch. After LPN B assisted Resident #1 onto her left side, LPN B lifted the back of Resident #1's shirt to expose her lower back. A Lidoderm Patch dated 03/06/2026 and without initials was visible on Resident #1's back. LPN B stated the resident (Resident #1) should not have had that (a previous Lidoderm Patch) on. She stated she did not know why Resident #1 had it on because she, LPN B, did not work the last two days, 03/06/2026 and 03/07/2026, and therefore had not seen Resident #1's back over those two days. She stated she believed the Lidoderm Patch was only supposed to be on the resident for 12 hours and was not sure why it had not been removed the prior evening. She stated she was unsure why the prior day's administration had been missed or if the administering staff member mis-dated the patch. She stated that this type of error was unacceptable and that the resident was at risk of getting more medication or a higher dosage of the medication than she should. LPN B was observed to ask Resident #1 if she was in pain and Resident #1 responded, no. LPN B was observed to ask Resident #1 if she knew when the Lidoderm Patch was last put on and Resident #1 responded, the day before but was not sure. During an interview on 03/09/2026 at 04:46 p.m., MA A stated she normally worked double weekends as a medication aide. She stated she had worked as the medication aide on 03/07/2026 from 06:00 a.m. to 10:00 p.m. She stated she remembered administering Resident #1 her medications on 03/07/2026 and remembered applying the Lidoderm Patch. She stated if she put the patch on, she would know the patch would need to be removed in the afternoon but did not recall taking Resident #1's patch off. She stated she remembered administering Resident #1's evening medications and she remembered asking Resident #1 to turn onto her side and Resident #1 stating she was in pain in her arm. MA A stated she most likely told Resident #1 she would be back and then the requirement to remove the Lidoderm Patch slipped her mind. She stated the patches were expected to be on 11.5 to 12 hours. MA A stated she could have put the wrong date on the patch. She stated there were times when she had discovered she was putting the wrong date when administering and had to go back and cross the date out and correct it. She stated she did not know how putting the wrong date on the patch or the resident having the patch on longer than 12 hours would have impacted the resident. During an observation on 03/09/2026 at 06:22 p.m., Resident #1's Lidoderm Patch reflected Lidocaine Patch 5% and under directions for use, Apply the prescribed number of patches, only once for up to 12 hours within a 24 hour period. During an interview on 03/09/2026 at 06:52 p.m., the DON stated her expectation was for staff to initial and date the Lidoderm or Lidocaine Patches when administering. She stated the lidocaine patch should be removed in 12 hours unless the provider changes the order. She stated the impact of a resident having a Lidoderm or Lidocaine Patch longer than the expected time was that it could possibly cause Lidocaine toxicity. She stated the impact of not providing the patch per order was that the resident might have complaints of pain. She stated the impact of the patch having possibly been dated wrong was that a person observing the labeled date might interpret that as a treatment was missed or not administered. During an interview on 03/09/2026 at 07:20 p.m., the ADMIN stated his expectation was for staff to follow the doctor's order, when to give the medication, when to take it off, when to replace it, and when to discontinue it. He stated the impact of not removing the medication per order was that it could cause skin irritation. He stated the impact of possibly incorrectly labeling the patch was that it could cause confusion over when the medication was administered or result in double dosing. He stated the impact of possibly missing an administration was that the resident could be in pain. Record review of Policy / Procedure - Nursing Clinical Section: Medication Administration Subject: Administration of Drugs, dated revised 08/2020, reflected: Policy:It is the policy of this facility that medications shall be administered as prescribed by the attending physician.Procedures: .2. Medications must be administered in accordance with the written orders of the attending physician.

Based on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 4 residents (Resident #1) reviewed for care plan revisions. The facility failed to ensure Resident #1's care plan was comprehensive and updated to reflect Resident #1 had wandering and exit seeking behaviors. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. The findings included: Record review of Resident #1's face sheet, dated 8/21/25, revealed an admission date of 3/7/25 with diagnoses including: cerebral infarction (when blood flow to a part of the brain is obstructed typically by a blood clot causing death to the brain cells), disorder of visual pathways in (due to) vascular disorders left side (the visual pathway consist of structures that carry visual information from the retina to the brain. Lesions in that pathway cause a variety of visual field defects), other abnormality of gait and mobility, and cognitive communication deficit. Record review of Resident #1's care plan, updated 8/20/25, revealed the resident would wander related to impaired safety awareness, unintentionally intrudes on the privacy of others or activity related to impaired cognition. An intervention to redirect resident from wandering by reorienting Resident #1 and direct/assist to his room was also added on 8/20/25. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Section E Behavior revealed he had no wandering behaviors. Record review of Resident #1's nursing progress notes, dated 8/21/25, revealed: -3/10/25 at 9:24 a.m. Resident wandering the hall, looking for his room. He is A/O x2 currently and does not remember why he is here. Easily redirected and compliant with directions. [NP] updated about patient status. Will continue to monitor. Written by RN A-8/5/25 at 12:07 a.m. Resident was up and walking around and going into other resident's rooms. Resident was redirected and got angry at staff, also attempted to walk to the front door, but redirected to go back to his room. Resident was screaming down the hallway not wanting to go to his room. Staff encouraged resident to stay in bed during the night and use his wheelchair while his OOB. Staff attempted to take resident back to his room and but refused, resident is sitting by the nurse's station being observed. Written by LVN B. Record review of Resident #1's Elopement and Wandering Evaluation assessment, dated 6/10/25, revealed answers to question revealed he had no history of, or current behavior of wandering and he was a low risk. Record review of Resident #1's assessment on 8/21/25, revealed two wandering assessments were completed in the past. One was completed on 3/7/25 with low risk and another on 6/10/25 with low risk. No other wandering/elopement assessment were found. During an interview on 8/20/25 at 1:44 p.m. RN A stated Resident #1 was known to go into other residents' room. RN A stated when other residents would complain about the resident being in their rooms she would go check and he would be taking products like toilet paper he already had in his room. RN A stated she would redirect him to retrieve the items from his room. During an interview on 8/21/25 at 10:35 a.m. interview with Resident #2 who's room was across the hall from Resident #1 stated once Resident #1 had come in her room. She stated she was coloring and facing her window when Resident #1 tapped her on the shoulder and stated something in Spanish as he pointed out the window. Resident #2 stated she told him to leave her room, and he did. During an interview on 8/21/25 at 11:47 a.m. MDS C stated she was informed on 8/20/25 that Resident #1 had behaviors of looking for a family member and would require staff to reorient him. MDS C stated they would normally run a 24-hours report in the morning and filter for key words to find any resident with changes in condition. MDS C stated the ADONs also assist with looking over the 24-hour reports and updating any assessments or care plans. MDS C stated she had recently been out for personal reasons and was not aware the resident had a change in condition. MDS C stated by not updating changes in the resident's care plan staff would not be aware of how to treat the resident. The MDS C stated staff used the care plan to be aware of resident behaviors and would also prompt care areas in the point of care nursing aides used. During an interview on 8/21/25 at 12:09 p.m. ADON D they would run a 24-hour report and read the report to see if any residents had a change in condition. ADON D stated there were 3 ADONs who would split up the reports according to hallways. ADON D stated however 1 of the ADONs had recently started and another ADON had been out of FMLA. The ADON stated the DON was also helping her read the 24-hour reports daily. ADON D stated she was not aware of the nursing progress note from 8/5/25 where the resident was exhibiting exit seeking and wandering behaviors. ADON D stated had she seen that note she would have spoken to the resident to see what was going on, spoken to the nursing staff, and made the DON aware. ADON D stated they would also notify the doctor and see if they needed to update any orders. ADON D stated they would also need to look at his elopement and wandering assessment and update it. ADON D stated failing to update the resident assessments could cause someone to miss a new onset mental issue or condition and implementing any interventions to protect other residents and respect their privacy. During an interview on 8/21/25 at 12:23 p.m. the DON stated the ADONs would look over the 24-hour reports, notify MDS, and bring up any changes in patient conditions during their morning meetings. The DON stated she became aware of Resident #1's nursing note from 8/5/25 on 8/20/25 while performing an audit. The DON stated they care planned the behaviors. The DON stated she was unaware the resident ever had wandering behaviors and no one ever reported to her he had any behaviors of being in other resident rooms. The DON stated the ADONs were responsible for reviewing the 24-report and updating the wandering assessment. The DON stated it was important to update care plans and assessments so staff could follow the residents plan of care and return him to his room safely. Record review of the facility's policy titled Comprehensive [NAME]-Centered Care Planning, dated 12/23, stated Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.4. The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MOS) and will include resident's needs identified in the comprehensive assessment. 6. The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Based on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) whose assessments were reviewed, in that: Resident #1's wandering assessment and MDS did not reflect he had wandering behaviors. This failure could place residents at risk for inadequate care due to inaccurate assessments. The findings were: Record review of Resident #1's face sheet, dated 8/21/25, revealed an admission date of 3/7/25 with diagnoses including: cerebral infarction (when blood flow to a part of the brain is obstructed typically by a blood clot causing death to the brain cells), disorder of visual pathways in (due to) vascular disorders left side (the visual pathway consist of structures that carry visual information from the retina to the brain. Lesions in that pathway cause a variety of visual field defects), other abnormality of gait and mobility, and cognitive communication deficit. Record review of Resident #1's care plan, updated 8/20/25, revealed the resident would wander related to impaired safety awareness, unintentionally intrudes on the privacy of others or activity related to impaired cognition. An intervention to redirect resident from wandering by reorienting Resident #1 and direct/assist to his room was also added on 8/20/25. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 10, indicating moderate cognitive impairment. Section E Behavior revealed he had no wandering behaviors. Record review of Resident #1's nursing progress notes, dated 8/21/25, revealed: -3/10/25 at 9:24 a.m. Resident wandering the hall, looking for his room. He is A/O x2 currently and does not remember why he is here. Easily redirected and compliant with directions. [NP] updated about patient status. Will continue to monitor. Written by RN A-8/5/25 12:07 a.m. Resident was up and walking around and going into other resident's rooms. Resident was redirected and got angry at staff, also attempted to walk to the front door, but redirected to go back to his room. Resident was screaming down the hallway not wanting to go to his room. Staff encouraged resident to stay in bed during the night and use his wheelchair while his OOB. Staff attempted to take resident back to his room and but refused, resident is sitting by the nurse's station being observed. Written by LVN B Record review of Resident #1's Elopement and Wandering Evaluation assessment, dated 6/10/25, revealed answers to question revealed he had no history of or current behavior of wandering and he was a low risk. Record review of Resident #1's assessment on 8/21/25, revealed two wandering assessment were completed in the past. One was completed on 3/7/25 with low risk and another on 6/10/25 with low risk. No other wandering/elopement assessment were found. During an interview on 8/20/25 at 1:44 p.m. RN A stated Resident #1 was known to go into other residents' room. RN A stated when other residents would complain about the resident being in their rooms she would go check and he would be taking products like toilet paper he already had in his room. RN A stated she would redirect him to retrieve the items from his room. During an interview on 8/21/25 at 10:35 a.m. interview with Resident #2 who's room was across the hall from Resident #1 stated once Resident #1 had come in her room. She stated she was coloring and facing her window when Resident #1 tapped her on the shoulder and stated something in Spanish as he pointed out the window. Resident #2 stated she told him to leave her room, and he did. During an interview on 8/21/25 at 11:47 a.m. MDS C stated she was informed on 8/20/25 that Resident #1 had behaviors of looking for a family member and would require staff to reorient him. MDS C stated they would normally run a 24 hours report in the morning and filter for key words to find any resident with changes in condition. MDS C stated the ADONs also assist with looking over the 24 hour reports and updating any assessments or care plans. MDS C stated she had recently been out for personal reasons and was not aware the resident had a change in condition. MDS C stated by not updating changes in the resident's care plan staff would not be aware of how to treat the resident. The MDS C stated staff used the care plan to be aware of resident behaviors and would also prompt care areas in the point of care nursing aides used. During an interview on 8/21/25 at 12:09 p.m. ADON D they would run a 24-hour report and read the report to see if any residents had a change in condition. ADON D stated there were 3 ADONs who would split up the reports according to hallways. ADON D stated however 1 of the ADONs had recently started and another ADON had been out of FMLA. The ADON stated the DON was also helping her read the 24-hour reports daily. ADON D stated she was not aware of the nursing progress note from 8/5/25 where the resident was exhibiting exit seeking and wandering behaviors. ADON D stated had she seen that note she would have spoken to the resident to see what was going on, spoken to the nursing staff, and made the DON aware. ADON D stated they would also notify the doctor and see if they needed to update any orders. ADON D stated they would also need to look at his elopement and wandering assessment and update it. ADON D stated failing to update the resident assessments could cause someone to miss a new onset mental issue or condition, and implementing any interventions to protect other residents and respect their privacy. During an interview on 8/21/25 at 12:23 p.m. the DON stated the ADONs would look over the 24-hour reports, notify MDS, and bring up any changes in patient conditions during their morning meetings. The DON stated she became aware of Resident #1's nursing note from 8/5/25 on 8/20/25 while performing an audit. The DON stated they care planned the behaviors. The DON stated she was unaware the resident ever had wandering behaviors and no one ever reported to her he had any behaviors of being in other resident rooms. The DON stated the ADONs were responsible for reviewing the 24-report and updating the wandering assessment. The DON stated it was important to update care plans and assessments so staff could follow the residents plan of care and return him to his room safely. Record review of the facility's policy titled Resident Assessment, no date, stated Policy: It is the policy of this facility to perform resident assessment. Procedure: Each resident will be assessed by the licensed nurse. 2. Each time there is a change in the mental or physical condition of the resident that may significantly affect his or her ability to perform the activities of daily living 3. Every quarter. 4. If there is a significant change, it will be reported to physician and orders to carried out. Additional assessments will be performed as needed. (i.e., fall risk assessment, pain evaluations, enabling device assessment, etc).

Based on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional guidelines for three of eight medication carts (200 hall nurse cart, 200 hall medication aide cart, and 400 hall medication aide cart) assessed for medication storage and labeling. The nurse cart for the 200 hall contained two unlabeled pills lying in the drawer. The medication aide cart for the 200 hall contained one unlabeled pill lying in the drawer. The medication aide cart for the 400 hall contained four unlabeled pills lying in the drawer. This failure could place residents who receive medications at risk of not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others. The findings included: During an observation and interview on [DATE] at 9:00 AM of the 200 hall nurse cart with RN A, 2 loose pills were observed in the bottom of the cart drawer, unlabeled. RN A stated she would toss the pills because you don't even know what it is. RN A stated she tosses them to be safe, because it could be a huge hazard, and you may not know what you are giving. During an observation on [DATE] at 9:30 AM of the 200 hall medication aide cart with RN A, 1 loose pill was observed in the bottom of the cart drawer, unlabeled. During an observation on [DATE] at 9:35 AM of the 400 hall medication aide cart with RN A, 4 loose pills were observed in the bottom of the cart drawer, unlabeled. During an interview with MA B on [DATE] at 9:50 AM regarding the loose pills in the 200 hall medication aide cart, MA A stated there could be contamination, people can give it, and it can be wrong, or it could be expired. During an interview with MA C on [DATE] at 9:55 AM regarding the loose pills in the 400 hall medication aide cart, MA C stated there could be a med error, or a patient might not be getting their pill. MA C stated she would throw away the pill. During an interview with the DON on [DATE] at 2:56 PM, regarding the loose pills in the medication carts, the DON stated a loose pill could fall out of the cart, and someone could grab it who was not supposed to. The DON stated her expectation is to make sure the loose pills are destroyed. Review of the facility policy titled Labeling of Medications and Biologicals revised on ,d+[DATE], noted It is the policy of this facility that mediations and biologicals are labeled in accordance with facility requirements, state and federal laws.

Based on interview and record review, the facility failed to provide pharmacological 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 2 of 10 residents (Resident #1 and Resident #2 ) reviewed for pharmacy services. 1. LVN A administered Cefazolin (Antibiotic) 6 GM in 250 ML instead of Cefazolin 6 GM in 1000 ML to Resident # 1. The non-compliance was identified as past non-compliance. The noncompliance began on 06/11/2024 and ended on 06/12/24. The facility had corrected the non-compliance before the survey began. 2. The facility failed to ensure that controlled medications were secured. The non-compliance was identified as past non-compliance. The noncompliance began on 7/17/2024 and ended on 7/18/24. The facility had corrected the non-compliance before the survey began. These deficient practices could affect all residents who receive medication from the facility and place them at risk for adverse reactions, decline in physical health. Findings were : 1. Record review of Resident #1's face sheet, dated 02/11/25, revealed an initial admitted [DATE]. Resident #1 had diagnoses that included: Post Traumatic Stress Disorder (a mental health condition that some people develop after they experience or witness a traumatic event), Depression. (persistent symptoms of sadness, and a loss of interest in daily activities) and Prosthetic joint infection (defined as infection involving the joint prosthesis and adjacent tissue). Record review of Resident #1's Admission MDS assessment, dated 6/11/24, revealed a BIMS score of 15, which indicated intact cognition. Record review of Resident #1's Care plan, initiated on 06/11/2024 and revised on 7/28/2024, revealed a focus of: [residents name] is on antibiotic therapy related to orthopedic device, receiving Cefazolin via PICC line. Interventions: Administer medication Cefazolin as ordered. Record review of Resident #1's physician orders, dated 06/07/2024, revealed medication Cefazolin Sodium Injection Solution Reconstructed 3 GM (Cefazolin Sodium) use 6 grams intravenously every shift for infection related to Orthopedic Device. Record review of Resident #1's electronic medication administration record for 6/11/24 revealed that Cefazolin 6 GM in 1000 ML was administered by LVN A at 8 PM via PICC. Interview with LVN A on 2/11/25 at 10:55 A.M. revealed that on 6/11/24 after she administered the IV medication to Resident #1, she realized after the IV infusion, the empty IV bag read Cefazolin 6 GM in 250 ML, not Cefazolin 6 GM in 1000 ML. LVN A called DON, who instructed her to call the facility nurse practitioner and pharmacy. LVN A stated she thought she was giving the correct dose, but by not double-checking the IV bag with the medication administration record, a medication error occurred, which could have harmed the resident. Interview with the Pharmacy consultant on 2/11/25 at 1:20 P.M. revealed that this error occurred as a pharmacy oversight, sending incorrect concentration. The pharmacist consultant stated No harm to Resident # 1 occurred as medication was simply given in less normal saline, which was nonirritant to veins as it was administered via a PICC line. Interview with the facility nurse practitioner on 2/11/25 at 2:20 PM revealed he was not concerned with the medication error as the IV antibiotic was administered with less normal saline, and no adverse effects occurred to Resident # 1 because LVN A recognized the error quickly and had it corrected. Interview with DON on 2/11/25 at 3:15 P.M. revealed that on 6/11/24, at approximately 830 PM, she was notified by LVN A that an IV medication error had occurred. DON stated that she expected all licensed nurses to follow policy and procedure regarding medication administration, as failure to do so could negatively impact residents. She currently has her ADON's review all new admission orders and medication delivered by the pharmacy to ensure the correct medication has been delivered and she audits this at random. Prior to survey entrance, the facility provided Inservice to 100 % of Nursing staff on 6/11/24 - 6/12/24 regarding the Following 5 medication rights: 1. right Patient 2. right person 3. right time 4. Right route 5. right dose. During staff interviews on 2/12/2024 at 8:45 a.m -10 AM., with (LVN B), ( LVN C) , (LVN D) , (LVN E) , (LVN F), ( LVN G) and (RN H), (RN I), (RN J) from all shifts staff stated they had been in-serviced on following the 5 rights to medication administration. Observation on 2/12/25 at 10:33 a.m. revealed DON randomly checked new admission orders, ensuring the five medication rights. Record review of facility policy Medication Administration, IV Medication, dated 8/2020, revealed compare label with a physician order. 2 Record review of resident # 2's face sheet dated 2/13/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included: Dysphagia (difficulty swallowing foods or liquids), Renal Dialysis (a procedure that filters excess fluid and waste and Coronary Angioplasty Status (A procedure that opens the blocked artery). Record review of Resident # 2's Admission MDS assessment dated [DATE] reflected a BIMS score of 15, which indicated that cognition was intact. Record review of Resident's # 2's monthly physician orders for June 2024 revealed an order for Ativan 1 MG, administer one tablet by mouth every 24 hours as needed for anxiety for 14 days. Record review of Resident # 2's progress noted dated 6/27/24 revealed that Resident # 2 was transported to the hospital due to a change of condition and did not return. Record review of Resident # 2's narcotic sheet for Ativan 1 mg reflected 24 Ativan were received on 6/20/24 and 14 Ativan were present on 6/26/24. Record review of Resident # 2's narcotic sheet for Ativan 1 mg revealed nurses were signing after each shift verifying medication Ativan 1 mg quantity 14, was present from 6/26/24 - 7/17/24 . Interview with the DON on 2/13/25 at 10:34 A.M., revealed on 7/17/24 , she was conducting monthly drug destruction when she discovered the narcotic sheet for Ativan 1 MG for Resident # 2 was present, but the blister pack was missing. Interview on 2/13/25 at 11:00 A.M., the DON stated that this medication-drug discrepancy occurred because of outdated controlled drug counting practices. During drug counts on each shift, nurses only counted the amount of medication in a blister pack and did not read the resident's name to include the name of the medication and the amount left. The DON stated on 6/17/24 -6/18/24, in-service was conducted moving forward, all as-needed narcotic medication required two licensed nurses' signatures, and the narcotic drug counting practice was updated. Prior to the survey entrance, the facility in-serviced 100 % all nursing staff on 6/17/24 - 6/18/24 on the updated narcotic medication counting process and all as-needed medication requiring two licensed nurses' signatures. During staff interviews on 2/13/2024 at 6:45 a.m 8:00 AM., with (LVN B), ( LVN C) , (LVN D), (LVN E) , (LVN F), ( LVN G) and (RN H), (RN I), (RN J) from all shifts staff stated they had been in-serviced on following narcotic medication counting process and as-needed narcotic medication requiring two licensed nurses' signatures Observation on 2/14/25 at 6:33 a.m., revealed LVN B and RN H counting narcotics at shift change updated narcotic medication counting process. Observation on 2/14/25 at 9:05 a.m., revealed LVN G and LVN E signing for an as-needed narcotic medication. Record review of the facility policy Controlled Medications, December 2019, reflected Any discrepancy in controlled substance medication counts is reported to the DON immediately.

Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for quality of care, in that: The facility failed to coordinate care with hospice and implement interventions to address Resident #1's mental health needs. Resident #1 was readmitted to the facility with the diagnosis of depression, hospice had communicated to the facility staff that was overheard by ADON C, that the resident had tried to harm himself when he was at home. On 11/01/2024, Resident #1 hung himself with a gait belt attached to the bar in the closet that resulted in his death. An IJ was identified on 11/04/2024. The IJ template was provided to the facility on [DATE] at 8:32 PM. While the IJ was removed on 11/07/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility needed to monitor the implementation of the plan of removal. The failure placed all residents at risk for serious injury, harm, and/or death. The findings included: Record review of Resident #1's Admission Record (face sheet), dated 11/02/2024, revealed he was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. The Admission Record did not indicate when he was discharged prior to his readmission 07/19/2024. Resident #1 was [AGE] year-old male with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction (partial weakness and paralysis of one side of the body due to a stroke), dysphagia (difficulty swallowing), dysarthria (speech sound disorder caused by brain damage), and depression (feelings of severe despondency and dejection). Record review of Resident #1's Discharge Summary and Post-Discharge Plan of Care, dated 07/01/2024, revealed the resident received skilled nursing services and hospice services while he was in the facility from 12/31/2023 to 07/01/2024 and was discharged to home on 07/01/2024 with hospice services from Hospice A. Record review of Resident #1's MDS Admission Assessment, dated 07/25/2024, reflected Resident #1 had diagnoses which included stroke and depression, received hospice services, and had a BIMS of 6 out of 15, an indication of severe cognitive impairment. Resident #1's MDS revealed he used a wheelchair for mobility which he could propel 150 feet without assistance; was dependent on staff for toileting and lower body dressing; required substantial/maximal assistance with upper body dressing, putting on/taking off footwear, personal hygiene, sit-to stand, and toilet transfer. Record review of Resident #1's Care Plans revealed a care plan for Antidepressant medication use r/t [related to] insomnia for medication Trazodone initiated 07/31/2024 and there was no care plan for depression or for the anti-depressant Zoloft. Record review of Resident #1's electronic Physician Orders revealed an order to Admit to Hospice A services with a start date of 07/19/2024. Record review of Resident #1's electronic Physician Orders revealed an order for Activity - Chairbound, can stand for transfers with a start date of 07/19/2024. Record review of Resident #1's electronic Physician Orders revealed an order for DNR/Do Not Attempt Resuscitation [when the heart has stopped beating] with a start date of 07/19/2024. Record review of Resident #1's electronic Physician Orders revealed an order for Use erase [white] board with resident to communicate with a start date of 07/19/2024. Record review of Resident #1's electronic Physician Orders revealed an order for Zoloft (medication for major depressive disorder) 50 mg 1 tab once a day for depression with a start date of 07/26/2024. Record review of Resident #1's electronic Physician Orders revealed an order for Trazodone (medication for depression and insomnia) 50 mg 1 tab once a day at bedtime for insomnia with a start date of 07/30/2024. Record review of Resident #1's electronic Physician Orders revealed an order to monitor anti-depressant targeted behavior with the following codes: 0=no behavior, 1=social isolation, 2=tearfulness, 3=refusal to eat, and 4=other, with a start date of 07/31/2024. Record review of Resident #1's electronic Physician Orders revealed an order for isolation contact/droplet precautions with a start date of 10/29/24. Record review of Resident #1's electronic Physician Orders from 07/19/2024 to 11/01/2024 revealed there were no orders for mental health services. Record review of Resident #1's July 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 07/26/2024 to 07/31/2024, and trazodone 50 mg tab daily from 07/30/2024 to 07/31/2024, and the anti-depressant targeted behavior monitoring was coded as 0. Record review of Resident #1's August 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 08/01/2024 to 08/31/2024, and trazodone 50 mg tab daily from 08/01/2024 to 08/31/2024, and the anti-depressant targeted behavior monitoring was coded as 0 every day. Record review of Resident #1's September 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 09/01/2024 to 09/30/2024, and trazodone 50 mg tab daily from 09/01/2024 to 09/30/2024, and the anti-depressant targeted behavior monitoring was coded as 0 every day. Record review of Resident #1's October 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 10/01/2024 to 10/31/2024, and trazodone 50 mg tab daily from 10/01/2024 to 10/31/2024, and the anti-depressant targeted behavior monitoring was coded as 0 every day. Record review of Resident #1's Resident Mood Interview PHQ-9 (Patient Health Questionnaire is a nine-item tool that assesses the severity of depressive symptoms) dated 07/23/2024 revealed a score of 0 which could be interpreted as no depression, and was completed by Social Services Staff A. Record review of Resident #1's Social Services Assessment, completed by Social Services Staff A dated 07/23/2024, revealed Resident #1 was pleasant and engaging; alert and oriented to person, place, time, and situation; non-speaking, understood and communicated via white board and hand gestures to make his needs known; was diagnosed with depression with no prescribed medication, no behaviors, no trauma assessed to interfere with his care. Record review of Resident #1's Resident Mood Interview PHQ-9, dated 10/25/2024, completed by Social Services Staff A revealed the resident was feeling tired or having little energy for 7-11 days, and a score of 2 which could be interpreted as minimal depression. Resident #1 responded No to all the other questions which included Feeling bad about yourself, or that you are a failure or have let yourself or your family down and Thoughts that you would be better off dead, or of hurting yourself in some way. Record review of Resident #1's Social Services Assessment, completed by Social Services Staff A dated 10/25/2024, revealed Resident #1 was pleasant and engaging; alert and oriented to person, place, time, and situation; non-speaking, understood and communicated via white board and hand gestures to make his needs known; resident participated in PHQ-9 interview and scored 2, minimal depression, has diagnosed of depression with prescribed Zoloft medication, no behaviors, no trauma assessed to interfere with his care. Record review of Resident #1's Hospice A Binder revealed a Comprehensive Assessment, dated 09/12/2024, with a note from Hospice Social Worker dated 08/08/2024, This [Social Worker] sat in the care plan meeting for Resident #1 at his nursing home. The meeting was attended by Hospice RN A, nursing staff from the facility and facility Social Services Staff A .A review of the [resident's] current medications was discussed along with the erratic behavior that was displayed at home when he returned there recently. It was noted that [resident] is not displaying this degree of violent behavior that was displayed at home when he was . at home. [Resident] has been taking Trazodone at night to assist with his sleeping. [Resident] will be screened for possible psychiatric care at the facility .There were no immediate concerns expressed by the nursing staff. No other actions. Record review of Resident #1's facility Nurses' Note, dated 08/09/2024 by ADON B, revealed Per hospice physician .may refer to psych [psychiatric services] with VA and there was no indication the resident needed to be monitored for behaviors of self-harm or to ensure his environment was free of accident hazards. Record review of Resident #1's Hospice A Binder revealed a Comprehensive Assessment, dated 09/26/2024, p.3 Resident #1 .admitted to Hospice with a DX [diagnoses] of left sided CVA [Cerebral Vascular Accident - stroke], .He resides at Nursing Facility. He is alert and oriented x 3. He was always very angry and unreasonably demanding. Spent 3 weeks at home but family unable to care for him. Meds were started shortly after he arrived to (sic) facility because of heightened emotions and him threatening to harm himself before he left home. He is nonverbal but communicates by writing on eraser [white] board. Since then meds have been effective in calming his behavior .he did ask to be off the Zoloft because 'can't focus'. His family wants him on the meds because they agreed improvement in behavior. Had a care plan meeting at facility and they were going to request VA to have a psychiatric evaluation. It was denied and ADON [did not specify which ADON] asked if the facility can pay for it, Still pending. Record review of Resident #1's Hospice A Binder revealed a Comprehensive Assessment, dated 09/26/2024, p.4, a note from Hospice Social Worker, dated 09/13/2024, This [social worker] met with the patient [Resident #1] just outside of his room. Patient [Resident #1] recognized this [social worker] from previous visits and was alert and oriented x3. He nodded that things were going okay but he wrote on this [social worker's] note pad that he's tired of his depression meds. He also noted that .his new room is working out okay for him. When asked if Family Member A is still visiting him on a regular basis he wrote on the notepad that Family Member A visits him every Tuesday and Thursday. Patient [Resident #1] still stands up next to his wheelchair to stretch .This [social worker] spoke to the patient's [Resident #1] Family Member A .and she said that patient's [Resident #1] mood had been better since he is now on Zoloft .she had no immediate concerns for him at this time . Record review of Resident #1's Hospice A Binder revealed a Comprehensive Assessment, dated 09/26/2024, p.8, a note from Hospice RN A, dated 09/13/2024, Resident #1 sitting in wheelchair. Spoke to MDS Nurse A about update for having psychiatric evaluation .she said she will bring it up in the morning meeting . Record review of the facility's EHR for Resident #1, revealed a Psychotropic IDT note dated 09/18/24 by ADON B, had Resident is not currently on psych services. Record review of Resident #1's Nurses' Note, dated 11/01/2024 by ADON B, revealed at 1520 [3:20 PM] Resident #1 was sitting in doorway in room and waved me over. When I went to see what he needed, he wheeled back in the room and pointed to his tv remote on the floor. I picked it up and gave it to him and he shook his head and smiled and gave me a fist bump. I asked if he needed anything else and he shook his head no, Resident #1 was in good spirits at this time. Record review of Resident #1's Nurses' Note, dated 11/01/2024 at 17:36 [5:36 PM] by LVN H revealed Resident #1 was witnessed in wheelchair in the doorway of his room approximately 10 min [minutes] prior to incident, resident had no c/o [complaints of] pain or discomfort, and no s/s [signs/symptoms] of facial grimacing noted, Resident #1 was in stable condition while sitting in entry way of his room, Resident #1 was his usual self .Hospice CNA A entered the room and communicated resident was noted to be in closet in an upright position with the gait belt noted around his neck. Hospice CNA A alerted CNA PP and CNA GG who alerted this nurse at approximately 1612 [4:12 PM]. This nurse entered room and noticed Resident #1 appeared to be of blue discoloration and hanging from the closet rod with a gait belt noted around his neck. LVN J, ADON B, MA A had followed behind this nurse and assisted Resident #1 to the floor, RN B called 911 at 1613 [4:13 PM], police arrived at 16:18 [4:18 PM], 911 EMS arrived, and medic called time of death at 1623 [4:23 PM] and pronounced by Medical Examiner .this nurse called hospice at 1627 [4:27 PM]. Hospice A notified this nurse that, they would contact resident's Family Member A. Family Member B and Family Member A arrived to (sic) facility approximately 20 minutes later .body was released to medical examiner. Record review of Resident #1's Nurses' Note, dated 11/01/2024 at 16:13 [4:13 PM] by RN B revealed This nurse made call to .911 and they are in route and will arrive shortly. Record review of Resident #1's undated Inventory List revealed no belt or gait belt was on the Inventory List that was signed by Family Member A. Record review of an undated typed Time line (sic) of events on 11/1/24 for Resident #1 provided by the facility revealed Nurse Practitioner A saw Resident #1 at 1500 (3 PM) sitting in doorway to his room. ADON B had seen Resident #1 at 1520 (3:20 PM) sitting in the doorway to his room. LVN H saw Resident #1 in his wheelchair in the doorway to his room approximately 10 minutes prior to the incident. At approximately 1612 (4:12 PM) Hospice CNA A alerted CNA PP and CNA GG who alerted LVN H. EMS was called by RN B at 1613 (4:13 PM). The Administrator was notified at 1615 (4:15 PM). Local police arrived at 1618 (4:18 PM). EMS arrived and medic called time of death at 1623 (4:23 PM) and was pronounced. Hospice A was notified at 1627 (4:27 PM). The Medical Examiner picked up Resident #1 at 1800 (6 PM). The Ombudsman was notified at 2000 (8 PM). The Medical Director was notified at 2002 (8:02 PM). Record review of the statement from CNA BB, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 sitting in his doorway around 2 PM, she told him she was leaving for the day, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of the statement from MA B, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 in his wheelchair around 1345 (1:45 PM), Resident #1 indicated he wanted CNA BB to change him, she did not see any difference in his mood, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of the statement from CNA PP, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 at approximately 1400 (2 PM) sitting in his doorway and she assisted with his face mask, his mood was okay, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of the Statement from NP A, dated 11/01/2024, revealed Around 1500 (3 PM) I walked into [the facility] and walked into the ADON's office on the 200 hall. At that time, I saw Resident #1, out of bed and in his wheelchair in the entryway of his room Record review of the statement from LVN F, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 sitting in his wheelchair in the doorway to his room wearing a mask around 1530 (3:30 PM), he was fine, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of the statement from ADON C, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 sitting in his doorway about 20 minutes before the incident, he appeared to be in good spirits and gave her a thumbs up sign, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of the statement from LVN H, dated 11/02/2024, revealed she had last seen Resident #1 on 11/01/2024 sitting in his doorway in his wheelchair about 10 minutes prior to the event, she did not have an impression of his mood, he had just wanted his routine bolus feeding, and he did not show any signs of depression, pain, or sadness; and the resident had not ever displayed suicidal ideations with his communication board. Record review of Hospice CNA A's undated typed statement revealed she arrived at the facility on 11/01/2024 at approximately 3:50 PM. She gathered towels to give Resident #1 a bed bath, spoke to facility CNA PP who informed her the resident was positive for COVID. Hospice CNA A stopped outside the door to his room to don PPE, then entered the room a little past 4 PM. The first thing I saw was the resident's empty wheelchair facing his closet. When I looked down at the floor, I saw Resident #1's feet. I then went to the door [of his room] and from the door[way] I yelled to the CNA's 'Resident #1 is on the floor!' and they replied 'What?' and again I said, 'Resident #1 is on the floor!' and rushed back towards Resident #1. I said out loud, 'Resident #1's first name, what are you doing on the floor' and that's when I fully arrived to (sic) the closet and saw that Resident #1 had the gait belt around his neck and the gait belt was around the closet bar. I turned around to notify the CNA's, but they had already arrived to the room and I said 'Resident #1 is hanging in the closet'. That's when CNA GG and CNA PP alerted the other facility staff. I exited the room and went to the restroom to call Hospice Staff at 4:14 PM but there was no answer. I then called Hospice RN A at 4:15 PM but there was no answer .So I called Hospice A office at 4:17 PM and I spoke with secretary, and she transferred me to Hospice DCS. That's when I told Hospice DCS about what I had just witnessed with Resident #1 and she said I could go home .After speaking with [Hospice DCS], I attempted to return to the room, but the cops had arrived and stated .that I could not enter. I then went to speak with LVN H at the facility who said she was already speaking with the office staff at Hospice A. So, I left and got in my car at 4:35 PM. Interview on 11/02/2024 from 3:12 PM to 3:25 PM, MDS Nurse A stated Resident #1 would give her a high-five and fist bumps with his hands to her every day. She described his mood as stable, fine and there was nothing to indicate an issue with the resident. MDS Nurse A said Resident #1 was placed on isolation precautions on 10/29/24 or 10/30/24 because he was positive for COVID. MDS Nurse A stated on 11/01/2024 she assisted Resident #1 by placing his shoes on him and the footrests on his wheelchair, he was in good spirits at that time with no indication he was feeling down before she left the facility at 2:55 PM. He gave her a fist pump and thumbs up sign before she left his room. She returned to the facility around 3:45 PM and about 20 minutes later she heard help, ran to where she heard help. MDS Nurse A said when she entered Resident #1's room, other staff were trying to lift him up and get the gait belt off his neck, she assisted with trying to lift him up and get the gait belt off him, he didn't have a pulse and his body was still warm to touch. MDS Nurse A stated she could not think of who the other staff were assisting with lifting Resident #1 up. In a telephone interview on 11/05/2024 at 2:59 PM, LVN H stated on 11/01/2024 she was Resident #1's nurse for the 2 PM to 10 PM shift, and she saw Resident #1 sitting in his wheelchair in the doorway as she sat at the nurses' station around 4 PM. LVN H stated later, at approximately 4:15 PM, she saw Resident #1's hospice CNA and the facility CNAs waved her into his room. LVN H said when she walked into Resident #1's room, he was hanging in the closet with a gait belt around his neck, was bluish in color, and his wheelchair near him and his right leg was under part of the wheelchair. LVN H stated she lifted him up, his neck was bent, the gait belt was around his neck so tight that she could not get a finger underneath the gait belt and was trying to loosen it with one hand while holding the resident with her other arm. Other staff entered the room and assisted her with getting Resident #1 down. LVN H stated she called 911 and hospice who said they would contact Resident #1's family. LVN H said Resident #1 didn't appear to be depressed, and he seemed to be level headed. In a telephone interview on 11/06/2024 at 12:07 p.m., CNA PP stated on 11/01/2024 she saw Resident #1 around 2 PM sitting in the doorway to his room, CNA PP got a mask for him and with the assistance of MDS Nurse A, put his shoes on him, the foot pedals on his wheelchair and he was fine. In a further interview in person on 11/06/2024 at 2:04 PM, CNA PP stated on 11/01/2024 Hospice CNA A went into Resident #1's room to bathe him and came out screaming. CNA PP went into his room and found him in the closet and the CNA went and asked for help. CNA PP said Resident #1 had never expressed he wanted to hurt himself and he did not show any signs of depression to her. Interview on 11/02/2024 from 4:44 PM to 4:59 PM, CNA GG stated she had not seen Resident #1 on 11/01/2024 before the incident, the last time she saw him was on 10/30/2024 and was good that day. CNA GG said on 11/01/2024 Hospice CNA A had entered Resident #1's room, found him on the floor, came out of the room, and yelled for staff to assist her. CNA GG said she and another CNA went into Resident #1's room, she saw him on the floor in the closet with a gait belt around his neck and thought it was attached to the closet bar. She ran out of his room and yelled for a nurse to assist them. CNA GG said Resident #1's wheelchair was by the closet and Resident #1 was leaning toward his left side when she entered the room. Interview on 11/02/2024 from 5:10 PM to 5:24 PM, LVN J stated she had only cared for Resident #1 a few times when she worked the night shift, he would come out in the hallway to do his sit-to-stand exercises [holding onto the handrail], used his white board to communicate, and would laugh with the CNAs. LVN J stated she was working on another hall on 11/01/2024 on the 2 PM to 10 PM shift and only saw Resident #1 after the incident. LVN J stated she entered Resident #1's room following behind LVN H, along with ADON B and MA A. LVN J stated when she entered Resident #1's room he was hanging by a cloth gait belt in the closet, LVN H was trying to undo the gait belt and lift Resident #1 up but couldn't. MA A had entered the room and assisted the nurses with lifting Resident #1 up, undoing the gait belt and they got him down. LVN H said ADON B had checked for a pulse on Resident #1. Interview on 11/06/2024 at 1:08 PM, MA A stated on 11/01/2024 he was by the medication cart when he heard ADON B call for help. When MA A entered the room, Resident #1 was in the closet dangling by a gait belt face forward [towards the closet] on his knees with his knees touching the floor. MA A stated he and LVN J grabbed Resident #1 and picked him up, ADON B got between them to help lift Resident #1 up. They were all trying to undo the gait belt that was cinched tightly around his neck and cinched tightly to the closet bar. MA A stated he was able to get the gait belt off the closet bar, then they laid Resident #1 down and then they were able to get the gait belt off his neck. Someone yelled to call 911, and shortly after the fire department came followed by the police. MA A stated Resident #1 had never expressed to the MA that he was feeling down or depressed. Interview on 11/02/2024 from 5:25 PM to 5:30 PM, ADON B said she last saw Resident #1 on 11/01/2024 around 3:20 or 3:30 PM when she had gone into her office that was near his room. Resident #1 had gestured for her to come over and pointed to his TV remote that was on the floor. ADON B said she went into his room, picked up the remove for him and he gave her the thumb up sign. ADON B said later she heard staff calling for help, she ran down the hall. When she entered Resident #1's room, she saw him on the floor, she bent down and grabbed his legs, several staff were trying to pick him up, he was hanging with a gait belt around his neck and attached to the bar in the closet. ADON B said she felt Resident #1, his body was warm, asked if he was a DNR and another nurse had called 911 before she entered the room. Interview on 11/02/2024 from 5:40 PM to 5:55 PM, ADON C said on 11/01/2024 she saw Resident #1 twenty minutes before the incident, he was sitting in his doorway with the door open. ADON C said she educated him that the isolation was not going to last long, to keep his mask on when he was in the doorway, and he was in a good mood. ADON C stated she was in the office [near his room], she heard commotion of staff calling for the floor nurse and she came out of the office area, walked into his room, thought the other nurses were trying to get him off the floor and that was when she saw the gait belt around Resident #1's neck and he was hanging from the closet bar. They were all trying to get him off the gait belt, they finally got him loose. ADON C stated when Resident #1 fell between her legs, he didn't have any signs of life at that time, ADON B did sternal rubs to see if there was any sign of life, Resident #1 was not responsive, other staff had called 911 and when the police and EMS arrived, ADON C said she stepped out of the room. Interview on 11/03/2024 from 11:15 AM to 11:19 AM, NP A said Resident #1 was not on her case load. On 11/01/2024 she saw Resident #1 around 1500 (3 PM) when she went into the nursing office near his room. NP A stated Resident #1 was sitting in his wheelchair in the doorway to his room and was waving at people as they walked by him, and he did not appear to be in distress from what she could see from a far. On 11/03/2024 at 11:34 AM, Hospice CNA A was called with no answer, and she had no voice mail box to leave a message. A text message was sent to the CNA with no response back. Interview on 11/03/2024 from 11:46 AM to 12:00 PM, CNA S said she would not use a gait belt on Resident #1 when she transferred him from his bed to his wheelchair because once he was in a sitting position with his feet on the floor, he could stand up, turn and pivot and sit down in his wheelchair with stand-by-supervision, and was steady most of the time when he was transferred. CNA S stated she saw Resident #1 sitting in his doorway communicating with another CNA on 11/01/2024 around 2 PM before her shift ended and he appeared to be fine at that time. Interview on 11/03/2024 from 12:19 PM to 12:43 PM, Social Services Staff A stated the PHQ-9 assessments were completed by her and the LMSW, it was a way to see if a resident had signs of depression or hopelessness, and scores under 10 were less of a concern than a score above 10, and stated it's always a concern if it's [PHQ-9 score] not a zero. Social Services Staff A said when a resident's PHQ-9 score increases, if the resident was not on any anti-psychotic medication, she would talk to the NP to get a referral for psychiatric services. Social Services Staff A said Resident #1 would use his white board to communicate his answers to the PHQ-9 questions, and his PHQ-9 score increased to a 2 on his 10/25/2024 PHQ-9 assessment because he answered he was feeling tired, having little energy and had answered zero [which was a no] to questions of feeling helpless, depressed, feeling bad about himself, thoughts hurting yourself. Social Services Staff A stated that sometimes feeling tired could be from feeling sick or not feeling their normal energy. Social Services Staff A stated when Resident #1's PHQ-9 score increased to a 2, she didn't think his medications were changed and thought that he might not have been feeling well or was just feeling tired. Interview on 11/03/24 at 4:03 PM, Social Services Staff A said on 10/25/2024, when she asked Resident #1 the PHQ-9 questions and he responded that he was tired, she did not ask him why he was tired, did not ask if he wanted any counseling services or psych services, and did not inform anyone the score had increased. Social Services Staff A said if Resident #1 had responded yes to the self-harm questions, she would have probed further and asked if he wanted any psychiatric services and would notify other staff at that point. Interview on 11/03/2024 at 4:11 PM, the LMSW stated the PHQ-9 assessment score had ranges: 0-4 indicated there was no depression, mild was 5-9, and 10 or above indicated start of moderate depression which was a red flag that something was going on and they would reach out to a health provider at that point. Interview on 11/03/2024 at 5:23 PM, Administrator stated when he went into Resident #1's room after the incident, he saw the gait belt on the floor, it was a light-colored cloth gait belt, and he thought it had writing on it but was not positive. Later when he went back into the room after the police, EMS and medical examiner had left, the belt was no longer in the room. The Administrator said he thought the police or medical examiner had taken it. The Administrator stated the facility switched to a black plastic gait belt sometime during the pandemic and thought it was in 2022 or 2023; and he didn't know where it came from or how long the cloth gait belt had been in Resident #1's room. In a telephone interview on 11/04/2024 at 9:05 AM, Employee A from the Medical Examiner's office stated Resident #1's death was suicide hanging. In a telephone interview on 11/04/2024 from 9:21 AM to 9:31 AM, Hospice DCS stated on 11/01/2024 the receptionist received a phone call from Hospice CNA A who was very frantic. Hospice DCS spoke with Hospice CNA A around 4:19 PM who reported the CNA had found one of the residents [Resident #1] who had hung themselves. Hospice CNA A informed her she had gathered the things she needed to give Resident #1 a bath before she entered his room since he was COVID positive. When Hospice CNA A entered Resident #1's room, she found him hanging from a gait belt in his closet, she panicked, ran out of the room yelling for help and she didn't go back into the room because the facility staff went into his room to see what happened. Hospice DCS said she asked for a statement from Hospice CNA A but the CNA indicated she was too upset to speak about it but she did send the Hospice DCS a written statement in an email. In a telephone interview on 11/04/2024 at 10:18 AM, Hospice MD A stated he couldn't remember how long he had been Resident #1's physician, he had recommended a psychiatric consult, but it never was done that he remembered. He did not remember Resident #1 had any thoughts of suicide of history or suicide. Hospice MD A stated he thought the hospice nurse had informed him of the increase in Resident #1's PHQ-9 score that was done on 10/25/2024. In a telephone interview on 11/04/2024 from 11:22 AM to 12:08 PM, Hospice RN A said she had been Resident #1's hospice nurse since he was first admitted to the facility in December 2023 until July 2024 when he went home for 19 days, then he was under the care of another hospice nurse, and she resumed care of him when he returned to the facility on [DATE]. Hospice RN A said when she had Resident #1 from December 2023 to July 2024, he was very demanding, very impatient, it was my way or no way with Resident #1. Hospice RN A stated the VA worked on getting home care for Resident #1 because he wanted to go home so that Family Member A would not be overwhelmed trying to care for him at home. Hospice RN A said it didn't work out for Resident #1 to be at home because Family Member A could not care for him, and the private care giver had quit. Hospice RN A said when Resident #1 was readmitted to the facility in [NAME][TRUNCATED]

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #1's diagnosis of depression and anti-depressant medication Zoloft. This failure could place residents at risk for not having their needs and preferences met. The findings included: Record review of Resident #1's Admission Record (face sheet), dated 11/2/2024, revealed he was admitted to the facility on [DATE], readmitted on [DATE] and discharged on [DATE]. Resident #1 was a [AGE] year-old male with diagnoses which included hemiplegia and hemiparesis following a cerebral infarction (partial weakness and paralysis of one side of the body due to a stroke), dysphagia (difficulty swallowing), dysarthria (speech sound disorder caused by brain damage), and depression (feelings of severe despondency and dejection). Record review of Resident #1's MDS Admission Assessment, dated 07/25/2024, reflected Resident #1 had diagnoses which included stroke and depression. Resident #1's MDS Assessment also reflected a BIMS of 6, indication of severe cognitive impairment. Record review of Resident #1's electronic Physician Orders revealed an order for Trazodone (medication for depression and insomnia) 50 mg 1 tab once a day at bedtime for insomnia with a start date of 07/30/2024, and an order for Zoloft (medication for major depressive disorder) 50 mg 1 tab once a day for depression with a start date of 07/26/2024. Record review of Resident #1's July 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 07/26/2024 to 07/31/2024, and trazodone 50 mg tab daily from 07/30/2024 to 07/31/2024. Record review of Resident #1's August 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 08/01/2024 to 08/31/2024, and trazodone 50 mg tab daily from 08/01/2024 to 08/31/2024. Record review of Resident #1's September 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 09/01/2024 to 09/30/2024, and trazodone 50 mg tab daily from 09/01/2024 to 09/30/2024. Record review of Resident #1's October 2024 MAR revealed he received Zoloft 50 mg 1 tab daily from 10/01/2024 to 10/31/2024, and trazodone 50 mg tab daily from 10/01/2024 to 10/31/2024. Record review of Resident #1's Care Plans revealed a care plan for Antidepressant medication use r/t [related to] insomnia for medication Trazodone initiated 07/31/2024 and there was no care plan for depression or for the anti-depressant Zoloft. Interview on 11/3/2024 at 4:58 p.m., MDS Nurse A stated she had missed creating a care plan for Resident #1's depression and anti-depressant Zoloft when the medication was ordered. MDS Nurse A said she would look at the order listing reports in the morning to determine if a resident needed to have a new care plan developed. Interview on 11/04/2024 from 3:31 p.m. to 4:10 p.m., the DON stated Resident #1 did not have a care plan for his anti-depressant medication Zoloft or for his diagnosis of depression. The DON said care plans for residents were started with 48-hours of their admission to the facility, and the harm of not having a care plan could result in the lack of continuity of care. Interview on 11/04/2024 from 7:00 PM to 7:40 PM, the Administrator stated a care plan should be initiated when there is a change in a resident's condition or a change in their medications. The Administrator stated morning meetings were held daily to discuss changes in the residents' care and standard of care meetings were held to ensure their care plans would be updated. The Administrator stated the harm of not having a resident's care plan updated could result in the resident missing appointments, treatments, or a variety of other things. Record review of the facility's Comprehensive Person-Centered Care Planning policy, revised 08/2017, revealed It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.

Based on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 2 of 3 Residents (Residents #1 and #2) reviewed for treatments and services. The facility failed to ensure Residents #1(missed 2 IV dressing changes) and #2(missed 2 IV dressing changes) received dressing changes to their intravenous catheters every 7 days as ordered by physician. and the failure to obtain an MD order for the dressing change for Resident #2 until 9 days after admission. This deficient practice could affect residents with intravenous catheters and place them at risk for infection. Findings included: Record review of Resident #1's electronic medical record face sheet dated 7/12/2024 revealed a [AGE] year-old male with an initial admitted [DATE] and a readmitted [DATE]. His diagnoses included cytomegaloviral disease (CMV is related to the viruses that cause chickenpox, herpes simplex and mononucleosis Complications for healthy adults include problems with the digestive system, liver, brain and nervous system.), Diabetes Mellitus 2, acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue), hypertension, gastrointestinal hemorrhage (bleeding in the stomach), and anemia (low blood). Record review of Resident #1's iniital MDS assessment dated [DATE] revealed in section C, a BIMS score of 10 which indicted he was moderately cognitively impaired. Record review of Resident #1's physician orders on 6/26/2024 reflected an order for Midline(IV) care to left upper arm change dressings, change each lumen injection caps with each dressing change every day shift every 7 days and prn. Record review of Resident #1's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/4/2024 by LVN A as having changed midline dressing to left arm of Resident #1. During a phone interview on 7/12/2024 at 9:26 am hospital staff member(RN) stated Resident #1 was admitted on [DATE] from facility and had an IV dressing on his left upper arm dated 6/24/2024. She further stated the dressing appeared to be old and dirty. She stated, the IV dressing was coming loose at the edges and was stiff feeling, not like a IV dressing should feel. During an interview on 7/15/2024 at 9:10 am LVN A stated he was the charge nurse for Resident #1 on 7/4/2024. He further stated he had documented in the EMR he had changed the IV dressing on Resident #1. He stated he documented first and then was going to change the IV dressing but got busy and did not go back and change the dressing. He stated the IV dressings are changed every 7 days and as needed. He further revealed it is important that the dressing be changed to prevent infection. Record review of Resident #2's electronic medical record face sheet dated 7/15/2024 revealed an [AGE] year old male with an admitted [DATE].His diagnoses included sepsis due to enterococcus (bacterial infection that can spread to body and cause serious illnesses.), MRSA(,Infections caused by specific bacteria that are resistant to commonly used antibiotics) hypertension(high blood pressure), atrial fibrillation(irregular heart rate), cardiac pacemaker(device iimplanted in body to help heart beat correctly), and heart failure(when heart cannot pump blood as should). Record review of Resident #2's MDS assessment dated [DATE] revealed in section C a BIMS score of 15 which indicted he was cognitively intact. Record review of Resident #2's physician orders on 7/11/2024 reflected an order for PICC(IV which is inserted in body to accept fluids) line dressing change every 7 days. Record review of Resident #2's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/14/2024 LVN B changed the PICC line dressing. Unable to contact LVN B after 2 attempts (7/12/2024 at 10:40 am, and 7/15/2024 at 9:46 am) for an interview during investigation period. During an observation and interview on 7/15/2024 at 9:30 am Resident #2 stated he had a right arm IV for his antibiotics. Observed clear dressing over insertion site to right upper arm with a date of 6/28/24. During an observation and interview on 7/15/2024 at 9:31 am Treatment nurse observed with surveyor dressing to Resident #2's right arm with date of 6/28/2024. Treatment nurse stated IV dressings are changed every 7 days. She further stated Resident #2's IV dressing should have been changed 7 days after 6/28/2024 which would have been 7/5/2024 and then again on 7/12/2024.The IV dressing was intact. During an observation and interview on 7/15/2024 at 9:35 am LVN A stated he was Resident #2's nurse Monday thru Friday on the day shift. He further stated IV dressings should be changed every 7 days and as needed. He confirmed by observation that Resident #2's IV dressing had a date of 6/28/2024 on it and the date should have reflected a closer date to 7/15/2024. He stated he did not know why the dressing to the IV site had not been changed as ordered but that it was very important to have a clean IV dressing to help prevent infection to the resident. During an interview on 7/15/2024 at 10:00 am facility ADON stated she did not know why the dressings to the IV site's of Resident #1 and Resident #2 had not been changed as ordered but it was very important to have a clean IV dressing to help prevent infection to the residents. She further stated there was not a particular policy on the time frame for changing IV dressings and the nurses followed physician orders. She further stated Resident #2 had a PICC line on admission and he should have had an order on admission to change IV drsg every 7 days. But no one noticed until 7/11/24.She said she did not know why this was not done. When asked who checks the new orders. She stated we all do meaning adons x3. During an interview on 7/15/2024 at 10:30 am facility Administrator stated the nurses should have looked at the IV dressings on the residents (#1 and #2) and noticed the dates. Since they are to be changed every 7 days then they should have been changed every 7 days.

Based on interview and record review, the facility failed to maintain clinical records on each resident that were accurate and complete in accordance with accepted professional standards and practices for 2 03 3 residents (Resident #1 and #2) in that: LVN A and LVN B failed to demonstrate competency in skills by failing to correctly document and perform IV dressing changes on Resident #1 and Resident #2. This failure has potential to affect residents by placing them at an increased and unnecessary risk of pain and exposure to communicable diseases and infection. Findings include: Record review of Resident #1's electronic medical record face sheet dated 7/12/2024 revealed a [AGE] year-old male with an initial admitted [DATE] and a readmitted [DATE]. His diagnoses included cytomegaloviral disease (CMV is related to the viruses that cause chickenpox, herpes simplex and mononucleosis (complications for healthy adults include problems with the digestive system, liver, brain and nervous system.), Diabetes Mellitus 2, acute kidney failure (A condition when an abrupt reduction in kidneys' ability to filter waste products occurs within a few hours or a few days. Symptoms include legs swelling and fatigue), hypertension, gastrointestinal hemorrhage (bleeding in the stomach), and anemia (low blood). Record review of Resident #1's MDS assessment dated [DATE] revealed in section C, a BIMS score of 10 which indicted he was moderately cognitively impaired. Record review of Resident #1's physician orders on 6/26/2024 reflected an order for Midline care to left upper arm change dressings, change each lumen injection caps with each dressing change every day shift every 7 days and prn. Record review of Resident #1's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/4/2024 by LVN A as having changed midline dressing to left arm of Resident #1. Record review of Resident #2's electronic medical record face sheet dated 7/15/2024 revealed an [AGE] year old male with an admitted [DATE]. His diagnoses included sepsis due to enterococcus, MRSA, hypertension,atrial fibrillation, cardiac pacemaker, and heart failure. Record review of Resident #2's MDS assessment dated [DATE] revealed in section C a BIMS score of 15 which indicted he was cognitively intact. Record review of Resident #2's physician orders on 7/11/2024 reflected an order for a PICC line dressing change every 7 days . Record review of Resident #2's ETAR dated 7/1/2024-7/31/2024 revealed documentation on 7/14/2024 of LVN B changing PICC line dressing. Unable to contact LVN B after 2 attempts (7/12/2024 at 10:40 am, and 7/15/2024 at 9:46 am) for an interview during investigation period. During an observation and interview on 7/15/2024 at 9:30 am Resident #2 stated he had a right arm IV for his antibiotics. Observed clear dressing over insertion site to right upper arm with a date of 6/28/24. During an observation and interview on 7/15/2024 at 9:31 am Treatment nurse observed with surveyor dressing to Resident #2's right arm with date of 6/28/2024. Treatment nurse stated IV dressings are changed every 7 days. She further stated Resident #2's IV dressing should have been changed 7 days after 6/28/2024 which would have been 7/5/2024 and then again on 7/12/2024. During an observation and interview on 7/15/2024 at 9:35 am LVN A stated he was Resident #2's nurse Monday thru Friday on the day shift. He further stated IV dressings should be changed every 7 days and as needed. He confirmed by observation that Resident #2's IV dressing had a date of 6/28/2024 on it and the date should have reflected a closer date to 7/15/2024. He stated he did not know why the dressing to the IV site had not been changed as ordered but that it was very important to have a clean IV dressing to help prevent infection to the resident. During an interview on 7/15/2024 at 10:00 am facility ADON stated she did not know why the dressings to the IV site's of Resident #1 and Resident #2 had not been changed as ordered but it was very important to have a clean IV dressing to help prevent infection to the residents. She further stated there was not a particular policy on the time frame for, and the nurses followed physician orders. Record review on 7/15/2024 of competencies and training for LVN A dated 10/18/2023 included certificate of completion in Intravenous Therapy which included dressing changes for IV sites. Intravenous Therapy competencies and training specifically included Midline IVs and PICC lines. Record review on 7/15/2024 of competencies and training for LVN B dated 10/18/2023 included certificate of completion in Intravenous Therapy which included dressing changes for IV sites.Intravenous Therapy competencies and training specifically include Midline IVs and PICC lines.

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, in that: 1. There was a gallon-sized container of sweet tea in the walk-in cooler that had been opened and was not labeled with a use-by date. 2. The DS wore a wristwatch on his left wrist while engaged in food preparation in the kitchen. 3. DA C wore a wristwatch on her left wrist while engaged in food preparation in the kitchen. 4. Cook D had facial hair and was not wearing a facial hair restraint while engaged in food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness. The findings included: 1. Observation on 03/12/2024 at 9:58 AM in the walk-in cooler revealed a gallon-sized container of sweet tea that had been opened and had approximately one pint of tea remaining in the container. The container was not labeled with the date it was opened and a use-by date. During an interview on 03/12/2024 at 10:37 AM the DS stated the container of tea was not labeled with the use-by date and should have been labeled by the staff member storing the container in the cooler. 2. Observation on 03/14/2024 at 10:12 AM in the kitchen revealed the DS wore a wristwatch on his left wrist while engaged in food preparation. The DS removed a pan of meatloaf from the oven, took the temperature of the meatloaf, and returned it to the oven. The DS then wrapped a log of raw beef in plastic wrap for storage. Further observation at 11:55 AM revealed the DS stirred a pot of soup on the stove in the kitchen. 3. Observation on 03/14/2024 at 10:16 AM in the kitchen revealed DA C wore a wristwatch on her left wrist while engaged in food preparation. DA C used a dispenser to fill plastic cups with tea and juice and poured milk from a container before covering the cups with plastic lids. Further observation at 11:45 AM in the kitchen revealed DA C placed food items on trays for the residents' lunch meal. During an interview on 03/14/2024 at 1:25 PM the DS stated he knew both he and DA C should not have worn any jewelry on their wrists while engaged in food preparation in the kitchen. The DS further stated he wanted to help his staff prepare the meal since that day's menu took a while to prepare and he forgot to remove his watch. 4. Observation on 03/14/2024 at 10:35 AM in the kitchen revealed Cook D had facial hair approximately 1/4 in length on his upper lip. Further observation on 03/13/2024 at 10:40 AM revealed Cook D chopped raw cabbage and cooked the cabbage on a flat top grill for the lunch meal. Cook D did not wear a facial hair restraint. During an interview on 03/14/2024 at 10:36 AM Cook D stated he always had facial hair on his upper lip and was not aware he needed a facial hair restraint. During an interview on 03/14/2024 at 10:36 AM the DS stated Cook D had facial hair on his upper lip and should have worn a facial hair restraint. The DS stated he trained his staff during their orientation to the kitchen upon hire and all staff members had current food handlers certificates. The consultant dietitian conducted inspections during monthly visits but did not provide training to the staff. When asked for policies on dating food for storage, jewelry prohibition in the kitchen, and hair restrains, the DS stated the facility used the TFER as their policy manual and provided a copy of the 2015 edition of the TFER. Record review of the Texas Food Establishment Rules (TFER), October 2015, S228.75(f)(1)(a) revealed, refrigerated, ready-to-eat, time/temperature controlled 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 held at a temperature of 41 degrees Fahrenheit or less 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 .(A) the day the original container is opened in the food establishment shall be counted as Day 1 .(I) A food specified in subsection (g) (1) or (2) of this section shall be discarded if it .(B) is in a container or package that does not bear a date or day, or (C) is appropriately marked with a date or day that exceeds a temperature and time combination as specified in subsection (g) (1) of this subsection. Record review of the Texas Food Establishment Rules (TFER), October 2015, S228.40. revealed, Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Record review of the Texas Food Establishment Rules (TFER), October 2015, S228.43. revealed, Hair Restraints. (a) Except as provided in subsection (b) of this section, food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single-service and single-use articles. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022 U.S. Department of H&HS, revealed 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. Commercially prepared food. (B) Except as specified in (E) -(G) of this section, 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. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2017, U.S. Department of H&HS, revealed, 2-303.11 Jewelry Prohibition. Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, 2-402.11, revealed, (A) Except as provided in (B) of this section, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food; clean equipment, utensils, and linens; and unwrapped single service and single-use articles.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 5 residents (Resident #17, #253, and #80) reviewed for infection control, in that: 1. Medication Aide G did not utilize appropriate hand hygiene during the medication pass. 2. LVN A did not utilize appropriate hand hygiene during the medication pass. 3. Medication Aide F did not sanitize the wrist blood pressure cuff between resident use. This deficient practice could place residents at risk of infection or transmission of communicable diseases and a decline in health. The findings included: 1. Record review of Resident #17's face sheet, dated 3/15/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included respiratory failure (condition in which the lungs can't get enough oxygen into the blood), type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), anterior dislocation of right hip (usually caused by a forceful movement of the limb away from the midline of the body with external rotation of the thigh), and angina pectoris (any of a number of disorders in which there is an intense localized pain). Record review of Resident #17's most recent 5-day MDS assessment, dated 2/28/24 revealed the resident was moderately cognitively impaired for daily decision-making skills and received pain medications as needed. Record review of Resident #17's Order Summary Report, dated 3/15/24 revealed the following: - Remove Lidocaine Patch to right hip at bedtime for pain, with order date 3/8/24 and no end date - Lidocaine External Patch 4%, apply to right hip topically one time a day related to anterior dislocation of right hip, remove after 12 hours, with order date 3/8/24 and no end date Observation on 3/14/24 at 8:52 a.m., during the medication pass, revealed Medication Aide G, after administering oral medications to Resident #17, put on a pair of gloves without washing or sanitizing her hands first. Medication Aide G then moved Resident #17's bedside table to one side, took the bed remote to raise the resident's bed, pulled back the resident's blanket, unfastened the resident's incontinent brief, and removed the old Lidocaine patch that was on the resident's right hip. Medication Aide G, while still wearing the same gloves, then applied a new Lidocaine patch to Resident #17's right hip. Medication Aide G, while still wearing the same gloves, then re-fastened Resident #17's incontinent brief, pulled the blanket over the resident, took the bed remote and lowered the bed and adjusted the resident's oxygen nasal canula observed on the resident's face. During an interview on 3/14/24 at 8:56 a.m., Medication Aide G stated, I should have changed my gloves after touching Resident #17's belongings because it was cross contamination, and the resident could get an infection. 2. Record review of Resident #80's face sheet, dated 3/14/24 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included type 2 diabetes (a chronic, long-lasting health condition that affects how your body turns food into energy), muscle wasting, gastroparesis (a condition that affects the stomach muscles and prevents proper stomach emptying), nausea with vomiting, heart failure, gastro-esophageal reflux disease (occurs when stomach acid repeatedly flows back into the tube connecting your mouth and stomach [esophagus]), and dysphagia oropharyngeal phase (difficulty swallowing occurring in the mouth and/or the throat). Record review of Resident #80's most recent quarterly MDS assessment, dated 12/20/23 revealed the resident was moderately cognitively impaired for daily decision-making skills and required a feeding tube. Record review of Resident #80's Order Summary Report, dated 3/14/24 revealed the following: - NPO (Nothing by mouth), with order date 12/16/23 and no end date -Enteral Feed Order every shift check g-tube placement and patency prior to each feeding/flushing/medication administration, with order date 12/16/23 and no end date -Enteral Feed Order every shift, flush g-tube with 30-50 ml (milliliters) of water before and after medication administration, with order date 12/16/23 and no end date -Flush peg tube (g-tube) with 180 ml of water every 6 hours, with order date 12/27/23 and no end date Record review of Resident #80's comprehensive care plan, revision date 12/17/23 revealed the resident had a peg tube in place related to a nutritional problem and diabetic gastroparesis and gastroesophageal reflux. Observation during the medication pass on 3/14/24 at 9:12 a.m. revealed LVN A, after cleaning Resident #80's g-tube site with a split sponge soaked in normal saline, removed her gloves, did not wash or sanitize her hands, and put on a new pair of gloves. LVN A then proceeded to continue with g-tube medication administration. During an interview on 3/14/24 at 10:13 a.m., LVN A revealed she was not aware she had not washed or sanitized her hands after putting on gloves. LVN A revealed she should have washed or sanitized her hands between glove changes because it was an infection control issue, and it could cause the resident to get an infection. During an interview on 3/14/24 at 5:18 p.m., the DON stated it was her expectation staff should practice hand hygiene to prevent cross contamination and could cause the resident to get an infection. The DON revealed, it was expected staff should be sanitizing their hands before and after putting on gloves. 3. Record review of Resident #253's face sheet, dated 3/15/24 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included hyperlipidemia (high cholesterol) and hypertension (high blood pressure). Record review of Resident #253's baseline care plan, dated 3/7/24 revealed the resident had an infection with interventions that included to maintain standard precautions when providing resident care. Observation and interview on 3/14/24 at 4:51 p.m. with Med Aide F revealed he was in the middle of medication pass and was observed retrieving the wrist blood pressure cuff from the medication cart counter to obtain a blood pressure on Resident #253. Med Aide F was not observed sanitizing the wrist blood pressure cuff prior to retrieving it from the medication cart counter. Observation on 3/14/24 at 4:56 p.m., revealed Med Aide F returned to the medication cart, and prepared the medications for Resident #80. Med Aide F then retrieved the same wrist blood pressure cuff used on Resident #253 and obtained Resident #80's blood pressure without sanitizing the wrist blood pressure cuff first. During an interview on 3/14/24 at 5:02 p.m., Med Aide F stated, the wrist blood pressure cuff should have been sanitized after using it on Resident #253 and before using it on Resident #80. Med Aide F revealed, he had forgotten to sanitize the wrist blood pressure cuff because he was nervous, but revealed it was important to sanitize the wrist blood pressure cuff because it was an infection control issue resulting in cross contamination and could result in passing an infection from one resident to the other. During an interview on 3/14/24 at 5:34 p.m., the DON revealed it was her expectation that staff sanitize any blood pressure cuff used between residents to prevent cross contamination. The DON further revealed, if cross contamination had occurred, the resident could get an infection. Record review of the facility policy and procedure titled, Cleaning and Disinfection of Resident Care Items and Equipment, undated, revealed in part, .It is the policy of this facility to maintain clean items and equipment for the residents .Reusable resident items are cleaned and disinfected between residents .Intermediate and low-level disinfectants will be utilized for non-critical items include: stethoscope, blood pressure machines, etc .

Based on interview and record review, the facility failed to ensure residents received adequate supervision with the use of a mechanical lift to prevent accidents for 1 of 2 residents reviewed for accidents (Resident #2). The facility failed to ensure adequate supervision while utilizing the mechanical lift to move Resident #2 in the shower room, resulting in Resident #2 having a fractured nose and a laceration to the hand. The failure contributed to Resident #2's fractured nose and laceration of the hand. This failure could place residents who required the use of a mechanical lift for accidents. Findings included: Record review Face Sheet dated 11/09/2023 indicated Resident #2 was a [AGE] year-old admitted on [DATE] with the diagnosis of Charcot's Join, multiple sites (joint disease that causes pain), morbid obesity (more than 80 to 100 pounds over ideal body weight), lack of coordination and major depressive disorder (feeling sad for a larger percentage of time over a prolonged period for no particular reason). Record review of an MDS dated [DATE] indicated Resident #2 had a BIMS of 15, indicating the resident was cognitively intact. The same MDS indicated Resident required total dependence for bathing-self performance and one-person physical assist for bathing: support provided. In addition the MDS reflected Resident #2 required extensive assistance and two+ persons physical assist for transfer-how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position (excludes to/from bath/toilet). Record review of a Care Plan most recently updated on 06/09/2022 reflected during the time of the incident, Resident #2 required (physical assistance) with transferring. Hoyer lift when transferring to shower bed on Shower Day, transfer: requires assistance with (weight bear, pivot, use arms to support). The intervention reflected a start date of 03/09/21 and a revision date of 06/09/2022. Record review of the most recent care plan on 11/09/2023 reflected Resident #2 required physical help from staff for bathing and resident to use shower bed for showers requires assistance with: transfers with mechanical lift x 2 persons with a revision dated of 06/22/2023. Record review of Nursing Home to Hospital Transfer Form dated 6/22/2023 stated Resident was being transferred from showed bed to wheel chair via hoyer lift when hoyer became unsteady and fell to its side with resident about two feet in the air near wheel chair. Hoyer lift fell over and struck resident in her forehead and gave her a skin tear under her right eye. During a phone interview on 11/08/2023 at 3:05 p.m., CNA C (a former employee of the facility), said she alone utilized the mechanical lift to get Resident #2 to and from the shower bed in the shower room on 06/22/2023. CNA C said she asked for help but was unable to get another staff member to help and she wanted Resident #2 to be able to have her preference of getting a shower using the shower bed. CNA B said she now knows she should not have done that but at the time the transfer took place she did not. CNA C said at the time she received training in the facility for mechanical lift transfers she was told one person could use the mechanical lift with a resident if needed. CNA C said Resident #2 was injured during the transfer using the mechanical lift. CNA C explained she did not know exactly what happened to make the lift move during the transfer but remembered Resident #2 jarred their head into the lift when the attempt was made to move Resident #2 from the shower bed to the wheelchair and believed that was the possible cause. During an interview on 11/08/2023 at 1:44 p.m., Resident #2 said she and CNA C were the only two people in the shower room on 06/22/2023 when she sustained an injury to her nose and her hand. Resident #2 said she did not know exactly what happened but did her nose and hand were injured when being transferred from the shower bed to her wheelchair, I felt my face and hand hit the cold floor, I think I had my eyes closed. During a phone interview on 11/09/2023 at 1:28 p.m., ADON B (a former employee of the facility), said at the time she was at the facility during her training of CNA staff she did provide education that one person can use a mechanical lift if needed however best practice was always to use two staff members when using the mechanical lift with a resident. ADON B said, it just depends on the patient. ADON B was no longer employed by the facility and did not comment further. During an interview on 11/10/2023 at 9:48 a.m., the Administrator said Resident #2 sustained and injury on 06/22/2023 in the shower room while being transferred by one CNA C described using the mechanical lift alone. The Administrator said, at that time and now best practice for use of the mechanical lift was two persons, however the manufacturer's recommendation was two person use with the lift but it can handle one person transfers depending on the healthcare professionals judgement. The Administrator said he believed CNA C, with her experience, felt confident in being able to transfer the resident along with Resident #2's approval and request. The Administrator said he did not know for sure how the Resident was injured. During an interview on 11/10/2023 at 3:57 p.m., LVN D said she was the charge nurse for Resident #2's hallway. LVN D said, she nor any other staff was in the shower room at the time of Resident #2's sustained an injury on 06/22/2023, she did not know what happened further stating, I didn't see I was not in the room. Record review of the hospital records dated 06/22/2023 indicated Resident #2 was seen on 06/22/2023 and treated for a nasal bone fracture, facial trauma, and a hand contusion. Record review of an undated Hydraulic Lift policy provided by the facility Administrator indicated Hydraulic Lift- Follow manufacturers transfer and maintenance recommendations. A Review of the facility provided owner's manual revealed the following information on page 24 of 52: the company name recommends that two assistants be used for all lifting preparation and transferring to/from procedures; however, our equipment will permit proper operation by one assistant. The use of one assistant is based on the evaluation of the health care professional for each individual case.

Based on interview and record review, the facility failed to implement written policies and procedures that prohibited neglect for two (#3 and #4) of eight residents reviewed for neglect. 1. Resident #4 was not appropriately assessed or care planned for use of an electric scooter, fell from the scooter and was hospitalized and passed away. Physical Therapy staff identified the safety issues and this communication was never passed on to direct care staff. These failures resulted in an Immediate Jeopardy (IJ) which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. 2. Resident #3 had a fractured left femur. The facility did not treat the pain prior to being transferred to the hospital after extreme pain was first observed. The resident returned to the facility, placed on hospice, and died within the month. This was determined to be past non-compliance at an Immediate Jeopardy level due to the facility's implementation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] to [DATE]. The facility's corrected action was completed on [DATE]. These deficient practices placed 6 residents identified as having poor safety awareness and 5 residents identified as having increased confusion at risk for risk of accidents and injury to include death and 10 residents identified with having pain at risk for experiencing long periods of pain Findings include: 1. Review of Resident #4's face sheet dated [DATE] revealed he was admitted on [DATE]. Further review revealed Resident #4 had [DIAGNOSES REDACTED]. Review of Resident #4's hospital death summary dated [DATE] revealed under preliminary cause of death: Immediate cause: (Final diseases or condition resulting in death)[MEDICAL CONDITION], Hepatic [MEDICAL CONDITIONS] and right side sub arachnoid hemorrhage .ED course: ( discharged from the facility on [DATE] after he fell from his motor scooter in the parking lot) intubated on arrival neurosurgery and neurology consulted for sub arachnoid hematoma on CT and [MEDICAL CONDITION]. Review of Resident #4's initial mobility fall risk assessment dated [DATE] revealed he scored low risk for falls on admission. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls . with a Yes to does the resident display any of the following behaviors: easily distracted; periods of altered perception of awareness of surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varies over the course of the day; wanders. Under section 11 Gait .Impaired, has difficulty rising from chair, grasps furniture, person or aid when ambulating. Cannot walk unassisted. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls .with overestimates or forgets limits. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed under problem .ADL self care performance deficit r/t CONFUSION, LACK OF COORDINATION, MUSCLE WEAKNESS. Further review of this document revealed under interventions .staff will assist with transfers and visually check the resident every two hours and as needed. Interview on [DATE] at 11:29 a.m. with ADON B revealed that Resident #4's motorized chair arrived sometime around [DATE]st, 2016, and it was not with him when he arrived on the week of the 20th. He said that Resident #4 originally received the motor scooter from the Veteran's Administration, and had used it previously. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed it did not address his motorized chair. Interview on [DATE] at 12:40 p.m. with the MDS nurses A and B revealed that Resident #4's motorized chair needed to be care planned and they did not know why it was not. Review of the facility's Power Mobility Device policy and procedure (undated) revealed that .since a power mobility device can pose a potential risk to the safety, property, and well-being of its user and to others and their property, each facility will assess and document each resident's individualized need regarding appropriate interventions proposed to meet the residents needs. Review of Resident #4's 14 day scheduled MDS assessment dated [DATE] revealed on section [MEDICAL CONDITION] revealed that he had disorganized thinking or was incoherent . behavior present continuously and does not fluctuate. Further review indicated under section G0300 Balance during Transitions and Walking that he was not steady, only able to stabilize with staff assistance. Further review of this document revealed Resident #4 required extensive assist and two person physical assist with transfers .locomotion on unit required supervision and one person physical assist, and supervision off unit required limited assistance and one person physical assist. Review of Resident #4's Care Plan Conference Summary dated [DATE] revealed under Risks/Consequences .potential for falls. Review of Resident #4's Physical Therapy note dated [DATE] at 2:39 p.m. revealed under NOTE: Pt trained in safe power wheel chair mobility to increase safety and decrease risk of injury to self and others. Pt instructed in steering, obstacle negotiation and maneuvering in small spaces. Pt continues to require stand by assistance and visual cueing of the above mentioned skills. Review of Resident #4's comprehensive plan of care initiated [DATE] revealed under problem that due to an unsteady gait he had a fall. Further review of this document revealed that under the section approach .anticipate needs, provide prompt assistance. No revisions were noted. Review of the facility Fall Investigation Worksheet dated [DATE] at 5:45 a.m. revealed that Resident #4 fell while trying to go to the restroom. Under did resident require supervision .response was yes. Further review of this same document revealed resident was found on floor seated and leaning against his bed .stated he was trying to go to bathroom when he got caught by his covers and slipped while grabbing on to his bed mattress. He was reminded to use his call light. Review of the facility Fall Investigation Worksheet dated [DATE] revealed that Resident #4 had a fall at 12:00 a.m. in his room witnessed by the room mate who said that resident was reaching for something that fell on floor and he fell out of bed. Further review of this document revealed that Resident #4 received skin tears to both forearms Review of Resident #4's Progress Notes dated [DATE] at 12:36 a.m. revealed resident experienced fall. residents room mate witnessed the fall. said he was rolling around in bed and fell out. residents bed was locked in lowest position. skin tears to both forearms noted. Review of the facility incidents for [DATE] and [DATE] revealed Resident #4 had falls in his bedroom and was unsteady. Interview on [DATE] at 11:04 a.m. with the DON revealed that Resident #4 had fluctuations with confusion and lucidity, and that he had falls on [DATE] and [DATE]. She reported that Resident #4 should have had a formal assessment for safety to drive his motorized wheel chair and it needed to be care planned which did not happen. Interview on [DATE] at 09:50 a.m. with RN A revealed Resident #4 was acting very anxious the week before his fall on [DATE]. She was informed on [DATE] that the resident was acting confused over the weekend when she got report. She stated that Resident #4 was not very balanced, when referring to his level of physical stability. RN A stated that she sent Resident #4 out to the hospital on [DATE] because soon after she came on for her shift from 6:00 a.m. to 2:00 p.m., the morning after the fall she discovered Resident #4 in his room without his clothes on, and he had a blank stare and would not respond. Review of facility Progress Notes (page 3) written by LVN C and dated [DATE] at 12:08 p.m. revealed, Pt appears to have fallen face first onto surface, has multiple new skin issues including most notable lesion to right brow that was bleeding moderately, pt also has multiple new skin tears to face and extremities. During an interview on [DATE] at 11:35 a.m. with PTA A and the PT who worked for the corporation revealed Resident #4 had a history of [REDACTED]. PTA A stated that some days the resident was very confused, and at times impossible to work with the resident on the days he was confused. PTA A confirmed that there would have been no line-of-sight supervision for the resident on the day he fell off the scooter as to where he fell outside, and that he should not have been outside without supervision. The PT confirmed that Resident #4 was a stand by assist, so he needed to have someone standing by and assisting him. She said that Resident #4 needed verbal cues, in order to avoid things like trash cans and other obstacles the resident had to navigate while operating his scooter. She said that Resident #4 needed this assistance not only on the motorized chair, but also in a regular wheel chair. She said that therapy was usually very good at communicating resident needs to the nursing staff, but that this time it did not happen. PTA A stated that he was very surprised to hear that Resident #4 was outside in his power scooter. He stated that nursing had access to all of the therapy notes. The PT said the resident had poor safety awareness, in that he had a hard time being convinced that he could not do some of the same activities he could do when he was younger. She said that he did not have his power scooter on the day of his initial mobility assessment on [DATE]. Interview on [DATE] at 2:07 p.m. with CNA G, revealed that most of the time the Physical Therapy Department informally communicated with the staff regarding the needs of the resident, but said that she was not told anything specific, and that it was not on her assignment sheet. When asked if Resident #4 was getting stand by assistance or visual cueing while in his electric wheel chair, she said no. She stated that Resident #4 should not have been outside by himself without supervision because of his confusion. Interview on [DATE] at 1:55 p.m. with the facilities Medical Director revealed that she typically goes with the opinion of therapy regarding the screening of residents, and that she was not aware of the resident having safety awareness issues with the scooter, but was aware of his falls. Interview on [DATE] at 4:00 p.m. with the Physical Therapy Director, Administrator and DON revealed that there was not a formal method of communicating therapy information to nursing staff in place .and that was why his need for supervision addressed by therapy was never noted by the direct care staff who took care of him. Interview on [DATE] at 09:30 a.m. with the OTA A and PTA A revealed that Resident #4's behaviors would fluctuate from being lucid to being confused. PTA A said Resident #4's judgement would be confused. He stated that the resident advised her he had an electric scooter and then one day, he showed up with it. PTA A and OTA A both agreed that Resident #4 had safety awareness issues and he was not safe being outside without supervision because of his fluctuations and confusion. Telephone interview on [DATE] at 1:33 p.m. with the witness revealed she saw Resident #4 on the ground behind the facility in the parking lot on [DATE] between 6:30 p.m. and 7:00 p.m. She stated that Resident #4 was bleeding near the right eye, and she went for help. Telephone interview on [DATE] at 1:45 p.m. with Resident #4's emergency contact revealed he was deceased , and that she spoke to him the evening of his fall and said that he sounded different, , but she just assumed he did not have his dentures in .and sounded confused, and did not tell her about the fall. Interview on [DATE] at 2:32 p.m. with LVN B revealed he assessed Resident #4 after he had his fall and he assisted LVN C with getting Resident #4 back into his chair and to his room. He said that resident #4 had a large wound above his right eye. Interview on [DATE] at 2:40 p.m. with LVN C revealed he was alerted on [DATE] that Resident #4 was lying on his right side on the ground in the back of the facility and he said that he did some first aide on the skin tears and the resident did not appear to have fractured anything. He said the resident informed staff that his electric chair fell off the curb. The Administrator was notified of noncompliance at an IJ level on [DATE] at 3:30 p.m. and a plan of removal was requested. The facility plan of removal on [DATE]: -Residents using electric wheel chairs were reassessed by the ADON and administrative nursing staff for safety by [DATE]. -Care plans were checked to ensure residents had a plan of care that recognized and addressed resident's safety needs related to electric wheelchair use by [DATE]. -Nursing staff were trained on recognizing residents with potential of having intermittent confusion by [DATE]. -Existing residents using electric wheel chairs would be assessed quarterly and with any significant change by nursing, therapy and maintenance by [DATE]. -New admissions with electric wheel chairs would be assessed by nursing, therapy, and maintenance prior to use as of [DATE]. -Electric wheel chair assessments would be brought to the weekly IDT meeting for review, and any changes to the plan of care would be communicated through the CNA assignment sheets by [DATE]. -These actions were taken to QA for approval on [DATE]. Confirmation of plan of removal was staff who were interviewed on [DATE] included LVN's, CNAs, and a Med Aide regarding recent in-services, assessments, documenting on the 24 hour book, monitoring of residents, and understanding of the dot system (explains residents ' needs) The topics discussed with each staff person depended on their discipline. Physical Therapy developed a new system of integrating information into the morning facility meetings to disseminate safety concerns of residents to direct care staff. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The number of residents at high risk for safety issues (6) and with increased confusion (5) was provided by the DON. 2. Review of Resident #3's face sheet revealed she was admitted on [DATE] and readmitted on [DATE] on Hospice, after she was transferred to the hospital on [DATE] with a [MEDICAL CONDITION] femur. Further review of this same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS with an ARD of [DATE] revealed Resident #3 could understand and be understood. Further review revealed she scored a ,[DATE] on her BIMS indicating severe cognitive impairment. She was assessed to have no pain and had not taken any PRN pain medication during the review period. Review of Resident #3's physician orders dated [DATE] to [DATE] revealed she had orders to be monitored for pain every shift and to use pain scale (A) ,[DATE] for alert residents and (B) for confused residents. This order originated on [DATE]. Further review revealed orders for [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 Hours PRN for pain and [MEDICATION NAME] HCL Tablet 50 MG, Give 1 tablet by mouth every 4 hours as needed for pain, and Tylenol Extra Strength Tablet 500 MG, Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's MAR for ,[DATE] revealed she was assessed for pain every shift and had no pain indicated for days ,[DATE], however, she was assessed to have a level 6 pain documented on [DATE] for the 6 a.m.- 2 p.m., 2 p.m.-10 p.m., and the 10 p.m.-6 a.m. ([DATE]-[DATE]) shifts. Review of Resident #3's MAR for [DATE] revealed she was provided a [MEDICATION NAME] 7XXX[DATE] ML, 10 ML by mouth as needed for pain at 4:25 p.m. Review of Resident#3's nursing note by LVN B written on [DATE] at 4:45 p.m. revealed [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 hours PRN for pain given .Resident c/o pain in LEFT knee. When questioned regarding cause/onset resident was easily distracted and could not elaborate on the pain and could not specify location. Would mention that her back hurt but would point to her LEFT thigh. Review of Resident #3 's hospital flow-sheet, dated [DATE], revealed a displaced [MEDICAL CONDITION] diaphysis (long thigh bone) and metaphysis (wide part of the long thigh bone) of the femur. There is an oblique fracture through the distal diaphysis and distal metaphysis of the femur. The distal fragment is displaced laterally 8 mm .the main distal fragment is displaced posteriorly nearly 1 cm. Review of Resident #3's Comprehensive plan of care created on [DATE] and revised on [DATE] revealed she had impaired cognitive function related to dementia. Further review revealed she had pain related to disease process of [MEDICAL CONDITION]. Interventions include: Nursing to monitor/record/report any signs or symptoms of non-verbal pain and verbal complaints of pain, or request for pain medications .notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Interview on [DATE] at 12:55 p.m. with ADON A revealed Resident #3 arrived to the facility on hospice and was then removed from hospice because she was doing well. Furthermore, ADON A stated the resident started declining and was having numerous UTIs and ended up getting ESBL and was on isolation. ADON A said the resident could not understand why she was on isolation and, . started to change, mentally. She said the resident got out of isolation and started yelling, screaming and kicking at the door, and then on the late afternoon of [DATE] complained of back and knee pain. The ADON said the resident was assessed and then given a pain pill. ADON A said the resident was sent to a hospital the next day for excessive pain and LOC. ADON A said the hospital did an x-ray because the resident had a swollen leg and determined there had been a fracture. The ADON said the hospital did not do any reparations and the resident was sent back to the facility on hospice and passed away weeks later. Interview on [DATE] at 10:29 a.m. with LVN G revealed the resident was very social so being in isolation was very difficult for her. She said the resident was more confused than usual the day she left. She said the resident was seen kicking the door the day before she left the facility. LVN G said the morning she sent the resident out on [DATE] she called the ambulance because the resident was acting confused but said when she pulled the resident ' s sheets up and began turning the resident at about 10:30 a.m. and she screamed in pain and complained of leg pain. LVN G said she noticed swelling above the knee. She said she was unsure if the resident was going into shock but did not scream when still without movement, which is why she did not give the resident any pain medication. The nurse acknowledged she would have done it differently looking back by issuing the resident pain medication. The nurse said if the resident had been more vocal she could have been able to communicate her pain and would have been more likely to have been issued pain medication. She said she advised the ambulance driver the resident was complaining of severe pain before she left the facility. She said she spoke to CNA A from the evening shift prior, who asked if the resident was sent out for her legs. She said CNA A informed her that the resident had been complaining of leg pain during his shift on [DATE]. Review of the LVN G ' s Progress Note dated [DATE] revealed, Resident transferred at 1220pm, to the hospital. Interview on [DATE] at 10:59 a.m. with the DON confirmed on [DATE] at 4:45 p.m., the resident got her first and only dose of pain medication ([MEDICATION NAME] 7XXX[DATE] ML PRN every 4 hours) from the time she complained of pain until the time she was discharged the next day. Review of the facility ' s SBAR dated [DATE] time of 11:25 a.m., on page one for Resident #3 revealed, change in condition calling about minimally responsive, moaning and grimacing in pain, lethargic .this started on [DATE], since then had gotten worse. Review of page 5 of 6 of the SBAR note revealed Resident resting in bed with eyes closed, but very restless, moaning and jumpy. While repositioning, resident cries out in pain, focusing on left leg, just above the knee. Review of Resident #3 ' s Medication Review Report, dated [DATE], page 3 of 5, for date range [DATE]-[DATE] revealed a PRN prescription for [MEDICATION NAME] 7XXX[DATE]ML PO Q 4 HOURS PRN FOR PAIN. Interview on [DATE] at 11:50 a.m. with CNA A revealed Resident #3 was complaining of pain the day before she left for the hospital. CNA A said the resident first started complaining of pain in her left knee around 4 p.m. on [DATE]. He said he saw the resident try to move but said that she could not because of the pain in her leg. He said he noticed, . something was going on with her. He said he talked to LVN G the next day to see if the resident got an x-ray because she was complaining about her leg. The CNA said the resident would display confusion at times. He said the resident informed him on [DATE] that she had, a lot of pain. He said when he was doing his morning rounds at 6:00 a.m. on [DATE] when he saw Resident #3 shaking and grimacing so he went to talk to LVN G who told him the resident would be going to the hospital. The CNA stated he had been trained to notify a nurse when a resident had a change in condition. Interview with CNA D on [DATE] at 12:30 p.m. revealed CNA D first noticed Resident # 3 crying in pain around 6:45 a.m. on [DATE], telling her and CNA A, No no, don ' t move my leg. CNA D said she told LVN G that CNA A informed her the resident was in pain and was told by LVN G to leave the resident in her bed. She said normally the resident would get up for breakfast but said this time the resident refused to get up. CNA D said the nursing staff were checking on the resident about 30 or 40 minutes after she had seen the resident. CNA D stated she had been trained to notify a nurse when a resident has a change in condition. Telephone interview on [DATE] at 1:10 p.m. with LVN H who worked the overnight shift with the resident from [DATE]-[DATE] revealed he was not made aware of the resident complaining of pain during his shift. He could not explain why a pain assessment had been done on his shift with a score of 6. He said he had been in to put ointment on Resident #3's bottom and that she did not appear to be in pain. Interview on [DATE] at 1:15 p.m. with the DON revealed Resident #3 should have been sent out quicker or given something for pain for the six hours and 20 minutes (on [DATE] from 6:00 a.m. until discharge to hospital at 12:20 p.m.) she waited for the ambulance. Interview on [DATE] at 11:59 a.m. with LVN B revealed he saw slight swelling on Resident #3's knee. When asked why the nurse did not note the resident ' s pain in his 24 hour report he stated that he was unsure. He said the resident was initially complaining about her back and said it took a while to find out the resident ' s pain was in her legs. He acknowledged the resident ' s level of pain indicated a, . change of condition. When asked if the nurse notified the doctor he said he did not but said, I probably should have. The nurse stated he gave the resident 1 dose of her PRN [MEDICATION NAME] at 4:45 p.m. during his shift to on [DATE] to manage the resident's leg pain. Interview on [DATE] at 12:44 p.m. with ADON A revealed she was informed after the morning meeting on [DATE], at 10:30 a.m. by LVN G that, something was going on with Resident #3 and she was going to send her to the hospital. She said the resident was, . making a very odd noise. She stated the resident did not appear comfortable. She said she observed this when CNAs A and D were changing the resident. She said she assessed the resident and noticed her left knee area was swollen. She said she asked LVN G what had happened to the resident and was informed by the nurse that the resident was kicking the door the day prior. When asked why the resident was not medicated for pain when she had medication ordered, ADON A said she was told by LVN G that the resident appeared like she could not have swallowed a pill. When asked why the resident wasn ' t ' ordered and given a liquid pain medication she speculated that LVN G may have thought the resident could not swallow anything. ADON A agreed that she could have crushed pain medication and put it into apple sauce or other type of method. When asked what other medication the nurse could have given the resident she said [MEDICATION NAME] which the resident already had a prescription for. When asked why ADON A did not say anything about the resident ' s pain, she said she did not anticipate the discharge to the hospital would take so long. Interview on [DATE] at 1:46 p.m. with the Facility ' s Medical Director revealed she thought the Resident's first complaint of the pain did not involve any swelling so she felt the resident would not have needed an x-ray. When asked if the Medical Director felt she should have been called for x-ray she said she would have if the resident presented with [MEDICAL CONDITION] she would have. Review of the facility policy and procedure on Pain Management Program Revised ,[DATE] revealed Effective pain recognition and management requires ongoing facility-wide commitment to resident comfort .the onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. Review of facility policy on Abuse and Neglect (not dated) revealed, NEGLECT (as defined in 40 TAC 19.101(1)) The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility must determine if an injury, harm, to or death of a resident was due to a facility failure to provide services, treatment or care to a resident The Administrator was notified on [DATE] at 3:30 p.m. that a past non compliant Immediate Jeopardy was identified due to the above failures. The facility demonstrated the following measures to correct the past noncompliance and had initiated correction with in-services on [DATE] with neglect and on [DATE] with pain management, assessments and change in condition: Pain Assessment · Pain evaluations will be completed for current residents. New admissions will be assessed for pain upon admission. · Physician will be notified for changes of condition regarding new onset or changed pain; pain management will be implemented per physician ' s orders. · Nursing staff will be reeducated regarding completion of pain evaluations upon admission, quarterly, and with changes in condition. Nursing managers will review the 24-Hour binders for changes in condition & review new telephone orders in the morning clinical meeting. Nursing managers will review changes to ensure follow-up documentation is in place along with MD & RP/resident notifications. The weekend nursing supervisor will review the 24-Hour binders for changes in condition in regards to pain issues & ensure appropriate follow-up is documented including appropriate notification of the MD & RP/resident for changes. · Residents will continue to have pain levels monitored every shift & documented on the MAR; interventions will be implemented according to needs. · Performance Improvement Plan for pain control will be reviewed monthly in the QAPI meeting with the Medical Director for recommendations for improving identification of resident pain. · Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Review of information provided by the facility on [DATE] revealed there were 2 residents with changes of condition, and 10 residents being treated for [REDACTED].

Based on interview and record review, the facility failed to implement written policies and procedures that prohibited neglect for two (#3 and #4) of eight residents reviewed for neglect. 1. Resident #4 was not appropriately assessed or care planned for use of an electric scooter, fell from the scooter and was hospitalized and passed away. Physical Therapy staff identified the safety issues and this communication was never passed on to direct care staff. These failures resulted in an Immediate Jeopardy (IJ) which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. 2. Resident #3 had a fractured left femur. The facility did not treat the pain prior to being transferred to the hospital after extreme pain was first observed. The resident returned to the facility, placed on hospice, and died within the month. This was determined to be past non-compliance at an Immediate Jeopardy level due to the facility's implementation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] to [DATE]. The facility's corrected action was completed on [DATE]. These deficient practices placed 6 residents identified as having poor safety awareness and 5 residents identified as having increased confusion at risk for risk of accidents and injury to include death and 10 residents identified with having pain at risk for experiencing long periods of pain Findings include: Review of the facilities Power Mobility Device policy and procedure (undated) revealed that .since a power mobility device can pose a potential risk to the safety, property, and well-being of its user and to others and their property, each facility will assess and document each resident's individualized need regarding appropriate interventions proposed to meet the residents needs. Review of the facility policy and procedure on Pain Management Program Revised ,[DATE] revealed Effective pain recognition and management requires ongoing facility-wide commitment to resident comfort .the onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. Review of facility policy on Abuse and Neglect (not dated) revealed, NEGLECT (as defined in 40 TAC 19.101(1)) The failure to provide goods or services, including medical services that are necessary to avoid physical or emotional harm, pain, or mental illness. The facility must determine if an injury, harm, to or death of a resident was due to a facility failure to provide services, treatment or care to a resident Review of Resident #4's face sheet dated [DATE] revealed he was admitted on [DATE]. Further review revealed Resident #4 had [DIAGNOSES REDACTED]. Review of Resident #4's hospital death summary dated [DATE] revealed under preliminary cause of death: Immediate cause: (Final diseases or condition resulting in death)[MEDICAL CONDITION], Hepatic [MEDICAL CONDITIONS] and right side sub arachnoid hemorrhage .ED course: ( discharged from the facility on [DATE] after he fell from his motor scooter in the parking lot) intubated on arrival neurosurgery and neurology consulted for sub arachnoid hematoma on CT and [MEDICAL CONDITION]. Review of Resident #4's initial mobility fall risk assessment dated [DATE] revealed he scored low risk for falls on admission. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls . with a Yes to does the resident display any of the following behaviors: easily distracted; periods of altered perception of awareness of surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varies over the course of the day; wanders. Under section 11 Gait .Impaired, has difficulty rising from chair, grasps furniture, person or aid when ambulating. Cannot walk unassisted. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls .with overestimates or forgets limits. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed under problem .ADL self care performance deficit r/t CONFUSION, LACK OF COORDINATION, MUSCLE WEAKNESS. Further review of this document revealed under interventions .staff will assist with transfers and visually check the resident every two hours and as needed. Interview on [DATE] at 11:29 a.m. with ADON B revealed that Resident #4's motorized chair arrived sometime around [DATE]st, 2016, and it was not with him when he arrived on the week of the 20th. He said that Resident #4 originally received the motor scooter from the Veteran's Administration, and had used it previously. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed it did not address his motorized chair. Interview on [DATE] at 12:40 p.m. with the MDS nurses A and B revealed that Resident #4's motorized chair needed to be care planned and they did not know why it was not. Review of Resident #4's 14 day scheduled MDS assessment dated [DATE] revealed on section [MEDICAL CONDITION] revealed that he had disorganized thinking or was incoherent . behavior present continuously and does not fluctuate. Further review indicated under section G0300 Balance during Transitions and Walking that he was not steady, only able to stabilize with staff assistance. Further review of this document revealed Resident #4 required extensive assist and two person physical assist with transfers .locomotion on unit required supervision and one person physical assist, and supervision off unit required limited assistance and one person physical assist. Review of Resident #4's Care Plan Conference Summary dated [DATE] revealed under Risks/Consequences .potential for falls. Review of Resident #4's Physical Therapy note dated [DATE] at 2:39 p.m. revealed under NOTE: Pt trained in safe power wheel chair mobility to increase safety and decrease risk of injury to self and others. Pt instructed in steering, obstacle negotiation and maneuvering in small spaces. Pt continues to require stand by assistance and visual cueing of the above mentioned skills. Review of Resident #4's comprehensive plan of care initiated [DATE] revealed under problem that due to an unsteady gait he had a fall. Further review of this document revealed that under the section approach .anticipate needs, provide prompt assistance. No revisions were noted. Review of the facility Fall Investigation Worksheet dated [DATE] at 5:45 a.m. revealed that Resident #4 fell while trying to go to the restroom. Under did resident require supervision .response was yes. Further review of this same document revealed resident was found on floor seated and leaning against his bed .stated he was trying to go to bathroom when he got caught by his covers and slipped while grabbing on to his bed mattress. He was reminded to use his call light. Review of the facility Fall Investigation Worksheet dated [DATE] revealed that Resident #4 had a fall at 12:00 a.m. in his room witnessed by the room mate who said that resident was reaching for something that fell on floor and he fell out of bed. Further review of this document revealed that Resident #4 received skin tears to both forearms Review of Resident #4's Progress Notes dated [DATE] at 12:36 a.m. revealed resident experienced fall. residents room mate witnessed the fall. said he was rolling around in bed and fell out. residents bed was locked in lowest position. skin tears to both forearms noted. Review of the facility incidents for [DATE] and [DATE] revealed Resident #4 had falls in his bedroom and was unsteady. Interview on [DATE] at 11:04 a.m. with the DON revealed that Resident #4 had fluctuations with confusion and lucidity, and that he had falls on [DATE] and [DATE]. She reported that Resident #4 should have had a formal assessment for safety to drive his motorized wheel chair and it needed to be care planned which did not happen. Interview on [DATE] at 09:50 a.m. with RN A revealed Resident #4 was acting very anxious the week before his fall on [DATE]. She was informed on [DATE] that the resident was acting confused over the weekend when she got report. She stated that Resident #4 was not very balanced, when referring to his level of physical stability. RN A stated that she sent Resident #4 out to the hospital on [DATE] because soon after she came on for her shift from 6:00 a.m. to 2:00 p.m., the morning after the fall she discovered Resident #4 in his room without his clothes on, and he had a blank stare and would not respond. Review of facility Progress Notes (page 3) written by LVN C and dated [DATE] at 12:08 p.m. revealed, Pt appears to have fallen face first onto surface, has multiple new skin issues including most notable lesion to right brow that was bleeding moderately, pt also has multiple new skin tears to face and extremities. During an interview on [DATE] at 11:35 a.m. with PTA A and the PT who worked for the corporation revealed Resident #4 had a history of [REDACTED]. PTA A stated that some days the resident was very confused, and at times impossible to work with the resident on the days he was confused. PTA A confirmed that there would have been no line-of-sight supervision for the resident on the day he fell off the scooter as to where he fell outside, and that he should not have been outside without supervision. The PT confirmed that Resident #4 was a stand by assist, so he needed to have someone standing by and assisting him. She said that Resident #4 needed verbal cues, in order to avoid things like trash cans and other obstacles the resident had to navigate while operating his scooter. She said that Resident #4 needed this assistance not only on the motorized chair, but also in a regular wheel chair. She said that therapy was usually very good at communicating resident needs to the nursing staff, but that this time it did not happen. PTA A stated that he was very surprised to hear that Resident #4 was outside in his power scooter. He stated that nursing had access to all of the therapy notes. The PT said the resident had poor safety awareness, in that he had a hard time being convinced that he could not do some of the same activities he could do when he was younger. She said that he did not have his power scooter on the day of his initial mobility assessment on [DATE]. Interview on [DATE] at 2:07 p.m. with CNA G, revealed that most of the time the Physical Therapy Department informally communicated with the staff regarding the needs of the resident, but said that she was not told anything specific, and that it was not on her assignment sheet. When asked if Resident #4 was getting stand by assistance or visual cueing while in his electric wheel chair, she said no. She stated that Resident #4 should not have been outside by himself without supervision because of his confusion. Interview on [DATE] at 1:55 p.m. with the facilities Medical Director revealed that she typically goes with the opinion of therapy regarding the screening of residents, and that she was not aware of the resident having safety awareness issues with the scooter, but was aware of his falls. Interview on [DATE] at 4:00 p.m. with the Physical Therapy Director, Administrator and DON revealed that there was not a formal method of communicating therapy information to nursing staff in place .and that was why his need for supervision addressed by therapy was never noted by the direct care staff who took care of him. Interview on [DATE] at 09:30 a.m. with the OTA A and PTA A revealed that Resident #4's behaviors would fluctuate from being lucid to being confused. PTA A said Resident #4's judgement would be confused. He stated that the resident advised her he had an electric scooter and then one day, he showed up with it. PTA A and OTA A both agreed that Resident #4 had safety awareness issues and he was not safe being outside without supervision because of his fluctuations and confusion. Telephone interview on [DATE] at 1:33 p.m. with the witness revealed she saw Resident #4 on the ground behind the facility in the parking lot on [DATE] between 6:30 p.m. and 7:00 p.m. She stated that Resident #4 was bleeding near the right eye, and she went for help. Telephone interview on [DATE] at 1:45 p.m. with Resident #4's emergency contact revealed he was deceased , and that she spoke to him the evening of his fall and said that he sounded different, , but she just assumed he did not have his dentures in .and sounded confused, and did not tell her about the fall. Interview on [DATE] at 2:32 p.m. with LVN B revealed he assessed Resident #4 after he had his fall and he assisted LVN C with getting Resident #4 back into his chair and to his room. He said that resident #4 had a large wound above his right eye. Interview on [DATE] at 2:40 p.m. with LVN C revealed he was alerted on [DATE] that Resident #4 was lying on his right side on the ground in the back of the facility and he said that he did some first aide on the skin tears and the resident did not appear to have fractured anything. He said the resident informed staff that his electric chair fell off the curb. The Administrator was notified of noncompliance at an IJ level on [DATE] at 3:30 p.m. and a plan of removal was requested. The facility plan of removal on [DATE]: -Residents using electric wheel chairs were reassessed by the ADON and administrative nursing staff for safety by [DATE]. -Care plans were checked to ensure residents had a plan of care that recognized and addressed resident's safety needs related to electric wheelchair use by [DATE]. -Nursing staff were trained on recognizing residents with potential of having intermittent confusion by [DATE]. -Existing residents using electric wheel chairs would be assessed quarterly and with any significant change by nursing, therapy and maintenance by [DATE]. -New admissions with electric wheel chairs would be assessed by nursing, therapy, and maintenance prior to use as of [DATE]. -Electric wheel chair assessments would be brought to the weekly IDT meeting for review, and any changes to the plan of care would be communicated through the CNA assignment sheets by [DATE]. -These actions were taken to QA for approval on [DATE]. Confirmation of plan of removal was staff who were interviewed on [DATE] included LVN's, CNAs, and a Med Aide regarding recent in-services, assessments, documenting on the 24 hour book, monitoring of residents, and understanding of the dot system (explains residents ' needs) The topics discussed with each staff person depended on their discipline. Physical Therapy developed a new system of integrating information into the morning facility meetings to disseminate safety concerns of residents to direct care staff. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The number of residents at high risk for safety issues (6) and with increased confusion (5) was provided by the DON. 2. Review of Resident #3's face sheet revealed she was admitted on [DATE] and readmitted on [DATE] on Hospice, after she was transferred to the hospital on [DATE] with a [MEDICAL CONDITION] femur. Further review of this same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS with an ARD of [DATE] revealed Resident #3 could understand and be understood. Further review revealed she scored a ,[DATE] on her BIMS indicating severe cognitive impairment. She was assessed to have no pain and had not taken any PRN pain medication during the review period. Review of Resident #3's physician orders dated [DATE] to [DATE] revealed she had orders to be monitored for pain every shift and to use pain scale (A) ,[DATE] for alert residents and (B) for confused residents. This order originated on [DATE]. Further review revealed orders for [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 Hours PRN for pain and [MEDICATION NAME] HCL Tablet 50 MG, Give 1 tablet by mouth every 4 hours as needed for pain, and Tylenol Extra Strength Tablet 500 MG, Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's MAR for ,[DATE] revealed she was assessed for pain every shift and had no pain indicated for days ,[DATE], however, she was assessed to have a level 6 pain documented on [DATE] for the 6 a.m.- 2 p.m., 2 p.m.-10 p.m., and the 10 p.m.-6 a.m. ([DATE]-[DATE]) shifts. Review of Resident #3's MAR for [DATE] revealed she was provided a [MEDICATION NAME] 7XXX[DATE] ML, 10 ML by mouth as needed for pain at 4:25 p.m. Review of Resident#3's nursing note by LVN B written on [DATE] at 4:45 p.m. revealed [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 hours PRN for pain given .Resident c/o pain in LEFT knee. When questioned regarding cause/onset resident was easily distracted and could not elaborate on the pain and could not specify location. Would mention that her back hurt but would point to her LEFT thigh. Review of Resident #3 's hospital flow-sheet, dated [DATE], revealed a displaced [MEDICAL CONDITION] diaphysis (long thigh bone) and metaphysis (wide part of the long thigh bone) of the femur. There is an oblique fracture through the distal diaphysis and distal metaphysis of the femur. The distal fragment is displaced laterally 8 mm .the main distal fragment is displaced posteriorly nearly 1 cm. Review of Resident #3's Comprehensive plan of care created on [DATE] and revised on [DATE] revealed she had impaired cognitive function related to dementia. Further review revealed she had pain related to disease process of [MEDICAL CONDITION]. Interventions include: Nursing to monitor/record/report any signs or symptoms of non-verbal pain and verbal complaints of pain, or request for pain medications .notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Interview on [DATE] at 12:55 p.m. with ADON A revealed Resident #3 arrived to the facility on hospice and was then removed from hospice because she was doing well. Furthermore, ADON A stated the resident started declining and was having numerous UTIs and ended up getting ESBL and was on isolation. ADON A said the resident could not understand why she was on isolation and, . started to change, mentally. She said the resident got out of isolation and started yelling, screaming and kicking at the door, and then on the late afternoon of [DATE] complained of back and knee pain. The ADON said the resident was assessed and then given a pain pill. ADON A said the resident was sent to a hospital the next day for excessive pain and LOC. ADON A said the hospital did an x-ray because the resident had a swollen leg and determined there had been a fracture. The ADON said the hospital did not do any reparations and the resident was sent back to the facility on hospice and passed away weeks later. Interview on [DATE] at 10:29 a.m. with LVN G revealed the resident was very social so being in isolation was very difficult for her. She said the resident was more confused than usual the day she left. She said the resident was seen kicking the door the day before she left the facility. LVN G said the morning she sent the resident out on [DATE] she called the ambulance because the resident was acting confused but said when she pulled the resident ' s sheets up and began turning the resident at about 10:30 a.m. and she screamed in pain and complained of leg pain. LVN G said she noticed swelling above the knee. She said she was unsure if the resident was going into shock but did not scream when still without movement, which is why she did not give the resident any pain medication. The nurse acknowledged she would have done it differently looking back by issuing the resident pain medication. The nurse said if the resident had been more vocal she could have been able to communicate her pain and would have been more likely to have been issued pain medication. She said she advised the ambulance driver the resident was complaining of severe pain before she left the facility. She said she spoke to CNA A from the evening shift prior, who asked if the resident was sent out for her legs. She said CNA A informed her that the resident had been complaining of leg pain during his shift on [DATE]. Review of the LVN G ' s Progress Note dated [DATE] revealed, Resident transferred at 1220pm, to the hospital. Interview on [DATE] at 10:59 a.m. with the DON confirmed on [DATE] at 4:45 p.m., the resident got her first and only dose of pain medication ([MEDICATION NAME] 7XXX[DATE] ML PRN every 4 hours) from the time she complained of pain until the time she was discharged the next day. Review of the facility ' s SBAR dated [DATE] time of 11:25 a.m., on page one for Resident #3 revealed, change in condition calling about minimally responsive, moaning and grimacing in pain, lethargic .this started on [DATE], since then had gotten worse. Review of page 5 of 6 of the SBAR note revealed Resident resting in bed with eyes closed, but very restless, moaning and jumpy. While repositioning, resident cries out in pain, focusing on left leg, just above the knee. Review of Resident #3 ' s Medication Review Report, dated [DATE], page 3 of 5, for date range [DATE]-[DATE] revealed a PRN prescription for [MEDICATION NAME] 7XXX[DATE] ML PO Q 4 HOURS PRN FOR PAIN. Interview on [DATE] at 11:50 a.m. with CNA A revealed Resident #3 was complaining of pain the day before she left for the hospital. CNA A said the resident first started complaining of pain in her left knee around 4 p.m. on [DATE]. He said he saw the resident try to move but said that she could not because of the pain in her leg. He said he noticed, . something was going on with her. He said he talked to LVN G the next day to see if the resident got an x-ray because she was complaining about her leg. The CNA said the resident would display confusion at times. He said the resident informed him on [DATE] that she had, a lot of pain. He said when he was doing his morning rounds at 6:00 a.m. on [DATE] when he saw Resident #3 shaking and grimacing so he went to talk to LVN G who told him the resident would be going to the hospital. The CNA stated he had been trained to notify a nurse when a resident had a change in condition. Interview with CNA D on [DATE] at 12:30 p.m. revealed CNA D first noticed Resident # 3 crying in pain around 6:45 a.m. on [DATE], telling her and CNA A, No no, don ' t move my leg. CNA D said she told LVN G that CNA A informed her the resident was in pain and was told by LVN G to leave the resident in her bed. She said normally the resident would get up for breakfast but said this time the resident refused to get up. CNA D said the nursing staff were checking on the resident about 30 or 40 minutes after she had seen the resident. CNA D stated she had been trained to notify a nurse when a resident has a change in condition. Telephone interview on [DATE] at 1:10 p.m. with LVN H who worked the overnight shift with the resident from [DATE]-[DATE] revealed he was not made aware of the resident complaining of pain during his shift. He could not explain why a pain assessment had been done on his shift with a score of 6. He said he had been in to put ointment on Resident #3's bottom and that she did not appear to be in pain. Interview on [DATE] at 1:15 p.m. with the DON revealed Resident #3 should have been sent out quicker or given something for pain for the six hours and 20 minutes (on [DATE] from 6:00 a.m. until discharge to hospital at 12:20 p.m.) she waited for the ambulance. Interview on [DATE] at 11:59 a.m. with LVN B revealed he saw slight swelling on Resident #3's knee. When asked why the nurse did not note the resident ' s pain in his 24 hour report he stated that he was unsure. He said the resident was initially complaining about her back and said it took a while to find out the resident ' s pain was in her legs. He acknowledged the resident ' s level of pain indicated a, . change of condition. When asked if the nurse notified the doctor he said he did not but said, I probably should have. The nurse stated he gave the resident 1 dose of her PRN [MEDICATION NAME] at 4:45 p.m. during his shift to on [DATE] to manage the resident's leg pain. Interview on [DATE] at 12:44 p.m. with ADON A revealed she was informed after the morning meeting on [DATE], at 10:30 a.m. by LVN G that, something was going on with Resident #3 and she was going to send her to the hospital. She said the resident was, . making a very odd noise. She stated the resident did not appear comfortable. She said she observed this when CNAs A and D were changing the resident. She said she assessed the resident and noticed her left knee area was swollen. She said she asked LVN G what had happened to the resident and was informed by the nurse that the resident was kicking the door the day prior. When asked why the resident was not medicated for pain when she had medication ordered, ADON A said she was told by LVN G that the resident appeared like she could not have swallowed a pill. When asked why the resident wasn ' t ' ordered and given a liquid pain medication she speculated that LVN G may have thought the resident could not swallow anything. ADON A agreed that she could have crushed pain medication and put it into apple sauce or other type of method. When asked what other medication the nurse could have given the resident she said [MEDICATION NAME] which the resident already had a prescription for. When asked why ADON A did not say anything about the resident ' s pain, she said she did not anticipate the discharge to the hospital would take so long. Interview on [DATE] at 1:46 p.m. with the Facility ' s Medical Director revealed she thought the Resident's first complaint of the pain did not involve any swelling so she felt the resident would not have needed an x-ray. When asked if the Medical Director felt she should have been called for x-ray she said she would have if the resident presented with [MEDICAL CONDITION] she would have. The Administrator was notified on [DATE] at 3:30 p.m. that a past non compliant Immediate Jeopardy was identified due to the above failures. The facility demonstrated the following measures to correct the past noncompliance and had initiated correction with in-services on [DATE] with neglect and on [DATE] with pain management, assessments and change in condition: Pain Assessment · Pain evaluations will be completed for current residents. New admissions will be assessed for pain upon admission. · Physician will be notified for changes of condition regarding new onset or changed pain; pain management will be implemented per physician ' s orders. · Nursing staff will be reeducated regarding completion of pain evaluations upon admission, quarterly, and with changes in condition. Nursing managers will review the 24-Hour binders for changes in condition & review new telephone orders in the morning clinical meeting. Nursing managers will review changes to ensure follow-up documentation is in place along with MD & RP/resident notifications. The weekend nursing supervisor will review the 24-Hour binders for changes in condition in regards to pain issues & ensure appropriate follow-up is documented including appropriate notification of the MD & RP/resident for changes. · Residents will continue to have pain levels monitored every shift & documented on the MAR; interventions will be implemented according to needs. · Performance Improvement Plan for pain control will be reviewed monthly in the QAPI meeting with the Medical Director for recommendations for improving identification of resident pain. · Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Review of information provided by the facility on [DATE] revealed there were 2 residents with changes of condition, and 10 residents being treated for [REDACTED].

Based on interview and record review, the facility failed to ensure that each resident had the required supervision to prevent accidents for one (Resident #4) of 6 residents reviewed for supervision. Resident #4 was not appropriately assessed or care planned for use of an electric scooter, fell from the scooter and was hospitalized and passed away. Physical Therapy staff identified the safety issues and this communication was never passed on to direct care staff. This failure resulted in an IJ which was identified on [DATE]. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. This deficient practice placed 6 residents identified as having poor safety awareness and 5 residents identified as having increased confusion at risk for risk of accidents and injury to include death. Findings include: Review of Resident #4's face sheet dated [DATE] revealed he was admitted on [DATE]. Further review revealed Resident #4 had [DIAGNOSES REDACTED]. Review of Resident #4's hospital death summary dated [DATE] revealed under preliminary cause of death: Immediate cause: (Final diseases or condition resulting in death) Sepsis, Hepatic [DIAGNOSES REDACTED], seizures and right side sub arachnoid hemorrhage .ED course: ( discharged from the facility on [DATE] after he fell from his motor scooter in the parking lot) intubated on arrival neurosurgery and neurology consulted for sub arachnoid hematoma on CT and seizures. Review of Resident #4's initial mobility fall risk assessment dated [DATE] revealed he scored low risk for falls on admission. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls . with a Yes to does the resident display any of the following behaviors: easily distracted; periods of altered perception of awareness of surroundings; episodes of disorganized speech; periods of restlessness; periods of lethargy; mental function varies over the course of the day; wanders. Under section 11 Gait .Impaired, has difficulty rising from chair, grasps furniture, person or aid when ambulating. Cannot walk unassisted. Review of Resident #4's fall risk assessment on [DATE] revealed he was at risk for falls .with overestimates or forgets limits. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed under problem .ADL self care performance deficit r/t CONFUSION, LACK OF COORDINATION, MUSCLE WEAKNESS. Further review of this document revealed under interventions .staff will assist with transfers and visually check the resident every two hours and as needed. Interview on [DATE] at 11:29 a.m. with ADON B revealed that Resident #4's motorized chair arrived sometime around [DATE]st, 2016, and it was not with him when he arrived on the week of the 20th. He said that Resident #4 originally received the motor scooter from the Veteran's Administration, and had used it previously. Review of Resident #4's comprehensive plan of care initiated on [DATE] revealed it did not address his motorized chair. Interview on [DATE] at 12:40 p.m. with the MDS nurses A and B revealed that Resident #4's motorized chair needed to be care planned and they did not know why it was not. Review of the facility's Power Mobility Device policy and procedure (undated) revealed that .since a power mobility device can pose a potential risk to the safety, property, and well-being of its user and to others and their property, each facility will assess and document each resident's individualized need regarding appropriate interventions proposed to meet the residents needs. Review of Resident #4's 14 day scheduled MDS assessment dated [DATE] revealed on section Delirium revealed that he had disorganized thinking or was incoherent . behavior present continuously and does not fluctuate. Further review indicated under section G0300 Balance during Transitions and Walking that he was not steady, only able to stabilize with staff assistance. Further review of this document revealed Resident #4 required extensive assist and two person physical assist with transfers .locomotion on unit required supervision and one person physical assist, and supervision off unit required limited assistance and one person physical assist. Review of Resident #4's Care Plan Conference Summary dated [DATE] revealed under Risks/Consequences .potential for falls. Review of Resident #4's Physical Therapy note dated [DATE] at 2:39 p.m. revealed under NOTE: Pt trained in safe power wheel chair mobility to increase safety and decrease risk of injury to self and others. Pt instructed in steering, obstacle negotiation and maneuvering in small spaces. Pt continues to require stand by assistance and visual cueing of the above mentioned skills. Review of Resident #4's comprehensive plan of care initiated [DATE] revealed under problem that due to an unsteady gait he had a fall. Further review of this document revealed that under the section approach .anticipate needs, provide prompt assistance. No revisions were noted. Review of the facility Fall Investigation Worksheet dated [DATE] at 5:45 a.m. revealed that Resident #4 fell while trying to go to the restroom. Under did resident require supervision .response was yes. Further review of this same document revealed resident was found on floor seated and leaning against his bed .stated he was trying to go to bathroom when he got caught by his covers and slipped while grabbing on to his bed mattress. He was reminded to use his call light. Review of the facility Fall Investigation Worksheet dated [DATE] revealed that Resident #4 had a fall at 12:00 a.m. in his room witnessed by the room mate who said that resident was reaching for something that fell on floor and he fell out of bed. Further review of this document revealed that Resident #4 received skin tears to both forearms. Review of Resident #4's Progress Notes dated [DATE] at 12:36 a.m. revealed resident experienced fall. residents room mate witnessed the fall. said he was rolling around in bed and fell out. residents bed was locked in lowest position. skin tears to both forearms noted. Review of the facility incidents for [DATE] and [DATE] revealed Resident #4 had falls in his bedroom and was unsteady. Interview on [DATE] at 11:04 a.m. with the DON revealed that Resident #4 had fluctuations with confusion and lucidity, and that he had falls on [DATE] and [DATE]. She reported that Resident #4 should have had a formal assessment for safety to drive his motorized wheel chair and it needed to be care planned which did not happen. Interview on [DATE] at 09:50 a.m. with RN A revealed Resident #4 was acting very anxious the week before his fall on [DATE]. She was informed on [DATE] that the resident was acting confused over the weekend when she got report. She stated that Resident #4 was not very balanced, when referring to his level of physical stability. RN A stated that she sent Resident #4 out to the hospital on [DATE] because soon after she came on for her shift from 6:00 a.m. to 2:00 p.m., the morning after the fall she discovered Resident #4 in his room without his clothes on, and he had a blank stare and would not respond. Review of facility Progress Notes (page 3) written by LVN C and dated [DATE] at 12:08 p.m. revealed, Pt appears to have fallen face first onto surface, has multiple new skin issues including most notable lesion to right brow that was bleeding moderately, pt also has multiple new skin tears to face and extremities. During an interview on [DATE] at 11:35 a.m. with PTA A and the PT who worked for the corporation revealed Resident #4 had a history of [REDACTED]. PTA A stated that some days the resident was very confused, and at times impossible to work with the resident on the days he was confused. PTA A confirmed that there would have been no line-of-sight supervision for the resident on the day he fell off the scooter as to where he fell outside, and that he should not have been outside without supervision. The PT confirmed that Resident #4 was a stand by assist, so he needed to have someone standing by and assisting him. She said that Resident #4 needed verbal cues, in order to avoid things like trash cans and other obstacles the resident had to navigate while operating his scooter. She said that Resident #4 needed this assistance not only on the motorized chair, but also in a regular wheel chair. She said that therapy was usually very good at communicating resident needs to the nursing staff, but that this time it did not happen. PTA A stated that he was very surprised to hear that Resident #4 was outside in his power scooter. He stated that nursing had access to all of the therapy notes. The PT said the resident had poor safety awareness, in that he had a hard time being convinced that he could not do some of the same activities he could do when he was younger. She said that he did not have his power scooter on the day of his initial mobility assessment on [DATE]. Interview on [DATE] at 2:07 p.m. with CNA G, revealed that most of the time the Physical Therapy Department informally communicated with the staff regarding the needs of the resident, but said that she was not told anything specific, and that it was not on her assignment sheet. When asked if Resident #4 was getting stand by assistance or visual cueing while in his electric wheel chair, she said no. She stated that Resident #4 should not have been outside by himself without supervision because of his confusion. Interview on [DATE] at 1:55 p.m. with the facilities Medical Director revealed that she typically goes with the opinion of therapy regarding the screening of residents, and that she was not aware of the resident having safety awareness issues with the scooter, but was aware of his falls. Interview on [DATE] at 4:00 p.m. with the Physical Therapy Director, Administrator and DON revealed that there was not a formal method of communicating therapy information to nursing staff in place .and that was why his need for supervision addressed by therapy was never noted by the direct care staff who took care of him. Interview on [DATE] at 09:30 a.m. with the OTA A and PTA A revealed that Resident #4's behaviors would fluctuate from being lucid to being confused. PTA A said Resident #4's judgement would be confused. He stated that the resident advised her he had an electric scooter and then one day, he showed up with it. PTA A and OTA A both agreed that Resident #4 had safety awareness issues and he was not safe being outside without supervision because of his fluctuations and confusion. Telephone interview on [DATE] at 1:33 p.m. with the witness revealed she saw Resident #4 on the ground behind the facility in the parking lot on [DATE] between 6:30 p.m. and 7:00 p.m. She stated that Resident #4 was bleeding near the right eye, and she went for help. Telephone interview on [DATE] at 1:45 p.m. with Resident #4's emergency contact revealed he was deceased , and that she spoke to him the evening of his fall and said that he sounded different, , but she just assumed he did not have his dentures in .and sounded confused, and did not tell her about the fall. Interview on [DATE] at 2:32 p.m. with LVN B revealed he assessed Resident #4 after he had his fall and he assisted LVN C with getting Resident #4 back into his chair and to his room. He said that resident #4 had a large wound above his right eye. Interview on [DATE] at 2:40 p.m. with LVN C revealed he was alerted on [DATE] that Resident #4 was lying on his right side on the ground in the back of the facility and he said that he did some first aide on the skin tears and the resident did not appear to have fractured anything. He said the resident informed staff that his electric chair fell off the curb. The Administrator was notified of noncompliance at an IJ level on [DATE] at 3:30 p.m. and a plan of removal was requested. The facility plan of removal on [DATE]: -Residents using electric wheel chairs were reassessed by the ADON and administrative nursing staff for safety by [DATE]. -Care plans were checked to ensure residents had a plan of care that recognized and addressed resident's safety needs related to electric wheelchair use by [DATE]. -Nursing staff were trained on recognizing residents with potential of having intermittent confusion by [DATE]. -Existing residents using electric wheel chairs would be assessed quarterly and with any significant change by nursing, therapy and maintenance by [DATE]. -New admissions with electric wheel chairs would be assessed by nursing, therapy, and maintenance prior to use as of [DATE]. -Electric wheel chair assessments would be brought to the weekly IDT meeting for review, and any changes to the plan of care would be communicated through the CNA assignment sheets by [DATE]. -These actions were taken to QA for approval on [DATE]. Confirmation of plan of removal was staff who were interviewed on [DATE] included LVN's, CNAs, and a Med Aide regarding recent in-services, assessments, documenting on the 24 hour book, monitoring of residents, and understanding of the dot system (explains residents ' needs) The topics discussed with each staff person depended on their discipline. Physical Therapy developed a new system of integrating information into the morning facility meetings to disseminate safety concerns of residents to direct care staff. The IJ was removed on [DATE], but the facility remained out of compliance at a severity level of actual harm at pattern because the facility had not had time to monitor and evaluate the effectiveness of the Plan of Removal. The number of residents at high risk for safety issues (6) and with increased confusion (5) was provided by the DON.

Based on interview and record review, the facility failed to provide the necessary care and services to maintain the highest practical physical, mental, and psychosocial well-being for one of one resident with pain (Resident #3) in that: 1. Resident #3 had a fractured left femur. The facility did not treat the pain prior to being transferred to the hospital after extreme pain was first observed. The resident returned to the facility, placed on hospice, and died within the month. This was determined to be past non-compliance at an IJ level due to the facility's implementation of actions that corrected the non-compliance prior to the investigation on [DATE]. The facility was out of compliance from [DATE] to [DATE]. The facility's corrected action was completed on [DATE]. This deficient practice could affect 10 residents identified with having pain, and result in experiencing long periods of pain. Findings include: Review of Resident #3's face sheet revealed she was admitted on [DATE] and readmitted on [DATE] on Hospice, after she was transferred to the hospital on [DATE] with a [MEDICAL CONDITION] femur. Further review of this same document revealed Resident #3's [DIAGNOSES REDACTED]. Review of Resident #3's Quarterly MDS with an ARD of [DATE] revealed Resident #3 could understand and be understood. Further review revealed she scored a ,[DATE] on her BIMS indicating severe cognitive impairment. She was assessed to have no pain and had not taken any PRN pain medication during the review period. Review of Resident #3's physician orders dated [DATE] to [DATE] revealed she had orders to be monitored for pain every shift and to use pain scale (A) ,[DATE] for alert residents and (B) for confused residents. This order originated on [DATE]. Further review revealed orders for [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 Hours PRN for pain and [MEDICATION NAME] HCL Tablet 50 MG, Give 1 tablet by mouth every 4 hours as needed for pain, and Tylenol Extra Strength Tablet 500 MG, Give 1 tablet by mouth every 6 hours as needed for pain. Review of Resident #3's MAR for ,[DATE] revealed she was assessed for pain every shift and had no pain indicated for days ,[DATE], however, she was assessed to have a level 6 pain documented on [DATE] for the 6 a.m.- 2 p.m., 2 p.m.-10 p.m., and the 10 p.m.-6 a.m. ([DATE]-[DATE]) shifts. Review of Resident #3's MAR for [DATE] revealed she was provided a [MEDICATION NAME] 7XXX[DATE] ML, 10 ML by mouth as needed for pain at 4:25 p.m. Review of Resident#3's nursing note by LVN B written on [DATE] at 4:45 p.m. revealed [MEDICATION NAME] 7XXX[DATE] ML-Give 10 ML PO Q 4 hours PRN for pain given .Resident c/o pain in LEFT knee. When questioned regarding cause/onset resident was easily distracted and could not elaborate on the pain and could not specify location. Would mention that her back hurt but would point to her LEFT thigh. Review of Resident #3 's hospital flow-sheet, dated [DATE], revealed a displaced [MEDICAL CONDITION] diaphysis (long thigh bone) and metaphysis (wide part of the long thigh bone) of the femur. There is an oblique fracture through the distal diaphysis and distal metaphysis of the femur. The distal fragment is displaced laterally 8 mm .the main distal fragment is displaced posteriorly nearly 1 cm. Review of Resident #3's Comprehensive plan of care created on [DATE] and revised on [DATE] revealed she had impaired cognitive function related to dementia. Further review revealed she had pain related to disease process of [MEDICAL CONDITION]. Interventions include: Nursing to monitor/record/report any signs or symptoms of non-verbal pain and verbal complaints of pain, or request for pain medications .notify physician if interventions are unsuccessful or if current complaint is a significant change from residents past experience of pain. Interview on [DATE] at 12:55 p.m. with ADON A revealed Resident #3 arrived to the facility on hospice and was then removed from hospice because she was doing well. Furthermore, ADON A stated the resident started declining and was having numerous UTIs and ended up getting ESBL and was on isolation. ADON A said the resident could not understand why she was on isolation and, . started to change, mentally. She said the resident got out of isolation and started yelling, screaming and kicking at the door, and then on the late afternoon of [DATE] complained of back and knee pain. The ADON said the resident was assessed and then given a pain pill. ADON A said the resident was sent to a hospital the next day ([DATE]) for excessive pain and LOC. ADON A said the hospital did an x-ray because the resident had a swollen leg and determined there had been a fracture. The ADON said the hospital did not do any reparations and the resident was sent back to the facility on hospice and passed away weeks later. Interview on [DATE] at 10:29 a.m. with LVN G revealed the resident was very social so being in isolation was very difficult for her. She said the resident was more confused than usual the day she left. She said the resident was seen kicking the door the day before she left the facility. LVN G said the morning she sent the resident out on [DATE] she called the ambulance because the resident was acting confused but said when she pulled the resident ' s sheets up and began turning the resident at about 10:30 a.m. and she screamed in pain and complained of leg pain. LVN G said she noticed swelling above the knee. She said she was unsure if the resident was going into shock but did not scream when still without movement, which is why she did not give the resident any pain medication. The nurse acknowledged she would have done it differently looking back by issuing the resident pain medication. The nurse said if the resident had been more vocal she could have been able to communicate her pain and would have been more likely to have been issued pain medication. She said she advised the ambulance driver the resident was complaining of severe pain before she left the facility. She said she spoke to CNA A from the evening shift prior, who asked if the resident was sent out for her legs. She said CNA A informed her that the resident had been complaining of leg pain during his shift on [DATE]. Review of the LVN G ' s Progress Note dated [DATE] revealed, Resident transferred at 12:20pm, to the hospital. Interview on [DATE] at 10:59 a.m. with the DON confirmed on [DATE] at 4:45 p.m., the resident got her first and only dose of pain medication ([MEDICATION NAME] 7XXX[DATE] ML PRN every 4 hours) from the time she complained of pain until the time she was discharged the next day. Review of the facility ' s SBAR dated [DATE] time of 11:25 a.m., on page one for Resident #3 revealed, change in condition calling about minimally responsive, moaning and grimacing in pain, lethargic .this started on [DATE], since then had gotten worse. Review of page 5 of 6 of the SBAR note revealed Resident resting in bed with eyes closed, but very restless, moaning and jumpy. While repositioning, resident cries out in pain, focusing on left leg, just above the knee. Review of Resident #3 ' s Medication Review Report, dated [DATE], page 3 of 5, for date range [DATE]-[DATE] revealed a PRN prescription for [MEDICATION NAME] 7XXX[DATE] ML PO Q 4 HOURS PRN FOR PAIN. Interview on [DATE] at 11:50 a.m. with CNA A revealed Resident #3 was complaining of pain the day before she left for the hospital. CNA A said the resident first started complaining of pain in her left knee around 4 p.m. on [DATE]. He said he saw the resident try to move but said that she could not because of the pain in her leg. He said he noticed, . something was going on with her. He said he talked to LVN G the next day to see if the resident got an x-ray because she was complaining about her leg. The CNA said the resident would display confusion at times. He said the resident informed him on [DATE] that she had, a lot of pain. He said when he was doing his morning rounds at 6:00 a.m. on [DATE] when he saw Resident #3 shaking and grimacing so he went to talk to LVN G who told him the resident would be going to the hospital. The CNA stated he had been trained to notify a nurse when a resident had a change in condition. Interview with CNA D on [DATE] at 12:30 p.m. revealed CNA D first noticed Resident # 3 crying in pain around 6:45 a.m. on [DATE], telling her and CNA A, No no, don ' t move my leg. CNA D said she told LVN G that CNA A informed her the resident was in pain and was told by LVN G to leave the resident in her bed. She said normally the resident would get up for breakfast but said this time the resident refused to get up. CNA D said the nursing staff were checking on the resident about 30 or 40 minutes after she had seen the resident. CNA D stated she had been trained to notify a nurse when a resident has a change in condition. Telephone interview on [DATE] at 1:10 p.m. with LVN H who worked the overnight shift with the resident from [DATE]-[DATE] revealed he was not made aware of the resident complaining of pain during his shift. He could not explain why a pain assessment had been done on his shift with a score of 6. He said he had been in to put ointment on Resident #3's bottom and that she did not appear to be in pain. Interview on [DATE] at 1:15 p.m. with the DON revealed Resident #3 should have been sent out quicker or given something for pain for the six hours and 20 minutes (on [DATE] from 6:00 a.m. until discharge to hospital at 12:20 p.m.) she waited for the ambulance. Interview on [DATE] at 11:59 a.m. with LVN B revealed he saw slight swelling on Resident #3's knee. When asked why the nurse did not note the resident ' s pain in his 24 hour report he stated that he was unsure. He said the resident was initially complaining about her back and said it took a while to find out the resident ' s pain was in her legs. He acknowledged the resident ' s level of pain indicated a, . change of condition. When asked if the nurse notified the doctor he said he did not but said, I probably should have. The nurse stated he gave the resident 1 dose of her PRN [MEDICATION NAME] at 4:45 p.m. during his shift to on [DATE] to manage the resident's leg pain. Interview on [DATE] at 12:44 p.m. with ADON A revealed she was informed after the morning meeting on [DATE], at 10:30 a.m. by LVN G that, something was going on with Resident #3 and she was going to send her to the hospital. She said the resident was, . making a very odd noise. She stated the resident did not appear comfortable. She said she observed this when CNAs A and D were changing the resident. She said she assessed the resident and noticed her left knee area was swollen. She said she asked LVN G what had happened to the resident and was informed by the nurse that the resident was kicking the door the day prior. When asked why the resident was not medicated for pain when she had medication ordered, ADON A said she was told by LVN G that the resident appeared like she could not have swallowed a pill. When asked why the resident wasn ' t ' ordered and given a liquid pain medication she speculated that LVN G may have thought the resident could not swallow anything. ADON A agreed that she could have crushed pain medication and put it into apple sauce or other type of method. When asked what other medication the nurse could have given the resident she said [MEDICATION NAME] which the resident already had a prescription for. When asked why ADON A did not say anything about the resident ' s pain, she said she did not anticipate the discharge to the hospital would take so long. Interview on [DATE] at 1:46 p.m. with the Facility ' s Medical Director revealed she thought the Resident's first complaint of the pain did not involve any swelling so she felt the resident would not have needed an x-ray. When asked if the Medical Director felt she should have been called for x-ray she said she would have if the resident presented with [MEDICAL CONDITION] she would have. Review of the facility policy and procedure on Pain Management Program Revised ,[DATE] revealed Effective pain recognition and management requires ongoing facility-wide commitment to resident comfort .the onset of acute pain may indicate a new injury or a potentially life-threatening condition or illness. The Administrator was notified on [DATE] at 3:30 p.m. that a past non compliance IJ was identified due to the above failures. The facility implemented the following measures to correct the noncompliance: Pain Assessment · Pain evaluations will be completed for current residents. New admissions will be assessed for pain upon admission. · Physician will be notified for changes of condition regarding new onset or changed pain; pain management will be implemented per physician ' s orders. · Nursing staff will be reeducated regarding completion of pain evaluations upon admission, quarterly, and with changes in condition. Nursing managers will review the 24-Hour binders for changes in condition & review new telephone orders in the morning clinical meeting. Nursing managers will review changes to ensure follow-up documentation is in place along with MD & RP/resident notifications. The weekend nursing supervisor will review the 24-Hour binders for changes in condition in regards to pain issues & ensure appropriate follow-up is documented including appropriate notification of the MD & RP/resident for changes. · Residents will continue to have pain levels monitored every shift & documented on the MAR; interventions will be implemented according to needs. · Performance Improvement Plan for pain control will be reviewed monthly in the QAPI meeting with the Medical Director for recommendations for improving identification of resident pain. · Education will continue each shift until 100% of the staff is educated on the above. Those employees on leave will have their education completed upon arrival for the start of the next scheduled shift to work. Review of information provided by the facility on [DATE] revealed there were 2 residents with changes of condition, and 10 residents being treated for [REDACTED].