**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for one (100 Hall) of two halls and two (room [ROOM NUMBER] and room [ROOM NUMBER]) of six rooms reviewed for decent living environment. 1. 100 Hall had a leak from the ceiling tile opening, with a trashcan and bucket in the middle of the hallway floor to catch the water. 2. room [ROOM NUMBER] had a socket hanging from the wall. 3. room [ROOM NUMBER] light switch in the bathroom was not fully covered. These failures could result in a resident's diminished quality of life due to an unsafe environment that is not homelike. Findings Included:In an observation and interview on 07/22/25 at 10:05 AM, reflected a half covered light switch in the bathroom of room [ROOM NUMBER]. The resident in room [ROOM NUMBER] stated the covering kept falling off the light switch. The resident in room [ROOM NUMBER] stated it did not cause issues, but her roommate could not see well, and it might have been a problem for her. The light switch covering was sitting in the bathroom. The Maintenance Director stated he covered the light switch the other day and one side of it must have come off. He stated he was not aware that part of the covering had fallen off. He stated the light switch needed to be covered for the safety of the resident, to prevent any possible harm. An observation of the 100 Hall on 07/22/25 at 12:29 PM, reflected missing tile on the ceiling with wires and pink insulation exposed. There was a pink wash basin in the ceiling, with a black, small trashcan and blue bucket, sitting on a towel on the floor, in the middle of the hallway, directly below the opening. There was no water present at the time of the observation. An observation and interview on 07/22/25 at 1:10 PM, reflected the wall socket in room [ROOM NUMBER] was hanging from the wall. The residents in room [ROOM NUMBER] stated the socket had been like that but was still working. Their Family Member was present and stated the wall socket had been like that a while, and the facility knew about it. In an interview on 07/22/25 at 1:56 PM, the Maintenance Director stated he did not do anything with the leak yet, because he was waiting on the facility's corporate office to approve a bid. He stated the roof was not sealed properly when the roof was repaired three years ago. The Maintenance Director stated the leak only happened when there was a downpour of rain. He stated the leak first happened about two months ago. The Maintenance Director stated the risk of the leak was possibly major damage to the roof. The Maintenance Director stated the wall socket was repaired in room [ROOM NUMBER]. He stated there was no risk since the socket was always in the wall unless the resident's bed was moved, which would sometimes pull the socket away from the wall.In an interview on 07/22/25 at 3:31 PM, The Administrator stated she addressed the concern with the leak with the facility's regional office, but they prioritize repairs in their own way. She stated the regional office asked why the bid was so high to repair the leak and more bids were requested. The Administrator stated the regional office now, was trying to determine if they will fix part of the roof or the entire roof. She stated the leak only occurred when it rained. The Administrator stated repairs have been completed quickly in the past if the Maintenance Director was aware of the issues. The Administrator stated the risk of repairs not happening in the facility was the resident's not having a decent environment.Record review of the facility's policy, dated, December 2009, and titled, Maintenance Service, reflected the following: Policy statement Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to:a. Maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines.b. Maintaining the building in good repair and free from hazards.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the confidentiality of personal health care information for two of six (Resident #6 and Resident #65) residents reviewed for confidentiality of records. The facility failed to ensure LVN F locked and closed the laptop during a medication pass, which exposed Resident #6's personal information to include some of his medication orders. The facility failed to ensure LVN A locked the computer prior to leaving the Nurse's Station, which exposed Resident #65's personal information to include some of her diagnoses. This failure could affect residents by placing them at risk for loss of privacy and dignity. Findings included: Review of Resident #6's Face Sheet, dated 09/10/24, reflected he was an [AGE] year-old male, who admitted to the facility on [DATE], with diagnoses including dementia (a general term for a range of conditions that cause a decline in cognitive functioning, such as thinking, remembering, and reasoning), schizoaffective disorder/bipolar type (a mental health condition that combines schizophrenia and bipolar disorder - people with this condition experience both manic episodes and depressive episodes, along with psychotic symptoms like hallucinations and delusions), major depressive disorder (a mental health condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable), and type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't make enough insulin or doesn't use it properly, resulting in high blood sugar levels). Review of Resident #65's Face Sheet, dated 09/10/24, reflected she was a [AGE] year-old female, who admitted to the facility on [DATE], with diagnoses including major depressive disorder (a mental health condition that can cause a persistent low mood and loss of interest in activities that were once enjoyable), type 2 diabetes mellitus (a chronic disease that occurs when the body doesn't make enough insulin or doesn't use it properly, resulting in high blood sugar levels), and alcoholic cirrhosis of the liver with ascites (a condition that occurs when a person has a buildup of fluid in their abdomen due to cirrhosis of the liver, which is often caused by drinking too much alcohol). Observation on 09/08/24 at 9:12AM revealed the computer screen on LVN F's medication cart was unlocked and unsupervised for approximately 1-2 minutes while LVN F was down the hallway. Resident #6's personal information, including medication orders, was exposed to staff, residents, and visitors who were present on the hall. Observation on 09/08/24 at 9:14AM revealed the computer screen at the Nurse's Station in which LVN A was assigned was unlocked and unsupervised for approximately 1-2 minutes while LVN A was providing care in a resident's room. Resident #65's personal information, including some of her diagnoses, was exposed to staff, residents, and visitors who were present on the hall. During an interview with LVN F on 09/08/24 at 9:20AM, she stated she did not know why she left the computer screen unlocked and unsupervised. She stated she had been in-serviced on the importance of maintaining the privacy and confidentiality of residents, and the computer screen should have been locked prior to walking away from the medication cart. During an interview with LVN A on 09/08/24 at 9:26AM, she stated there was no good reason as to why she left the computer screen unlocked and unsupervised while providing care for another resident. She stated she had been in-serviced on the importance of maintaining the privacy and confidentiality of residents, and the computer screen should have been locked prior to leaving the Nurse's Station. During an interview with the DON on 09/10/24 at 1:55PM, he stated facility staff were expected to maintain the privacy and confidentiality of residents, which included ensuring their personal information was not left visible to other staff, residents, and visitors. He stated the risk of staff leaving their computers unlocked with resident information visible was that individuals who were not privy to those residents' information could have access to it. Review of the facility's Confidentiality of Information and Personal Privacy policy, dated 08/2024, reflected, .the facility will safeguard the personal privacy and confidentiality of all resident personal and medical records .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 (Resident #19) of 2 Residents who were observed for transfers. LVN A failed to use the gait belt as needed due to the resident having unsteady gait while repositioning Resident #19 in the wheelchair. The deficient practices could affect residents who require assistive devices during transfers and could contribute to avoidable falls. The findings were: Review of Resident #19's face sheet, dated 09/10/24, revealed she was admitted to the facility on [DATE] with some of the diagnoses including history of falling, repeated falls, muscle waiting and atrophy and muscle weakness. Review of Resident #19's quarterly MDS assessment dated [DATE] revealed her BIMS was 10 reflective of mild cognitive impairment; had a history of fall after admission and required maximum assistance from sitting to standing. Review of Resident #19's Care Plan, revised 2/26/24, revealed, Focus, (Resident 19) has HX of falls and remains at risk for falls r/t impaired mobility/balance, unsteady gait, . Goal, The resident will be free from falls through the review date. Observation on 09/08/24 at 02:15 PM revealed Resident #19 was in the wheelchair, family was in the room, and the family member stated the resident had said she was having pain in her back, and she was not sat well in the wheelchair. The resident's family member left the room and came back with LVN A. LVN A was observed lifting Resident #19 from the wheelchair by putting her arms below the resident's arm. The resident's family member assisted pulling the resident's pants in position, and then LVN A assisted Resident #19 to sit back in the wheelchair. In an interview on 09/08/24 at 02:37 PM with LVN A she stated, she was aware she did not use the gait belt because she was old school. LVN A stated per the facility policy she was supposed to use the gait belt, but she did not have one with her because normally she did not do transfers. LVN A stated gait the belt was required to transfer the resident to prevent falls or harming the resident because it could cause a fracture. In an interview on 09/10/24 at 02:34 PM with the DON, he stated per the facility policy, staff were required to use a gait belt while assisting the resident with a transfer. The DON stated the staff should have the gait belt with them and some of the gait belts were in the residents' rooms. The DON stated staff were supposed to use a gait belt to prevent harm through falls or causing any fracture on the residents. Review of the facility policy revised July 2017, titled Safe Lifting and Movement of Residents, reflected, In order to protect the safety and well-being of staff and residents and to promote quality care, this facility uses appropriate techniques and devices to lift and move residents.4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts, lateral boards) and mechanical lifting devices. 5. Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 1(Resident #74) of 8 residents reviewed for infection control in that; During a wound dressing change for Resident #74, LVN C did not sanitize her hands or change gloves in between removal of an old dressing and cleansing and application of a new dressing. The deficient practices could place residents at-risk for infection due to improper care practices. Findings Included: Record review of Resident #74's face sheet revealed she was [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included, dementia, essential hypertension, muscle wasting and atrophy, muscle weakness and need for assistance for personal care. Record review of Resident #74's significant change in status MDS dated [DATE] revealed her Brief Interview for Mental Status (BIMS) was a 6 out of 15 revealing cognitive impairment. Her ADL status revealed she needed limited assistance of one person for bed mobility, total dependence of one staff for toilet use. Resident #74 was always incontinent of bladder. Observation on 09/09/24 at 11:04 AM revealed LVN C providing surgical wound care to Resident #74. LVN C gowned and gloved and then took off the dressing from Resident #74's right toe and revealed all the right toes had been amputated and the resident had sutures on the wounds. LVN C cleaned the surgical area with normal saline and gauze, pat dried and then applied betadine and dry dressing and then wrapped with ace wrap. LVN C used the same gloves for the entire wound care and did not change gloves or complete hand hygiene. In an interview on 09/09/24 at 12:15 PM with LVN C she stated she forgot to change gloves and complete hand hygiene during the wound care. LVN C stated she was supposed to wash hands and change gloves and complete hand hygiene after cleaning the resident's wound to prevent the spread of infection. She stated she had received an in-service on infection control about 6months ago. In an interview on 09/10/14 at 01:34 PM with the DON he stated he was the infection preventionist. The DON stated the facility had in-serviced staff on hand washing and PPE on 08/28/24 with nursing staff and it was random. The DON stated he expected the staff to maintain infection control and complete hand hygiene during wound care. The DON stated he expected the staff to maintain infection control to prevent the spread of infection. Review of the facility policy revised October 2018 and titled Infection Prevention and Control Program reflected, .3. The infection prevention and control program is a facility-wide effort involving all disciplines and individuals and is an integral part of quality assurance and performance improvement program.11. Prevention of infection 8. following established general and disease-specific guidelines such as those of the Center for Disease Control (CDC)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one of thirteen resident (Resident # 74) reviewed for ADLs. The facility failed to provide Resident #74 with ADL care (incontinent care). This deficient practice could place residents who required extensive assistance with ADLs at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological wellbeing. Finding included: Record review of Resident #74's face sheet revealed she was [AGE] year-old female admitted to the facility on [DATE]. Resident's diagnoses included, dementia, essential hypertension, muscle wasting and atrophy, muscle weakness and need for assistance for personal care. Record review of Resident #74's significant change in status MDS dated [DATE] revealed her Brief Interview for Mental Status (BIMS) was a 6 out of 15 revealing cognitive impairment. Her ADL status revealed she needed limited assistance of one person for bed mobility, total dependence of one staff for toilet use. Resident #74 was always incontinent of bladder. Record review of Resident #74's care plan revised 05/02/24 reflected, Focus . (Resident #74) has bladder incontinence r/t cognitive deficit and impaired mobility. Goal, the resident will remain free from complications r/t incontinence such as UTIs through the review date. Intervention . Monitor for incontinence. Wash, rinse and dry the perineum. Monitor for incontinence and provide incontinent care or barrier cream as needed. Observation on 09/10/24 at 02:02 PM revealed Resident #74 was in bed, and the aide was providing care. The aide started providing care after positioning the resident. The resident was soiled with urine, also the linens were soiled with urine and the fitted sheet had a ring of urine around where the resident was lying. Initially the staff cleaned the resident and applied the clean brief, and when the surveyor was asked if the linens were wet that was when the aide stated the linens were wet and removed the linens and then the resident stated, I am soaking wet. No indication of skin breakdown. In an interview on 09/10/24 at 02:08 PM with CNA B she stated she had checked the resident early and the resident was dry, but she did not specify what time. In an Interview on 09/10/24 at 02:09 PM with Resident #74 she stated while the CNA B was in the room that she had not been changed since the night before. Resident #74 stated CNA B had assisted her with her breakfast, but CNA B did not check if she was wet. Then the resident stated the aide might have been busy taking care of other residents. After the resident stated she had not been changed since last night, then CNA B stated she was busy, and she was not able to change the resident throughout the shift. CNA B stated she was expected to check the resident routinely and provide incontinent care to prevent skin breakdown and making sure the resident was well groomed. In an interview on 09/10/24 at 02:32 PM with the DON he stated he expected CNA B to complete and assist the resident with her ADLs care. The DON stated he expected Resident #74 to be provided with incontinent care routinely to prevent skin breakdown and maintain resident's dignity. The DON stated he was responsible and the charge nurses to check and make sure the residents are changed and ADLs cares completed timely. Review of the facility policy revised March 2018, titled Activities of Daily Living (ADLs) Supporting, reflected, Residents will be provided with care, treatments, and services to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive services necessary to maintain good nutrition, grooming and personal and oral hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1(Resident #67) of 3 residents reviewed for pressure ulcers. The facility failed to prevent the development of a pressure ulcer for Resident #67. This failure placed residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain, and infection. Findings Include: Record review of Resident #67's face sheet dated 09/10/24 revealed, an [AGE] year-old female who admitted to the facility originally on 01/05/23 and readmitted on [DATE] with the following diagnoses which included; dementia, essential hypertension, protein calorie malnutrition and muscle weakness Record review of Resident #67's Quarterly MDS dated [DATE] revealed, severely impaired cognition as indicated by a BIMS score of 00 out of 15, total dependence with most ADL's, total dependence with most functional abilities including shower/bathe self, upper body dressing, substantial/maximal assistance (helper does more than half the effort) assistance with personal hygiene (includes washing and drying hands). The resident was at risk for developing pressure ulcer/injury. Record review of Resident #67's care plan revised 03/21/24 revealed, Focus: [Resident #67] has potential for impairment to skin integrity/pressure ulcer development r/t impaired mobility requiring assist, nutritional deficits and incontinence of B/B.Goal, The resident will have no evidence of skin breakdown noted through the review date.Intervention, .Complete weekly skin assessment. Encourage good nutrition and hydration in order to promote healthier skin Review of the physician's order dated 09/10/24 for the month on September (2024) reflected, Clean area to L back of the ear, pat dry, apply skin prep daily. everyday shift for Maintain skin integrity, order date 09/09/24. Clean underneath left ear with normal saline pat dry and apply TAO for 5days . every day shift, order date 09/09/24. Assess bilateral back of the ears daily, ensure ear protectors are in place, document/report any skin breakdown as indicated every shift for Maintain skin integrity. Observation on 09/09/24 at 01:14 PM during wound care revealed Resident #67 was in bed. LVN D completed wound care on Resident #67's left heel, right heel, right buttock and behind the right knee. During care the resident reported pain but declined to take pain medication. The times when the resident was being positioned on the left side, she reported pain to her ear. Resident #67 was using oxygen via nasal cannula and the tubing was behind her ears. The Surveyor asked LVN D if she could assess the resident's ears and on assessment the resident was noted with a wound behind the left ear. There was some drainage and hair were attached on the drainage that had already dried. In an interview on 09/09/24 at 02:05 PM with LVN D, who was completing the wound care, she stated she had taken care of the resident last on Friday (09/06/24) and she did not assess the resident's ears because she did not think she had any wounds to her ear. LVN D stated today was when she noted the wound after the resident complained of ear pain. LVN D stated the resident was supposed to have ear protectors to prevent the skin breakdown, she noted the tubing pulling on the ears. LVN D stated the charge nurses were to assess the resident ears periodically (no specific time provided) for any skin breakdown due to the use of oxygen tubing. LVN D stated not being aware of the resident having a wound could result to the wound getting worse and getting infected. LVN D stated she would inform the resident's primary care provider of the new wound. In an interview on 09/09/24 at 02:43 PM with RN E, she stated she took care of Resident #67 last week, and she did not notice the open area behind the resident's ear, and she did not assess the resident's ears. RN E stated she completed wound care rounds with the wound care Dr, and there were no reports of the resident having any wounds to her ear. RN E stated the charge nurse were responsible to assess the resident's ears for any skin breakdown frequently. RN E stated wounds that were not addressed timely could lead to wound infection and wounds getting worse. Observation on 09/10/24 at 11:21 AM of an assessment with RN E revealed Resident #67 had an open area on the back of the left ear, no drainage, open to air, wound bed was red, and there were no signs or symptoms of infection. RN E stated the resident was assessed by the primary care provider on 09/09/24 and gave new orders for treatment for five days. The nurse stated the nurses were to assess the resident ear's daily and make sure the resident had the protective foam on the oxygen tubing to prevent any skin breakdown. In an interview on 09/10/24 at 02:05 PM with the DON he stated he was not aware Resident #67 had a wound to the left ear. The DON stated per the skin assessment completed on 09/02/24 the resident did not have any skin issues. The DON stated the nurses were responsible to monitor for the resident's skin breakdown and inform the resident's primary care provider and follow the orders. The nurses should assess the resident ears since she had oxygen tubing to make sure the resident was not having skin breakdown. The DON stated lack of wound care could lead to the wound getting worse and the wound getting worse. Review of the facility policy revised 10/2020, titled Wound care reflected, Purpose. This procedure provides guidelines for the care of wound care to promote healing. Facility did not have a policy regarding addressing new wounds.

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. The facility failed to ensure food on the steam table reached the appropriate temperature before plating food for resident consumption. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/08/24 beginning at 9:20 AM revealed: - 6 cucumbers with fuzzy white spots; - 3 cut tomatoes in a box open and exposed to air; - 1 onion with black spots; - 7 withered tomatoes; - 1 bag of shredded lettuce with brown lettuce leaves; - 1 bucket of pork chops thawing on the second shelf above eggs; - 1 box of bacon open and exposed to air; - individually wrapped sandwiches cut in half with no date; - pasta salad with no date; - 2 green bell peppers with black spots; - 4 withered green bell peppers; and - 1 bag of shredded cheese open and exposed to air. Observation of the facility's freezer on 09/08/24 beginning at 9:51 AM revealed: -1 box of cut green beans open and exposed to air; and - 1 box of green peas open and exposed to air. Observation of the facility's dry storage in the kitchen on 09/08/24 beginning at 10:12 AM revealed: -1 bag of macaroni noodles open and exposed to air. Observation of the facility's seasoning shelf on 09/08/24 beginning at 10:21 AM revealed: -1 container of onion powder open and exposed to air; and - 1 container of quick creamy wheat open and exposed to air. Observation of the facility's steam table on 09/10/24 beginning at 11:46 am revealed the pork loin reached 131 degrees Fahrenheit. The dietary staff plated approximately 20 plates of pork loin on two rolling carts. The carts were taken to the dining room to serve to residents. There were six residents served pork loin prior to Surveyor intervention. The Dietary Supervisor pulled and discarded all plates containing pork loin. The dietary staff reheated the pork loin to 150 degrees Fahrenheit. In an interview with the Dietary Supervisor on 09/10/24 at 3:30 PM revealed she completed walk throughs of the kitchen in the morning and evening. She stated she was responsible for ensuring dietary staff were storing food properly. She stated dietary staff were supposed to label and seal foods. She stated anything in the refrigerator after three days old was thrown away. She stated she ensured staff were aware of food temperatures by posting signs and having information in the temperature log books. She stated the pork loin at a temperature of 131 degrees Fahrenheit was not supposed to be served to residents. She stated the pork loin should have been pulled and warmed up to hold a temperature of 165 degrees Fahrenheit for 15 seconds. She stated improper food storage and undercooked pork loin could cause harm to residents such as contamination and food borne illnesses. Record review of the facility policy titled Food Storage: Dry Storage, dated February 2023 (revised), revealed All packaged and canned food items will be kept clean, dry, and properly sealed. Record review of the facility policy titled Food Storage: Cold Foods, dated February 2023 (revised), revealed All foods will be stored wrapped or in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Record review of the facility policy titled Food: Preparation, dated February 2023 (revised), revealed All foods will be held at appropriate temperatures, greater than 135 degrees Fahrenheit (or state regulation requires) for hot holding, and less than 41 degrees Fahrenheit for cold food holding. Review of the Food and Drug Administration Food Code, dated 2022 reflected, .3-305.11 Food Storage. (A) .food shall be protected from contamination by storing the food: (1) In a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #2) of 5 residents reviewed for notification of changes. The facility failed to notify Resident #2's designated emergency contact [Family Member] when he developed altered mental status and sustained a head injury while nearly falling out of bed. This failure could place residents at risk of their responsible parties not being notified or involved in their plan of care. Findings included: Record review of Resident #2's admission Record dated [DATE] revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Under Contacts, Resident #2 was listed as being his own responsible party and the name and phone number Resident #2's Family Member was included as his additional contact. Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed he had diagnoses including anemia (lack of enough red blood cells needed to carry oxygen throughout the body), orthostatic hypotension (low blood pressure that happens when sitting or lying down that can cause dizziness), cirrhosis (liver damage), anxiety, depression, and chronic obstructive pulmonary disease (lung disease that can make breathing difficult). He had clear speech, he was usually understood and could usually understand others. He had a BIMS score of 11 indicating he had moderately impaired cognition. The MDS reflected it was very important for him to have his family or close friend involved in discussions about his care and he required substantial/maximum assistance to transfer from his bed to a chair. The MDS reflected he was almost constantly in pain that frequently made it hard to sleep and he had sustained one fall since readmission with no injury. He was receiving hospice care while a resident. Record review of resident #2's Care Plans revealed an entry dated initiated [DATE] that reflected, [Resident #2] has had an actual fall r/t Unsteady gait [DATE]. Interventions/Tasks included checking range of motion and providing activities that promote exercise and strength building where possible. There were no facility care plans related to any other incidents or his hospice care. Record review of Resident #2's Physician's orders revealed an entry dated [DATE] which reflected, admitted to [hospice company name] Hospice diagnosis of [COPD] . Record review of Resident #2's Progress Notes reflected the following nursing entries for [DATE]: [DATE] 11:57 AM: Skin Only Evaluation. Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Signed by the DON. [DATE] 10:21 PM: Resident refused medications this shift. Signed by LVN V. [DATE] 7:51 AM LATE ENTRY Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Seems different than usual At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 135/76 - [DATE] 07:53 Position: Lying r/arm - Pulse: P 68 - [DATE] 07:54 Pulse Type: Irregular - new onset - RR: R 26 - [DATE] 07:54 - Temp: T 97.1 - [DATE] 07:55 Route: Tympanic - Weight: W 130.0 lb -[DATE] 09:36 Scale: Wheelchair - Pulse Oximetry: O2 81 % - [DATE] 07:55 Method: Oxygen via Nasal Cannula - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: K74.60 UNSPECIFIED CIRRHOSIS OF LIVER E44.0 MODERATE PROTEIN-CALORIE MALNUTRITION F32.A DEPRESSION, UNSPECIFIED D64.9 ANEMIA, UNSPECIFIED K59.00 CONSTIPATION, UNSPECIFIED F41.9 ANXIETY DISORDER, UNSPECIFIED G89.4 CHRONIC PAIN SYNDROME M87.059 IDIOPATHIC ASEPTIC NECROSIS OF UNSPECIFIED FEMUR B18.2 CHRONIC VIRAL HEPATITIS C F51.05 INSOMNIA DUE TO OTHER MENTAL DISORDER Z79.891 LONG TERM (CURRENT) USE OF OPIATE ANALGESIC J18.9 PNEUMONIA, UNSPECIFIED ORGANISM R53.1 WEAKNESS R29.6 REPEATED FALLS J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED I95.89 OTHER HYPOTENSION Relevant medical history is: COPD Code Status: DNR Advance directives are: Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin [blood thinners]: No The result of last INR: Date: Resident/Patient is on anticoagulant [blood thinner] other than warfarin: No Resident/Patient is on: Outcomes of Physical Assessment : Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Behavioral Status Evaluation: - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: No changes observed - GU/Urine Status Evaluation: No changes observed - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? Yes - Neurological Status Evaluation: No changes observed Nursing observations, evaluation, and recommendations are: Generalized weakness, gasping for air, refused to eat or drink. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: [name of hospice] HOSPICE B. New Testing Orders: [blank] C. New Intervention Orders: [blank]-- Comments: [blank] Signed by LVN Q and the DON. [DATE] 4:27 PM: V/S assessed 130/65,68,16,97.8, 96% O2 @ 2 via n/c, resident not responding when called by his name, and unable to eat or drink. [name of hospice] hospice contacted spoke to [Hospice RN] on call and requested for RN to come back and reassess resident, [Hospice RN] said he will send a nurse. Signed by LVN V. [DATE] 7:42 PM: Writer called resident [Family Member] to update her, said she 5mins aware [sic]. write heard door alarm going off upon arriving noted [Family Member] pulled and held the door until the door opened. [Family Member] called writer to the room and stated what happened to [Resident #2's] right side of head you better call your administrator here or someone this is abuse and neglect because i'm on the phone with the corps [sic] and channel 5 will be here and state will be here too Administrator and DON made aware. Noted redness to resident right side of head, skin assessment performed and no other skin issues noted. Morphine and Xanax administered per [Family Member] request. Police arrived and took statement from writer, hospice contacted again for comfort kit to be delivered spoke to [Hospice nurse] again, said they don't use comfort kit anymore but the nurse is on the way and will place order for atropine [used to decrease mouth secretions and congestion] and other meds needed. Resident made comfortable in bed. [Hospice nurse] here. Administrator and DON arrived. Signed by LVN V. [DATE] 10:18 PM: 9:55 pm Administrator called wanting to talk to residents [Family Member]. Notified the [Family Member] that Admin would like to talk to her on the phone, she said NO I want her to come in the building message relayed to the Administrator. Signed by LVN O. [DATE] 11:00 PM: Skin Only Evaluation: Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Skin note: the skin is intact, small discoloration to the right side scalp noted Signed by RN B. [DATE] 11:19 PM: This resident [Family Member] called at 1515 [3:15 PM] stated Hospice called me .no one called me writer made [Family Member] aware that the change in condition was noted today and previous shift nurse notified hospice. [DATE] 11:45 PM: Resident's [Family Member] called the nurse requesting more pain medication that [Resident #2] seemed to be in much pain and anxiety. 0.25 ml of morphine [pain medication] and XANAX [anxiety medication] 2mg 1 tab administered sublingual and effective. Signed by RN B. [DATE] 2:00 AM: . complete skin assessment done, no skin issues noted except small discoloration on right side of scalp. resident repositioned every 2 hrs and incontinent care provided. Signed by RN B. [DATE] 10:12 AM: [hospice nurse] arrived and pronounced resident at 0916 [9:16 AM]. [funeral home] picked up resident remains at 1012am. Record review of Resident #2's hospice Visit Description Log revealed the following visits made by hospice staff to Resident #2 in [DATE]: [DATE]-Hospice Aide CC [DATE]-Hospice Aide CC [DATE]-Hospice Nurse DD [DATE]-Hospice Aide CC [DATE]-Hospice Aide CC Record review of Resident #2's hospice Physician Order documents revealed medication changes were made for pain control on [DATE] by Hospice Nurse EE, and [DATE] by Hospice Nurse DD and Hospice Nurse FF. No hospice nursing assessments or other visit information were located within Resident #2's electronic medical record. Review of the facility's Provider Investigation Report dated [DATE] reflected Resident #2's Family Member had made an allegation of abuse stating Resident #2 had a bruise on his head. The report reflected the following Description of Injury: Upon charge nurse assessment, no bruise or bump noted on his head, Resident was in the active dying phase. The report reflected the following Provider Response: Charge nurse completed skin assessment and pain assessment. No noted bruising or pain noted. [Resident #2] was currently in the active dying phase and staff were making him comfortable. The Investigation Summary reflected: Based on the investigation; including staff interviews and resident safe surveys, no evidence of abuse can be founded . [Family Member] arrived at the facility after being notified of his decline .charge nurse reported the [Family Member] wanted to visit with the administrator about her concerns . nurse came back and stated the [Family Member] told her, No I won't talk to her on the phone. I expect her to show up at the facility to visit. Administrator and Director of Nursing went to facility She looked at me still yelling, look at these bruises! .I could see the director of nursing go up and look at what she was saying was a bruise. My director of nursing told her he did not see any bruising . Skin assessment and pain assessment completed. No signs of bruising noted . Skin assessments showed no bruising noted on his head An attached Skin Only Evaluation dated [DATE] at 11:00 PM reflected Resident #2's skin was warm and dry, skin color was within normal limits, and turgor (elasticity) was normal. Skin note reflected, the skin is intact, small discoloration to the right-side scalp noted. An attached SBAR Communication Form and Progress Note (used to document a change in condition) dated [DATE] reflected Resident #2's change in condition started on [DATE] and they were unable to determine whether it had gotten worse, better, or stayed the same. -The condition, symptom, or sign had not occurred before. -The resident evaluation reflected boxes checked for altered level of consciousness and needs more assistance with ADLs. -The Pain Evaluation section indicated he had worsening of chronic pain with an intensity of 7 [out of a 1-10 scale, 10 being the worst]. -Code status was DNR. -Appearance was described as Generalized weakness, gasping for air, refused to eat or drink. The Form reflected: Primary Care Clinician Notified: Yes. Date: [DATE] Time: 10:00 AM. Recommendations of Primary Clinicians (if any): [Hospice company name]. No nurses notes were included for additional information. Name of Family/Healthcare Agent Notified: [Family Member] Date: [DATE] Time: 1:00 PM The document was signed by the DON. Record review of photographs obtained from an outside source and identified as those taken of Resident #2 on [DATE] revealed there were two dark pink/purple round bruises approximately 1 cm in diameter on the top right side of his forehead close to his hairline. There was another bruise which was blue and pink and appeared to be raised situated between the two darker pink/purple areas. Another pink area with a scab was observed just inside his hairline on the top right side of his head. Record review of a Police Report, dated [DATE] and provided by the facility, revealed police were dispatched to the nursing facility on [DATE] at 9:04 PM. The report reflected the Police Officer had spoken with resident #2's Family Member who reported being upset that Resident #2 had two contusions and a laceration on his head that could not be explained by facility staff. The Police Officer made contact with LVN V who was unable to locate any documentation of the injuries. The report reflected, I took photographs of [Resident #2's] injuries that were uploaded through [NAME] Capture [police software]. There were no photographs included with the report. During an interview with Resident #2's Family Member on [DATE] at 10:41 AM, she stated she received a call from the hospice Social Worker at around 5:00 PM on [DATE] stating a hospice had been to visit Resident #2 and his death was imminent. She stated she called his hospice nurse who told her he had not been eating or drinking for three days and the nurse seemed surprised by the information. The Family Member stated the facility should have called the hospice nurse and should have called her as well because she was listed as his emergency contact. The Family Member stated she called the facility right afterward and the nurse told her she was just PRN, had not worked with him for a few days, and was not certain. The Family Member stated she told the nurse she wanted to speak with the ADON or DON and requested a call back. She stated she received a call back from the nurse who told her they did not need to call her because Resident #2 was his own Responsible Party. She stated the nurse confirmed her name and number were listed as his emergency contact. Family Member stated she began stroking Resident #2's head, felt some knots and noticed some bruises that appeared to be in different stages of healing and a hematoma that had a cut in it. She stated she was a nurse herself and was concerned he had been abused. She stated she asked the nurse about it who stated she was unaware, checked and could not find any documentation about it. She stated she again asked to speak with someone in administration. She stated she received no calls from any administrative staff and finally called 911 at around 9:00 PM. She stated the police arrived at about 9:22 PM, spoke with her and took pictures of Resident #2's injuries. Family Member stated, at around 9:46 PM, she stepped out of the room to make a phone call and notices two people in the hallway, a man had his arms crossed and was staring at her. She stated she did not notice and name badges on them and assumed they were there visiting someone else and went on with her call. She stated she returned and the two people entered Resident #2's room and stared at her. She asked them who they were, and they identified themselves as the Administrator and the DON. She stated when she asked them about the injuries on Resident #2's head, the man began aggressively poking on him, so she told him to stop and leave. She stated when she asked them if they were going to call and report the matter, the man laughed, shook his head and guided the Administrator away from the room. The Family Member cried and stated, had she known sooner that Resident #2 was nearing the end, she could have called other family to be there with them, but they lived several hours away. She stated she sat with him alone the rest of the night until he passed away. Family Member stated she was very upset that no one could account for his injuries, and no one had provided any further information since the incident. The Family Member stated she last saw Resident #2 a couple of weeks earlier, near the end of March and he was alert and doing very well. She stated she had not received any prior calls from the facility and only occasional calls from the hospice company, nothing that would have indicated his deterioration or explain his injuries. The local police department was called on [DATE] at 11:27 AM and a message was left for the responding officer. A request for police report was submitted. In an interview on [DATE] at 2:04 PM, LVN Q stated she had previously received in-service training related to abuse, neglect, and injuries of unknown origin. She stated any concerns or complaints related to abuse or neglect should be reported to the Administrator immediately. LVN Q stated, if bruises or injuries were noted, she would check the notes to see if a previous nurse had documented anything. She stated, if not, she should have assessed the resident, contacted the resident's physician, and noted any new orders, notify the family and notify the Administrator and DON. LVN Q stated the risk of failing of notify the emergency contact was it could upset the family very much if they didn't know, they need to know. She stated the family needed to know even if the resident was their own responsible party. When asked about Resident #2 and the events on [DATE], LVN Q stated that day he started to decline, she had called hospice and they arrived later after her shift. She could not recall who she had spoken with. She stated she did not call his family because there was no emergency contact listed. When shown Resident #2's admission Record with the Family Member's phone number, she stated she thought hospice was going to call them. She stated, I accept I made mistakes; it was the first time I had anyone decline like that and I should have called [Family Member]. LVN Q stated she had assessed Resident #2 and did not recall any skin issues. She stated administration had called her later that evening and asked whether she had noticed any injuries and she told them no. She stated she never spoke with his family. During a telephone interview on [DATE] at 6:38 PM, the police officer who had responded to the call related to Resident #2, he stated he recalled speaking to Resident #2's Family Member. The police officer stated he recalled seeing a knot and some bruises on Resident #2's head. He stated he spoke with facility staff and he was unable to determine how the injuries were sustained. During an interview with ADON AA on [DATE] at 8:50 AM, she identified herself as the facility's wound treatment nurse and began working in the facility in February 2024. She stated the nursing staff reported any new skin findings to her. She stated her responsibilities included assessing all facility wounds, including bruises and skin tears. She stated, if the wound was new, she requested treatment orders and notified family members. ADON AA stated she had never been notified of any skin conditions for Resident #2 and he had never been on her service. In an interview on [DATE] at 9:04 AM, the DON stated the procedures for a change in condition for residents receiving hospice services were the charge nurse was to call the hospice providers because they handled the orders. He stated the hospice nurses would usually indicate if they were going to contact the resident's family members and, if not, the charge nurse was to contact them. He stated any changes in a resident's condition and calls made related to the residents were documented in the progress notes. In an interview on [DATE] at 10:50 AM, LVN BB stated she had been caring for two hospice residents. She stated any changes in the resident's condition were called to the hospice nurse and the resident's family. She stated it was important to call the family because she could not be certain if the hospice nurse contacted them, and it was important they were notified of any changes. On [DATE] at 12:11 PM, attempts to call Resident #2's hospice company were unsuccessful, and no voice mailbox was available. During an interview on [DATE] at 12:20 PM, CNA U stated she had been working at the facility for two years and had begun working as a Restorative Aide about a month ago. She stated she had cared for Resident #2 during his stay. She stated she had noticed he was declining during the last week he was there. She stated, I'm a reporter, always go to the nurse first, anything I find out of the ordinary or I haven't seen before. When asked about his skin care, CNA U stated the hospice aides typically performed bathing, but the facility aides did everything else. When asked about the week leading up to [DATE], CNA U stated she was pretty sure there was a wound on his head, and she was pretty sure he had hit his head. CNA U stated she had entered his room and found him leaning out of the bed. She stated the upper part of his body was leaning to the side out of the bed, his right hand was on the floor, and his left hand was holding onto his bedside table as if trying to keep himself from falling to the floor. She stated he had a dresser and an oxygen concentrator next to his bed. CNA U stated she asked him what he was trying to do, and he was confused. She stated she assisted him back onto the bed and noticed his head was bleeding. She stated she thought he had hit his head on his oxygen concentrator. She stated she went to get the nurse and was pretty sure it was LVN Q. CNA U was unable to recall on what day the incident occurred but thought it was one or two days before Resident #2 died. She stated the nurse came, checked his vital signs and cleaned his wound. She stated the incident occurred near the end of her shift and she went home. When asked if she had cared for him in the days after the incident, she replied, I might have but I don't remember. She stated she could not recall any other incidents involving Resident #2, but she could tell he was declining before the incident. She stated he had previously been able to tell them what he needed. CNA U stated she had previously had training about abuse and neglect and knew any incidents were to be reported to the Administrator and DON. She stated she did not report that incident because the nurse was caring for him and she assumed the nurse would have reported it. CNA U stated she did recall the DON later asking about Resident #2's skin and stated, I think I told him no though, I think I forgot. During another interview with LVN Q on [DATE] at 12:53 PM, when she was asked again about any skin issues with Resident #2, she replied, I checked, no issues. When asked whether she had received any reports that he had stopped eating, she stated she had only heard about his refusing to eat on [DATE] .I didn't see her [hospice nurse] before I left. LVN Q denied ever being told by CNA U that Resident #2 was found leaning out of bed with his head bleeding. She denied seeing any bruising or cuts on his head. LVN Q was shown the photos of Resident #2 obtained during the investigation. She stated, I did see the cut, I don't recall seeing the bruises. He was not hanging out of the bed, he was more to the side of the bed. We repositioned him. She pointed out the cut and stated, Yes, I saw that one, I cleaned it, it was a small cut. I told the hospice nurse that day, they came, and I reported the cut. She stated she did not report the injury to Resident #2's physician or his family member. She could not recall they day it occurred and stated, I called the hospice nurse and saw them the same day. She stated she thought it may have occurred the same day he had declined on [DATE]. When reminded she had already stated she never saw the hospice nurse on [DATE], she replied, Right. LVN Q stated she did not document the incident or injury anywhere and could not say why she did not. She stated she had only reported it verbally to the hospice nurse. She stated she had received training on abuse and neglect and should have reported the incident and completed an incident report. She stated she did not tell the DON about it when he had contacted her on the evening of [DATE] and asked her specifically about any injuries. She stated she forgot to tell him. LVN Q stated the risk for failing to report incidents and injuries was great injury and harm and apologized for her mistakes. During an interview on [DATE] at 1:16 PM, the DON was asked about the incident related to Resident #2 on [DATE]. He stated Resident #2 had been on hospice. The DON stated, on [DATE], Resident #2's nurse had notified hospice that he needed increased care and was told they would send someone out. He stated they did not arrive until later that evening, and he was not there when they arrived. The DON stated he had only come in later that evening because Resident #2's Family Member had complained of bruises, so he and the Administrator came to the facility. The DON stated he checked Resident #2 and there was nothing there other than typical color changes seen when someone was dying. The DON stated Resident #2's Family Member had not seen Resident #2 in years. He said he knew this because he had not seen her in the facility and their Social Worker had said the same. He stated they had attempted to contact the Family Member when After Resident #2 had returned from his last hospital trip and had elected to go onto hospice services. He stated Resident #2 had identified the Family Member as his emergency contact. He stated the nurses reported they had tried to reach the Family Member when Resident #2 had stopped eating but no one was picking up the phone. He stated he thought it was LVN Q or one of the other nurses who had given him that information. He stated he did not follow up on the calls because the hospice nurse was following up. The DON stated he was told the Family Member was irate, had called the police, and complained Resident #2 had an injury to his head and wanted to know what had happened. He stated the police were gone when he arrived. He stated he and the Administrator spoke with the nurse, went to Resident #2's room to speak with them and the hospice nurse was there. He stated the Family Member stepped out a short time later and he went in to assess Resident #2. The DON stated, I went in and assessed him, didn't see bruises or anything, just skin discoloration. He stated he called and spoke with LVN Q and CNA U to see whether they had seen anything and both [NAME] him no. He stated he spoke LVN V who was caring for him during the 2 PM to 10 PM shift. When asked whether he had seen the police report-the DON stated he had glanced at it. He did not recall seeing any photographs of Resident #2's injuries or the area on the report that indicated photographs were taken. The DON stated the Family Member told him there was something there, I didn't see anything, everyone I talked to said they didn't see anything. When the DON was shown the photos obtained during the investigation, he stated he did see the red spots. He stated he told the night shift nurse to complete a skin assessment. When asked about the blue raised area or the scabbed area, he stated he had not seen them during his assessment. He stated the room was dim and he did not look in the resident's hair. When asked why he did not document the red spots he had observed, the DON stated they had a nurse on the floor to do that. The facility's Provider Investigation Report was reviewed with the DON, and he was asked about the fact that he was identified as stating there were no signs of bruising noted. The DON stated he had attributed the areas he saw as skin changes due to the dying process and he did not believe they were bruises. The DON was informed of the information received during interviews with CNA U and LVN Q including their admission of noting Resident #2 had sustained an injury to his head and their failure to report the information. The DON stated he was previously unaware of the situation and repeated he had reached out to both of them to ask if they knew anything and was told no. The DON stated failure to report incidents and injuries placed the residents at risk of missed injuries and delayed treatment. He stated he expected his staff to follow their incident reporting protocol and report any incidents or injuries to himself and the Administrator. He was asked again to assist with locating the resident's hospice documentation. During an interview with Administrator A on [DATE] at 4:20 PM revealed the DON had spoken with her regarding the interview related to Resident #2. She stated she felt confident the staff interviews had been conducted during the investigation and staff surveys were conducted with other staff as well. She stated, on [DATE], she had received a call from the facility stating Resident #2's Family Member was upset. She stated she did not attempt to reach the Family Member on their phone because she did not have the number and had been told they wanted her to come to the facility. Administrator A stated she arrived at the facility and she stood near the doorway while the DON was speaking with the Family Member and she heard her say something about a gash and a bruise. Administrator A stated the Family Member was pointing toward Resident #2's head but she was unable to see anything from where she was standing. Administrator stated she asked the Family Member if they could tell her what was wrong, and she was told he had a bruise and a gash on his head. She stated she was unable to see it from where she was standing. Administrator A stated when she arrived the next morning, Resident #2 had died. She stated she looked at Resident #2 and did not see anything on the front of his forehead. She stated she was not a nurse, so she did not touch the resident. She stated she asked the DON, and he told her he had not seen anything. Administrator A was shown the photographs obtained during the investigation and she stated she did not see the injuries shown in the photographs when she observed Resident #2. She stated they could have been covered by his hair and she did not touch him. The DON joined the interview with Administrator A. The DON stated he spoke with LVN Q who insisted the injury to Resident #2's head occurred on [DATE] and that she had called the hospice company but had failed to document it and the hospice nurse arrived after she had gone home that day Administrator A stated the DON had shared with her already that the information they had received during their initial investigation was not what was learned this day. Administrator A stated if a resident was found with a head injury or any new injury, the nurse should notify the physician and family. She stated the nurse should then immediately notify herself and the DON so they could properly follow-up and investigate. Administrator A stated she expected the nurses to document and at least have a note documenting the assessment, the vital signs, a note detailing what happened. She stated notification of the physician and family should be noted as well and an incident report initiated. She stated she expected the nurse to treat any wounds and do whatever the situation entailed. She stated it could be many different scenarios. Administrator A stated there was always a risk of negative outcomes for residents sustaining injuries that were not reported. During an interview on [DATE] at 4:55 PM, Administrator A stated LVN Q had been suspended pending investigation. During an interview with the DON on [DATE] at 7:45 AM, he stated he was still unable to locate any additional hospice documentation for Resident #2. He stated he had been unable to reach anyone at the hospice company when

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #2) of 5 residents reviewed for neglect. LVN Q failed to document the assessment and treatment she performed on Resident #2. LVN Q failed to perform any additional assessments of the resident's injury and notify any other staff of the injury. These failures placed residents at risk of pain, diminished quality of life, delayed diagnosis, treatment, and serious physical harm. Findings included: Record review of Resident #2's admission Record dated 7/24/24 revealed he was a [AGE] year-old male originally admitted to the facility on [DATE] and readmitted on [DATE]. Under Contacts, Resident #2 was listed as being his own responsible party and the name and phone number Resident #2's Family Member was included. Record review of Resident #2's Significant Change MDS assessment dated [DATE] revealed he had diagnoses including anemia (lack of enough red blood cells needed to carry oxygen throughout the body), orthostatic hypotension (low blood pressure that happens when sitting or lying down that can cause dizziness), cirrhosis (liver damage), anxiety, depression, and chronic obstructive pulmonary disease (lung disease that can make breathing difficult). He had clear speech, he was usually understood and could usually understand others. He had a BIMS score of 11 indicating he had moderately impaired cognition. The MDS reflected it was very important for him to have his family or close friend involved in discussions about his care and he required substantial/maximum assistance to transfer from his bed to a chair. The MDS reflected he was almost constantly in pain that frequently made it hard to sleep and he had sustained one fall since readmission with no injury. He was receiving hospice care while a resident. Record review of Resident #2's Care Plans revealed an entry dated initiated 3/19/24 that reflected, [Resident #2] has had an actual fall r/t Unsteady gait 03/19/2014. Interventions/Tasks included checking range of motion and providing activities that promote exercise and strength building where possible. There were no facility care plans related to his hospice care. Record review of Resident #2's Physician's orders revealed an entry dated 3/21/24 which reflected, admitted to [hospice company name] Hospice diagnosis of [COPD] . Record review of Resident #2's Progress Notes reflected the following nursing entries for April 2024: 4/1/24 6:29 AM: Resident continued to call [Hospice company] complaining that he is in pain and needs Morphine. The Hospice nurse come to the facility, one time order for Morphine sulfate 30 mg tab was administered and effective. also new orders give: to D/C Morphine Sulfate30 mg ab po qhs, continue Morphine Sulfate 60 mg tab BID, Hydromorphone 2 mg 1 tab every 6 hrs prn for mild and moderate pain and dyspnea and 2 tabs every 6 hrs prn for severe pain and dyspnea. the new orders were immediately sent to pharmacy electronically by [Hospice company] Nurse. Signed by RN B. 4/5/24 11:57 AM: Skin Only Evaluation. Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Signed by the DON. 4/5/24 10:21 PM: Resident refused medications this shift. Signed by LVN V. 4/11/24 7:51 AM LATE ENTRY Situation: The Change In Condition/s reported on this CIC Evaluation are/were: Abnormal vital signs (low/high BP, heart rate, respiratory rate, weight change) Seems different than usual At the time of evaluation resident/patient vital signs, weight and blood sugar were: - Blood Pressure: BP 135/76 - 4/11/2024 07:53 Position: Lying r/arm - Pulse: P 68 - 4/11/2024 07:54 Pulse Type: Irregular - new onset - RR: R 26 - 4/11/2024 07:54 - Temp: T 97.1 - 4/11/2024 07:55 Route: Tympanic - Weight: W 130.0 lb -4/3/2024 09:36 Scale: Wheelchair - Pulse Oximetry: O2 81 % - 4/11/2024 07:55 Method: Oxygen via Nasal Cannula - Blood Glucose: Resident/Patient is in the facility for: Long Term Care Primary Diagnosis is: K74.60 UNSPECIFIED CIRRHOSIS OF LIVER . R53.1 WEAKNESS R29.6 REPEATED FALLS J44.9 CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED I95.89 OTHER HYPOTENSION Relevant medical history is: COPD Code Status: DNR Advance directives are: Resident/Patient had the following medications changes in the past week: Resident/Patient is on Coumadin/warfarin [blood thinners]: No The result of last INR: Date: Resident/Patient is on anticoagulant [blood thinner] other than warfarin: No Resident/Patient is on: Outcomes of Physical Assessment: Positive findings reported on the resident/patient evaluation for this change in condition were: - Mental Status Evaluation: Altered level of consciousness (hyperalert, drowsy but easily aroused, difficult to arouse) - Functional Status Evaluation: Needs more assistance with ADLs - Behavioral Status Evaluation: - Respiratory Status Evaluation: - Cardiovascular Status Evaluation: - Abdominal/GI Status Evaluation: No changes observed - GU/Urine Status Evaluation: No changes observed - Skin Status Evaluation: No changes observed - Pain Status Evaluation: Does the resident/patient have pain? Yes - Neurological Status Evaluation: No changes observed Nursing observations, evaluation, and recommendations are: Generalized weakness, gasping for air, refused to eat or drink. Primary Care Provider Feedback: Primary Care Provider responded with the following feedback: A. Recommendations: [name of hospice] HOSPICE B. New Testing Orders: [blank] C. New Intervention Orders: [blank]-- Comments: [blank] Signed by LVN Q and the DON. 4/11/24 3:03 PM: Hospice nurse here at beginning n/o rec'd to crush meds mix with applesauce put under the in the check or under the tongue. Ativan Qhrs as needed DX anxiety. Signed by LVN V. 4/11/24 4:27 PM: V/S assessed 130/65,68,16,97.8, 96% O2 @ 2 via n/c, resident not responding when called by his name, and unable to eat or drink. [name of hospice] hospice contacted spoke to [Hospice RN] on call and requested for RN to come back and reassess resident, [Hospice RN] said he will send a nurse. Signed by LVN V. 4/11/24 7:42 PM: Writer called resident [Family Member] to update her, said she 5mins aware [sic]. write heard door alarm going off upon arriving noted [Family Member] pulled and held the door until the door opened. [Family Member] called writer to the room and stated what happened to [Resident #2's] right side of head you better call your administrator here or someone this is abuse and neglect because I'm on the phone with the corps [sic] and channel 5 will be here and state will be here too Administrator and DON made aware. Noted redness to resident right side of head, skin assessment performed and no other skin issues noted. Morphine and Xanax administered per [Family Member] request. Police arrived and took statement from writer, hospice contacted again for comfort kit to be delivered spoke to [Hospice nurse] again, said they don't use comfort kit anymore but the nurse is on the way and will place order for atropine [used to decrease mouth secretions and congestion] and other meds needed. Resident made comfortable in bed. [Hospice nurse] here. Administrator and DON arrived. Signed by LVN V. 4/11/24 10:18 PM: 9:55 pm Administrator called wanting to talk to residents [Family Member]. Notified the [Family Member] that Admin would like to talk to her on the phone, she said 'NO I want her to come in the building' message relayed to the Administrator. Signed by LVN O. 4/11/24 11:00 PM: Skin Only Evaluation: Skin: Skin warm & dry, skin color WNL and turgor is normal. Resident does not have an external device. Skin note: the skin is intact, small discoloration to the right side scalp noted Signed by RN B. 4/11/24 11:19 PM: This resident [Family Member] called at 1515 [3:15 PM] stated Hospice called me and told me [Resident #2] has not eaten for the past three days and no one called me writer made [Family Member] aware that the change in condition was noted today and previous shift nurse notified hospice. 4/11/24 11:20 PM: Hospice nurse was in resident's room with resident's [Family Member] the time this nurse arrived and doing her round. new orders are given from Hospice nurse to give Dilaudid [pain medication] 2mg tab 1-2 tabs every 2 hours as needed for pain or SOB. Hyoscyamine 0.125 mg 1 tab sublingually every 4 hours as needed for excess secretions. TO hold scheduled meds and food, drink due to inability to swallow. PRN meds can be crushed, mixed with water with 0.25 ml of water and give sublingually [under the tongue]. Signed by RN B. 4/11/24 11:30 PM: this nurse noticed resident's room call light on, arrived there, the hospice nurse said that the resident needs pain med. Dilaudid 2mg 1 tab administered sublingually. resident's [Family Member] on side of bed. Signed by RN B. 4/11/24 11:45 PM: Resident's [Family Member] called the nurse requesting more pain medication that [Resident #2] seemed to be in much pain and anxiety. 0.25 ml of morphine [pain medication] and XANAX [anxiety medication] 2mg 1 tab administered sublingual and effective. Signed by RN B. 4/12/24 2:00 AM: Resident is declining, vital signs BP 118/69, P 108, R 14, 02SAT 79 on oxygen. resident's body is sweating but temperature reads low. hospice nurse is aware of changes of condition. after giving new orders, hospice nurse left saying that he will come back later in day. complete skin assessment done, no skin issues noted except small discoloration on right side of scalp. resident repositioned every 2 hrs and incontinent care provided. Signed by RN B. 4/12/24 2:35 AM: Hydromorphone 2mg 2 tablets administered for pain. resident remains on comfort care. Signed by RN B. 4/12/24 7:07 AM: V/S assessed at 0707 unpon [sic] arrival to the facility 73/55,107,12,97.1 sat 72%-75% on 02. [Family Member] at bedside. Signed by LVN V. 4/12/24 7:54 AM: Approx 0722 went to administer pain meds, no rise and fall of chest noted, [Family Member] stated 'i think he's gone and writer unable to obtain any V/S. Vitas hospice contacted spoke [Hospice nurse] on call, said she will send a nurse out, [Family Member] made aware. DON and [doctor] notified. Resident cleaned at this time by writer, call light within reach. Signed by LVN V. 4/12/24 10:12 AM: [hospice nurse] arrived and pronounced resident at 0916 [9:16 AM]. [funeral home] picked up resident remains at 1012am. Record review of Resident #2's hospice Visit Description Log revealed the following visits made by hospice staff to Resident #2 in April 2024: 4/2/24-Hospice Aide CC 4/4/24-Hospice Aide CC 4/5/24-Hospice Nurse DD 4/9/24-Hospice Aide CC 4/11/24-Hospice Aide CC Record review of Resident #2's hospice Physician Order documents revealed medication changes were made for pain control on 4/1/24 by Hospice Nurse EE, and 4/11/24 by Hospice Nurse DD and Hospice Nurse FF. No hospice nursing assessments or other visit information were located within Resident #2's electronic medical record. Review of the facility's Provider Investigation Report dated 4/15/24 reflected Resident #2's Family Member had made an allegation of abuse stating Resident #2 had a bruise on his head. The report reflected the following Description of Injury: Upon charge nurse assessment, no bruise or bump noted on his head, Resident was in the active dying phase. The report reflected the following Provider Response: Charge nurse completed skin assessment and pain assessment. No noted bruising or pain noted. [Resident #2] was currently in the active dying phase and staff were making him comfortable. The Investigation Summary reflected: Based on the investigation; including staff interviews and resident safe surveys, no evidence of abuse can be founded. [Resident #2] was alert and oriented and able to make all needs known prior to his medical decline. [Family Member] arrived at the facility after being notified of his decline. It was at this time once she arrived, according to staff that she started yelling at staff; unplugged the call light, called police department and threatened to call the news station. Charge nurse called the administrator and reported [Family Member] was exhibiting some unruly and inappropriate behavior, yelling at the staff, calling the police (police showed up) and charge nurse reported the [Family Member] wanted to visit with the administrator about her concerns. Administrator attempted multiple times to visit with [Family Member], via phone unsuccessful. At approximately 10:00 pm, administrator attempted to visit with the [Family Member] via phone again, nurse came back and stated the [Family Member] told her, No I won't talk to her on the phone. I expect her to show up at the facility to visit. Administrator and Director of Nursing went to facility. Both admin and the director of nursing arrived a little after 10:30 pm and I attempted to introduce myself to the [Family Member]. She said, Who are you? I explained who I was, and she started yelling at me stating you need to get out of here. I explained to her that she asked me to come. I came and wanted to hear her concerns. She looked at me still yelling, look at these bruises! I attempted to look, but she said, you are not welcome in here. You need to leave. I did step out of the room, but I stayed at the doorway, and I could see the director of nursing go up and look at what she was saying was a bruise. My director of nursing told her he did not see any bruising. Then she kicked the director of nursing out too. At that time, the Director of Nursing and administrator started investigation. Skin assessment and pain assessment completed. No signs of bruising noted. [Resident #2] was nonresponsive as he was actively dying. No signs or symptoms of distress noted. Charge nurse continued to provide palliative and comfort care through the night. Skin assessments showed no bruising noted on his head. [Resident #2] passed early the next day; [Family Member] stayed the night and left in the morning once he passed. Charge nurse stated [Family Member] was calm all night long and did not continue yelling behavior. [Resident #2] was on hospice for end stage disease. Resident safe surveys completed. No concerns noted. Staff safe surveys completed. No concerns noted. An attached Skin Only Evaluation dated 4/11/24 at 11:00 PM reflected Resident #2's skin was warm and dry, skin color was within normal limits, and turgor (elasticity) was normal. Skin note reflected, the skin is intact, small discoloration to the right-side scalp noted. An attached SBAR Communication Form and Progress Note (used to document a change in condition) dated 4/11/24 reflected Resident #2's change in condition started on 4/11/24 and they were unable to determine whether it had gotten worse, better, or stayed the same. -The condition, symptom, or sign had not occurred before. -The resident evaluation reflected boxes checked for altered level of consciousness and needs more assistance with ADLs. -The Pain Evaluation section indicated he had worsening of chronic pain with an intensity of 7 [out of a 1-10 scale, 10 being the worst]. -Code status was DNR. -Appearance was described as Generalized weakness, gasping for air, refused to eat or drink. The Form reflected: Primary Care Clinician Notified: Yes. Date: 4/11/24 Time: 10:00 AM. Recommendations of Primary Clinicians (if any): [Hospice company name]. No nurses notes were included for additional information. Name of Family/Healthcare Agent Notified: [Family Member] Date: 4/11/24 Time: 1:00 PM The document was signed by the DON. Record review of photographs obtained from a confidential person, identified as those taken of Resident #2 on 4/11/24 revealed there were two dark pink/purple round bruises approximately 1 cm in diameter on the top right side of his forehead close to his hairline. There was another bruise which was blue and pink and appeared to be raised situated between the two darker pink/purple areas. Another pink area with a scab was observed just inside his hairline on the top right side of his head. Record review of a Police Report, dated 4/11/24 and provided by the facility, revealed police were dispatched to the nursing facility on 4/11/24 at 9:04 PM. The report reflected the Police Officer had spoken with resident #2's Family Member who reported being upset that Resident #2 had two contusions and a laceration on his head that could not be explained by facility staff. The Police Officer made contact with LVN V who was unable to locate any documentation of the injuries. The report reflected, I took photographs of [Resident #2's] injuries that were uploaded through [NAME] Capture [police software]. There were no photographs included with the report. During an interview with Resident #2's Family Member on 7/24/24 at 10:41 AM, she stated she received a call from the hospice Social Worker at around 5:00 PM on 4/11/24 stating a hospice had been to visit Resident #2 and his death was imminent. She stated she called his hospice nurse who told her he had not been eating or drinking for three days and the nurse seemed surprised by the information. The Family Member stated the facility should have called the hospice nurse and should have called her as well because she was listed as his emergency contact. The Family Member stated she called the facility right afterward and the nurse told her she was just PRN, had not worked with him for a few days, and was not certain. The nurse told her his tray had just been delivered and she would check on him. The Family Member stated she told the nurse she wanted to speak with the ADON or DON and requested a call back. She stated she received a call back from the nurse who told her they did not need to call her because Resident #2 was his own Responsible Party. She stated she became angry and demanded a call back from someone in charge. She stated the nurse confirmed her name and number were listed as his emergency contact. The Family Member stated when she arrived to Resident #2's room, a hospice chaplain was present with Resident #2 he stated she began stroking Resident #2's head, felt some knots and noticed some bruises that appeared to be in different stages of healing and a hematoma that had a cut in it. She stated she was a nurse herself and was concerned he had been abused. She stated she asked the nurse about it who stated she was unaware, checked and could not find any documentation about it. She stated she became infuriated and again asked to speak with someone in administration. She stated she received no calls and finally called 911 at around 9:00 PM. She stated the police arrived at about 9:22 PM, spoke with her and took pictures of Resident #2's injuries. The Family Member stated she missed a call from the ADON while the police were there and did not bother to call them back. She stated, at around 9:46 PM, she stepped out of the room to make a phone call and notices two people in the hallway, a man had his arms crossed and was staring at her. She stated she did not notice and name badges on them and assumed they were there visiting someone else and went on with her call. She stated she returned and the two people entered Resident #2's room and stared at her. She asked them who they were, and they identified themselves as the Administrator and the DON. She stated when she asked them about the injuries on Resident #2's head, the man began aggressively poking on him, so she told him to stop and leave. She stated when she asked them if they were going to call and report the matter, the man laughed, shook his head and guided the Administrator away from the room. The Family Member cried and stated, had she known sooner that Resident #2 was nearing the end, she could have called other family to be there with them, but they lived several hours away. She stated she sat with him alone the rest of the night until he passed away. The Family Member stated the nurses who cared for him that night were very kind and compassionate. She stated she was very upset that no one could account for his injuries, and no one had provided any further information since the incident. The Family Member stated she last saw Resident #2 a couple of weeks earlier, near the end of March and he was alert and doing very well. She stated she brought him his favorite snacks and he was happy watching his favorite western movies. She stated she had not received any prior calls from the facility and only occasional calls from the hospice company, nothing that would have indicated his deterioration or explain his injuries. The local police department was called on 7/24/24 at 11:27 AM and a message was left for the responding officer. A request for police report was submitted. In an interview on 7/24/24 at 2:04 PM, LVN Q stated she had previously received in-service training related to abuse, neglect, and injuries of unknown origin. She stated any concerns or complaints related to abuse or neglect should be reported to the Administrator immediately. LVN Q stated, if bruises or injuries were noted, she would check the notes to see if a previous nurse had documented anything. She stated, if not, she should have assessed the resident, contacted the resident's physician, and noted any new orders, notify the family and notify the Administrator and DON. LVN Q stated the risk of failing of notify the emergency contact was it could upset the family very much if they didn't know, they need to know. She stated the family needed to know even if the resident was their own responsible party. When asked about Resident #2 and the events on 4/11/24, LVN Q stated that day he started to decline, she had called hospice and they arrived later after her shift. She could not recall who she had spoken with. She stated she did not call his family because there was no emergency contact listed. When shown Resident #2's admission Record with the Family Member's phone number, she stated she thought hospice was going to call them. She stated, I accept I made mistakes; it was the first time I had anyone decline like that and I should have called [Family Member]. LVN Q stated Resident #2 had stopped eating and was only taking sips of water. She stated she cared for him the day before and he was fine. LVN Q stated she had assessed Resident #2 on 4/11/24 and did not recall any skin issues . She stated administration had called her later that evening and asked whether she had noticed any injuries and she told them no. She stated she never spoke with his family. During a telephone interview on 7/24/24 at 6:38 PM, the police officer who had responded to the call related to Resident #2, he stated he recalled speaking to Resident #2's Family Member. The police officer stated he recalled seeing a knot and some bruises on Resident #2's head. He stated he spoke with facility staff and he was unable to determine how the injuries were sustained. During an interview with ADON AA on 7/25/24 at 8:50 AM, she identified herself as the facility's wound treatment nurse and began working in the facility in February 2024. She stated the nursing staff reported any new skin findings to her. She stated her responsibilities included assessing all facility wounds, including bruises and skin tears. She stated, if the wound was new, she requested treatment orders and notified family members. ADON AA stated she had never been notified of any skin conditions for Resident #2 and he had never been on her service. In an interview on 7/25/24 at 9:04 AM, the DON stated the procedures for a change in condition for residents receiving hospice services were the charge nurse was to call the hospice providers because they handled the orders. He stated the hospice nurses would usually indicate if they were going to contact the resident's family members and, if not, the charge nurse was to contact them. He stated any changes in a resident's condition and calls made related to the residents were documented in the progress notes. The DON stated the hospice providers left binders at the nurses' stations with the residents' hospice documentation. The DON was asked to provide all hospice documentation related to Resident #2. In an interview on 7/25/24 at 10:50 AM, LVN BB stated she had been caring for two hospice residents. She stated the hospice companies kept binders at the nurses' stations that contained the resident's hospice documents. She stated any changes in the resident's condition were called to the hospice nurse and the resident's family. She stated it was important to call the family because she could not be certain if the hospice nurse contacted them, and it was important they were notified of any changes. She stated she had not cared for Resident #2 during his stay there. A contact number for the hospice company used by Resident #2 was provided by LVN BB as it was the same utilized by her residents. On 7/25/24 at 12:11 PM, attempts to call Resident #2's hospice company were unsuccessful, and no voice mailbox was available. During an interview on 7/25/24 at 12:20 PM, CNA U stated she had been working at the facility for two years and had begun working as a Restorative Aide about a month ago. She stated she had cared for Resident #2 during his stay. She stated she had noticed he was declining during the last week he was there. She stated, [Resident #2] used to feed himself, then I had to feed him, then he wouldn't take anything. He wouldn't open his mouth for food and would sleep more. She stated anything she found like that, she would report to the nurse. She stated she knew she had reported it to LVN Q and she would attempt to feed him. She stated the thought she recalled reporting it to LVN W as well. She stated, I'm a reporter, always go to the nurse first, anything I find out of the ordinary or I haven't seen before. She stated she documented the resident's meal intakes in the computer software. When asked about his skin care, CNA U stated the hospice aides typically performed bathing, but the facility aides did everything else. When asked about the week leading up to 4/11/24, CNA U stated she was pretty sure there was a wound on his head, and she was pretty sure he had hit his head. CNA U stated she had entered his room and found him leaning out of the bed. She stated the upper part of his body was leaning to the side out of the bed, his right hand was on the floor, and his left hand was holding onto his bedside table as if trying to keep himself from falling to the floor. She stated he had a dresser and an oxygen concentrator next to his bed. CNA U stated she asked him what he was trying to do, and he was confused. She stated she assisted him back onto the bed and noticed his head was bleeding. She stated she thought he had hit his head on his oxygen concentrator. She stated she went to get the nurse and was pretty sure it was LVN Q. CNA U was unable to recall on what day the incident occurred but thought it was one or two days before Resident #2 died. She stated the nurse came, checked his vital signs and cleaned his wound but did not state how or what items she used to cleanse Resident #2's wound. She stated the incident occurred near the end of her shift and she went home. When asked if she had cared for him in the days after the incident, she replied, I might have but I don't remember. She stated she could not recall any other incidents involving Resident #2, but she could tell he was declining before the incident. She stated he had previously been able to tell them what he needed. CNA U stated she had previously had training about abuse and neglect and knew any incidents were to be reported to the Administrator and DON. She stated she did not report that incident because the nurse was caring for him and she assumed the nurse would have reported it. CNA U stated she did recall the DON later asking about Resident #2's skin and stated, I think I told him no though, I think I forgot. During another interview with LVN Q on 7/25/24 at 12:53 PM, when she was asked again about any skin issues with Resident #2, she replied, I checked, no issues. When asked whether she had received any reports that he had stopped eating, she stated she had only heard about his refusing to eat on 4/11/24 and stated, that's why I called the hospice nurse, they said they would tell his nurse to come. I didn't see her before I left. LVN Q denied ever being told by CNA U that Resident #2 was found leaning out of bed with his head bleeding. She denied seeing any bruising or cuts on his head. LVN Q was shown the photos of Resident #2 obtained during the investigation. She stated, I did see the cut, I don't recall seeing the bruises. He was not hanging out of the bed, he was more to the side of the bed. We repositioned him. She pointed out the cut and stated, Yes, I saw that one, I cleaned it, it was a small cut. I told the hospice nurse that day, they came, and I reported the cut. She stated she did not report the injury to Resident #2's physician or his family member. She could not recall they day it occurred and stated, I called the hospice nurse and saw them the same day. She stated she thought it may have occurred the same day he had declined on 4/11/24. When reminded she had already stated she never saw the hospice nurse on 4/11/24, she replied, Right. LVN Q stated she did not document the incident or injury anywhere and could not say why she did not. She stated she had only reported it verbally to the hospice nurse. She stated she had received training on abuse and neglect and should have reported the incident and completed an incident report. She stated she did not tell the DON about it when he had contacted her on the evening of 4/11/24 and asked her specifically about any injuries. She stated she forgot to tell him. LVN Q stated the risk for failing to report incidents and injuries was great injury and harm and apologized for her mistakes. During an interview on 7/25/24 at 1:16 PM, the DON was asked about the incident related to Resident #2 on 4/11/24. He stated Resident #2 had been on hospice and had been in decline for 2 to 3 days before then, staying in bed and not eating. He stated he knew that because he would pass through and saw the nurses' notes. He stated he was unsure whether his meal percentages had been documented in the computer system. The DON stated, on 4/11/24, Resident #2's nurse had notified hospice that he needed increased care and was told they would send someone out. He stated they did not arrive until later that evening, and he was not there when they arrived. The DON stated he had only come in later that evening because Resident #2's Family Member had complained of bruises, so he and the Administrator came to the facility. The DON stated he checked Resident #2 and there was nothing there other than typical color changes seen when someone was dying. The DON stated Resident #2's Family Member had not seen Resident #2 in years. He said he knew this because he had not seen her in the facility and their Social Worker had said the same. He stated they had attempted to contact the Family Member when After Resident #2 had returned from his last hospital trip and had elected to go onto hospice services. He stated, at that time, the Family Member had instructed them to allow Resident #2 to make that decision. He stated Resident #2 had identified the Family Member as his emergency contact. He stated the nurses reported they had tried to reach the Family Member when Resident #2 had stopped eating but no one was picking up the phone. He stated he thought it was LVN Q or one of the other nurses who had given him [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the interdisciplinary team determined self-administration of medication was safe for 1(Resident # 43) of 1 resident reviewed for medication self-administration. The facility failed to prevent Resident #43 from possessing and administering four prescribed eye drops and an inhaler without an assessment to determine if he could safely self-administer the medication. This failure could place all residents who self-administered medications at risk of not receiving the therapeutic dose of their medication as ordered. Findings included: Record review of Resident #43's face sheet, dated 07/28/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (disorder of the central nervous system), acute kidney failure, asthma (narrow and inflamed airways), cataract disease (cloudiness in the lens of the eye), and glaucoma (disease of optic nerve). Review of Resident #43's care plan, revised 07/10/23, revealed the resident had an ADL self-care performance deficit related to blindness. Interventions included assistance and supervision by staff with ADLs. The care plan did not address self-administration of medications. Record review of Resident #43's admission MDS assessment, dated 06/20/23, revealed Resident #43 was cognitively intact with a BIMS score of 13 and required limited assistance of one-person with most ADLs. Record Review on 07/26/23 at 2:45 PM of Resident #43's assessments in his EHR revealed there was not an assessment for self-administration of medication. Observation and interview on 07/26/23 at 12:15 PM with Resident #43 revealed he was sitting on the side of his bed with personal items and four bottles of prescription eyedrops lying on the bed and not in a secure place. The eye drops observed on the bed included: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Resident #43 stated he was completely blind but was able to administer his own eye drops as he had done it for 28 years. He stated he did not trust the facility to administer them properly because he had a bad experience at a different facility in the past. Resident #43 stated he demanded that he keep his eye drops on the day he was admitted to the facility, which they allowed him to do. Resident #43 denied being assessed to see if he could safely administer the eye drops and insisted that he did not need to be assessed as he was smart and more capable than the staff. Resident #43 stated he was able to distinguish the difference in the eye drops and identified each one by the size of the bottles, design of the caps, and the position of labels. Resident #43 stated he did not need the eye drops spread on his bed to identify them; he was just never told to put them in a secure place. Resident #43 stated he knew the eye drops could be toxic to others, but he had a keen sense of his environment. He stated he could tell if someone was coming near his bed if he was there in the room; however, he sometimes left the room and did not put the eye drops in a secure place. Observation on 07/27/23 at 9:30 AM revealed the following eye drops were still not secured and on Resident #43's bed: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Interview on 07/28/23 at 11:15 AM with LVN D revealed she had worked at the facility for two weeks. She stated she worked with Resident #43. LVN D stated she was aware the resident had prescribed eye drops in his possession and that he refused to let the nurses keep them. LVN D stated Resident #43 was able to administer the eye drops himself, but she would stand and watch him administer them. Interview on 07/28/23 at 11:20 AM with ADON B revealed she had worked at the facility since September 2022. She stated she was familiar with Resident #43 and was not aware that he had possession of his prescribed eye drops. ADON B stated the eye drops should have been in the medication cart. ADON B stated she did not know if Resident #43 had an assessment for self-administration of medication but agreed to check. She stated Resident #43 should have been assessed if he was administering his own eye drops. Interview on 07/28/23 at 11:30 AM with the Administrator revealed it was her expectation for residents to be assessed by the clinical team before self-administering medication. She stated she was unaware that Resident #43 had possession of his medications and was self-administering without an assessment. When asked if the medications that were self-administered needed to be in a secured box or location, the Administrator stated they did not have to be if the resident was assessed determined safe to have the medication. When asked about other residents getting ahold of the medications, the Administrator stated there were no residents on the hall who exhibited behaviors of wandering and going into other rooms, since those residents would be in the facility's secured unit. Interview on 07/28/23 at 12:24 PM with the DON revealed he was unaware that Resident #43 had possession of his eye drops or that he was self-administering them. The DON stated Resident #43 had only requested to self-administer his eye drops on 07/26/23 and the physician was notified then for an order. The DON stated an assessment was given to Resident #43 on 07/26/23 as well. The DON stated the risk of a resident having possession of medication and self-administering without being assessed could be inappropriate consumption and the wrong resident getting ahold of the medication. Interview and observation on 07/28/23 at 1:45 PM with Resident #43 revealed there were no eye drops on the resident's bed. When asked where the eye drops were, Resident #43 opened his drawer and stated he was asked by staff to store them there. Resident #43 stated, Can you believe that after 40 days of being here someone came in my room this morning to assess me and see if I could safely give myself these eye drops. When asked if the nurses watched him before when he administered his eye drops, he stated No. Resident #43 proceeded to pull an albuterol inhaler out of the drawer and stated, They didn't say anything about this. Resident #43 stated he was able to administer his own inhaler but did not use it often. He stated he had to keep it on him because it would be hard to ask for it while unable to breathe. Interview on 07/28/23 at 1:15 PM with LVN D revealed she was not aware that Resident #43 had possession of his albuterol inhaler. She stated it was PRN and she did not have to sign off for it on a regular which is how it likely got overlooked. Interview on 07/28/23 at 3:00 PM with ADON B revealed she recalled Resident #43 telling her on 07/26/23 during a smoke break that he had his eye drops in his room. ADON B stated she immediately completed a self-administration of medication assessment on the resident. ADON B provided the surveyor with an assessment. Record review of Resident #43's self-administration of medication assessment revealed it had an effective date and time of 07/26/23 at 9:04 AM. The assessment revealed Resident #43 was fully capable of administering eye drops and needed assistance with administering inhalants. Interview on 07/28/23 at 4:24 PM with the DON revealed he was also unaware that Resident #43 had possession of his albuterol inhaler. Review of the facility's policy titled Self-Administration of Medication, revised February 2021, revealed in part the following: Policy Heading-Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administration of medications is safe and clinically appropriate for the resident .8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 1 resident (Resident #43) of 8 residents reviewed for pharmacy services, in that: The facility failed to ensure that Resident #43's prescribed eye drops and albuterol inhaler was stored in a secured place. This failure could place all residents on the 200 Hall North at risk of drug diversion or misuse of medications. Findings included: Record review of Resident #43's face sheet, dated 07/28/23, revealed the resident was admitted to the facility on [DATE] with diagnoses that included: Parkinson's disease (disorder of the central nervous system), acute kidney failure, asthma (narrow and inflamed airways), cataract disease (cloudiness in the lens of the eye), and glaucoma (disease of optic nerve). Review of Resident #43's care plan, revised 07/10/23, revealed the resident had an ADL self-care performance deficit related to blindness. Interventions included assistance and supervision by staff with ADLs. The care plan did not address self-administration of medications. Record review of Resident #43's admission MDS assessment, dated 06/20/23, revealed Resident #43 was cognitively intact with a BIMS score of 13 and required limited assistance by one person with most ADLs. Observation and interview on 07/26/23 at 12:15 PM with Resident #43 revealed he was sitting on the side of his bed with personal items and 4 bottles of prescription eyedrops lying on the bed, and not in a secure place. The eye drops observed on the bed included: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Resident #43 stated he had never been told by staff that his medication had to be locked or put in a secure place. Resident #43 stated he was completely blind did not need the eye drops spread on his bed to identify them because he was able to identify his medications by size, design of the caps, and the position of labels. Resident #43 stated he knew the eye drops could be toxic to others, but he had a keen sense of his environment and could tell if someone was coming near his bed if he was there in the room. However, he stated that he sometimes left the room and did not put the eye drops in a secure place. Observation on 07/27/23 at 9:30 AM revealed the following eye drops were still not secured and on Resident #43's bed: Simbrinza Ophthalmic Suspension 1-0.2 % (Brinzolamide-Brimonidine Tartrate), Rhopressa Ophthalmic Solution 0.02 % (Netarsudil Dimesylate), Pilocarpine HCl Ophthalmic Solution 1 % (Pilocarpine HCl), and Dorzolamide HCl-Timolol Mal Ophthalmic Solution 22.3-6.8 MG/ML (Dorzolamide HCl-Timolol Maleate). Interview on 07/28/23 at 11:30 AM with the Administrator revealed medications that were self-administered did not need to be in a secured box or location if the resident was assessed and determined safe to have the medications. When asked about other residents getting ahold of the medications, the Administrator stated there were no residents on the hall who exhibited behaviors of wandering and going into other rooms, and that those residents would be in the facility's secured unit. Interview on 07/28/23 at 12:24 PM with the DON revealed he was unaware that Resident #43 had possession of his eye drops. The DON stated Resident #43 had only requested to self-administer his eye drops on 07/26/23 and the physician was notified then for an order. The DON stated an assessment was given to Resident #43 on 07/26/23 as well. The DON stated the risk of a resident having possession of medication and self-administering without being assessed could be inappropriate consumption and the wrong resident getting ahold of the medication. Interview and observation on 07/28/23 at 1:45 PM with Resident #43 revealed there were no eye drops on the resident's bed. When asked where the eye drops were, Resident #43 opened his drawer and stated he was asked by staff to store them there. Resident #43 proceeded to pull an albuterol inhaler out of the drawer and stated, They didn't say anything about this. He stated he had to keep it on him because it would be hard to ask for it while unable to breathe. Interview on 07/28/23 at 1:15 PM with LVN D revealed she was not aware that Resident #43 had possession of his albuterol inhaler. She stated it was PRN and she did not have to sign off for it on a regular which is how it likely got overlooked. Interview on 07/28/23 at 4:24 PM with the DON revealed that he was also unaware that Resident #43 had possession of his albuterol inhaler. Review of the facility's Self-Administration of Medication policy, revised February 2021, revealed in part the following: Policy Heading-Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: .8. Self-administered medications are stored in a safe and secure place, which is not accessible by other residents. The facility census dated 07/26/23 revealed 19 residents resided on the 200 Hall North.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 3 residents (Residents #19, #24, and #47) of 3 residents reviewed for oxygen. The facility failed to ensure Residents #19, #24 and #47 had orders for oxygen administration. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment. Findings included: Record review of Resident #19's face sheet, dated 07/28/23, revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: dementia without behavioral disturbance (decrease in memory and thinking abilities), chronic obstructive pulmonary disease (inflammatory lung disease), schizoaffective disorder (mood disorder), congestive heart failure, and type II diabetes. Review of Resident #19's care plan, revised 07/27/23, revealed the resident received oxygen therapy as needed. Interventions included Change oxygen tubing and clean concentrator filter weekly, provide extension tubing or portable oxygen apparatus, monitor for s/sx of respiratory distress and report to MD PRN, notify charge nurse if oxygen tubing needs to be removed/replaced, oxygen via nasal prongs set at (2)L, and promote lung expansion and improve air exchange by positioning with proper body alignment. Record review of Resident #19's quarterly MDS assessment, dated 06/07/23, revealed Resident #19 was cognitively intact with a BIMS score of 13 and required limited assistance by one person with most ADLs. Record review on 07/26/23 at 2:25 PM of Resident #19's physician orders revealed no current orders for oxygen use. Review of discontinued orders revealed the last order for oxygen use was for oxygen at 2-3 liters per minute via nasal cannula continuous per concentrator with a start date of 07/14/20 and a discontinued date of 04/02/21. Record review on 07/27/23 at 9:00 AM of Resident #19's current physician orders revealed an order for oxygen as needed at 2 liters per minute per nasal cannula with a start date of 06/28/23 and a created date of 07/26/23. Record review of Resident #24's face sheet, dated 07/28/23, revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: chronic obstructive pulmonary disease (inflammatory lung disease), acute and chronic respiratory failure, type II diabetes, generalized epilepsy (seizure disorder), and hypoxic ischemic encephalopathy (brain injury). Review of Resident #24's care plan, revised 07/12/23, revealed the resident received oxygen therapy related to chronic obstructive pulmonary disease, respiratory failure, and shortness of breath. Interventions included Give medications as ordered by physician monitor for s/sx of respiratory distress and report to MD PRN, oxygen at 2-4 liters per minute per nasal cannula, and position resident to facilitate ventilation/perfusion matching. Record review of Resident #24's quarterly MDS assessment, dated 05/17/23, revealed Resident #24: - cognition moderately impaired (BIMS 11). -required extensive assistance and one-person assist with most ADLs. Record review on 07/26/23 at 2:27 PM of Resident #24's physician orders revealed no current orders for oxygen use. Review of discontinued orders revealed the last order for oxygen use was for oxygen at 2-4 liters per minute via nasal cannula per every shift with a start date of 07/01/22 and a discontinued date of 11/20/22. Record review on 07/27/23 at 9:05 AM of Resident #24's current physician orders revealed an order for oxygen at 2 liters per minute via nasal cannula with a start date of 06/27/23 and a created date of 07/26/23. Record review of Resident #47's face sheet, dated 07/27/23, revealed the resident was a [AGE] year-old female with an initial admission date of 02/11/22 and re-admission date of 05/18/23. The resident's diagnoses included: Malignant neoplasm of the mouth (is where a tumor develops on the surface of the tongue, mouth, lips, or gums) and carcinoma in situ of buccal mucosa (cancer that affects flat cells that make up the top layer of the buccal mucosa). Record review of Resident #47's MDS assessment, dated 06/01/23, revealed she had a BIMS score of 7, which indicated the resident's cognition was severely impairment. The MDS reflected the resident was on oxygen. Record review of Resident #47's care plans, on 07/27/23 at 2:54 PM oxygen use was not addressed. Record review of Resident #47's July 2023 physician orders revealed there were no orders for oxygen. Interview and observation on 07/26/23 at 11:16 AM with Resident #19 revealed he was sitting in his wheelchair with a portable oxygen tank on the back, but the resident was not wearing the nasal cannula tubing. Resident #19 stated he only used the oxygen when he felt short of breath. Resident #19 stated he did not always need the oxygen. Observation revealed there was an oxygen concentrator in the resident's room that was not plugged in. Resident #19 stated there were not enough outlets to keep the oxygen concentrator plugged in and besides he did not use it often. Observation on 07/26/23 at 11:31 PM revealed Resident #47 was receiving 2 liters of oxygen via nasal cannula. The tubing was dated 07/26/23 Interview and observation on 07/26/23 at 11:25 AM with Resident #24 revealed he was lying in bed and was wearing his nasal cannula with the oxygen concentrator on and set at 2 liters per minute. Resident #24 stated he used the oxygen continuously. He stated the nurses always checked his oxygen concentrator and made sure that he was wearing the nasal cannula. Observation on 07/27/23 at 10:45 AM with Resident #24 revealed he was lying in bed and was wearing his nasal cannula with the oxygen concentrator on and set at 2 liters per minute. Resident #24 was asleep and did not show any signs of distress. Observation on 07/27/23 at 11:10 AM with Resident #19 revealed he was going down the hallway in his wheelchair with his portable oxygen tank and was wearing the nasal cannula. The oxygen setting was at 2 liters per minute. Resident #19 stated he felt like he needed to use the oxygen. The resident stated he was fine and did not show any signs of distress. Interview on 07/27/23 at 1:30 PM with LVN C revealed she had worked at the facility for about one year. She stated she worked with Resident #19 and Resident #24. LVN C stated both residents used oxygen and she saw them both with the oxygen on continuously. When asked what the physician orders stated regarding oxygen use for Resident #19 and Resident #24. LVN C stated she had to check the orders in the system because she did not know by memory. After checking the orders, LVN C stated Resident #19 had an order for oxygen at 2 LPM as needed, and Resident #24 had an order for oxygen at 2 LPM continuously. LVN C stated she relied on the orders and MAR to administer the right medication and treatments to the residents. LVN C stated she could not recall if the physician orders for oxygen use was in the system prior to 6:00 PM on 07/26/23 for Resident #19 and Resident #24. She stated the orders should have been there. Interview on 07/27/23 at 1:45 PM with CNA E revealed she had worked at the facility for 2 years. CNA E stated she worked with Resident #19 and Resident #24. She stated she only saw Resident #19 use his oxygen sometimes. CNA E denied knowing the physician's order for Resident #19's oxygen use and stated that was beyond her scope of work. CNA E stated the nurses assisted residents with their oxygen and would only let the aides know if there was a change in how often the residents should be seen with the oxygen on. CNA E stated Resident #24 always had his oxygen on and denied knowing the physician's order for his oxygen use as well. CNA E stated the aides had access to the care plans, which would tell them if a resident required oxygen. Observation and interview on 07/27/23 at 2:54 PM with Resident #47 revealed she was on the hallway without oxygen. She stated she uses oxygen while in her room and she did not know how many liters she was supposed to be on. Resident #47 stated she did not have shortness of breath, and she did not know whether she needed to be on oxygen. Interview with the DON on 07/27/23 at 4:20 PM revealed resident #47 was on oxygen. DON stated Resident #47 had been in and out of hospital and he thought the system dropped the orders and staffs did not notice. DON stated the re-admitting nurses were supposed to re-enter the orders with each readmission. DON stated the failure was nurses knew their residents on oxygen and every time they go to hospital and back, they administer oxygen and they had not been verifying whether the orders are in the system. Interview on 07/28/23 at 11:20 PM with the Administrator revealed it was her expectation for the clinical team to ensure that all active physician orders were entered in the system. She stated the facility recently went through a change of ownership and switched their electronic health record system around 07/06/23. She stated the switch caused issues with data, including the orders, being carried over which could have been why there was a delay in some of the orders being entered into the system. The Administrator stated not having active physician orders in the system could place the residents at risk of not receiving the appropriate treatment. Interview on 07/28/23 at 11:54 AM with the DON revealed he had been employed at the facility since 10/2022. He stated Resident #19 and Resident #24 had received oxygen therapy from the time he started as DON and before then according to the notes. The DON looked at the discontinued and active physician orders for Resident #19 and stated the resident had an order for oxygen as needed with a start date of 06/28/23 and he acknowledged that the order was created on at 6:50 PM on 07/26/23. The DON stated Resident #19 had multiple orders for oxygen use starting in the year of 2020 that went from continuous use to PRN. The DON stated Resident #19 had an order for continuous oxygen use at 2-3 LPM with a start date of 07/14/2020 and a discontinued date of 04/02/2021. The DON stated he could not find another order for oxygen use until the order that was started on 06/28/23 and created in the system at 6:50 PM on 07/26/23. The DON could not state why there was no order in place for oxygen use for Resident #19 prior to him working at the facility; however, he stated the resident may not have needed oxygen during those times. The DON also could not state why Resident #19 did not have an order for oxygen use in place after he started as DON until 06/28/23. He stated there should have been an as needed order for oxygen in place for Resident #19 at that time. The DON looked at the discontinued and active physician orders for Resident #24 and stated the resident had an order for continuous oxygen with a start date of 06/27/23 and he acknowledged that the order was created on at 6:45 PM on 07/26/23. The DON stated Resident #24 had an order for oxygen use that was discontinued on 11/22/22 and he could not find another order for oxygen use until the order that started on 06/27/23. The DON stated there should have been an ongoing order for oxygen use in place for Resident #24. The DON stated it was the responsibility of the clinical management team and nurses to ensure that all active orders were in the system. He stated the facility had been experiencing issues with their new system and the orders not carrying over, and they were working on getting everything updated. The DON stated with Resident #19 and Resident #24 both being diagnosed with chronic obstructive pulmonary disease, the risk of not having orders for oxygen use in the system could be not being treated appropriately and respiratory failure. Interview with the DON on 07/28/23 at 11:58 AM revealed resident #47 did not have orders for oxygen. DON stated they failed to put oxygen orders on re-admission on [DATE] and it was his responsibility to monitor and audit all orders are in medication administration record. DON stated he has no excuse of not having orders for Resident #47. DON stated Resident #47 had been in and out of hospital and he thought the system dropped the orders and staffs did not notice since Resident #47 was put on oxygen as a needed when she had COVID on 2/11/22. DON stated the re-admitting nurses were supposed to re-enter the orders with each re-admission. DON stated the failure was nurses knew Resident #47 was on oxygen and every time she went hospital and back, they administer oxygen and they have not been verifying whether the orders are in the system. He stated the risk of administering oxygen with no orders can interfere with her health since she has a lot of comorbidities (presence of two or more diseases or medical conditions in a patient). DON stated he has done competency training yearly and randomly on staffs. Interview on 07/28/23 at 2:20 PM with ADON A revealed she had worked at the facility since 10/2022. She stated she was helping on the floor and was working with Resident #19 and Resident #24. ADON A could not state if the residents had physician orders for oxygen use in the system prior to 6:00 PM on 07/26/23 as she did not routinely work with the residents. ADON A stated she had to check for the current physician orders to know how the residents' oxygen needed to be administered since she did not normally work with them. ADON A stated if she ever saw where physician orders were not entered in the system and she knew a resident typically received a certain treatment, she would use her nursing judgement and notify the physician. Interview with LVN H on 07/28/23 at 04:28 PM revealed Resident #47 was supposed to be on oxygen as needed but she was not sure of the orders and how many liters she was supposed to be on. LVN H stated Resident#47 had been in and out of hospital and she does not remember the last time she checked on her tank to see how many liters she was on. LVN H stated she knew she was supposed to check on the resident's oxygen flow rate and physician orders every shift. She stated the resident was supposed to have orders to be on oxygen. LVN H stated the risk of administering oxygen with no orders might cause oxygen poisoning. Record review of the facility's undated policy titled, Medication Administration, revealed in part the following: Policy heading-medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation: .4. Medications are administered in accordance with prescriber orders, including any required time frame On 07/28/23 at 2:30 PM a policy on oxygen/respiratory treatment was requested from the DON and he stated the facility did not have one. Record review of the Resident Census and Conditions of Residents Form CMS-672, provided by the Administrator, reflected there were five residents who had received respiratory treatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of two staff (LVN F and LVN G) which resulted in a 45.16% medication error rate after 31 opportunities with 14 errors for three of six residents (Residents #32, Resident #42, and Resident #8) reviewed for medications. 1. LVN F crushed all medications together and mixed them on one cup of pudding without an order to mix the medications together for Resident #32. 2. LVN G failed to follow the physician orders for flushing Resident #42's gastrostomy tube with 5-10 mL (or prescribed amount) of water before, between, and after medications, when she administered medication. 3. LVN G removed Resident #8's patch and immediately placed another one on without allowing 12 hours for rest after removal. These failures could place residents at risk of physical and chemical incompatibilities leading to an altered therapeutic response and put residents who received medications via gastrostomy tube at risk for gastronomy tube blokage and medication interaction. Findings included: 1. Record review of Resident #32's quarterly MDS assessment, dated 06/04/23, revealed a [AGE] year-old male who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was severely impaired with a BIMS score of 5. The resident had diagnoses which included epilepsy (disorder of the brain characterized by repeated seizures), hepatic failure (acute liver failure) and anxiety (feeling of fear, dread, and uneasiness). Record review of Resident #32's, March 2023, Physician Orders revealed the following order: Please crush medication and add to pudding or yogurt. 2. Review of Resident #42's MDS dated [DATE], revealed the resident was a [AGE] year-old female admitted to the facility on [DATE] and re-admission on [DATE]. The assessment reflected Resident #42 had severely impaired cognition and had diagnoses which included gastrostomy status and dysphagia, oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Review of Resident #42's July 2023 Physician Orders reflected there was orders for flushing gastrostomy tube with 5-10 ml of free water between each medication administration. 3. Record review of Resident #8's quarterly MDS assessment, dated 06/28/23, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. The assessment reflected the resident cognition was moderately impaired, with a BIMS score of 11. The resident had diagnoses which included low back pain. Record review of Resident #8's July 2023 Physician Orders revealed the following order: Lidocaine Pain Relief 4 % Patch; Apply to Lower back topically one time a day for pain. Observation on 07/27/23 at 7:25 AM, revealed LVN F crushed the following five medications for Resident #32 and opened one capsule put them together in one medication cup and mixed with pudding: - Aptiom 800 mg 1 tablet for seizure, - Keppra 1000 mg 1 tablet for seizure, - Carbamazepine 200 mg 1 tablet for seizure, - Topiramate 100 mg 1 tablet for seizures , - Vitamin B 25 mcg 5 tablets (5000 i u) dietary supplement, - Loratadine 10 mg 1 tablet for allergies, and - Gabapentin 300 mg 1 capsule for seizures. She then administered all eleven medications embedded in pudding in one cup by mouth to Resident #32. Observation on 07/27/23 at 8:24 AM revealed LVN G washed hands donned gloves and she was to apply a lidocaine patch on Resident #8's lower back. She was observed removing an old patch dated 07/26/23 and she applied a new patch dated 07/27/23 revealing the old patch was not removed after 12 hours of application. Interview with LVN G on 07/27/23 at 8:34 AM revealed she was aware the evening shift were the ones supposed to remove the patch on Resident #8. LVN G revealed she works with Resident #8 five days in a week and every morning she was the one that removed the patch the evening shift do not remove. LVN G stated she had informed the DON and she could not remember when. She stated she was aware Resident #8 was supposed to have the patch for 12 hours and rest for 12 hours. LVN G stated failure to remove the patch after 12 hours could cause overdose and skin problems. Observation on 07/27/23 at 8:44 AM revealed LVN G prepared Bupropion (depression) 100 mg and Memantine 10 mg for (dementia), put the medication in different cups. LVN G crushed the medication and put in separate cups and went to Resident #42's room. LVN G positioned Resident #42 in an upright position. LVN G checked for the gastrostomy tube placement and checked for residual. She flushed the gastrostomy tube with 10 ml of water administered medication one at a time, she did not flush the gastrostomy tube with water between medications. LVN G flushed the gastrostomy tube with 10 ml of water after medications. Interview with LVN G on 07/27/23 at 9:04 AM revealed she was aware of the order to flush gastrostomy tube with 5-10 ml of water before, between, and after medication administration through gastrostomy tube for Resident #42. She said she forgot to flush the gastrostomy tube between medication administration. She stated it was her responsibility and best nursing standard of practice to check the orders before administration of any medication. LVN G stated failure to check orders could lead to gastrostomy tube blockage and medication interactions. She stated she had received training on medication administration via gastrostomy tube. Interview with LVN F on 07/27/23 at 1:06 PM revealed she had a physician's order to crush medications for Resident #32, but she did not have an order for mixing all the medications together. She stated she was not sure of the effects medications would have on Resident #32 if crushed and administered while mixed with other medications, but she thought there would be some effects due to interactions. She stated she had completed training on medication administration. Interview with DON on 07/27/23 at 2:44 PM revealed the facility policy did not classify whether to crush each medication separately. The DON stated they had orders to crush unless contraindicated. The DON stated he is not sure whether they should have orders to mix after crushing all the medications together. The DON stated the best standard of practice was to put each medication in each cup after crushing. He stated his expectation was nurses should put all medications in different cups because of contraindications and interactions. The DON stated he had completed training on medication administration with staff but not on mixing oral medications. Interview with the DON on 07/27/23 at 2:51 PM revealed his expectation was for the nurses to flush the gastrostomy tube before, between, and after each medication administration as per the doctor's orders and follow the facility policy. He stated failure to check orders to flush the gastrostomy tube may lead to gastrostomy tube being clogged and medication interaction. The DON stated he had trained the nurses on medication administration via gastrostomy tubes. Interview with DON on 07/27/23 at 3:30 PM revealed his expectation was the staff would follow the physician orders. He stated the patch should be off after 12 hours. He stated failure for staff having the patch removed it could contribute to skin issues and Resident #8 could get double dose. He stated he noticed there was no order for removal of the patch after 12 hours. He stated he noticed there was a problem with the way the order was entered to the computer system, it was not completed. Interview with LVN J on 07/27/23 at 3:47 PM revealed she was aware the evening shift were the ones supposed to remove the patch on residents with patches, but she was not aware Resident # 8 had a patch. LVN J stated Resident #8 had no orders for removal. She stated she was aware Resident #8 was supposed to have the patch for 12 hours and rest for 12 hours. LVN J stated failure to have orders to remove the patch after 12 hours could cause Resident #8 to have skin irritation and she should not be getting the recommended therapy. Record review of the facility's current Administering Medication policy revised April 2019, reflected the following: .medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include a) enhancing optimal therapeutic effect of the medication; b) preventing potential medications or food interactions. .24. Topical medications used in treatment's are recorded on the resident's treatment record (TAR) Review of the facility's current Administering Medication Through Enteral Tube policy, dated November 2018, reflected the following: .1. Verify that there is physician's medication order for this procedure. 3. Administer each medication separately and flush between medications. .6. Verify placement of feeding tube. 10. Administer each medication separately .13. If administering more than one medication, flush with 15mls (or prescribed amount) warm sterile water or between medications

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately consult with the physician and notify resident's responsible party when there was a change in the resident's physical, mental or psychosocial status for 1 (Resident #1) of 6 residents reviewed for resident rights in that: 1. The facility failed to notify Resident #1's physician of significant bruising to the right side of her face until 12/19/2022, two days after it was observed. 2. The facility failed to notify Resident #1's responsible party of significant bruising to the right side of her face until 12/19/2022, two days after it was observed. This failure placed residents at risk for neglect and/or a decline in health status. Findings included: Record review of Resident #1's face sheet, dated 12/20/2022, revealed Resident #1 was a [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted on [DATE]. She was diagnosed with Alzheimer's disease (progressive brain disorder that causes memory loss), muscle atrophy (wasting of muscle mass), osteoarthritis (degenerative joint disease), and a history of falling. Record review of Resident #1's Quarterly Minimum Data Set Assessment, dated 10/25/2022, revealed her Brief Interview for Mental Status score was unscored due to resident being unable to complete the interview, indicating a severe cognitive impairment. The MDS revealed that Resident #1 required extensive assistance with bed mobility and transferring and limited assistance with locomotion on the unit. Resident #1 used a wheelchair as a mobility device. The MDS also revealed that Resident #1 had a history of falling. Record review of Resident #1's care plan, last updated on 10/07/2022, revealed she was a high fall risk related to occasional incontinence, unsteady gait, and potential side effects of Anxiolytic medications (anti-anxiety medications). Interventions included anticipating and meeting resident's needs, keeping call light within reach, ensuring that resident wore appropriate footwear when ambulating, keeping furniture locked in position and keeping needed items within reach. The care plan also revealed that Resident #1 had multiple witnessed and unwitnessed falls from 09/20/2020-12/10/2022. Record review of Progress Notes, dated 12/10/2022, revealed LVN C documented at 1:23 PM the following: Resident was found on the floor face down. Noticed a laceration to left side of forehead. No other injuries noted. Wheelchair was behind her and locked. CNA was sitting in dining room with residents and heard a loud noise. She found resident laying on the floor in dining room. I was notified to come to the dining room ASAP. I came to the dining room and found resident laying on the floor with laceration to forehead and bleeding. She was able to move her upper and lower extremities well. Applied pressure to forehead with gauze and applied ice to stop bleeding. I was able to stop bleeding and applies steri-strips. Notified Doctor and got orders for STAT (with no delay) x-ray skull series and start neuro checks. Notified DON, administrator and family. No signs of pain or discomfort. Will continue to monitor resident. Record review of Progress Notes, dated 12/11/2022, revealed LVN C documented at 10:19 AM the following: Resident continues on f/u for fall day 2/3. Neuro checks in place. No delayed injuries and no signs of pain. Resident sitting in dining room reading a magazine. Steri-strips intact . Record review of Progress Notes, dated 12/13/2022, revealed the ADON documented at 12:45 AM the following: Resident laying in bed. Left forehead has minimal swelling at this time. No s/s of pain or distress verbally or physically. No delayed injuries noted. Neuros continued . Record review of Progress Notes, dated 12/17/2022, revealed LVN D documented at 5:29 AM the following: .delayed injury to right forehead related to previous fall. Record review of Progress Notes, dated 12/20/2022, revealed LVN B documented at 3:48 PM the following: New orders noted for STAT Xray skull series 2 view BIOSTAT notified. Record review Resident #1's radiology interpretation, dated 12/10/2022, revealed: No evidence of skull fracture present. Record review of Resident #1's orders revealed a STAT x-ray skull series 2 view was ordered by primary physician on 12/20/2022 at 3:43 PM. Record review Resident #1's radiology interpretation, dated 12/20/2022, revealed: No acute osseous abnormality of the skull; intracranial hemorrhage not excluded; for persistent or worsening symptoms, repeat examination with CT or MRI could prove beneficial. Similar to December 10, 2022. Observation on 12/21/2022 at 12:13 PM of Resident #1 revealed she had a scab on her left forehead from a healing laceration. Resident #1 also had a deep purple circular bruise on the right side of forehead with yellowing in the center. The bruise extended down, covering her right eye and right cheek. Resident #1 was unable to state how she sustained the injury due to cognitive deficit. An interview on 12/1/2022 at 11:12 AM with Resident #1's RP revealed the facility contacted him on 12/19/2022 to report that resident had an injury that likely came from an unwitnessed fall. However, they were not certain. The RP revealed the facility always called to notify him of any incidents, and he was aware of the fall Resident #1 had on 12/10/2022. RP denied having concerns for abuse or neglect of Resident #1. RP stated he had witnessed Resident #1 attempt to walk without assistance and fall without trying to brace herself so he was not surprised at the number of injuries she had sustained. An interview on 12/21/2022 at 12:40 PM with CNA A revealed she had worked at the facility for almost two years. She stated she worked on the facility's secure unit on the 6:00 AM-2:00 PM, Monday-Friday shift. CNA A stated she worked on 12/10/2022 when Resident #1 had a fall and sustained a laceration to her left forehead. CNA A stated she witnessed the fall and only observed the injury to the left side of resident's face. CNA A stated she worked with the resident throughout the week and denied seeing any injuries on the right side of Resident #1's face until she returned to work on Monday, 12/19/2022. CNA A stated there were no reports of Resident #1 having another fall. She stated she was unaware of how the injury to the right side of Resident #1's face occurred. An interview on 12/21/2022 at 1:12 PM with LVN E revealed she had worked at the facility for about three months. She denied working on 12/10/2022 when Resident #1 had a fall. However, it was reported to her when she worked on 12/12/2022. LVN E stated it was reported Resident #1 did not go to the hospital, but she received an in-house skull x-ray that was negative for fractures. LVN E stated she observed Resident #1 with a hematoma and scab on left side of forehead. LVN E denied seeing any bruising to the right side of Resident #1's face on that date. LVN E stated she worked with Resident #1 again on 12/15/2022 and denied seeing any bruising to the right side of Resident #1's face on that date. LVN E stated when she worked on 12/19/2022 was when she noticed bruising to the right side of Resident #1's face. LVN E denied receiving any reports of Resident #1 having any other falls since 12/10/2022. An interview on 12/21/2022 at 2:09 PM with LVN B, revealed she had worked at the facility for over two years. LVN B stated she worked on 12/10/2022 when Resident #1 had a fall. LVN B stated Resident #1 fell prior to her shift, but she received report about it. LVN B stated she observed a laceration to the left side of Resident #1's face. She denied seeing any injuries to the right side of Resident #1's face. LVN B stated when she worked on 12/19/2022, she observed bruising to the right side of Resident #1's face. LVN B stated there were no reports of a fall and no one could tell her how Resident #1 sustained the new injury. LVN B stated she immediately reported the injury to the Administrator as she had been trained to do. An interview on 12/21/2022 at 2:46 PM with LVN C revealed she worked 12-hour weekend shifts, Saturday and Sunday, at the facility. LVN C stated she worked on 12/10/2022 when Resident #1 had a fall and sustained a laceration to her left forehead. LVN C stated Resident #1 fell during her shift, and she was the nurse who assessed her. She stated she notified the resident's primary physician on that date. LVN C stated she noted the laceration to Resident #1's left forehead and there may have been bruising towards the right side, but she was not certain. LVN C stated Resident #1 was a high fall risk, and the resident had multiple falls resulting in bruising. LVN C stated when Resident #1 hit her head, she would normally get bruising across her entire face due to being on a blood thinner. LVN C stated it was not uncommon for bruises to appear on Resident #1 days after an incident. LVN C stated when she worked on 12/17/2022, she noticed Resident #1 had a circular bruise on the right side of her forehead and bruising near her eye. LVN C denied contacting the Primary Physician or Responsible Party because she assumed it was an injury from Resident #1's fall on 12/10/2022. LVN C could not state if it had ever taken as long as a week for injuries to appear on Resident #1 after an incident in the past. An interview on 12/21/2022 at 2:54 PM with LVN D, revealed he had worked at the facility for four years. He stated he currently worked overnight shifts on rotating days. LVN D stated he worked with Resident #1 on 12/17/2022. He stated Resident #1 was normally asleep when his shift started. However, on this date, she was awake and sitting up on the side of her bed. LVN D stated when he went in to check on her, he found a purplish bruise on the right side of Resident #1's face. LVN D stated the color indicated to him that it was an older bruise, so he assumed it was a delayed injury from her fall on 12/10/2022. LVN D denied seeing any injuries to the right side of Resident #1's face when he worked with her on 12/16/2022. However, she was not awake on that night. LVN D was unable to confirm that the coloring indicated the bruise was a week old and stated it was possible that another incident had occurred, although there were no reports or documentation of a new incident. LVN D stated he continued with his thought that the injury on the right side of Resident #1's face was a delayed injury due to the lack of documentation. An interview on 12/21/2022 at 3:00 PM with the ADON revealed she had worked at the facility for about three months. The ADON stated she sometimes worked on the secure unit, and she last worked with Resident #1 on 12/13/2022. The ADON stated she was aware that Resident #1 had fallen on 12/10/2022 and sustained a laceration and bruising to the left side of her face. The ADON stated she observed the laceration on the left side of Resident #1's face and denied seeing any bruising or injuries on the right side. The ADON stated it was reported on 12/19/2022 by LVN B that Resident #1 had an injury to the right side of her face. The ADON stated she observed that Resident #1 had a bruise to her right forehead that appeared to be a dark purple circle with yellowing in the center. The ADON stated the bruising was dissipating down the right side of Resident #1's face. The ADON stated the yellowing was an indication that the bruise was older and healing. The ADON stated she contacted the Physician on 12/19/2022 at 6:35 PM. However, there was no immediate response. The ADON stated she then contacted a corporate nurse due to the DON being on vacation and was advised to follow protocol and get a skull series x-ray. The ADON stated this decision was made after 10:00 PM due to waiting on a response from the Physician, so the x-ray was not completed until 12/20/2022. The ADON stated that Resident #1 was placed on neuro checks and remained alert with good vitals and no apparent adverse reactions. The ADON stated it was possible that the injury on the right side of Resident #1's face was from a new and separate incident from 12/10/2022. However, there were no new incidents reported. The ADON denied being aware that the bruising to the right side of resident's face was first discovered on 12/17/2022 as it was not reported to anyone until 12/19/2022. The ADON stated the delay in reporting the injury could have placed Resident #1 at risk of an undetected concussion or more serious head injury. However, the yellowing of the bruising and clear neuro checks indicated that Resident #1 was past the point of a concussion. An interview on 12/21/2022 at 4:15 PM with the DON revealed he had been on vacation for a week, and his first day back was on this date. The DON stated he had been briefly updated on all incidents that occurred while he was out of the facility, including Resident #1's fall on 12/10/2022 and her injury of unknown origin that was reported to the state on 12/19/2022 and being investigated on this date. The Administrator was at the facility on the day of the incidents; however, she was not available for an interview on this date. The DON stated Resident #1 was a high fall risk due to her unsteady gait and Alzheimer's disease. The DON stated the resident had had multiple witnessed and unwitnessed falls with and without injuries at the facility. He stated it was possible for Resident #1 to have delayed injuries, even though she bruised easily, due to being on a blood thinner. He stated based on the resident's history he understood how the nurses took it as a delayed injury. The DON stated it was still his expectation for the nurses to follow the change of condition protocol for any new injuries that appeared on residents if it had been several days since the last known incident. The DON stated the protocol would have been for the Physician, DON, Administrator and family to be notified. The DON stated the new injury should have been reported on 12/17/2022 when it was first observed. The DON stated the risk was that Resident #1 could have had a fracture, brain bleed or concussion. Record review of the facility's policy entitled Change of Condition Foundation of Care, dated 03/13/20, revealed in part: Change of condition in a resident should target many areas of interdisciplinary team function. Skill, assessment, and intervention to any change of condition will vary depending on that change and involvement of the interdisciplinary team when necessary. To ensure the optimal outcome for the resident, nursing process of assessment, plan, intervention, and evaluation will be used. Physician involvement is always required following the INTERACT process without exclusion of the Licensed Professional's judgement, as is follow-up assessment per Federal Regulatory Guidelines .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident medical, nursing, mental, and psychosocial needs for one (Resident #25) of eight residents reviewed for care plans. The facility failed to develop a care plan with measurable objectives and time frames to address Resident #25's communication impairment, resident only speaks Vietnamese. This failure could place residents at risk of receiving inadequate interventions and care not individualized to their care needs. Findings included: Review on 06/16/22 of Resident #25's EHR revealed she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including stroke, diabetes, Covid-19 exposure and dementia. Review of Resident #25's MDS, dated [DATE], indicated her BIMS score was not completed related to her dementia. Her mobility function indicated she required assistance with mobility and toileting, but was independent in her other ADLs. Her CAA indicated Resident has impaired ability to communicate due to language barrier. Family assists with communication. Review on 06/15/22 at 12:37 PM of Resident #25's EHR revealed the Nursing Progress note from admission stated: Resident admitted [DATE] from Legends Nursing and Rehabilitation. Resident has a son who is the responsible person of contact. Resident is [AGE] years old. Resident is Vietnamese and has four kids. Resident has a spouse who currently lives at home. Resident has plans to live in nursing home long term. Resident is unable to communicate in English. SS will get with activities to get a translation to be able to communicate with resident. Family had an initial care plan to discuss her concerns and wishes from the family. IDT team also discussed the type of meds Resident will have quarterly care plan from initial admission. Review on 06/16/22 of Resident #25's care plan, dated 10/20/21, revealed she was not care planned for communication impairment. Interview on 06/16/22 at 11:40 AM with CNA E, CNA F, and LVN B, they stated that the only non-English speaking resident in the memory care unit was Resident #25, she only spoke Vietnamese. LVN B stated they have communication boards in her room to aid with basic communication, and they have a language line available via phone to assist if needed, and they also call her son if necessary. They revealed the resident can say some basic words in English such as food, pain, and bathroom. Interview and observation on 06/16/22 at 11:48 AM with Resident #25 revealed resident smiling, bowing, and saying yes when asked questions. Interview on 06/14/22 at 12:42 PM with family member stated some family member visits the resident once or twice a week. He stated the facility will call him if there was something they can't communicate with the resident about or if there was an issue. Interview on 06/16/22 at 10:05 AM with the Administrator she stated that the MDS coordinator position was currently vacant, coordinator had resigned about 2 weeks ago. Regional Social Worker was filling in when needed. MDS coordinator was responsible for care plans. She stated that any resident with a communication barrier, such as speaking another language, should have that care planned for. As a default that information was also put on the resident's [NAME], by the MDS coordinator, so that staff have it readily available to them. Failling to alert staff to communication issues could result in lack of care for the resident. Review on 06/16/22 10:23 AM of Resident #25's [NAME] revealed no category or interventions in place related to language barriers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were stored securely for 1 of 24 residents (Resident #67) on one hall reviewed for storage of medications. Resident #67 had 1 Gabapentin tablet at his bed side unsupervised. This failure could place residents at risk of consuming unsafe medications. Findings included: 1. Review of Resident #67's Face sheet, dated 06/16/2022, revealed the resident was a [AGE] year-old male with an admission date of 05/13/22. Resident #67's diagnoses included cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery, Type 2 diabetes mellitus without complications, hyperlipidemia, and atrial fibrillation. Review of Resident #67's MDS Assessment, dated 05/17/2022, revealed the resident had moderate cognitive impairment with a BIMS score of 11. Record review of Resident #67's physician order dated 05/13/2022, revealed he had an order for Gabapentin Tablet 600 MG, give 1 tablet by mouth every 6 hours for Neuropathy. Observation and interview on 06/14/22 at 12:42 p.m. revealed Resident #67 in his room, on his bed watching TV. There was a clear cup on bedside table with 1 tablet in it. Resident #67 stated that his nurse brought it to him after for his noon medication. Resident #67 stated the nurse usually stays in the room with him however today she just dropped it off and left. Resident #67 stated the nurse dropped it off about 15-20 minutes ago. Observation and interview with LVN A on 06/14/22 at 12:50. p.m. revealed she observed the medication on Resident #67 bedside table. She stated it was his gabapentin medication and it was scheduled for noon. LVN A stated she provided the medication around 12 pm. LVN A stated she had to step out to assist another resident and she was supposed to come back to the room, but she forgot. She stated the risk of leaving medication unattended could cause another resident to take it. Interview with DON on 06/14/22 at 2:39 p.m., revealed when her nurses were providing residents with their medications her expectations were for the nurses to see the residents take their medications before they leave the room. She said she was informed Resident #67 had a pill on his bedside table. The DON stated that was not acceptable. She stated the risk of leaving medication in rooms could lead to another resident taking it and have an adverse effect on it or the resident not taking the medication. Record review of facility's Medication Storage policy, dated 10/2021, revealed the following, During a medication pass, medications must be under the direct observation of the person administering medications or licked in the medication storage area/cart.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for four (Residents #23, #59, #60, and #69) of eight residents reviewed for infection control. RN C and LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #23, #59, #60, and #69. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Review on 06/16/22 of Resident # 23 EHR revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including emphysema, schizoaffective disorder, diabetes, and cognitive communication deficit. Review of Resident #23's care plan, dated 03/31/22, had him care planned for impaired immunity related to recent hospitalization and subsequent exposure to Covid-19, and impaired cognitive function and impaired thought process, related to his comorbidities. Review of Resident #23's MDS, dated [DATE], revealed a BIMS score of 11, indicating moderately impaired, and his functional status indicated that he required assistance with his mobility and ADLs. Review on 06/16/22 of Resident #59's EHR revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including skin infection of right lower leg, chronic Hepatitis C, and dementia. Review of Resident #59's care plan, dated 05/17/22, had her care planned for mild self care deficit related to her dementia, and poor safety awareness and history of compulsive behaviors. Review of Resident #59's MDS, dated [DATE], revealed a BIMS score was not performed related to her dementia. Her functionality status indicated she required assistance with her ADLs and was only independent in her mobility. Review on 06/16/22 of Resident #60's EHR revealed she was a [AGE] year-old female admitted to the facility on [DATE], with diagnoses including Lupus, Covid-19, Major Depressive Disorder, and schizoaffective disorder. Review of Resident #60' care plan, dated 04/18/22, revealed she was care planned for poor safety awareness and compulsive behavior. She is also care planned for behavioral problems Review of Resident #60's MDS, dated [DATE], revealed a BIMS score of 3, indicating severe impairment, and her functionality status indicated she required assistance with all of her ADLs. Review on 06/16/22 of Resident #69's EHR revealed he was a [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included diabetes, paranoid schizophrenia, heart failure, and emphysema. Review of Resident #69's care plan, dated 06/16/22, revealed he was care planned for fall risk related to weakness, self care deficit, and behavioral problems, Review of Resident #69's MDS, dated [DATE] revealed a BIMS score was 11, indicating moderate impairment, and his functionality status indicated he required assistance with his ADLs. Observation on 06/15/22 at 8:00 AM of RN C, while administering morning medications on Hall 100, revealed that he did not sanitize the reusable blood pressure cuff between blood pressure checks on Resident #23 and #69. Observation on 06/15/22 at 9:34 AM of LVN B, while administering morning medications on Hall 100, revealed she did not sanitize the reusable blood pressure cuff between blood pressurechecks on Resident #59 and #60. Interview on 06/15/22 02:05 PM with RN C, he stated that reusable medical equipment should be disinfected between each resident use. He stated that he did not realize that he had not disinfected the cuff between the two residents because of all of the distractions and interruptions during medication pass. He stated there was a risk of transmitting an infection if the blood pressure cuff wasn't disinfected between resident usage. Interview on 06/15/22 02:19 PM with LVN B, she stated that reusable medical equipment should be disinfected between resident use. She stated that this morning's med pass was chaotic and she did not realize she had not disinfected the cuff. She state there was a risk of causing an infection or cross contamination if the blood pressure cuff isn't disinfected properly between residents. Interview on 06/15/22 04:02 PM with the DON she stated the expectation was that reusable medical equipment was to be disinfected between each resident use. They had a policy regarding that. She stated there was a risk of spreading an infection if the blood pressure cuff was not sanitized between uses. Review on 06/16/22 of facility's undated policy Cleaning and Disinfection of Resident-Care Equipment revealed 'Reusable multi-resident items included blood pressure cuffs. In Section 2 b it states each user is responsible for routine cleaning and disinfection of multi-resident items after each use, particularly before use for another resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure a beef roast maintained a temperature of below 41 degrees Fahrenheit while thawing in a sink of standing water. 2. The facility failed to ensure food items and clean dishes were kept away from airborne contaminants and chemicals. 3. The facility failed to ensure the bottom of both freezers were free of debris and sanitary. These failures could place 68 of 70 residents, who receive food from the kitchen, at risk for food contamination and food-borne illness. Findings included: An observation and interview on 06/14/2022 at 10:10 AM with [NAME] G revealed a large, completely thawed, roast in the sink at the back of the kitchen, covered in standing water. The dispensing hose for an Ecolab chemical dispenser containing Orange Force Multipurpose Degreaser drained into the sink. She said staff from the night before staff left the roast in the sink to thaw because it was there when she came to work at 5:30 AM on 06/14/2022. She said the roast should be thawed in the refrigerator or under cold running water. She put a thermometer into the center of the roast resulting in a 51-degree reading. A second temperature reading revealed 60 degrees. She said she needs to put the roast into the refrigerator because the roast should not be under 41 degrees at any time while thawing. Food particles and a frozen yellow substance was observed on the bottom of the inside of both freezers. [NAME] G said she did not know what the yellow substance was, but it should not be there. She said there is no cleaning schedule, but she just cleaned the freezers a few days ago. She said this issue place residents at risk of food-borne illness. An observation on 06/14/2022 at 10:00 AM revealed steam table inserts on the shelf under the stainless-steel prep table in the kitchen. The shelf was covered with food and dust food particles. The shelf under the steam table was also covered with dust and food particles. Fuzz and dust were stuck to the wall and vent behind the food prep area was fluttering from the air flow of the vent. A shelving unit on that wall contained clean dessert cups and plate covers. The plate covers were touching the fuzzy dust clumps on the wall. Two vents and the wall above the milk cooler were covered with dust and fuzz. An interview on 06/14/2022 at 10:25 AM with Dietary Aide H revealed the shelves under the prep area and steam table are cleaned weekly but did not know when they were last cleaned. He said there is not a cleaning schedule. He said meat should be defrosted under cold running water or in the fridge overnight. He said he came to work at 6am and the roast was thawing in the sink submerged in water. He stated any food under 41 degrees could pose a risk of food [NAME] illness to all residents that eat from the kitchen. He said any dust particles or fuzz on the walls and vents could get blown into the food or on the clean dishes used to serve food. He said this is an infection control concern and could cause food borne illness. He said this impacts all residents eating from the kitchen. An interview and observation on 06/14/2022 at 12:10 PM with the Kitchen Manager revealed he does not have a cleaning schedule in place, but the freezers are cleaned weekly. He could not say when they were cleaned last. He said the roast should not have been thawed in standing water in the sink. He said he did not know how long it was in the sink, but it was fully thawed with a temperature of 60 degrees sand needs to be thrown out because it poses a risk to residents of contracting a food-borne illness. He said all food should be thawed in the refrigerator or under cold running water to ensure it remains under 41 degrees. He said any fuzz or dust in the walls, vents, ceiling, or shelves could get into food cause contamination. The Kitchen Manager was observed taking the roast from the refrigerator and throwing it on the trash. He said he will have his staff clean the dust, fuzz and food particles from the walls, vent, shelves, and freezers by the end of the day. He said [NAME] G would be written up for placing the thawed roast into the refrigerator after discovering the 60-degree temperature. An interview on 06/15/2022 at 7:25 AM with the Administrator revealed the kitchen is contacted to a food service company. She said the contractor is responsible for all cleaning in the kitchen, but it is the facility's responsibility to ensure the kitchen maintained in a safe and sanitary condition. She stated the roast thawing in the sink with a temperature of 60 degrees should have been thrown out immediately. She said the temperature should be below 41 when thawing or it places residents at risk of contracting a food-borne illness. She said she had the Kitchen Manager in-service kitchen staff on proper thawing techniques. An interview on 06/15/2022 at 8:11 AM with the Director of Plant Operations revealed the kitchen contractor is responsible for all kitchen duties including cleaning the walls and vents. He said he is responsible for equipment repairs and vent hood maintenance. An interview and observation on 06/15/2022 10:06 AM with the District Manager of the contract food services company revealed they are responsible for all cleaning and daily activities in the kitchen. He said thawing meat is only to be done in the refrigerator to maintain a temperature of less than 41 degrees. He said the roast's temperature of 60 degrees for an unknown amount of time poses a risk of food-borne illness to any resident receiving food from the kitchen. He stated the Ecolab chemical dispenser containing Orange Force Multipurpose Degreaser would be removed to prevent any risk of contamination of food in or near the sink. Observation of the vents, walls, shelves, and freezers revealed they had been cleaned and free of dust and food particles. A record review on 06/15/2022 at 8:53 AM of in-services completed by the Kitchen Manager and dated 06/14/2022 revealed kitchen staff were trained on the following: Cleaning and sanitizing your section and following the cleaning chart in essential to having clean food. Clean surface with soap then sanitize and let air dry. Walls and ceilings are also very important as dust and particles can fall onto dishes or into food. Proper thawing procedure - the cook thaws frozen items requiring defrosting before preparation under refrigeration, in a microwave for immediate use, or in a sealed container immersed in cold running water. A record review on 06/15/2022 at 2:04 PM of the Food Preparation Policy dated 09/2017 revealed, All foods are prepared in accordance with the FDA Food Code.Dining service staff will be responsible for food preparation procedures that avoid contamination by potentially harmful physical, biological, and chemical contamination .the dining services director/cook(s) will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41 degrees and /or less than 135 degrees or per state regulation .the cook(s) thaw frozen items that requires defrosting prior to preparation using one of the following methods: thawing in the refrigerator, in a drip-proof container, and in a manner that prevents cross contamination; completely submerging the item in cold water (at least 70 degrees F or below) that is running fast enough to agitate and float off loose ice particles; cooking directly from the frozen state, when directed. A record review on 06/16/22 at 10:50 AM of the kitchen policy addressing Environment, no date revealed, .All food areas, food services areas, and dining areas will be maintained in a clean and sanitary condition .The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces . An observation on 06/16/2022 at 10:34 AM revealed the Ecolab chemical dispenser containing Orange Force Multipurpose Degreaser was removed. A record review on 06/29.2022 at 3:00 pm of FDA Food Code dated 2017 section 92 3-501.13 revealed Thawing: TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be thawed: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or (B) Completely submerged under running water: (1) At a water temperature of 21oC (70oF) or below, (2) With sufficient water velocity to agitate and float off loose particles in an overflow, and (3) For a period of time that does not allow thawed portions of READY-TO-EAT FOOD to rise above 5oC (41oF), or (4) For a period of time that does not allow thawed portions of a raw animal FOOD requiring cooking as specified under 3-401.11(A) or (B) to be above 5oC (41oF), for more than 4 hours including: (a) The time the FOOD is exposed to the running water and the time needed for preparation for cooking, or (b) The time it takes under refrigeration to lower the FOOD temperature to 5oC (41oF); and section 3-305.14 Food Preparation revealed: During preparation, unpackaged FOOD shall be protected from environmental sources of contamination.