Every finding on record at Aviata at Oldsmar

Based on observations, interviews, and record review, the facility failed to ensure residents were from significant medication errors for 14 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) of 32 residents who evacuated from Facility A to Facility B, for four of four days reviewed (10/18/24, 10/19/24, 10/20/24 and 10/21/24). Findings included: 1. During a post storm assessment tour conducted on 10/21/24 at 3:10 p.m., Resident #1 was heard from the hallway screaming and yelling. An observation revealed the resident lying on her bed making twisting and turning movements on the bed. The resident did not respond to the interview. An immediate interview was conducted with Staff A, Registered Nurse (RN) assigned to Resident #1 on 10/21/24 at 3:10 p.m. She stated she was not familiar with the resident because she was one of the evacuees from Facility A. Staff A stated the resident had been loud and agitated all day. Staff A said, The only problem I have is that she does not have her medications. She is supposed to receive Hydrocodone-Acetaminophen 10-325 mg for pain. Staff A confirmed this resident had not received her pain medication which was regularly scheduled. Review of the admission record for Resident #1 revealed an admitted [DATE] with diagnosis to include chronic pain syndrome. Review of October 2024 physician orders for Resident #1 showed the resident had orders for Hydrocodone-Acetaminophen oral tablet 5-325 MG (Milligram), Give 1 tablet by mouth every 12 hours for chronic pain. Review of October 2024 Medication Administration Record (MAR) showed the resident received Hydrocodone twice daily. The review showed the medication was not given from 10/17/24 to 10/21/24. Review of progress notes for Resident #1 dated 10/19/24 - 10/21/24 showed, medications were not administered, or awaiting medications to be delivered from another facility. A progress note dated 10/19/24 showed the Patient is unreliable historian. Nursing reports patient needs new prescription for her pain medication, which she takes regularly. 2. Resident #2 was admitted to Facility B on 09/19/24 with diagnoses to include Parkinson's disease, Type 2 diabetes, chronic pain and unspecified dementia. On 10/21/24 at 3:05 p.m., an interview was conducted with Staff A, RN. She stated Resident #2 did not have his medications. She said, He did not receive his Aspirin 81 MG for prophylaxis, and he did not get his pain patch. He does not have any narcotics available. He is supposed to receive Lorazepam for anxiety. He does not have any and I don't know where the medications are. Staff A stated this resident had displayed anxiety. She said, It could be storm related or just the whole move. Staff A stated she had not discussed the problem with the DON. She said, I was just about to. Review of October 2024 MAR and Physician orders showed the resident received Asperflex Pain Relieving Patch daily. The review showed the resident did not receive the pain patch. The review further showed the resident did not receive his Aspirin 81 MG. Review showed Lorazepam tablet 0.5 MG was ordered on 10/17/24 for anxiety. The record showed the resident had not received the medication yet. 3. On 10/21/24 at 3:08 p.m., an interview was conducted with Staff A, RN. She stated the nurse from the previous shift had reported Resident #3 had not received his insulin dose at 11:30 a.m. because the resident was out of the medication. Staff A, RN stated the physician had been notified and the insulin had been ordered. She stated they were waiting for delivery. Staff A stated she did not know if there was stock insulin that could have been administered. She stated she would check the inventory. Resident #3 was admitted to the receiving facility on 10/18/24 with diagnoses to include Type 2 Diabetes with diabetic neuropathy. On 10/21/24 at 3:10 p.m., an observation and interview was conducted with Resident #3. The resident said, I'm feeling fine now. I was a bit frustrated. I normally receive anywhere from 4 units to 8 units of insulin before meals. The nurse said I will get my insulin tonight. The resident stated the nurse did not test his blood sugar before lunch this day. The resident stated he had not received his insulin consistently while at this facility. Review of October 2024 MAR for Resident #3 showed there was no record of the resident's blood sugar check from 10/21/24 at 11:30 a.m. Review further showed insulin was not administered. The review showed on 10/19/24 and 10/20/21 the resident did not receive Donepezil HCI 5 MG for dementia. The documentation showed 9 was documented which means See progress notes. Review of progress notes revealed no documentation related to the dementia medication. Review of a progress note dated 10/19/24 showed Novolog Flex pan 100/unit/ML (milliliters) Medication on order, MD (Medical Doctor) aware. 4. On 10/21/24 at 3:30 p.m., an interview was conducted with Staff B, Licensed Practical Nurse (LPN). She stated she did not have narcotics for two of her residents (#5 and #4). She stated she had not administered any of their meds and to her knowledge, they had not had these medications all weekend. Staff B stated she did not have access to the facility's Emergency Drug Kit (EDK). Staff B stated Resident #4 and #5 had a scheduled narcotics but they did not bring the medications when they evacuated the residents from Facility C. Staff B stated [Resident #5] had an infection in his eye and she did not have eye drops for him. Review of Resident #4's admission record revealed an admitted [DATE] with diagnoses to include hereditary and idiopathic neuropathy, chronic peptic ulcer and other disorders of circulatory system. Review of October 2024 MAR for Resident #4 showed the resident was prescribed Hydrocodone acetaminophen tablet 10-325 MG, Give 1 tablet by mouth every 4 hours for pain. The review showed this resident did not receive the medication from Friday, 10/18/24 through Monday 10/21/24. The documentation showed a 9 was entered, meaning see other/progress notes. Review of Resident #4's progress notes dated 10/18/24 - 10/21/24 showed medication was not available, with the following notes, still waiting for script, still waiting delivery. Review of Resident #5's admission record revealed an admitted [DATE] with diagnoses to include chronic kidney disease , stage 3B, Type 2 diabetes mellitus with diabetic neuropathy, and unspecified sleep disorder among others. Review of Resident #5's October 2024 MAR showed this resident did not receive scheduled medications. This included Modafinil 200 MG, give 200 mg in the morning for sleep disorder, Lyrica Oral capsule 25 MG (Pregabalin), Give 1 capsule by mouth two times a day related to Type 2 diabetes mellitus with diabetic neuropathy and did not receive Gatifloxacin Ophthalmic solution 0.5%, instill 1 drop in right eye four times a day for bacterial conjunctivitis for 7 days. A progress note dated 10/19/24 showed the medication was not available to be given. 5. Review of the admission record for Resident #6 showed the resident was admitted on [DATE] with a primary diagnosis of chronic respiratory failure. Review of the October MAR for Resident #6 showed the following medications were not administered as ordered: Eliquis 2.5 MG tablet, give 1 tablet by mouth twice a day for atrial Fibrillation. Documentation showed the medication was not administered from 10/18/24 to 10/20/24. Trazodone HCI Oral tablet, Give 1 tablet by mouth every morning related to major depressive disorder. Documentation showed the medication was not administered from 10/18/24 to 10/20/24. Benzonatate capsule 100 MG, Give 1 capsule by mouth three times a day for cough for 10 days. Documentation showed the medication was not administered from 10/18/24 to 10/21/24. Spironolactone tablet 100 MG, Give 1 tablet by mouth one time a day for leg edema. Documentation showed the medication was not administered from 10/18/24 to 10/20/24. Fluticasone SPR 50 MCG (microgram) 1 spray in nostril one time a day related to allergic rhinitis, unspecified. Documentation showed the medication was not administered from 10/18/24 to 10/21/24. Azelastine HCI 0.05 % solution, instill 1 drop in both eyes one time day for Ocular allergies. Documentation showed the medication was not administered from 10/18/24 to 10/21/24. Glycerin-Hypromellose-PEG, 400 Opthalmic solution 0.2 - 0.21%, instill 1 drop in both eyes once a day for dry eyes. Documentation showed the medication was not administered from 10/18/24 to 10/21/24. Symbicort inhalation Aerosol 80-4.5 MCG/ACT, 2 puffs inhale orally two times a day for SOB (Shortness of Breath). Documentation showed the medication was not administered from 10/18/24 to 10/21/24. 6. On 10/21/24 at 3:38 p.m., an interview was conducted with Staff C, RN. Staff C stated her residents did not have the medications they needed. Staff C said, They did not anticipate these residents needs at all. They should have their medications here by now. It is not acceptable. Staff C stated she had notified the weekend supervisor from Facility A the residents did not have their medications. Staff C said, I notified [Staff D, RN/Weekend supervisor from Facility A] on Saturday. He had an attitude. Our hands were tied. Staff C stated Resident #7 did not have his anxiety medications and had been asking. She stated this resident was prescribed Clonazepam tablet 2 mg, one tablet by mouth every morning and bedtime for anxiety. Staff C said, That is just one of them. I have a resident in room [ROOM NUMBER] B, he has no medications at all. 7. On 10/21/24 at 3:56 p.m., an interview was conducted with Staff E, LPN. She stated one of her residents (#8) missed medications on Saturday (10/19/24) and Sunday (10/20/24) because the nurses could not access the Emergency Drug Kit (EDK). Staff E stated some of the medications were obtained from the kit, but some of them were still unavailable for example she said, [Residents #6, #9, #10] do not have a bunch of meds. Staff E stated she had notified Staff F, LPN/ Unit Manager (UM) on Friday the 18th when the residents arrived that they needed medications. She stated they did not receive any narcotics, inhalers, creams, ointments and eye drops. Staff E stated some of the medications could not be obtained from the EDK and they had requested new orders. Staff E provided a list of 6 residents who had missed their medications. Review of the admission record showed Resident #8 was admitted to the facility on [DATE] with a primary diagnosis of Alzheimer's disease with early onset. Review of Resident #8's October 2024 MAR showed some medications were not administered from 10/18/24 to 10/20/24. The medications included: Amlodipine Besylate oral tablet , give 5 MG by mouth once a day for HTN (Hypertension). Jardiance 25 MG, Give by mouth once a day for DM (Diabetes Mellitus), Losartan Potassium Oral Tablet 25 MG, give once a day for HTN (Hypertension) and Nystatin powder 100000 topical, apply to under breast and groin topically BID (Twice daily) for candidiasis cutaneous. 8. Review of the admission record showed Resident #9 was admitted to the facility on [DATE] with a primary diagnosis of Osteomyelitis, Right ankle and foot. Review of Resident #9's October 2024 MAR showed medications were not administered as follows: Gabapentin oral cap 100MG, Give 1 capsule every day for neuropathy on 10/18/24 and 10/19/24. Alprazolam Oral tablet 0.5 MG, give 0.5MG by mouth every 12 hours for anxiety was not administered on 10/18/24 and 10/19/24. Eliquis oral tablet 5MG was not documented as administered on 10/18/24. 9. Resident #10 was admitted to the facility on [DATE] with diagnoses to include unspecified dementia, end stage renal disease, Type 2 diabetes and low back pain. Review of Resident #10's October 2024 MAR showed orders to administer Oxycodone acetaminophen tablet 5-325 MG, give 1 tablet by mouth every 12 hours for pain. The record showed this medication was not administered from 10/17/24 to 10/21/24. The MAR further showed the resident did not receive Trazodone oral tablet, give 0.25MG two times a day for anxiety on 10/18/24-10/20/24 and Arnuity Ellipta 200 MCG/ACT aerosol powder, inhale 1 puff one time a day for COPD (Chronic Obstructive Pulmonary Disease) was not administered on 10/20/24 and 10/21/24. Progress notes for Resident #10 dated 10/18/24 - 10/20/24 showed the medications were on order and the MD had been notified. 10. Review of a facility document provided by the Nursing Home Administrator (NHA) titled, Resident's missing medications showed: Resident #11 was missing Breo Ellipta 100-25 MG/ACT powder, Amiodarone HCI 200mg, Flonase 50 MCG, Glycerin-Hypromellose-PEG 400 Ophthalmic solution, Pantoprazole sodium 20 MG and Lisinopril 20MG. Resident #11 was admitted to the facility on [DATE] with a primary diagnosis of COPD. Resident #12 was missing Divalproex sodium 250MG and Lactulose 20 GM/30ML. The resident was admitted to the facility on [DATE] with a primary diagnosis of paranoid schizophrenia. Resident #13 was missing Tramadol HCL 50 MCG, give 50 MG by mouth every 12 hours as needed for pain breakthrough. The resident was admitted to the facility on [DATE] with a primary diagnosis of Atherosclerosis of native arteries of extremities with intermittent claudication, bilateral legs. Resident #14 was missing Rosuvastatin Calcium 5 MG, give 1 tablet by mouth one time a day for HDL (High Density Lipoprotein). The Resident was admitted to the facility on [DATE] with a primary diagnosis of post procedural retroperitoneal abscess. On 10/21/24 at 4:05 p.m., an interview was conducted with the Director of Nursing (DON), Facility B. The DON stated it was noted on Saturday 10/19/24 that something was wrong with the medications. She stated Staff D, RN from Facility A was coordinating the resident transfers. She stated corporate was notified the medications were missing and Staff D was sent to the previous location, Facility C to locate the medications. The DON stated the medications could not be located. She stated they had been working on obtaining new orders. On 10/21/24 at 4:11 p.m., an interview was conducted with Staff F, LPN Unit Manager Facility B. She stated she became aware this morning the residents had not been receiving their medications. She stated she was trying to obtain new scripts. She stated they were having problems obtaining the scripts because they did not have access to Facility A's profile and pharmacy information. Staff F stated the resident's narcotics were never received from Facility C. On 10/21/24 at 4:20 p.m., a telephone interview was conducted with Staff D, RN weekend supervisor Facility A. He stated the residents who were missing medications were their residents who evacuated from Facility A to Facility C and had now moved to Facility B. He stated he did not participate in the transfer process. He said, I became aware of the missing medications on Saturday. I drove to Facility C but could not locate the narcotics. I reported to my NHA that some of the residents did not have their medications. The NHA said to go to all the other facilities and find the medications. Staff D stated he could not locate the unaccounted medications including narcotics. On 10/21/24 at 4:41 p.m., a telephone interview was conducted with Staff G, Acting NHA from facility A. She stated the residents should all have their medication by now. She said, They called and reported the residents did not have their meds and I had the nurse practitioner write new orders. I thought this was all taken care of. Staff G Acting NHA stated she was notified on Saturday 10/19/24 there were problems with medications availability. She said, It should have been resolved. An interview was conducted on 10/21/24 at 4:49 p.m. with Facility B's NHA. He stated they had received 34 residents who were originally from Facility A but had evacuated to Facility C. He stated he did not know there were medication concerns until this afternoon. He said, I did not know anything until you mentioned it. The DON is following up now. On 10/21/24 at 5:10 p.m. an interview was conducted with the Regional Nurse Consultant. The RNC stated she had been at the facility all morning and did not know there was a problem with medications. She stated no one had notified her, otherwise the issues would have been resolved. The RNC said, I was here when the residents from Facility A arrived to Facility B. I helped receive and reconcile all the medications that were received. The RNC stated the following morning Staff D, RN from Facility A was at Facility B ordering medications. The RNC stated the residents should not have missed their medications. She stated they could have been pulled from the Emergency Drug Kit. She stated they had most of the medications available if not all. The RNC stated all the nurses needed to do was to pull the medications from the EDK or notify her if they did not have access. On 10/21/24 at 7:23 p.m., an interview was conducted with The RNC, The NHA, The DON and the Regional [NAME] President. The RNC stated they had just audited all medication carts and ensured all medications that were unavailable were ordered STAT, meaning immediately. She stated any medications that were in the emergency medication storage would be accessed while awaiting supply to be delivered from the pharmacy. The DON stated she had started education for the nurses on accessing the emergency drugs. She stated the problem was that they did not have access, and they did not notify anyone. She said, Our nurses had a problem pulling medications for Residents from Facility A from Facility B's Emergency Drug Kit. She stated that was a system issue. The Regional VP stated they had not executed their emergency plan effectively if they could not pull emergency drugs to meet the resident's emergent needs. The NHA said, Now we know. Review of a facility policy titled, Physician Orders, Revised on 3/3/21 showed the center will ensure that physician orders are appropriately and timely documented in the medical record. The procedure showed for admission orders, information received from the referring facility or agency to be reviewed, verified with the physician and transcribed to the electronic medical record. The attending physician will review and confirm orders. Confirmation of admission orders requires that the physician sign and date the order during or as soon as practicable after it is provided, to maintain an accurate medical record.

Based on observations and interview, the facility failed to dispose of garbage appropriately for two of two (In front of kitchen door, to the right of kitchen door) outside dumpster areas. Findings included: Observations on 02/05/24 at 10:11 a.m., during the initial tour of the kitchen, an inspection of the dumpster area was conducted and the following was noted. -A green dumpster was noted in the rear parking area directly in front of the kitchen door. The dumpster lip was noted to be partially open and exposing the garbage inside, additionally there were crates and debris noted to be stored on the side and back of the dumpster wall. (Photographic evidence obtained) -A blue dumpster was noted in the far right corner of the rear parking lot. It was noted that there were two mattresses stored next to the dumpster. Additionally debris was noted on the ground in front of the dumpster. At this time, an interview with the Staff N, Interim Dietary Manager revealed these dumpster areas were used by the entire building and the area should be kept clean. (Photographic evidence obtained) Review of the undated facility policy titled Trash Handling revealed the following: -5. Outside dumpsters and the surrounding area are to kept clean and free of debris. -6. Dumpster doors should remain closed. This includes the dumpster and enclosed dumpster area doors.

Based on observations, interview, and policy review, the facility did not ensure proper infection control practices for two out of two units related to staff not using personal protective equipment (PPE), staff not knowing isolation precaution procedures, and uncovered oxygen equipment. Findings included: An observation was conducted on 2/5/24 at 9:55 a.m. of multiple rooms on the 400 unit with Enhanced Barrier Precaution signs. Some rooms had contact and enhanced barrier signs. At that time, an interview was conducted with Staff Q, Registered Nurse (RN.) Staff Q said she did not know why some rooms had both signs. She said with enhanced barrier precautions, staff should wear a gown at all times, but no mask and with contact precautions, staff should wear gown, gloves, and mask. An observation was conducted on 2/5/24 at 9:58 a.m. of Staff S, Certified Nursing Assistant (CNA.) entering room [ROOM NUMBER], which had an enhanced barrier precaution sign on the door. Staff S had gloves on but no gown. She pulled the curtain around the resident's bed and proceeded to change the resident's colostomy bag. An interview was conducted with Staff S at that time. She said she felt like a lot of rooms had signs that do not need isolation precautions. She said staff see it so often and do not pay attention. Staff S confirmed she did not put on a gown to change the wafer on the resident's colostomy bag and added that she did not put on a gown for most of the rooms on the 400 unit. She said she did not believe they were really on isolation. An observation was conducted on 2/5/24 at 10:03 a.m. of a staff member providing care to a resident in room [ROOM NUMBER] with no PPE on. The room was posted as being on contact precautions. (Photographic evidence obtained.) An observation as conducted on 2/5/24 at 10:11 a.m. of Staff U, Housekeeper pushing a large gray trash can with a plastic liner enter room [ROOM NUMBER] with no gown or gloves. She opened and closed drawers in the room then exited without performing hand hygiene prior to entering room [ROOM NUMBER] with no gown or gloves. Staff U then entered room [ROOM NUMBER] without performing hand hygiene, opened and closed drawers then put gloves on and removed towels and placed them in a plastic bag in the gray trash can. She proceeded to remove her gloves and walk down the hall to dispose of them, went back to the gray trash can and pushed it to room [ROOM NUMBER] and entered the room without performing hand hygiene and began opening drawers. An interview was conducted with Staff U with help of an interpreter. Staff U said the signs on the doors meant staff needed to wear PPE. She confirmed she did not wear gloves in the rooms until she needed to remove towels from the one room. She said she used hand sanitizer in the rooms, but it dried quickly on her hands. An observation was conducted on 2/5/24 at 10:16 a.m. of a continuous positive airway pressure (CPAP) mask lying on a wheelchair uncovered in room [ROOM NUMBER]. The mask remained uncovered on 2/6 and 2/7/24. (Photographic evidence obtained.) An interview was conducted on 2/5/24 at 10:30 a.m. with Staff T, CNA regarding isolation precautions. She said enhanced barrier precautions meant staff should wear gloves all of the time and contact precautions means staff should wear a mask all of the time. An interview was conducted on 2/5/24 at 10:50 a.m. with Staff Q, RN. She said she just put a precaution sign up on room [ROOM NUMBER] due to the resident being COVID + and not having a sign on the door. She said the resident should have been on droplet precautions. An interview was conducted on 2/5/24 at 10:55 a.m. with Staff V, Licensed Practical Nurse (LPN). Staff V said enhanced barrier was just a fancy word for contact precautions and there was no real difference between the two. An observation was conducted on 2/5/24 at 11:51 a.m. of lunch trays being delivered to residents. Staff W, CNA was observed entering room [ROOM NUMBER] with a gown on but no gloves on to deliver a lunch tray. She moved the over bed table, uncovered the food, and opened the curtains. She then exited the room and walked across the hall to the trash bin where she removed her gown. Staff W then walked to the PPE cart, removed another gown, and put in on, picked up another tray and entered room [ROOM NUMBER] with no gloves on. She proceeded to move the table and set up the resident's tray, exited room and removed gown, then walked down the hall with the gown in her hand to dispose of it. She then used hand sanitizer. An interview was conducted with Staff W at that time. She said enhanced barrier precautions means you have to wear a gown but not gloves. Staff W said she used hand sanitizer when entering and exiting each room. An observation was conducted on 2/6/24 at 8:58 a.m. of a personal cell phone observed on top of a medication cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 9:01 a.m. of Staff O, Registered Nurse, (RN) entering room [ROOM NUMBER], which had a contact precaution sign on the door, without donning PPE. At 9:04 a.m. Staff P, Certified Nursing Assistance (CNA) entered the same room to pick up a food tray with no PPE on. An interview was conducted on 2/6/24 at 9:05 a.m. with Staff O, RN, Staff P, CNA and Staff F, Licensed Practical Nurse (LPN.) When asked if they knew the resident was on contact precautions, they all said they were aware. Staff F, LPN spoke up and said the reason the resident was on precautions was bacteria in the urine and since they had a catheter it was contained, and they did not need to wear PPE. Staff O, and Staff P agreed. When asked if the resident had an order for contact precautions, should it be followed and Staff F, LPN agreed it should. An interview was conducted on 2/6/24 at 10:00 a.m. with Staff F, LPN. Staff F said with contact precautions staff should wear a gown and gloves and with enhanced barrier precautions she thought staff might have to wear a face shield all the time. Staff F said she did not know why a room would have both contact and enhanced barrier precaution signs. An interview was conducted on 2/6/24 at 10:10 a.m. with the Director of Nursing (DON.) She said when staff were caring for a resident on enhanced barrier precautions, they should wear a gown and gloves, but if they are just going to drop something off in the room and not touch anything they do not have to wear any PPE. The DON said if there were multiple types of precaution signs on a room staff would go with the highest level of precautions posted. The DON said all staff had been educated on precautions and she would expect them to know the information. An observation was conducted on 2/7/24 at 9:30 a.m. of Staff AA, CNA entering room [ROOM NUMBER], with posted droplet precautions, with no gown or mask, only donning gloves. An interview was conducted with Staff AA at that time. He said, oh the sign is just up. Doesn't mean anything. An observation was conducted on 2/7/24 at 1:33 p.m. of a pudding cup, used for medication administration, sitting open and uncovered on the medication cart in the north unit. (Photographic evidence obtained.) An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) She said if a resident had a diagnosis that warranted isolation, they notified the doctor to get orders and implement isolation. She said the resident was care planned for isolation, so the aides were also aware. Then signage and PPE was placed at the resident's door. The DON said even if the sign was not on the door, the CNAs should have known from their task list. The DON said she knew there were infection control concerns. She said nurses knew not to keep personal items on the medication carts but they choose not to listen. The DON said all oxygen equipment such as CPAP masks should be stored in a plastic bag and not left uncovered. She said unfortunately I am aware this happens. 48223 Review of the facility's policy titled Isolation - Categories of Transmission-Based Precautions dated at the bottom of the page revised October 2018. Policy Statement: Transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; Arrives for admission with symptoms of an infection; Or has a laboratory confirmed infection; And is at risk of transmitting the infection to other residents. Policy interpretation and implementation: 1. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status 3. The Centers for Disease Control and Prevention (CDC) maintains a list of diseases, modes of transmission and recommended precautions.5. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart, so the personnel and visitors are aware of the need for and the type of precaution. a. The signage informs the staff of the type of CDC precautions, instructions for use of personal protective equipment (PPE), and/or instructions to see a nurse before entering the room. b. Signs and notification comply with the residents right to confidentiality or privacy. Contact Precautions: . 4. Staff and visitors will wear gloves (clean, non-sterile) when entering the room. a. While caring for residents, staff will change gloves after having contact with infected material, (for example fecal material and wound drainage). b. Gloves will be removed, and hand hygiene performed before leaving the room. c. Staff will avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. 5. Staff and visitors will wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Droplet Precautions: 3. Masks will be worn when entering the room. 4. Gloves, gown and goggles should be worn if there is risk of spraying respiratory secretions.

Based on observations, interview, and policy review, the facility failed to ensure medications were stored as required for two (Residents #247 and #70) of two residents, two of two units, three of four medication carts, one of one treatment cart, and one of two medication storage rooms. Finding included: 1. An observation was conducted on 2/5/24 at 10:07 a.m. of a treatment cart on the South unit being unlocked with a resident sitting directly beside the cart. There were no nurses in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 10:16 a.m. of two bottles of Immune Support Supplements sitting on the bedside tray table of Resident #247. An interview was conducted with Resident #247 at that time. He said he bought the immune supplements and no staff member had ever said anything to him about them being in his room and he had not been offered somewhere to lock them up. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 10:45 a.m. of Resident #70 lying in bed. The over the bed table was half over the resident's waist, a small plastic cup was sitting on the over the bed table. In the cup was 6 pills (5 white of various shapes and sizes and one round red pill). Resident #70 stated, the nurse left them with me to take when I wanted. (Photographic Evidence Obtained) Review of Resident #70's active order summary for February 2024 revealed a no order for self-administration of medication. An observation was conducted on 2/5/24 at 4:50 p.m. of a medication cart unlocked on a resident hall on the South unit. No nurses were in view of the medication cart. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 4:52 p.m. of a medication cart unlocked in the hall next to the nurses' station on the North unit. No nurses were in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medications in a resident hall on the North unit. Staff F was observed dropping a medication tablet on the floor while preparing medications. She commented about dropping it but did not pick the medication up. Staff F continued down the hall completing her medication administration. The medication tablet remained on the floor outside of a resident room at 9:20 a.m. (Photographic evidence obtained.) An interview was conducted on 2/6/24 at 10:58 a.m. with Staff G, LPN. She said there were currently three nurses on the floor working and she was working an assignment split between the north and south unit. Staff G said the way the assignment was she had to share a medication cart for half of her residents with one nurse and share another medication cart with the other half of her residents with another nurse. She confirmed each cart only had one narcotic box inside and the nurses were sharing the narcotic box. Staff G said you have to have a lot of trust in your coworkers because you both have access to the same narcotics and narcotics counts were not done every time they each access the cart. An interview was conducted on 2/6/24 12.35 p.m. with Staff H, RN. She said nurses share a medication cart and narcotics box. She said they both use the cart during the shift and narcotics counts were only completed at the beginning and end of each shift. An observation was conducted on 2/6/24 at 1:52 p.m. of a treatment cart unlocked in a resident hall on the North unit. The cart remained unlocked at 2:23 p.m. and no nurses were in view of the cart. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 1:57 p.m. on the North unit of a medication cart unlocked near the nurses' station. At 1:59 p.m. a confused resident rolled up to the unlocked cart in his wheelchair and began messing with the cart and the trash can attached to the cart. No nurses were in view of the cart and no staff were monitoring the resident. At 2:08 p.m. the cart remained unlocked. This same resident was observed going to a medication cart that was locked and pulling on the drawers trying to open them. (Photographic evidence obtained.) An observation was conducted on 2/6/24 at 2:15 p.m. of the North unit medication storage room door propped open with a trash can blocking it from closing. No staff were at the nurses' station or in the medication storage room. Medications were observed to be in the cabinets and in the refrigerator in the medication storage room with no additional locks present. Staff F, LPN came down the hall and was interviewed about the medication storage room. She confirmed she had keys and was working on the North unit but said she did not know why the door was propped open and it should not be. (Photographic evidence obtained.) An audit was conducted on 2/6/24 at 4:33 p.m. of a north unit mediation cart shared by Staff F, LPN and Staff G, LPN. The medication cart had two loose pills in the top drawer of the cart and there were loose pills and debris under the bottom drawer of the medication cart. There was also a drawer on the cart that contained cigarettes, eyeglasses, a phone charger, and a bag with keys and miscellaneous items with the medication. The narcotics drawer contained a medication cup with pills inside, not labeled. Staff G, LPN was interviewed at that time. She said the nurses all keep the carts clean. She confirmed there should be no loose medication or items besides medication in the cart and she did not know why people used it for storage of other items. Staff G confirmed the pills in the medication cup were narcotics. She said Staff F, LPN inadvertently signed off narcotics on one of Staff G's resident's narcotic count sheet. Staff G said she is now waiting on Staff F so they can correct the error and dispose of the narcotic together. Staff G said, that is the joy of sharing a cart. (Photographic evidence obtained.) An interview was conducted on 2/6/24 at 4:3 p.m. with Staff F, LPN. She said, you've got to have a lot of faith in other nurses when sharing a narcotics box. An interview was conducted on 2/7/24 at 2:01 p.m. with the Director of Nursing (DON.) The DON said the facility had previous issues with unlocked medication carts and she still did audits. The DON said, I find the problem more than I would like to. The DON said medications should not be left in resident rooms and the nurses know better. She said the medication and treatment carts should always be locked when not in use if they had medication in them. The DON said narcotics should be counted every time the keys to the narcotics box change hands. She said when the nurses are sharing a narcotics box, both nurses need to be aware when someone pulls a narcotic out or one nurse needs to pull it out for the other one. The DON said she was calling the pharmacy to see about re-keying a medication cart with two narcotic drawers. She said it would be a nightmare if a drug diversion happened right now. 2. During observations on 02/05/24 at 12:40 p.m. while walking down the 200 hall towards the south wing nurses station, a resident was observed rummaging through the top drawer of a cart. Staff F, Licensed Practical Nurse (LPN) was noted to be behind the nurse's station and asked the resident what he wanted. The resident continued rummaging through the cart and said, I want a stirrer, where are all the stirrers I need one. The cart was noted to have the lock fully extended out and observation of the top drawer revealed tubes of topical creams. Staff F then proceeded to come around from behind the desk, told the resident that he could not be in the cart and then closed the top drawer and locked the cart. (Photographic evidence obtained). A interview on 02/05/24 at 12:45 p.m. with Staff F revealed she was assigned to the South wing and the cart was a treatment cart, and it was typically kept locked. She reported the facility had a treatment nurse and that she was not sure why the treatment cart was left unlocked. Observations on 02/07/24 at 11:46 a.m. of the south hall by the nurse's station revealed a treatment cart stored in the hallway in front of the nurse's station. The treatment cart was noted to have the lock open and fully extended and the second drawer down was noted to be held open with a box of sterile gauze. Topical ointments were noted to be stored in the treatment cart. Closer observation revealed a resident was seated in his wheelchair directly next to the cart. An unsuccessful attempt was made to locate a nurse on the south unit. A Certified Nursing Assistant (CNA) left the unit to find a nurse. (Photographic evidence obtained) An interview on 02/07/24 at 11:58 a.m. with Staff F revealed she had no idea why the cart was open But I can close it. She reported that she did not have keys to the treatment cart and that the treatment nurse had the key and might have left it open. An interview on 02/07/24 at 1:57 p.m. with the Director of Nursing (DON) revealed the treatment cart could be unlocked if empty, but that it should be secured if not empty. She reported staff had been trained to secure the medication and treatment carts. The DON reported she found the medication and treatment carts unsecured more than she would like to. Observations on 02/07/24 at 2:18 p.m. revealed a medication cart on South unit was noted to be unlocked. A successful attempt was made at opening the cart drawers. All drawers on the medication side were accessible. Closer observations at this time revealed a resident was mobile in his wheelchair and in close proximity to the cart. (Photographic evidence obtained) An interview on 02/07/24 at 2:22 p.m. with Staff B, LPN revealed she was assigned to the other cart on the unit and Staff F, LPN was assigned to this cart. She reported she saw Staff F leave the unit, but it was not communicated to her that she was leaving or as to where she went. She reported that the medication cart should never be left unlocked. Observations on 02/07/24 at 2:27 p.m. revealed Staff F had returned to the unit. At this time during an interview with Staff F she said, I probably forgot to close and lock it. She reported that every time you walk away from the cart it should be locked. 20311

Based on observations, interview and record review the facility failed to ensure that staff appropriately utilized hair restraints when preparing, distributing resident food. for 2 of 4 (Staff K, Staff M) staff working on the food tray-line. Findings included: On 02/07/24 at 11:20 AM at the time of the Comprehensive Tour of the kitchen and Tray line observations Staff N, Interim Dietary Manager approached Staff K, cook and whispered to him. The cook was observed to have facial hair around his mouth and chin with no hair restraint in place. The cook left the tray-line and returned after 3 minutes with a hair restraint covering his mouth and chin. Interview at this time with Staff K, Cook revealed that his face was uncovered and that he was directed by the dietary manager to cover the hair on his face. The staff person reported that he was not aware that he was supposed to keep his facial hair covered. Observations on 02/07/24 at 11:28 AM revealed that Staff M, Dietary Aide entered the kitchen and was noted with a hair net covering her head. Closer observations revealed that Staff M had a braided ponytail that extended down below her buttocks, which was not covered by the hair net on the top of her hair. Interview with the Dietary Manager revealed that all her hair should be up in the hair net, and should not be exposed. At this time the Dietary Manager directed Staff M to cover her hair. The aide was observed to place the ponytail up in a bun and then cover her head with the hairnet. Review of the facilities undated policy titled Hair Restraints/Jewelry/Nail Polish revealed the following: Food & nutrition services employees shall wear hair restraints and beard guards. Hairnet, hat or hair restraint will be worn at all times in the kitchen. Beard guards or masks will be worn as indicated

Based on interviews and record review, facility did not ensure there was a communication plan between hospice providers and the facility for two (Residents #50 and #247) of three reviewed for hospice services. Finding included: A review of admission records showed Resident #50 was admitted on [DATE] with diagnoses including Dementia, Type II Diabetes Mellitus, chronic pulmonary edema, brief psychotic disorder, and major depressive disorder. A review of Resident #50's physician orders showed an order, dated 1/29/24, for Hospice Order: [Company] admitting diagnosis Senial [sic] Degeneration of brain. An interview was conducted on 2/7/24 with the Director of Nursing (DON). She stated Resident #50 was currently receiving hospice services. An interview was conducted on 2/7/24 at 4:20 p.m. with Staff B, Licensed Practical Nurse (LPN) after not being able to locate a hospice communication book for Resident #50. Staff B said she was the nurse assigned to Resident #50 and he was not on hospice services. The Assistant Director of Nursing (ADON) joined the interview and stated she did not believe Resident #50 was on hospice services. The ADON checked the hospice binder where she said all hospice communication was kept, and there was no paperwork for Resident #50. The ADON reviewed Resident #50's electronic medical record and confirmed there was a hospice order in place. The ADON said she did not see any notes in the computer regarding hospice and they should be there. Staff were unable to locate a hospice care plan, hospice communication sheets, hospice team contact information, or a hospice care plan for Resident #50. An interview was conducted on 2/7/24 at 4:25 p.m. with the DON. She said generally items like hospice were discussed at the morning meetings. The DON reviewed Resident #50's medical record and confirmed the order for hospice was in place, but she did not know where it came from. She determined Staff I, Registered Nurse (RN)/Unit Manager (UM) put the order in the computer. An interview was conducted on 2/7/24 at 4:34 p.m. with Staff I, RN/UM. Staff I said Resident #50's wife had spoken to the resident's doctor because apparently the resident had been on hospice prior to being admitted to the facility. Staff I said the facility had been unaware because nothing from the hospital discharge paperwork noted the resident was receiving hospice services. After Staff I spoke with the wife and doctor, the order for hospice services was entered. She said hospice had been coming to see Resident #50, providing care and showers. Staff I said there should be hospice notes and a hospice care plan from the hospice providers. An interview was conducted on 2/7/24 at 4:49 p.m. with the ADON. She said she called and spoke to Resident #50's hospice nurse. The hospice nurse told the ADON she had emailed all of her notes to the email that had been provided to her, which was the business office email. The ADON said she gave the hospice nurse her email to send past and future notes. The business office manager was out and unavailable for interview. A review of Hospice notes for Resident #50 showed hospice care began on 12/8/23. A review of admission records showed Resident #247 was admitted on [DATE] with diagnoses including fracture of part of neck of right femur, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. Review of Resident #247's physician orders showed an order, dated 1/23/24 for Hospice admitting diagnosis: Malignant Neoplasm Prostate. An interview was conducted on 2/7/24 at 1:26 p.m. with Staff B, LPN. She confirmed she was the nurse for Resident #247 and he did receive hospice services. When asked where the hospice notes and care plan were, Staff B said they should be in the hospice book at the nurses' station. She was observed looking for Resident #247's hospice information and was unable to find it. Staff B said she had no idea where the information was and she would have to ask the Unit Manager. An interview was conducted on 2/7/24 at 1:29 p.m. with Staff I, RN/UM. She reviewed Resident #247's medical record and said she did not see any hospice notes. She confirmed the facility should have the resident's hospice notes and care plan. Staff I then stated the hospice company did not give them a book and she would have to call them. Staff I was observed going to Staff C, Minimum Data Set (MDS) Coordinator and asking her where the hospice information would be and Staff C said she did not know. Staff C checked Resident #247's medical record and was unable to find any hospice notes. She said, that's not good, I will have to ask. Staff I and Staff C were observed proceeding to the admissions office and asking the Admissions Director where Resident #247's hospice paperwork would be and the Admissions Director stated she would call the hospice company. Staff I confirmed hospice had been seeing the resident and Staff C confirmed there were no hospice notes or care plan in the resident's medical record. An interview was conducted on 2/7/24 at 1:40 p.m. with the DON. She said sometimes hospice documentation is in the electronic record and sometimes in the hospice binder. She said she had not worked with Resident #247's hospice provider before and they had not asked her for computer access, therefore the documents should be in a binder at the nurses' station. A follow-up interview was conducted on 2/7/24 at 1:49 p.m. with Staff B, LPN. She said if something happened with Resident #247 she would not know which hospice team to contact or how to get ahold of them. She said, it is pretty important to be able to reach the hospice team if needed. An interview was conducted on 2/7/24 at 3:03 p.m. with Resident #247's hospice nurse. She said she did any paperwork the facility requested and they had not asked for anything. She said she had faxed her notes to the facility twice a week and had also sent them the resident's hospice care plan. The hospice nurse pulled up her computer records and showed her fax confirmation on 1/17/24 and 1/31/24. The hospice nurse said she knew she had the correct fax number, due to the facility receiving prescriptions she had faxed to the same number. The hospice nurse said when she came to see Resident #247 she would speak with the nurse assigned to the resident. She also said the resident had developed a rash two days prior and the facility did not notify her. She said had she known, she would have come and assessed the resident at that time. The hospice nurse said Resident #247 appeared to have shingles. She said she notified the facility to put him on precautions and treatment started. Review of a facility policy titled Hospice Care, revised 9/20/17, showed the following: Policy The center supports the patient/resident's rights to a dignified existence and self determination. The center will assist the patient/resident and/or legal representative in arranging hospice services. Procedure . When hospice are provided in the center, the center should meet the following: -The center will furnish 24 hour room and board, and meet the patient/resident's personal and nursing care needs in coordination with hospice based on the patient/resident's individual plan of care. . To ensure continuity of care between the center and the hospice provider, the Director of Nursing will designate a clinical member of the interdisciplinary team to work with the hospice including the following: -Coordination of care plan process between the hospice and the center -Communication with hospice representatives, hospice medical director and the patient/resident's attending physician to ensure coordination of care. -Ensure the following information is obtained from the hospice: -Most recent hospice plan of care -Hospice election form -Physician certification and recertification of the terminal illness. -Names and contact information for hospice personnel involved in the care of the patient/resident(s). -How to access hospice's 24 hour on call system. -Medication information for the patient/resident(s). -Hospice physician and attending physician orders for the patient/resident(s). -Provide education to the hospice staff on the center policies and procedures, including: resident rights, documentation and forms. -The center will ensure the care plan includes the most current hospice plan of care and the center's plan to attain or maintain the patient/resident's highest practicable physical, mental and psychosocial well-being.

Based on observations, interviews, record review, facility policy review, and plan of correction review, the facility failed to ensure it had a functioning Quality Assurance and Performance Improvement (QAPI) committee. The facility was actively involved in the effective creation, implementation and monitoring of the plan of correction for deficient practice during a recertification and complaint survey conducted on 2/5/24 through 2/21/2024 and was cited F761. On 4/2/2024 the facility was recited F761. The facility had developed a Plan of Correction with a completion date 3/21/2024. Findings included: Review of the facility's plan of correction revealed: On 3-12-24 the Director of Nursing and/or Designee in-serviced licensed nursing staff on storage of medications and biologicals in medication carts, treatment carts, & medication rooms Any newly hired licensed nursing staff and/or any agency licensed nursing staff will be in-serviced on storage of medications and biologicals in medication carts, treatment carts, &medication rooms. The Director of nursing and/ or designee will complete an audit of the facilities medication/treatment carts, the medication rooms and resident rooms weekly for 4 weeks to ensure that medications and biologicals are stored in accordance to federal and state laws, then every other week until the QAPI [Quality Assurance Performance Improvement] committee determines that the facility is in substantial compliance with this regulation. 2. The findings of the audits will be reported in the monthly Quality Assurance Performance Improvement Committee meeting until committee determines substantial compliance has been met and recommends moving to quarterly monitoring by the QAPI committee. During the revisit survey on 4/2/24, the facility failed to ensure medications and biologicals were stored as required for three (100, 200, and 300) of four medication carts, and one (North Unit) of two medication storage rooms. A medication storage observation was conducted on 4/2/24 at 9:55 a.m. of the 100-hallway medication cart. The medication cart was observed to have 2 open insulin strip bottles in the top drawer and there was no open date labeled on the two insulin strip bottles. An interview was conducted at the time of the observation with Staff A Licensed Practical Nurse (LPN). She said the insulin strip bottles should be labeled with the open date on it because they are only good for 90 days after opening. A medication storage observation was conducted on 4/2/24 at 10:03 a.m. of the 200-hallway medication cart. The bottom drawer handles were observed to be rigid, with a rust-like color to them. There was one loose pink pill in the bottom drawer. The bottom two drawers of the medication cart were overflowing over the dividers with items such as, three glucometers, a sleeve of Styrofoam cups, a sleeve of plastic cups, earwax softener drops, ace wraps, three fingernail scrub brushes, nail clippers, nail file, three bags of resident labeled intravenous (IV) medications sitting inside a box of Safety Pen needles with intravenous medications tubing. In the same section as the three-resident labeled IV medication bags there was a drug buster bottle with a blackish brown substance along the side of the bottle and under the cap. In the same drawer, the divided section next to drug buster bottle there was a blackish, brownish substance covering the bottom of the drawer with a Styrofoam cup of individually packaged disposable syringes sitting on top of the substance. There was a plastic cup with a piece of folded cloth in it. An interview was conducted at the time of the observation with Staff B, LPN she said night shift is supposed to clean the medication carts. She said the glucometers in the bottom drawers were not being used and the medication cart should be cleaned, she was observed to discard items located in the bottom two drawers and when she discarded the plastic cup with the folded cloth in it, she said This looks like it's something for a wound dressing. She removed the loose pill and placed it in the drug buster bottle and said This looks like Eliquis. A medication storage observation was conducted on 4/2/24 at 10:34 a.m. of the 400-hallway medication cart. The top drawer of the medication cart was observed to have one Lantus insulin pen and one Basaglar insulin pen, both insulin pens were observed to be lying on top of a resident labeled pharmacy bag. An interview was conducted at the time of the observation with Staff C, Registered Nurse (RN). He confirmed the Basaglar insulin pen did not have a resident name or pharmacy drug label on it. He also said the Lantus insulin pen should be in the pharmacy labeled bag. He compared the pharmacy label located on the Lantus pen and the Lantus Pharmacy label on the bag, he confirmed it was for the same resident and the same medication, and placed the Lantus in the bag and discarded the Basaglar insulin pen. Staff C, RN said he received education recently that every medication is to be labeled with an open date and if it is a medication from the pharmacy and has a bag it should be stored in the pharmacy labeled bag. A medication storage observation was conducted on 4/2/24 at 10:25 a.m. of the North unit medication room. The side of the resident medication storage refrigerator was observed to have rigid and rust-like color to it, resident medication was observed to be in the refrigerator. In the bottom cabinet of the medication storage room, there was a full enteral nutrition bottle and a resident labeled medication bottle sitting next to a Ant & Roach spray bottle. An interview was conducted at the time of observation with Staff D, LPN. She was asked about the eternal nutritional bottle and the resident medication bottle being next to the Ant & Roach spray bottle and she said oh yeah. I don't know why that's there. then Staff D, LPN walked out of the medication room. An observation was conducted with the Director of Nursing (DON) on 4/2/24 at 1:06 p.m. of the 300-hallway medication cart handles. The handles of the medication cart were observed to be rigid and have a rust-like color to them. She confirmed the medication cart handles were worn and some of the handles felt rigid. An interview was conducted on 4/2/24 at 1:10 p.m. with the Director of Nursing (DON) she confirmed medications should be labeled and in the pharmacy labeled bag. She said the medication carts should be clean and items should be separated and not stacked on top of each other. She said the third shift is supposed to clean the medication carts but if something is spilled then that nurse should clean up the spill. An observation was conducted of the North unit medication room with the DON at this time. The DON observed the enteral nutrition bottle and a resident medication bottle next to the a Ant & Roach Spray bottle. The DON said the enteral nutritional bottle should not be in the medication room, it's not stored in this room. She also said she does not know where the ant and roach spray bottle came from. She discarded the enteral nutrition bottle, the resident medication, and the ant and roach spray bottle into the trash can. She also observed the refrigerator in the medication room, with resident medication in it and confirmed the refrigerator was rusted along the outside of it. An interview was conducted on 4/2/24 at 1:38 p.m. with the DON. She said all four medication carts needed new handles. An interview was conducted on 4/2/24 at 4:42 p.m. with the DON. She said, IV medications should be stored in the medication rooms and the nurse should obtain the medication when it's time to administer it. She said the medication carts should be clean and there should not be miscellaneous items stored with resident medications. A phone interview was conducted on 4/2/24 at 4:04 p.m. with the facility's Pharmacy Consultant. She said, the purpose of a clean medication cart is contamination of medications so if the medication is in a bag or not directly touching miscellaneous items then it is not being contaminated. She said she would like to see the medication carts clean and organized but there is not a regulation for organization. She said insulin pens should be stored with the label. She said the unlabeled insulin pen was probably an emergency use pen and that was why it didn't have a label on it. But it should not be in the medication cart if there was no label. She said resident medications should not be stored with ant and roach spray. She said the pharmacy is ordering new handles for the medication carts and I'm not sure yet when they are coming but brand-new handles are being delivered. Review of the back of the insulin strip bottle revealed Use within 90 days (3 months) of first opening. Review of the facility's Medication Storage In the Facility policy dated April 2018, revealed: Policy Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedures: .C. All medications dispensed by the pharmacy are stored in the container with the pharmacy label. .G. Potentially harmful substances such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants are clearly identified and stored in a locked area separately from medications. .I. Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity. .Infusion Therapy Storage and Labeling .E. Facility should assure that the infusion therapy product storage area is kept clean and free of clutter. .Expiration Dating (Beyond-use dating) .C. Certain medications or package types, such as .blood sugar testing solutions and strips, once opened, require an expiration date shorter than the manufacturer's expiration date to insure medication purity and potency D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1) The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration .The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating . Review of the facility's Quality Assurance Performance Improvement Program (QAPI) revised on 10/24/22. Policy: The Center and organization has a comprehensive, data-driven Quality Assurance Performance Improvement Program that focuses on indicators of the outcomes of care and quality of life. Procedure: Program Design and Scope 1. The center's QAPI is on-going comprehensive review of care and services provided to residents. Including but not limited to: .d. Pharmacy Services .Leadership: The Center Executive Director is accountable for the overall implementation and functioning of the QAPI program. This includes but is not limited to: a) Implementation b) Identify priorities c) Ensures adequate resources d) Ensures performance indicators, resident and staff input and other information is used to prioritize problems and opportunities e) Ensures corrective actions are implemented to address identified problems in systems f) Evaluates the effectiveness of actions g) Establishes expectations for safety, quality, rights and choice and respect .

Based on record review and interview the facility failed to provide residents who had Medicare days remaining with appropriate notice for 2 of 3 (#15, #59) residents sampled for beneficiary notification. Findings included: Review of Resident #15's record revealed that he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 14 (Cognitively Intact) dated 12/28/23. The residents last covered day for Part A service was 1/18/24. The resident elected to remain in the facility for Long Term Care (LTC). Review of the Beneficiary Protection Notification Review form and the notice given revealed that the resident only received the Advance Beneficiary Notice of Non-coverage (ABN CMS-10055) but did not receive the Notice of Medicare Non-Coverage (NOMNC CMS-10123). Review of Resident #59's record revealed that he was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 14 (Cognitively Intact) dated 1/3/24. The residents last covered day for Part A service was 12/4/23. The resident elected to remain in the facility for LTC. Review of the Beneficiary Protection Notification Review form and the notice given revealed that the resident only received the ABN CMS-10055 but did not receive the NOMNC CMS-10123. On 02/08/24 at 12:50 PM an Interview was conducted with the Social Service Director. The Social Service Director reported that he did not provide Residents #15 and #59 with the NOMNC CMS-10123 form because they both remained in the facility LTC. He reported that he was not aware that he was to provide those the NOMNC CMS-10123 to residents who remained in the facility and that this is the way he has always done things. Review of the facility undated policy provided, titled Form Instructions for the Notice of Medicare Non-coverage revealed the following: A Medicare health provider must give an advance, completed copy of the Notice of Medicare Non-Coverage (NOMNC) to enrollees receiving skilled nursing, home health (including psychiatric home health), or comprehensive outpatient rehabilitation facility services, no later than two days before the termination of services.

Based on observation, interview, and record review, the facility did not ensure prompt efforts were made to resolve grievances for Resident Council for six of six months reviewed and one (Resident #65) of three residents sampled. Findings included: A review of the Grievance Logs from August 2023 to January 2024, revealed an absence of grievance issue concern. Eight grievances were randomly chosen for review from September 2023 to January 2024. Review of a grievances dated 1/16/2024, 1/28/2024, and 1/31/2024, for Resident #65, revealed the grievance was filed by the resident related to not receiving medications as ordered and staff assistance. The investigative section and the date the grievance was resolved was blank. Review of the Resident Council Minutes dated September 2023, revealed Old Business concern relating to staff being on their phones and wearing ear buds while providing care. Under the section New Business: ongoing issues of cell phone/ear bud usage. Review of the Resident Council Minutes dated October 2023 revealed Old Business concern relating to staff hiding out in rooms on 3-11/11-7 (shifts) and dayrooms and call lights are on for a long time. Under the section New Business: ongoing issues of cell phone/ear bud usage and call lights. Review of the Resident Council Minutes dated December 2023 revealed the section New Business: ongoing issues of cell phone/ear bud usage; Certified Nursing Assistants (CNAs) not making beds when requested and call lights when staff are sitting at the nurses station. Review of the Resident Council Minutes dated January 2024 revealed the section New Business: CNAs continue to not make beds for residents when they request. During an interview on 2/8/2024 at 10:28 AM, the Social Service Director (SSD) reviewed the grievance process. The SSD said, Once the grievance is received, it is logged in by social services. I take the grievance to our morning meeting for discussion, at which all managers are in attendance. We decide who is responsible for investigating the grievance and that manager takes the grievance to complete the investigation, determine resolution and follow up with the resident/responsible party. Once completed, the grievance form is returned to social services. The SSD stated, we like to get them back in three to five days. The SSD stated the Administrator (NHA) and SSD meet weekly to discuss grievances. The SSD stated that the log did not track the type of concern and did not know if there were any trends. The NHA determined if there were trends based on our weekly meetings. The SSD stated most of the grievances got resolved, some were repeating. The SSD stated call lights seemed like it might repeat. The SSD stated, the call light does not get answered because the staff don't answer another staffs call light. Meaning the staff do not usually answer call lights that were not in their assigned rooms for coverage. The SSD confirmed the grievances for Residents #65 were incomplete and had not heard any further discussions regarding them. During an interview on 2/8/2024 at 12:55 PM, the NHA stated follow through on grievances should be to have them wrapped up in approximately 72 hours. The NHA stated she did not have any information regarding the grievances. The NHA stated the SSD did a trending of grievances and that she (NHA) did not. During an interview on 2/7/2024 at 12:15 PM, Resident #65 stated recollection of the grievance. Resident #65 stated nothing had changed, they (the facility) may come and speak to you, but nothing ever changes. During an interview on 2/8/2024 at 9:55 AM with the Resident Council President. The Resident Council President stated the concerns regarding: call lights, staff sitting around (hiding), and talking on their phones with ear buds on continued to be an ongoing issue. Review of the facility's policies and procedures titled Complaint/Grievance, with a revision date of 10/24/2022 revealed Policy: the center will support each resident's right to voice a complaint/grievance without fear of discrimination or reprisal. The center will make prompt efforts to resolve the complaint/grievance and inform the resident of progress towards resolution. Grievances will be reviewed by the quality assurance performance improvement committee. the center will inform residents of the right to file grievance orally and in writing, the right to file grievances anonymously, the contact information of the grievance officer, a reasonable time frame for completing the review of the grievance, the right to obtain written decision regarding the grievance, and contact information of independent entities with whom grievances may be filed . Procedure: . 4. The follow-up should be completed in a reasonable time frame; this should not exceed 14 days. 5. The findings of the grievance shall be recorded on the complaint/grievance form. 8. The individual voicing the grievance will receive follow up communication with the resolution, a copy of the grievance resolution will be provided to the resident upon request.

Based on interviews, records, and policy review, the facility failed to ensure the Admission Procedure was implemented for five (Residents #247, #245, #343, #143, and #144) of five residents who were reviewed for admission paperwork. Findings included: During an interview on 2/6/2024 at 10:30 AM, the Admissions Director (AD) stated no residents had been signed in since 1/1/2024. The AD stated she had not had time to get the paperwork completed by the resident or the resident representative. The AD continued to state there had been 32 admissions to date. Admission documentation for Residents #247, #245, #343, #143, and #144 were requested from the AD. The AD stated she did not have the Admission Packet completed for any of those residents. An interview was conducted with the Administrator (NHA) on 2/8/2024 at 12:55 PM. The NHA stated the AD had not mentioned the paperwork not being completed until after the AD met with the surveyor. The NHA confirmed the AD was the same as the Business Development Coordinator (BDC). Review of the facility's policies and procedures with the subject of Admissions Procedure, dated 8/19/2018 showed Policy: Every admission will be processed by the Business Development Coordinator (BDC) at the time of or prior to admission. BDC will attempt to obtain paperwork prior to admission. Appropriate paperwork will be reviewed with each resident and/or responsible party to ensure financial information is obtained, and the resident and/or the responsible party is informed as to their obligations, rights and responsibilities. The company will give equal consideration and access for admission of all referrals regardless of race, color, national origin, sex, age, disability, religion, or payer source. Procedure: The BDC will print out the admission packet for each patient with documents contained in the admission checklist in sufficient quantity to ensure availability, or in the event the computer system is unavailable. The BDC will: . obtain information via an interview with the resident and/or responsible party to complete the admission portion of the packet. Review the admission portion with the resident and/or responsible party. Obtain consent to photograph/publish. In the event the resident is their own responsible party yet chooses to delegate the signing of the admission paperwork to a member of their family, the resident must sign the Resident Delegation of Admission Form. The Resident Delegation of Admission Form must be completed and signed by the resident before the Admission Agreement packet is signed. complete all documents listed on the admission checklist including any state specific forms not listed. Provide information handbook and copies of all signed documents to the resident and or responsible party. The completed facility admission packet is then given to the business office no later than the next business day Review resident rights, responsibilities, and Advanced Directives with the resident and/or responsible party. Introduce the resident and their family to the social worker for further information on Advanced Directives. Introduce the resident and their family to the business office manager for further information on fiscal responsibility

Based on record review, and staff interviews, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR) for 1 of 3 (#1) sampled residents were revised for accuracy to include diagnoses recognized at the time of admission and later identified. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder . Review of Resident #1's PASARR Level I assessment dated [DATE] revealed a qualifying diagnosis of Depressive Disorder and that no PASARR Level II was required. Review of Resident #1's Diagnosis Report revealed additional qualifying diagnosis as follows: -Bipolar Disorder with date of onset 12/31/21 -Major Depressive Disorder with date of onset 12/31/21 -Dx Unspecified Dementia with date of onset 4/12/22 -Schizoaffective disorder with date of onset 1/12/23 -Generalized anxiety disorder with date of onset 1/12/23 -Parkinson's disease with date of onset 10/1/23 Review of the residents medical record revealed that the resident was not assessed for PASARR Level II as the resident acquired additional qualifying diagnosis. Interview on 02/08/24 at 10:41 AM with the Admissions Director revealed that her responsibility is to make sure that they get the PASARR forms from the hospital prior to admission and that she reviews for accuracy. She reported that she checks to see that the forms are signed, dated, and that she checks for diagnosis from the hospital transfer form (3008) or History and Physical. She reported that if the form is not accurate that she would check with the Minimum Data Set (MDS) staff, usually after admission. The Admissions Director reported that nursing staff or MDS would follow-up if there are new diagnosis. Interview on 02/08/24 at 10:56 AM with Staff J, Licensed Practical Nurse (LPN), MDS Coordinator, Staff C, LPN, MDS Coordinator, and the Social Service Director revealed that they get the PASARR's from admissions prior to resident arriving, and if they are not correct they would let admissions know. Staff J and Staff C reported that after reviewing the forms, that if they are incorrect they would notify the Social Service Director the resident/form would be reviewed during the morning meeting. Staff J and Staff C reported that during the morning meeting the resident/form would be where new diagnosis would be discussed, but that they do not know who would be responsible for re-doing the PASARR. Continued interview at this time revealed that the Social Service Director reported that Admissions would be responsible for the accuracy of the PASARR prior to admission and that MDS staff and the Social Service Director would be responsible for the PASARR if there are new diagnosis. Staff C, LPN, MDS Coordinator, reported that based on the documentation in the record there should have been a new PASARR completed to reflect the new diagnosis for Resident #1. Review of the facility policy titled Preadmission Screening and Resident Review (PASRR) with an original date of 11/08/2021 and a revision date of 11/08/2021 revealed the following: 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results.

Based on record review, interview, and review of the facility's policy, the facility failed to ensure the Level I Preadmission Screening and Resident Review (PASRR) was accurate upon admission for two (Residents #41 and #50) of nineteen residents sampled for PASRR. Findings included: 1. Review of the Admission Record showed Resident #41 had an original admitted on 09/13/22 with diagnoses that included but was not limited to unspecified Dementia, other specified anxiety orders, Major depressive disorder, recurrent, moderate, other specified persistent mood disorders and post-traumatic stress disorder (PTSD). A review of Resident #41's PASRR assessment, dated 09/13/22 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), none of the checkboxes were checked. Review of Resident #41's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #41 had diagnoses of Anxiety Disorder, Depression and Post Traumatic Stress Disorder. During an interview on 02/08/24 at 2:00 p.m., the Director of Nursing (DON) stated that when a new Resident was admitted to the facility a team of staff reviewed all PASRRs after the morning meeting to ensure the PASRR was correct. The DON stated if the team of staff found a PASRR to be inaccurate the facility would request for a new PASRR to be completed. The DON reviewed Resident #41's Level I PASRR and admitting diagnoses and stated the Level I PASRR was incorrect but was never corrected. 2. Review of admission records for Resident #50 showed he was admitted on [DATE] with diagnoses including dementia and major depressive disorder. The diagnoses of anxiety disorder and psychotic disorder were added on 1/3/24. Review of Resident #50's Preadmission Screening and Resident Review (PASRR) Level I screen, completed at the hospital on 12/28/23, showed the resident had anxiety disorder and depressive disorder. Section II #5 of the PASRR indicated Resident #50 had a primary diagnosis of Dementia. Question #7 said the individual had validating documentation to support dementia or related neurocognitive disorder. At the bottom of section II the PASRR screen showed, A Level II PASRR evaluation must be completed if the individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, and a suspicion or diagnosis of a Serious Mental Illness, Intellectual Disability, or both. Section IV: PASRR Screen Completion showed No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASRR evaluation not required. Review of medical records for Resident #50 did not show a PASRR Level II had been completed. An interview was conducted on 2/7/24 at 5:53 p.m. with the Director of Nursing (DON). She confirmed there was no PASRR Level II completed for Resident #50. After reviewing the resident's Level I screen, the DON said It appears a Level II should have been completed. The DON said the admissions office reviewed the PASRR Level I screen then nursing management reviewed them as part of the admission process. When asked if the staff were just looking at Section IV that said no Level II required versus reviewing the entire screening, she said, it appears to be that way. The DON said Resident #50 should have a PASRR Level II. An interview was conducted on 2/8/24 at 10:41 a.m. with the Admission Director. She said when they received a PASRR from the hospital, they checked to make sure the Level I screen was in the record. She said they verified it was signed and dated. When asked if that was all they checked she said, pretty much so, When asked if they checked for accuracy of the Level I screening she said yes, especially if we get them from certain hospitals. The Admission Director said they would compare the diagnoses from the hospital to make sure it was correct, then the PASRR was given to the nurses to review in their clinical meeting. She said if she noticed something was not correct, she would give it to the Minimum Data Set (MDS) Coordinator so they could put the codes in. She said if a resident needed a PASRR Level II she gave it to the Social Services Director (SSD) and MDS Coordinator and they took care of it. Regarding Resident #50, the Admission Director said one part said he needed a Level II and one part said he did not. She said she was not sure what should have been done in that case. She said she believed Resident #50's PASRR Level I screening should have gone to the MDS Coordinator, but she did no know if it did. An interview was conducted on 2/8/24 at 10:56 a.m. with Staff C, MDS Coordinator and the Social Services Director. Staff C said they received an admission email with the PASRR before the residents arrived, if they were incorrect, she would let admissions know because that part was prior to the resident arriving in the facility. The SSD said admission was responsible for new admission PASRRS and them being correct when the residents came in. The SSD said no one particular was in charge of making sure the PASRRs were correct and they were going to change the process so no one else fell through the cracks. Review of a facility policy titled Preadmission Screening and Resident Review (PASRR), dated 11/8/21, showed the following: Policy The center will assure that all Serious Mentally Ill (SMI) and Intellectually Disabled (ID) resident receive appropriate pre-admission screenings according to Federal/State guidelines. The purpose is to ensure that the residents with SMI or are ID receive the care and services they need in the most appropriate setting. Procedure 1. It is the responsibility of the center to assess and assure that the appropriate preadmission screenings, either Level I or Level II, are conducted and results obtained prior to admission and placed in the appropriate section of the resident's medical record. 4. If it is learned after admission that a PASRR Level II screening is indicated, it will be the responsibility of Social Services to coordinate and/or inform the appropriate agency to conduct the screening and obtain the results. 7. Social Services will be responsible for coordinating significant change updates of these screenings, conducted by the appropriate agency. These results, along with the results from the previous years will be kept in the appropriate sections of the residents' records. 41015 46234 #2

Based on observation, record review, and interview, the facility failed to ensure care plans were developed to address identified needs for five (Residents #50, #67, #69, #71, #247) of 31 sampled residents. Findings included: 1. Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. In an interview with Resident #71 on 02/05/24 at 12:30 p.m., she revealed she was having difficulty hearing and verbalized she needed hearing aids and had been waiting for them since before Christmas. A review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes A review of the resident's record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate there had been communication with a vendor related to Resident #71's hearing aids. A review of the residents care plans revealed no documentation that would indicate the facility developed a care plan for Resident #71 to address her hearing loss, the need for hearing aids, or the use of hearing aids. In an interview on 02/08/24 at 9:00 a.m., the Social Service Director revealed the resident's hearing aids were not working properly, that a vendor came in during the month of December and he took one of the hearing aids for repair and they were waiting for the hearing aid to come back. The Social Service Director reported the resident reached out to her insurance and was told that she was not due for a new set of hearing aids until August, so they were waiting for the repairs. The Social Service Director was unable to verbalize the name of the vendor or provide any documentation that would determine the status of Resident #71's hearing aids. An interview on 02/08/24 at 09:34 a.m. with Staff C, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Coordinator, revealed Resident #71 did not have a care plan in place to address her hearing loss, the need for hearing aids, or the use of hearing aids. Staff C said, I must have missed it, oversight on my part. Staff C said if someone required the use of hearing aids, typically a care plan was created to address this area of concern. 2. A review of admission records showed Resident #247 was admitted on [DATE] with diagnoses including fracture of part of neck of right femur, malignant neoplasm of prostate, and secondary malignant neoplasm of bone. A review of Resident #247's physician orders showed an order, dated 1/23/24 for Hospice admitting diagnosis: Malignant Neoplasm Prostate. A review of Resident #247's medical records did not reveal any care plans for hospice services. An interview was conducted on 2/8/24 at 9:41 a.m. with Staff C, Minimum Data Set (MDS) Coordinator. She said when Resident #247 came to the facility there were questions if the resident was going to be hospice or not. She said these kinds of things were discussed at the morning meeting, then the orders and care plans were put into the resident's record. Staff C said she did not remember hearing the final decision if Resident #247 was going to be hospice. She said there was no excuse, the resident should have had a hospice care plan in place. A review of admission records showed Resident #50 was admitted on [DATE] with diagnoses including dementia, type II diabetes mellitus, chronic pulmonary edema, brief psychotic disorder, and major depressive disorder. A review of Resident #50's physician orders showed an order, dated 1/29/24, for Hospice Order: [Company] admitting diagnosis Senial [sic] Degeneration of brain. A review of Resident #50's medical records did not reveal any care plans for hospice services. An interview was conducted on 2/7/24 at 4:24 p.m. with the DON. She confirmed Resident #50 began hospices services on 1/29/24. She reviewed the resident's medical record and confirmed there was no hospice care plan. The DON said this should have been reviewed in morning meetings, where the MDS Coordinators were present. They were then tasked with adding the care plans. 3. During an interview on 02/05/24 at 12:35 p.m., Resident #67 stated he has had a seizure disorder for a long while. Resident #67 stated he had been on medication for his seizures with no seizure activity for [AGE] years, however since tapering him off his original seizure medication he has had three seizures since being in the facility. A review of the Admission Record showed Resident #67 had an original admitted on 03/21/23 with diagnoses that included but was not limited to hypertensive disease with heart failure, chronic pulmonary embolism, chronic pulmonary disease, and seizures. A review of the Order Summary Report showed, Resident #67 had a current order dated 01/30/24 for Levetiracetam oral tablet 500 [milligrams] MG give 4 tablets by mouth at bedtime for anticonvulsant. A review of Resident #67's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #67 had a diagnosis of Seizure Disorder. Section C- Cognitive Patterns showed Resident #67 had a brief interview for mental status (BIMS) of 15 (cognitively intact). A review of a progress note dated 12/21/23 showed Resident #67 had a change of condition related to seizure with a new seizure medication recommended. An additional progress note dated 01/27/24 showed Resident #67 had a change of condition related to a seizure with a recommendation for the Resident #67 to be sent to the hospital for evaluation. A review of Resident #67's care plan showed no area of focus related to Resident #67's seizure disorder. During an interview on 01/18/24 at 2:05 p.m., the Director of Nursing stated there should have been a care plan in place for Resident 67's seizure disorder. The DON stated, I think what I did here. I searched for seizure and the other care plan that mentioned seizure came up, so I thought he had one. He is getting one now. He should have had a seizure care plan. A review of the Admission Record showed Resident #69 had an original admitted on 06/20/23 with diagnoses that included but was not limited to Depression, acquired absence of left leg above the knee, bipolar disorder, current episode mixed, unspecified, unspecified mood [Affective] disorder and anxiety disorder unspecified. Review of the Order Summary Report and February 2024 Medication Administration Record (MAR) showed, Resident #69 had the following medication orders: Sertraline HCl Oral Tablet 100 MG (Sertraline HCl)- Give 1 tablet by mouth in the morning for depression dated 12/06/23. Xanax Oral Tablet 0.5 MG (Alprazolam) *Controlled Drug*- Give 1 tablet by mouth two times a day for anxiety dated 12/18/23. Mirtazapine Oral Tablet (Mirtazapine)- Give 7.5 mg by mouth at bedtime for depression dated 12/06/23. A review of Resident #69's Quarterly Minimum Data Set (MDS) dated [DATE] Section I-Active Diagnoses showed Resident #69 had diagnoses of Anxiety Disorder, Depression and Bipolar Disorder. Section C- Cognitive Patterns showed Resident #69 had a brief interview for mental status (BIMS) of 15 (cognitively intact). A review of Resident #69's care plan showed no area of focus related to Depression, Anxiety, Bipolar or the use of psychotropic medications. During an interview on 02/08/24 at 2:05 p.m., the Director of Nursing stated there should have been care plans for his medications. The DON stated, I absolutely thought for sure we worked together to put in a care plan for his antidepressant, antipsychotic, and antianxiety. The DON stated the facility was on top of the drug changes, and we do that right at the time it is discussed. The DON stated, wonder when the facility changed companies some of the care plans went away? The DON confirmed the diagnoses and medications were not on the care plan and should have been. 46234 41015

Based on record review and interview, the facility failed to ensure care plans were revised to reflect two (Residents #10 and #41) out of 19 sampled residents current needs, preferences and changing goals. Findings included: 1. A review of the facility's current smokers list showed Resident #41 was a current smoker in the facility. A review of the Admission Record showed Resident #41 had an original admitted on 09/13/22 with diagnoses that included but was not limited to unspecified Dementia, other specified anxiety orders, Chronic Obstructive Pulmonary Disease (COPD), Atrial Fibrillation and anxiety disorder. A review of the Order Summary Report 02/07/24 showed no current physician order for smoking. A review of Resident #41's Quarterly Minimum Data Set (MDS) dated [DATE], Section C- Cognitive Patterns showed Resident #41 had a Brief Interview for Mental Status (BIMS) of 13 (cognitively intact). A review of a Smoking Evaluation dated 06/27/23 showed Resident #41 was not a current smoker in the facility. An additional Smoking Evaluation dated 06/01/23 showed Resident #41 was a current smoker in the facility and smoked 3-4 times a day. Further review of a Smoking Evaluation dated 05/07/23 showed Resident #41 was not a current smoker in the facility. An additional Smoking Evaluation dated 01/29/23 showed Resident #41 was not a current smoker in the facility. Further review of a Smoking Evaluation dated 09/13/22 showed Resident #41 was not a current smoker in the facility. Review of the care plan showed, Resident must smoke with supervision. A care plan goal showed, Resident will smoke safely with supervision throughout next review . The care plan interventions included: - Monitor for changes in / development of signs & symptoms of breathing difficulty and report to nurse if noted: SOB Cough (productive or non-productive) Fever Chills Difficulty speaking Bluish skin color Changes in cognition - Monitor oral hygiene - Notify charge nurse if it is suspected resident has violated facility smoking policy - Remind resident not to share smoking materials with other Resident who may be unsafe - Remind that it is an infection control hazard to smoke Butts from ashtray or ground - Resident oriented to smoking procedures and areas - Resident will demonstrate ability to physically hold the smoking device while smoking - Resident will demonstrate safe technique for putting out matches or lighter and disposing of ash - Resident will demonstrate the ability to verbalize understanding that smoking materials are for use only in designated smoking areas. During an interview on 02/07/24 at 5:26 p.m., Staff M Restorative Aid (RA) stated that she was the regular smoking aid and confirmed, Resident #41 was not a smoker. Staff M stated Resident #41 had never smoked. During an interview on 02/07/24 at 5:29 p.m., Resident #41 stated, I do not smoke. During an interview on 02/08/24 at 2:05 p.m., the Director of Nursing stated she had never seen Resident #41 outside smoking. The DON confirmed Resident #41 was on the facility's list of current smokers. The DON stated she would have expected the care plan to have been updated after last assessment. 48223 2. On 2/5/2024 at 9:30 a.m., Resident #10 was observed lying in her bed with the covers over her sleeping. Resident #10 had an Enhanced Barrier Precaution Sign on the door to her room. A review of Resident #10's Admission Record showed an admitted [DATE] and a re-admission of 1/25/2024. Resident #10 had diagnoses of: Sepsis, Pneumonia, Dementia and other co-morbidities. A review of Resident #10's Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form - AHCA Form 5000-3008, dated 1/17/2024 showed the resident had C. Auris and C. Diff. A review of Resident #10's Order Summary with an active date of 2/7/2024 showed no order for isolation. A review of Resident #10's Medication Administration Record (MAR) for February 2024 showed the resident was receiving treatment for C-Diff for 7 days. Start date was 1/26/204 to 2/2/2024. A review of Resident #10's Care Plan revealed a care plan with a focus of [Resident #10] has active infection in stool: C. Diff date initiated 1/26/2024. An interview was conducted with Staff C, Licensed Practical Nurse (LPN) Minimum Data Set (MDS) Coordinator on 2/8/2024 at 9:34 AM. Staff C, LPN confirmed she was responsible for updating and developing care plans along with the MDS for each resident. Staff C, LPN stated the care plan for Resident #10 should have been resolved for the C. Diff on 2/3/2024. Staff C, LPN continued to state Resident #10 should have a care plan for the C. Auris. Review of the facility's policies and procedures with the subject of Plans of Care dated 9/25/2017. Policy: an individualized person-centered plan of care will be established by the interdisciplinary team (IDT) with the resident and/or resident representatives to the extent practicable and updated in accordance with state and federal regulatory requirements. Plan of care is to be maintained as part of the final medical record. Procedure: . develop and implement an individualized person-centered comprehensive plan of care by the interdisciplinary team that includes but is not limited - to the attending physician, a registered nurse with responsibility for the resident, a nurse aide with responsibility for the resident, a member of food and nutrition services staff, and other appropriate staff or professionals in disciplines as determined by the residents needs or as requested by the resident, and, to the extent practicable, the participation of the resident and the residents representatives within seven days after completion of the comprehensive assessment (MDS). Review update and or revise the comprehensive plan of care based on changing goals, preferences and needs of the resident and in response to current interventions after the completion of each OBRA MDS (except discharge assessments), and as needed

Based on observation, record review and interview the facility failed to provide the appropriate treatment and assistive device to maintain residents hearing abilities for 1 of 31 (#71) total sampled residents. Findings included: Resident #71 was admitted to the facility on [DATE] and readmitted on [DATE] and had a Brief Interview for Mental Status (BIMS) score of 15 (Cognitively intact) dated 11/17/23. Interview with Resident #71 on 02/05/24 at 12:30 PM the resident revealed that she was having difficulty hearing and verbalized that she needs hearing aids and has been waiting for them since before Christmas. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that under the heading of Hearing the following was documented: -Moderate difficulty -Hearing aid Yes Review of the residents record revealed no documentation related to the resident having difficulty with hearing aids and no documentation that would indicate that there had been communication with a vendor related to Resident #71's hearing aids. Review of the residents care plans revealed no documentation that would indicate that the facility developed a care plan for Resident #71 to address her hearing loss, the need for hearing aids, and the use of hearing aids. Interview on 02/08/24 at 09:00 AM with the Social Service Director revealed that the residents hearing aids were not working properly, that a vendor came in during the month of December and he took one of the hearing aids for repair and that they were waiting for the hearing aid to come back. The Social Service Director reported that the resident reached out to her insurance and was told that she is not due for a new set of hearing aids until August, so they are waiting for the repairs. The Social Service Director was unable to verbalize the name of the vendor or provide any documentation that would determine the status of Resident #71's hearing aids. Interview on 02/08/24 at 09:34 AM with Staff C, Licensed Practical Nurse (LPN), Minimum Data Set (MDS) Coordinator, revealed that Resident #71 does not have a care plan in place to address her hearing loss, the need for hearing aids, and the use of hearing aids. Staff C reported that I must have missed it, oversight on my part. Staff C reported that if someone requires the use of hearing aids that they would typically create a care plan to address this area of concern. Review of the facilities policy titled Care of Hearing Aid with an effective date of 11/30/2014 and a revision date of 9/1/17 revealed that the facility is to Contact service agency if hearing aid fails to function properly.

Based on observations, record review, and interviews, the facility failed to ensure appropriate services and equipment related to splint application for one (Resident #64) of two sampled residents. Findings included: Multiple observations were conducted of Resident #64, from 2/5/2024 at 9:58 a.m. to 2/8/2024 at 10:00 a.m. Resident #64 was observed in bed, with the head of the bed slightly raised without any splints or braces on the upper body or hands. Both of the hands of Resident #64 were closed, fingers bent touching the palms, wrists were curved under toward the forearms. A review of the medical record for Resident #64 was conducted. The Admission Record revealed Resident #64 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: Acute Respiratory Failure with Hypoxia, Tracheostomy status, Gastrostomy Status, Contracture of Right Hand, Contracture of Left Hand, Persistent Vegetative State and other co-morbidities. The Minimum Data Set (MDS) assessment dated [DATE] revealed in Section G the upper extremities had impairment on both sides and the lower extremities had no impairment (bilaterally). The MDS revealed Resident #64 required total assistance with all activities of daily living (ADL) performance. The MDS dated [DATE] showed Section GG to have impairments on upper and lower extremities and did not have a restorative program marked. The physician's orders for Resident #64 showed an order initiated on 1/15/2024 for splints to bilateral hands to prevent contractures and increase range of motion daily per patient tolerance. The care plan for Resident #64 revealed a focus area for: [Resident #64] is at risk for alteration in comfort related to areas of impaired skin integrity, decreased range of motion to bilateral hands. 8/4/2022 impaired range of motion to the right elbow. 10/9/2022 impaired range of motion to the right elbow date initiated on 7/6/2022 and revised on 10/12/2022. Interventions to include: bilateral hand splints as ordered per Medical Doctor (MD). Date initiated on 9/14/2022 revised on 1/9/2024. Provide passive range of motion to bilateral upper extremities and bilateral lower extremities daily during ADL tasks. Date initiated 7/6/2022 revised on 1/9/2024. An interview was conducted with Staff W, Certified Nursing Assistant (CNA) on 2/7/2024 at 1:45 p.m. Staff W confirmed working with Resident #64 on a regular basis. Staff W, CNA stated, No, I do not do ROM for [Resident #64], Restorative does. An interview was conducted with Staff X, Occupational Therapy Assistant (OTA) on 2/7/2024 at 3:25 PM. Staff X confirmed filling in for the Director of Rehabilitation and stated the therapy department recommended residents for the Restorative Nursing Program if needed. When records were requested in regards to Resident #64, Staff X stated the rehabilitation department did not have any records for residents prior to November 2023. When the company was bought out (changed) the facility lost the ability to access the prior records. An interview was conducted with Staff Y, Occupational Therapist (OT) on 2/7/2024 at 3:30 PM. Staff Y stated there were no documents in the computer in regard to Resident #64. Staff Y stated this would mean Resident #64 was not on a Restorative Nursing Program for range of motion. An interview was conducted with Staff Z, CNA on 2/7/2024 at 3:45 p.m. Staff Z, CNA confirmed one of the responsibilities assigned to her was restorative. Staff Z stated I don't see [Resident #64] anymore, I am not sure why. [Resident #64] needs splints for the hands. [Resident #64] does not have splints. I have told therapy. I think they are supposed to order them. An interview was conducted with Staff H, Registered Nurse (RN) on 2/7/2024 at 5:00 p.m. Staff H stated the Restorative Certified Nursing Assistant was the only staff who completed Range of Motion (ROM) for Resident #64. An interview was conducted with the Director of Nursing on 2/8/2024 at 9:45 a.m. The DON stated the expectation was for the physician order to be followed, the splints should be worn as ordered. The CNAs are all responsible for ROM not just restorative. An interview was conducted with the Regional Nurse Consultant on 2/7/2024 at 12:35 p.m. The Regional Nurse Consultant stated that a Policy and Procedure for Range of Motion did not exist. The facility followed standards of Care.

Based on observations, interviews, and record review, the facility failed to ensure sufficient staffing in order to provide care and services for two (Residents #245 and #45) of five residents reviewed for timely medication administration. They also failed to ensure sufficient staffing to provide call light assistance for residents based on Resident Council Meeting Minutes for two of six months reviewed. Findings included: 1. An interview was conducted on 2/6/24 at 10:57 a.m. with Resident #245. The resident stated he had not yet received his 9:00 a.m. medication. An interview was conducted on 2/6/24 at 10:58 a.m. with Staff G, LPN. Staff G confirmed 9:00 a.m. medications had not been administered to all residents in room [ROOM NUMBER]-111, including Resident #245. Staff G said she was doing her best, but she was assigned 30 residents; two of which had a wound vacuum, 3 or 4 were on IV medications, some with fall risks, some new admissions, and some residents with aphasia. She said staffing is not done based on acuity of residents; it is only based on numbers. Staff G said she was also having to share a medication cart with other nurses due to the way the assignment was divided because there are only 3 nurses working on the floor and she was just given the keys to the medication cart. An observation was conducted on 2/6/24 at 11:19 a.m. of Staff G, LPN preparing and administering medication for Resident #45. Staff G prepared Bupropion, Spironolactone, and Eliquis. The resident refused Bupropion and was administered Spironolactone and Eliquis. Reconciliation with physician orders showed all three medications were scheduled to be administered at 9:00 a.m., they were administered two hours and 19 minutes late. An interview was conducted on 2/6/24 at 12:35 p.m. with Staff H, RN. She said, It's a lot. We don't have enough nurses. Staff H confirmed staff could not get all medication and care done when it was scheduled. An interview was conducted on 2/7/24 at 2:01 p.m. with the DON. She said she knew they needed more nurses on the floor, and she was trying to get approval for another nurse. An interview was conducted on 2/8/24 at 12:37 p.m. with Staff B, LPN. She said there definitely isn't time to get everything done and they need more staff to help. Staff B said medication was regularly late. She said she was working the split assignment (assigned residents from both units) and when she was on one unit, she could not keep her eyes on the residents she had on the other unit. She said if a resident were to yell out, she would not be able to hear them. Staff B also said call bells were not answered timely by The Certified Nursing Assistance (CNA)s because they were running themselves to death and can't get to everything. An interview was conducted on 2/8/24 at 12:43 p.m. with Staff D, CNA. She said she was not able to get all of her job done, not in a timely manner anyway. She said it was hard especially when a nurse was working on the assignment split between the two units. She said the nurse would be on one unit and the CNA on the other and residents were asking for medications. Staff D confirmed it took a while for CNAs to answer call bells for residents. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) As for late medication, the DON said, I know nurses don't have time to get all the medication administered on time. She said there had been complaints and concerns from family members and the facility needed four nurses working on the medication carts. On 2/8/24 the Nursing Home Administrator (NHA) and DON confirmed there was no policy related to staffing. 2. Review of the Resident Council Minutes dated October 2023 reveals Old Business concern relating to staff hiding out in rooms on 3-11/11-7 (shifts) and dayrooms and call lights are on for a long time. Under the section New Business: ongoing issues of cell phone/ear bud usage and call lights. Review of the Resident Council Minutes dated December 2023 reveals the section New Business: ongoing issues of cell phone/ear bud usage; Certified Nursing Assistants (CNAs) not making beds when requested and call lights when staff are sitting at the nurses station. Review of the Resident Council Minutes dated January 2024 reveals the section New Business: CNAs continue to not make beds for residents when they request. During an interview on 2/8/2024 at 9:55 AM with the Resident Council President. The Resident Council President stated the concerns regarding: call lights, staff sitting around (hiding), and talking on their phones with ear buds on continues to be an ongoing issue. Review of the grievances log for January 2024 revealed nine grievances related to call lights taking longer than 20 minutes to answer, and four related to medication administration times being late. During an interview on 2/8/2024 at 12:55 PM with the NHA. The NHA stated the facility strictly staffs based on number of residents, not acuity. 46234

Based on observations, interviews, and record review, the facility did not ensure the medication error rate was below 5% for three (Residents #79, #48, #45) out of five sampled residents who were administered medications. This resulted in seven errors from 27 medication administration opportunities for a medication error rate of 25.93%. Findings Included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. Review of Resident #79's physician orders showed an order for a multivitamin-minerals tablet to be administered at 9:00 a.m. Review of the Medication Administration Record (MAR) showed the medication was signed off but was not observed to be administered. There was a physician order, dated 12/26/23, for Metoprolol Tartrate 25 mg, 1 tablet given every 12 hours for hypertension and an order, dated 1/16/24, for Midodrine 2.5 mg, 1 tablet three times a day for hypotension; hold if systolic blood pressure is greater than 110. Staff F, LPN did not take Resident #79's blood pressure prior to administering the blood pressure medications. The resident was administered Midodrine for hypotension and Metoprolol for hypertension simultaneously. After administration Staff F, LPN asked another staff member to go take the resident's blood pressure because she was unable to check off the medication in the computer as administered without entering a blood pressure. Review of Resident #79's Weights and Vitals Summary show his blood pressure was taken at 9:31 a.m. on 2/6/24 and had a reading of 128/78, meaning the Midodrine should have been held due to the systolic blood pressure being 128 (greater than 110.) The Weights and Vitals Summary also showed the resident's blood pressure was not being taken before each administration of Midodrine to ensure the reading was within the physician outlined parameters and when it was taken his systolic blood pressure was greater than 110 from 2/1/24 through 2/7/24. Review of the MAR showed Midodrine had being administered to Resident #79 three times a day from 2/1/24-2/7/24. An observation was conducted on 2/6/24 at 9:15 a.m. of Staff F, LPN preparing and administering medication for Resident #48. The nurse administered the following medications: -Atenolol 50 mg x 2 tablets -Gemtesa 75 mg x 1 tablet -Apixaban 5 mg x 1 tablet -Iron 325 mg x 1 tablet -Keppra 100 mg/ml x 5 ml. -Magnesium oxide (not in the cart. Nurse said she will get a new bottle then administer) All medications were crushed and administered in pudding. Review of Resident #48's physician orders showed an order, dated 10/6/23, for Gemtesa 75 mg x 1 tablet via gastrostomy tube (g-tube) one time a day for overactive bladder and an order, dated 10/6/23, for Iron supplement oral elixir. Give alternating dose of 220 ml/5 ml via g-tube 5 ml two times a day for anemia. Staff F, LPN was observed to administer Gemtesa and Iron to Resident #48 by mouth. An interview was conducted on 2/6/24 at 4:50 p.m. with Staff F, LPN. She said Resident #48 takes medications by mouth and her g-tube and she thought that was a recent change. Staff F, LPN said she should have called the doctor to see if he wanted all the medications changed to oral. An observation was conducted on 1/6/24 at 11:19 a.m. of Staff G, LPN preparing and administering medication for Resident #45. The nurse administered the following medications: -Bupropion 75 mg x 1 tablet (resident refused) -Spironolactone 100 mg x 1 tablet -Apixaban 5 mg x 1 tablet Review of physician orders and the MAR showed these medications were scheduled to be administered at 9:00 a.m. They were administered at 11:19 a.m., 2 hours and 19 minutes after their scheduled time. The Bupropion 75 mg tablet was signed off on the MAR as given when the resident refused the medication. An interview was conducted with Staff G, LPN at the time of administration. She said she just received the keys to the medication cart due to two nurses sharing the cart and her having an assignment split between two units. The nurse said she had 30 residents assigned to her and she was not able to do her best work with that many residents. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) She said nurses had all recently been educated on medication administration. Regarding Resident #48 she said it seemed like the nurse did not check the route of administration and the nurse should have called the physician to see if it was ok to give the medication orally. As for late medication, the DON said, I know nurses don't have time to get all the medication administered on time. She said there have been complaints and concerns from family members and the facility needs four nurses working on the medication carts. Review of a facility policy titled Medication Administration-General Guidelines, dated April 2018, showed the following: Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so, Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration.) The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures A. Preparation . 4. FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just aft the dose is prepared and the medication put away. 5. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the residence medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. . B. Administration . 2. Medications are administered in accordance with written orders of the prescriber. . 11. A schedule of routine dose administration times is established by the facility and utilized on the administration records. 12. Medications are administered within 60 minutes of scheduled time, except before, with, or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. .

Based on observation, interview, and record review facility failed to ensure two residents (#79 and #65) out of three residents reviewed for blood pressure medication were free from significant medication errors related to blood pressure medication. Findings included: An observation was conducted on 2/6/24 at 9:05 a.m. of Staff F, Licensed Practical Nurse (LPN) preparing and administering medication for Resident #79. The nurse administered the following medications: -Midodrine 2.5 mg x 1 tablet -Folic acid x 1 tablet -Glipizide XL Extended Release (ER) 5 mg x 2 tablets -Loratadine 10 mg x 1 tablet -Metoprolol 25 mg x 1 tablet Staff F, LPN did not take Resident #79's blood pressure before administering these medications. Review of Resident #79's physician orders showed an order for a multivitamin-minerals tablet to be administered at 9:00 a.m. Review of the Medication Administration Record (MAR) showed the medication was signed off but was not observed to be administered. There was a physician order, dated 12/26/23, for Metoprolol Tartrate 25 mg, 1 tablet given every 12 hours for hypertension and an order, dated 1/16/24, for Midodrine 2.5 mg, 1 tablet three times a day for hypotension; hold if systolic blood pressure (SPB) is greater than 110. Staff F, LPN did not take Resident #79's blood pressure prior to administering the blood pressure medications. The resident was administered Midodrine for hypotension and Metoprolol for hypertension simultaneously. After administration Staff F, LPN asked another staff member to go take the resident's blood pressure because she was unable to check off the medication in the computer as administered without entering a blood pressure. Review of Resident #79's Weights and Vitals Summary show his blood pressure was taken at 9:31 a.m. on 2/6/24 and had a reading of 128/78, meaning the Midodrine should have been held due to the systolic blood pressure being 128 (greater than 110.) The Weights and Vitals Summary also showed the resident's blood pressure was not being taken before each administration of Midodrine to ensure the reading was within the physician outlined parameters and when it was taken his systolic blood pressure was greater than 110 from 2/1/24 through 2/7/24. Review of the MAR showed Midodrine had being administered to Resident #79 three times a day from 2/1/24-2/7/24 regardless of blood pressure reading. Review of admission records showed Resident #79 was admitted on [DATE] with diagnoses including traumatic subdural hemorrhage with loss of consciousness, atrial fibrillation, epilepsy, and dementia. The resident was not able to be interviewed. Review of physician orders for Resident #65 showed an order in place, dated 11/22/23, for Midodrine 5 mg every 8 hours for hypotension. Hold if SBP >110. The order was discontinued on 12/13/23. Review of the December MAR for Resident #65 showed the medication was administered nine times when the SBP was higher than 110 from 11/22/23 through 12/13/23. An order was in place from 12/13/23 to 12/15/23 for Midodrine 5 mg three times a day for Hypotension. Hold if SPB >110. Review of the December MAR for Resident #65 showed the medication was administered one time when the SBP was higher than 110 from 12/13/23 through 12/15/23. An order was in place beginning on 12/15/23 for Midodrine 5 mg every 8 hours for hypotension. Hold is SBP > 110. This order was put in without triggering to have the resident's blood pressure taken. Review of the December and January MAR showed this medication was administered three times a day with no regard for the resident's blood pressure. Review of admission records showed Resident #65 was admitted on [DATE] with diagnoses including critical illness polyneuropathy, anoxic brain damage, and history of sudden cardiac arrest. The resident was not able to be interviewed. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) She said nurses had all recently been educated on medication administration. She said there have been complaints and concerns from family members and the facility needs four nurses working on the medication carts. An interview was conducted on 2/20/24 at 1:05 p.m. with the Director of Nursing (DON.) She said she didn't know why it was not in the computer to trigger the blood pressure to be taken when giving blood pressure medication for Residents #79 and #65. Reviewing the medical records for Resident #79 and #65, the DON said blood pressure should have been taken every time the resident was scheduled to be administered Midodrine, due to the order having a parameter. The DON said, it doesn't make sense. The DON said when the order was entered into the system, the person ordering should be setting it to trigger the nurse to take the blood pressure. The DON said while reviewing resident records, she had just noticed some residents do not have parameters on their orders. The DON said she will be reaching out to providers to add parameters and she will be triggering blood pressures to be taken prior to administration. The DON reviewed Resident #65's MAR for December and confirmed the resident's blood pressure medication was administered on multiple occasions when the resident's blood pressure was not within the ordered parameter to be given. She said she can't say why that happened. An interview was conducted on 2/20/24 at 1:48 p.m. with the facility's consultant pharmacist. The pharmacist said there is not a specific guideline for taking blood pressure for resident's that were stable on blood pressure medication, however, if the doctor has written a parameter to hold or give then the blood pressure would need to be checked to make sure it is within those parameters. Review of a facility policy titled Medication Administration-General Guidelines, dated April 2018, showed the following: Policy Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so, Personnel authorized to administer medications do so only after they have been properly oriented to the facility's medication distribution system (procurement, storage, handling, and administration.) The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions. Procedures A. Preparation . 4. FIVE RIGHTS- Right resident, right drug, right dose, right route and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just aft the dose is prepared and the medication put away. 5. The medication administration record (MAR) is always employed during medication administration. Prior to administration of any medication, the medication and dosage schedule on the residence medication administration record (MAR) are compared with the medication label. If the label and MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule. . B. Administration . 2. Medications are administered in accordance with written orders of the prescriber. . 11. A schedule of routine dose administration times is established by the facility and utilized on the administration records. 12. Medications are administered within 60 minutes of scheduled time, except before, with, or after meal orders, which are administered based on meal times. Unless otherwise specified by the prescriber, routine medications are administered according to the established medication administration schedule for the facility. .

Based on observation, interview, and record review, the facility failed to ensure the proper diet, free of allergens, was served to one (Resident #42) of three reviewed for dietary restrictions. Findings included: An interview was conducted on 2/5/24 at 11:35 a.m. with a family member of Resident #42. The family member said Resident #42 was lactose intolerant and could not have dairy products and the facility continued to serve them to the resident. They said the resident had diarrhea when she consumed lactose products. The resident was observed to have a lunch tray with a grilled cheese sandwich. The family said they notified staff and asked them to send a different lunch for the resident. The family said they do not feel like dietary staff know what lactose is. (Photographic evidence obtained.) An observation was conducted on 2/5/24 at 11:50 a.m. of Resident #42's replacement lunch tray. The resident was sitting in a chair at her bedside eating her new lunch tray. The lunch consisted of chicken, broccoli, mashed potatoes, bread, and macaroni and cheese. The resident had eaten about half of the macaroni and cheese. She was asked if she knew what it was, and she said she didn't know. (Photographic evidence obtained.) A review of admission records showed Resident #42 was admitted on [DATE] with diagnoses including Type II Diabetes Mellitus, Protein-Calorie Malnutrition, Anemia, dysphagia, Vitamin D deficiency, and cognitive communication deficit. Resident #42's allergies included lactose intolerant. A review of medical records for Resident #42 revealed a care plan in place for Malnutrition r/t [related to] dysphagia, revised 10/11/23. Interventions included honor food preferences within meal plan and provide diet as ordered. A review of the facility's Allergy Report listed Resident #42 as being lactose intolerant at a moderate severity with the reaction listed as loose stools. A review of physician orders for Resident #42 showed an order, dated 12/29/23, for regular diet, regular texture. An interview was conducted on 2/5/24 at 4:45 p.m. with Resident #42 as she was leaving the dining room. The resident was asked what she had for dinner, and she said she had pizza. An unknown aide was walking by and confirmed the resident had eaten cheese pizza with no additional toppings. The resident nodded in agreement. An observation was conducted on 2/7/24 at 8:40 a.m. of Resident #42 finishing her breakfast. The resident was sitting in a chair at her bedside with her breakfast tray in front of her. Her plate was observed to have remnants of eggs and cheese. Her tray card showed MILK Lactaid and her diet was noted as Regular with Lactate* underneath. The tray card did not note lactose intolerance or no dairy products. For the days breakfast it said, No sub found for Cheese Omelet. (Photographic evidence obtained.) An interview was conducted on 2/7/24 at 11:38 a.m. with the Certified Dietary Manager. He said residents that were lactose intolerant should not get cheese on their eggs, they should only receive plain eggs. Additionally, he said if something like macaroni and cheese was being served the resident would be served an alternate item. An interview was conducted on 2/8/24 at 12:55 p.m. with Staff K, Cook. He said he served food on the serving line. He said for residents with allergies, the person working at the front of the line told him what allergies the residents had or diets they were on. He said from his understanding the person at the end of the line checked the tray cards and made sure the food was correct before putting the lid on the plate and placing the tray on the carts to be delivered. Staff K said, they are the last line of defense in the kitchen. He said they had a new company with different tray cards and the information the cards gave was pretty basic. An interview was conducted on 2/8/24 at 1:03 p.m. with Staff L, Interim Dietary Director. Staff L said the person at the front of the serving line should be letting the cook know what items residents could and could not have. Staff L reviewed Resident #42's tray card and noted it said Lactaid. He said staff should know that Lactaid meant the resident could not have milk products, but he was going to add more details to the tray card. Staff L was very surprised to hear Resident #42 had received dairy products multiple times in the last few days. He said this must have slipped through. An interview was conducted on 2/8/24 at 1:21 p.m. with the Director of Nursing (DON.) The DON said meal trays should be checked when they were loaded in the kitchen, but staff should also be verifying the diets when trays were passed to residents. She said the only reason a diet could vary was if a resident was competent and requested something. She said that was not the case with Resident #42. She said she would work with dietary to ensure they knew what someone with lactose intolerance could and could not have. Review of a facility policy titled Food Likes and Dislikes, undated, showed the following: Policy: The food likes, dislikes, allergies and intolerances of each resident are determined through a dietary assessment. Procedure: 1. A record shall be maintained of the resident's likes, dislikes, allergies, and intolerances. Such record will include how the resident prefers his/her food to be served. (i.e., cut, chopped, or ground.) 2. Residents shall be visited periodically to determine if any changes need to be made in order to meet the resident's needs. 3. Electronic database will be updated each time changes are made to the resident's needs.

Based on observation, review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to protect the resident's right to be free from abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, a Certified Nursing Assistant (CNA) reported to a Licensed Nurse Supervisor that Resident #7 was found in bed with a sheet tied across her midsection and fastened to the bedframe. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Nursing Home Administrator (NHA), who also served as the facility's Abuse Coordinator. The facility failed to implement a systematic process to carry out their abuse policy for Resident #7, a cognitively impaired resident who was dependent on staff for all care and services. The facility failed to identify the incident as abuse. The facility failed to take actions to report, thoroughly investigate, protect Resident #7, and take corrective action to determine the root cause of the abuse to ensure all facility residents would remain safe from a similar incident. This resulted in findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference F609, F610, and F835 On 11/01/2022 at 1:41 p.m., during an interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. On 10/31/2022 at 1:00 p.m., Staff D, LPN confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/UM] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . On 10/31/2022 at 11:38 a.m., an attempt was made to interview Resident #7. She was observed lying in her bed in her room. The television was on and no restraints were visible. Resident #7 was alert and her eyes were open. She made eye contact when addressed but did not respond verbally to simple questions. She closed her eyes during the visit and appeared to fall asleep. Review of Resident #7's medical record was conducted on 10/31/2022. The admission record revealed the resident was [AGE] years old and originally admitted to the facility on [DATE]. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a [CONDITION(S)], no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed: A focus area, initiated on 7/22/2022 and last revised on 7/28/2022, for alteration in her ability to perform self-care tasks related to weakness, impaired mobility and cognition, which required extensive assistance during Activities of Daily Living (ADL) tasks. Interventions included Staff to maintain [Resident #7's] safety and dignity while assisting her during ADL tasks. A focus area, initiated on 8/9/2022 and revised on 10/29/22, for exhibiting inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected. Interventions included: anticipate and meet the resident's needs (created 8/10/2022); caregivers to provide opportunity for positive interaction, attention (created 8/10/2022); intervene as necessary to protect the rights and safety of others (created 8/10/2022); and resident prefers to keep clothing on while in bed (initiated by the DON on 10/25/2022). A focus area, initiated and revised on 7/28/2022, for impaired cognitive function and/or impaired thought process related diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #7 is oriented to person, aphasic (mumbled speech), and speaks mostly Spanish which is an additional risk factor. Resident is sometimes understood and sometimes understands others. Interventions included: cue, reorient and supervise as needed; defer to Spanish speaking staff and/or family to assist with communication during times when resident reverts back to native language; and keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. A focus area, initiated and revised on 7/28/2022, for risk of falling related to weakness, impaired mobility, and cognition related to diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions included: be sure the resident's call light is within reach on her left side and encourage the resident to use for assistance as needed. The resident needs prompt response to all requests for assistance. Review of the progress notes for October 2022 revealed an entry dated 10/25/22 5:00 p.m. titled Skin/Wound Note authored by the NHA. The note read: This writer spoke with Resident #7's niece regarding resident's plan of care (POC). Res[ident] continues to be fidgety moving in/out of bed. Discussed alternatives such as psych interventions, reiterated facility is restraint free environment. Niece agrees with POC. Informed her of new open area on right lateral ankle identified earlier today. Treatment in place and wound care consultant scheduled for visit tomorrow. Niece consents/agrees with psych and wound consult. She reported son visited yesterday. No other issues or concerns identified. She plans to attend next care plan meeting as per usual schedule. There was another entry dated 10/25/22 3:26 p.m. authored by the DON and Staff C, LPN, UM titled, Skin Only that read: Skin Evaluation: Skin warm & dry, skin color WNL [within normal limits] .Resident has current skin issues. Skin Issue: Pressure Ulcer/Injury. Skin issue location: Right lateral ankle Pressure Ulcer/Injury Stage: Stage II - Partial thickness skin loss. Length: 2cm [centimeter] Width: 2cm Depth: 0cm . Skin Issue: Moisture Associated Skin Damage (MASD). Skin issue location: left flank . On 10/31/2022 the medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. Review of facility log titled Incidents By Incident Type was conducted on 10/31/2022. The log did not reveal any entries related to Resident #7 on 10/25/2022. Review of facility log titled Abuse/Adverse Event Log was conducted on 10/31 /2022. The log for October 2022 did not reveal any entries related to Resident #7. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H/CNA was suspended pending investigation but said Staff I/LPN and Staff J/LPN were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA said, there was never any indication from [Resident #7's niece] that she thought this was abuse related. The NHA stated the facility's Social Services Director (SSD) did a trauma assessment and said, and I think also a BIMS assessment. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. On 10/31/2022 at 5:00 p.m., a follow-up interview with the NHA revealed the SSD performed a psychosocial assessment on the wrong resident (another resident in the facility with the same last name), which was why it wasn't documented in Resident #7's medical record. She stated the consultant psychiatric provider did see Resident. #7 in response to the incident. The NHA stated she would provide the psychiatric note once it was sent over from the provider. On 11/02/2022 at 10:28 a.m., the SSD reported she was aware of the restraint incident involving Resident #7 on 10/25/2022. She confirmed she was informed about the incident by the DON either the same day (10/25/2022) or the next day (10/26/2022). The SSD said, I was asked to do an assessment on her including BIMS and trauma assessment, but she [the DON] told me the wrong person. She told me [another resident's name] instead of [Resident #7] so I did a BIMS on [other resident]. I went back and let them [the NHA and DON] know I had done the BIMS, didn't think to tell her name. The next day in morning meeting, they asked did I do the BIMS because they couldn't find it. That's when they clarified that it was Resident #7 . they said they directed me to do it after the clarification, but that's not what I understood. The SSD confirmed she had never completed any assessment of Resident #7 related to the incident on 10/25/2022 and said she had not conducted or documented any assessments on Resident #7 since beginning employment at the facility around 09/25/2022. Review of facility policy titled Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 1. The facility will develop and implement written policies and procedures that: a. Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property; b. Establish policies and procedures to investigate any such allegations; and c. Include training for new and existing staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, reporting procedures, and dementia management and resident abuse prevention; and d. Establish coordination with the QAPI (Quality Assurance and Performance Improvement) program. 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. 3. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. II. Employee Training A. New employees will be educated on abuse, neglect, exploitation and misappropriation of resident property during initial orientation. B. Existing staff will receive annual education through planned in dash services and as needed. C. Training topics will include: 1. Prohibiting and preventing all forms of abuse, neglect, misappropriation of resident property, and exploitation; 2. Identifying what constitutes abuse, neglect, exploitation, and misappropriation of resident property; 3. Recognizing signs of abuse, Neglect, Exploitation and misappropriation of resident property, such as physical or psychosocial indicators; 4. Reporting process for abuse, neglect, exploitation, and misappropriation of resident property, including injuries of unknown sources; 5. Understanding behavioral symptoms of residents that may increase the risk of abuse and neglect, such as: a. Aggressive and/or catastrophic reactions of residents; b. Wandering or elopement-type behaviors; c. Resistance to care; d. Outbursts or yelling out; and e. Difficulty in adjusting to new routines or staff. III. Prevention of Abuse, Neglect and Exploitation The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, and misappropriation of resident property, and exploitation that achieves: B. Identifying, correcting and intervening in situations in which abuse, neglect, exploitation, and\or misappropriation of resident property is more likely to occur with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned. Have knowledge of the individual resident's care needs and behavioral symptoms; D. The identification, ongoing assessment, care, planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect; F. Providing residents, representatives, and staff information on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed; H. Assigning responsibility for the supervision of staff on all shifts for identifying inappropriate staff behaviors. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse-mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. exercising caution and handling evidence that could be used in a criminal investigation. (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and\or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Reporting/Response A. The facility will have written procedures that include.: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified time frames: a. Immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve abuse . or b. Not later than 24 hours if the events that caused the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime . 5 Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and\or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. VIII. Coordination with QAPI A. The facility has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program. 1. Cases of physical or sexual abuse, for example by facility staff or other residents, will be reviewed for and receive corrective action and tracking by the QAA (Quality Assurance and Assessment) Committee. This coordinated effort results in the QAA Committee determining: a. If a thorough investigation is conducted; b. Whether the resident is protected; c. Whether an analysis was conducted as to why the situation occurred; d. Risk factors that contributed to the abuse (e.g., history of aggressive behaviors, environmental factors); and e. Whether there is further need for systemic action such as: i. Insight on needed revisions to the policies and procedures that prohibit and prevent abuse/neglect/misappropriation/exploitati [TRUNCATED]

Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's psychiatric practitioner, and the facility medical director, it was determined the facility failed to [MEDICATION(S)] to promptly report abuse of one (Resident #7) of three residents reviewed for abuse. On 10/25/2022 a nursing staff member reported to their superior that they found Resident #7 in her bed with a sheet tied across her midsection and fastened to the bedframe during performance of morning care tasks. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA). Resident #7 was a cognitively and physically impaired individual who had a communication deficit and was dependent on facility staff for all care and services. The facility's failure to report the incident in accordance with the regulations and the facility's abuse policy and procedure placed this resident and other residents at risk from a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, serious psychosocial harm (using the psychosocial severity guide), serious impairment or death due to ligature risk and resulted in findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference to F600, F610, and F835 Review of facility policy titled, Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: 2. The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse and certain resident to resident altercations. B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse 2. Physical marks such as bruises or patterned appearances such as a hand print, belt or ring mark on a resident's body 3. Physical injury of a resident, of an unknown source 4. Resident reports of theft of property, or missing property 5. Verbal abuse of a resident overheard 6. Physical abuse of a resident observed 7. Psychological abuse of a resident observed 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 4. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service; 5. Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. On 11/01/2022 at 1:41 p.m., Staff E, Certified Nursing Assistant (CNA) reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. On 10/31/2022 at 1:00 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/Unit Manager (UM)] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. An interview was conducted with Staff B, Licensed Practical Nurse (LPN) on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. Review of facility log titled Incidents By Incident Type and the Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs did not reveal any entries related to Resident #7 in October 2022. Review of Resident #7's medical record was conducted on 10/31/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a [CONDITION(S)], no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed she required extensive assistance during Activities of Daily Living (ADL) tasks; exhibited inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected; had impaired cognitive function, oriented to person only, and had impaired communication abilities both for understanding others and making herself understood; and was at risk for falls related to weakness, impaired mobility, and diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress notes for October 2022 revealed an entry dated 10/25/22 5:00 p.m. titled Skin/Wound Note authored by the NHA. The note read: This writer spoke with Resident #7's niece regarding resident's plan of care (POC). Res[ident] continues to be fidgety moving in/out of bed. Discussed alternatives such as psych interventions, reiterated facility is restraint free environment. Niece agrees with POC. Informed her of new open area on right lateral ankle identified earlier today. Treatment in place and wound care consultant scheduled for visit tomorrow. Niece consents/agrees with psych and wound consult. She reported son visited yesterday. No other issues or concerns identified . There was another entry dated 10/25/22 3:26 p.m. authored by the DON and Staff C, LPN, UM titled, Skin Only that read: Skin Evaluation: Skin warm & dry, skin color WNL [within normal limits] .Resident has current skin issues. Skin Issue: Pressure Ulcer/Injury. Skin issue location: Right lateral ankle Pressure Ulcer/Injury Stage: Stage II - Partial thickness skin loss. Length: 2cm [centimeter] Width: 2cm Depth: 0cm . Skin Issue: Moisture Associated Skin Damage (MASD). Skin issue location: left flank . On 10/31/22, Resident #7's medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H/CNA was suspended pending investigation but said Staff I/LPN and Staff J/LPN were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. On 11/02/2022 at 10:25 a.m., a telephone interview was conducted with Staff H, CNA. She confirmed she had worked both the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift from 10/24/2022 - 10/25/2022. She confirmed she was assigned care for Resident #7 for both shifts. She stated she had been a permanent employee at the facility since June 2022 and typically worked the 3:00 p.m. - 11:00 p.m. shift. Staff H said, [Resident #7] likes to dig in her diaper. She pull her diaper off. She pulls at her feeding tube. She digs in her poop. She'll look at you, she'll smile, she screams, she cries, all communication is unintelligible. Staff H stated Resident #7 was not able to make her basic needs known or respond to basic questions. She stated Resident #7 was dependent on facility staff for everything. Staff needed to anticipate her needs, provide all levels of care, and required a mechanical lift for transfers out of bed. Staff H stated she started her shift on 10/24/2022 at about 2:45 p.m. and she did her last resident rounds on 10/25/2022 at about 4:45 a.m. She reported that after she completes her final rounds she does her charting. Staff H thought she clocked out around 7:30 a.m. on 10/25/2022. Staff H reported she changed the resident during both shifts and said, my last rounding and care with [Resident #7] was a little bit after 5 a.m. She was in the bed, did not see a restraint at that time. Staff H said, I never saw that restraint on the resident at any time. Staff H stated she had never received any training on restraint use or abuse at any time from the facility. Staff H confirmed she was no longer employed by the facility and said, they terminated me because I wouldn't write a statement, but by law I don't have to write a statement . On 11/01/2022 at 11:31 a.m., Resident #7's Primary Care Physician (PCP) confirmed he was notified Resident #7 was found tied to her bed with a sheet. He said, it was last Tuesday [10/25/2022], they told me, and I was here in the building. [The DON] told me about it. He said, I inquired if they informed the family and they said they did. He stated he recommended the facility conduct a care plan meeting with the family. The PCP said, I was not a part of the investigation or any other steps because I am not the Medical Director here. The PCP said, I assessed the resident that day. She is nonverbal. I examined her. There were no bruises or marks on the body, vitals were normal. Regarding documentation for that visit the PCP said, I did not document that visit, don't always document all my visits. The PCP stated, restraints should not happen; we cannot do it legally. On 11/01/2022 at 9:30 a.m. the NHA provided a typed summary of the facility's investigation actions. She stated that when she had reviewed the investigation notes and the typed summary after being interviewed on 10/31/2022, she did not discover any additional steps in their investigation that had not already been shared. She confirmed the typed summary was comprehensive and there was nothing additional. She stated Resident #7 was someone who was not able to move and not able to get out of bed. She stated the restraint had not impacted on Resident #7's mobility, had not caused any physical injury or psychosocial harm, and therefore their findings were that no abuse had occurred, and nothing rose to the level of needing to be reported. Review of the typed investigation summary provided by the NHA on 11/01/2022 at 9:30 a.m. revealed: Based on the record review, staff interviews, resident observation and skin evaluation, there is no reason to believe this meets the definition of abuse. There does not appear to be any skin discoloration, injury, pain or psychological distress related to the situation. Unreasonable confinement was also not of concern as staff reported resident still had mobility in bed and movement was not restricted side to side. Although the root cause/purpose of the sheet being tied to the bed frame cannot be identified, it does not appear to be willfully inflicted on the resident. There is no data or evidence to indicate that the resident was harmed in any way or that harm was intended. Corrective action taken: 1. Skin evaluation completed for [Resident #7]. 2. [Staff H], CNA suspended pending investigation. She failed to cooperate with the investigation as she refused to provide a written statement. Her employment was terminated as a result of her insubordination and failure to cooperate with an ongoing investigation. 3. Informed attending MD (medical doctor) and Medical Director 4. [name of niece], niece, informed and aware of situation. 5. Audit: no other residents were identified as having a sheet tied across their abdomen. 6. Review with Regional Nurse Consultant/Regional Director of Operations. 7. DON initiated staff education re [regarding]: restraints. Staff were able to describe types of restraints. 8. Psychiatric ARNP [Advanced Registered Nurse Practitioner] was consulted on 10/27/22. Resident was determined to be at baseline, no changes needed. 9. [Resident #7's] normal body movement was not constricted in any way with the sheet tied across her abdomen. At her baseline, she is not ambulatory and cannot get out of bed. Staff interview revealed that [Resident #7] was still able to have mobility in the bed side to side. There was no skin issue, psychological distress or pain/harm caused secondary to the sheet. On 11/01/2022 at 1:28 p.m., a telephone interview with the facility's Medical Director confirmed the facility informed him of the restraint incident with Resident #7. The Medical Director said, I think they notified me afterwards because they didn't think it was a reportable incident. They notified me a few days later in morning meeting. The Medical Director stated the restraint was described to him as loosely tied. He said, we bantered this around, was almost like trying to make an analogy of a person in a wheelchair who was mobile and putting a laptop or safety belt around them, that would impede their mobility and be considered a restraint. But [Resident #7], I looked at her case, someone bedbound, total care, couldn't move, didn't look good but didn't impede mobility in reality. Regarding whether psychosocial impact was discussed he said, I don't think that came up, no, but that's a good point. He then stated, I think someone said her BIMS was basically zero meaning she wasn't alert and aware of her surroundings so because of that I wouldn't have been worried about psychosocial impact but if she had been alert and aware, I would have been concerned about that. The Medical Director stated he was not asked to participate in an investigation. He said, I don't know if they're done with their investigation, I know they were talking to some people, I don't know the outcome. The Medical Director stated there had been no QA process or meeting related to the incident that he was involved in and said, Our QA is coming up this Thursday so I'm sure it will come up. An interview was conducted with the NHA on 11/02/2022 at 2:00 p.m. She confirmed as of that date and time still no reporting had been done regarding the restraint incident with Resident #7 on 10/25/2022. Regarding how determinations were made on which incidents required reporting to law enforcement she stated the facility followed the elder abuse law and reported incidents when there was a possible crime such a misappropriation or abuse with injury. When asked to explain further she said, I'd have to consult the policy. An interview was conducted with the NHA, DON, and the RNC on 11/02/2022 at 4:07 p.m. The NHA stated that earlier that afternoon she had reported an allegation of abuse related to the incident with Resident #7 on 10/25/2022. She stated she had reported it to the Department of Children and Families (DCF), law enforcement, Resident #7's niece, and filed an immediate federal report to the state agency. She stated the decision to report was because she had received a progress note on 11/02/2022 from Resident #7's PCP for a service date of 10/25/2022 that included the words elder abuse. The RNC stated the assumption was the statement was referring to the incident of Resident #7 being found tied to the bed with a sheet. The NHA stated additional investigation had begun, staff education on abuse had been started, and no additional attention had been given to Resident #7 other than routine care. Regarding the decision to report the incident that day, when previously the decision had been made not to report the incident, the NHA stated the decision was made to report because the PCP used the words elder abuse. The RNC said, prior, based on the evidence there was no evidence of willful intent or psychosocial harm . it [the restraint] wasn't preventing her fr [TRUNCATED]

Based on review of the medical record, incident logs, policy and procedure review, and interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's medical director, it was determined the facility failed to conduct a thorough investigation in response to allegations of witnessed abuse and mistreatment for one (Resident #7) of three residents reviewed for abuse, failed to protect one (Resident #7) of three residents reviewed for abuse from further abuse and mistreatment, and failed to implement corrective action in a timely manner to protect all facility residents from a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, serious psychosocial harm (using the psychosocial severity guide), or serious impairment or death due to ligature risk. On 10/25/2022, a Certified Nursing Assistant (CNA) reported to their superior that Resident #7 was found in bed with a sheet tied across her midsection and fastened to the bedframe during performance of morning care tasks. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA), who also serves as the Abuse Coordinator. Resident #7 was a cognitively and physically impaired individual who had a communication deficit and was dependent on facility staff for all care and services. The facility's failure resulted in the findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference F600, F609, and F835 Review of the facility policy titled, Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Abuse means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; G. Revision of the resident's care plan if the resident's medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. VII. Response A. The facility will have written procedures that include.: 5 Taking all necessary actions as a result if [sic] the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and\or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. A telephone interview with Resident #7's niece on 11/01/2022 at 11:57 a.m. revealed she was contacted on 10/25/2022 by the NHA about a restraint. She stated the time of contact was around 4:54 p.m. She said, [NHA]) told me hey [Resident #7's] okay. There's no harm, but she just wanted to give me a rundown on what happened, that there's a policy or law about no restraints and it was brought to her attention that someone restrained my aunt. I asked restraints how? Did they tie her legs and arms to the rails? And she goes, no her arms and legs were not bonded. I think she said there was like a cover tied over her but her arms and legs were not. [NHA] told me that they found who the employee was and they were reprimanded. An interview was conducted with Resident #7's PCP on 11/01/2022 at 11:31 a.m. He confirmed he was made aware that Resident #7 was found tied to her bed with a sheet. Regarding when he was informed he said, it was last Tuesday, they told me and I was here in the building, [The DON] told me about it. He said, I inquired if they informed the family and they said they did. He stated he recommended the facility conduct a care plan meeting with the family. The PCP said, I was not a part of the investigation or any other steps because I am not the Medical Director here. Regarding whether he assessed Resident #7 post-incident on 10/25/2022 he said, I assessed the resident that day, she is nonverbal, I examined here, there were no bruises or marks on the body, vitals were normal. Regarding documentation for that visit the PCP said, I did not document that visit, don't always document all my visits. Regarding his thoughts about the findings of the Resident tied to her bed with a sheet he stated his thoughts were that should not happen and said, restraints should not happen, we cannot do it legally. Review of the facility logs titled Incidents By Incident Type and Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs revealed no entries related to Resident #7 for October of 2022. Review of Resident #7's medical record on 10/31/2022 revealed an admission record with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) with an assessment reference date and observation end date 10/27/2022 revealed a Brief Interview for Mental Status (BIMS) was completed but the resident was unable to answer any of the questions correctly resulting in a score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a [CONDITION(S)], no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed: A focus area, initiated on 7/22/2022 and last revised on 7/28/2022, for alteration in her ability to perform self-care tasks related to weakness, impaired mobility and cognition, which required extensive assistance during Activities of Daily Living (ADL) tasks. Interventions included Staff to maintain [Resident #7's] safety and dignity while assisting her during ADL tasks. A focus area, initiated on 8/9/2022 and revised on 10/29/22, for exhibiting inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected. Interventions included: anticipate and meet the resident's needs (created 8/10/2022); caregivers to provide opportunity for positive interaction, attention (created 8/10/2022); intervene as necessary to protect the rights and safety of others (created 8/10/2022); and resident prefers to keep clothing on while in bed (initiated by the DON on 10/25/2022). On 10/31/2022 the medical record did not contain any documentation related to the restraint that was identified by facility staff and administration on 10/25/2022. On 10/31/2022 at 11:38 a.m., an attempt was made to interview Resident #7. She was observed lying in her bed in her room. The television was on and no restraints were visible. Resident #7 was alert and her eyes were open. She made eye contact when addressed but did not respond verbally to simple questions. She closed her eyes during the visit and appeared to fall asleep. On 11/01/2022 at 1:41 p.m., during interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. Review of timecards revealed Staff E, CNA clocked in at 8:30 a.m. on 10/25/2022. Review of CNA task documentation in Resident #7's medical record revealed eating was charted by Staff E, CNA on 10/25/2022 at 9:00 a.m. On 10/31/2022 at 1:00 p.m., Staff D, Licensed Practical Nurse (LPN) confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. She also confirmed she was assigned to Resident #7's unit for the 7 a.m. - 3 p.m. shift on 10/25/2022 but was not the resident's assigned nurse. She said, The CNA [Staff E] came and got me because I guess her nurse was busy. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/Unit Manager (UM)] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. She said, The only thing I know is the CNA on night shift hasn't been back. I know they asked for her to write a statement, but she refused to. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for. She has dementia. An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 did occur. She said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. An interview was conducted with Staff B, LPN on 10/31/2022 at 11:40 a.m. She confirmed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/UM] go to the room so I went down there and saw it [the restraint]. Staff B could not recall the exact date the incident occurred and said, it was around 10:30 a.m., was last week I think. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and a skin check was performed. Staff B stated she did not perform the skin check and said, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. I believe she had one little area where the diaper was on too tight. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. Review of timecards revealed Staff B, LPN clocked in at 6:37 a.m. on 10/25/2022. Review of Resident #7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . On 11/02/2022 at 10:25 a.m., a telephone interview was conducted with Staff H, CNA. She confirmed she had worked both the 3:00 p.m. to 11:00 p.m. shift and the 11:00 p.m. to 7:00 a.m. shift from 10/24/2022 - 10/25/2022. She confirmed she was assigned care for Resident #7 for both shifts. She stated she had been a permanent employee at the facility since June 2022 and typically worked the 3:00 p.m. - 11:00 p.m. shift. Staff H said, [Resident #7] likes to dig in her diaper. She pull her diaper off. She pulls at her feeding tube. She digs in her poop. She'll look at you, she'll smile, she screams, she cries, all communication is unintelligible. Staff H stated Resident #7 was not able to make her basic needs known or respond to basic questions. She stated Resident #7 was dependent on facility staff for everything. Staff needed to anticipate her needs, provide all levels of care, and required a mechanical lift for transfers out of bed. Staff H stated she started her shift on 10/24/2022 at about 2:45 p.m. and she did her last resident rounds on 10/25/2022 at about 4:45 a.m. She said, when I do a double like that I start my last rounds at quarter to 5 and after I do my last rounds I chart. Staff H stated she thought she clocked out around 7:30 a.m. on 10/25/2022. Staff H reported she changed the resident during both shifts and said, my last rounding and care with [Resident #7] was a little bit after 5 a.m. I changed her because she was wet and pooped so I changed her. She was in the bed, did not see a restraint at that time. Staff H said, I never saw that restraint on the resident at any time. Staff H stated she had never received any training on restraint use or abuse at any time from the facility. Staff H confirmed she was no longer employed by the facility and said, they terminated me because I wouldn't write a statement, but by law I don't have to write a statement. I answered their questions just like I'm doing with you now and told them the same things. They said because I was the last one to take care of her I was the focus. Staff H said, I feel hurt. It hurt me because they tried to blame me for something I didn't do. I'm not the only one accountable for this because I wasn't the only one that was there .also there was no CNA to relieve me .somebody told me it was after 10 a.m. going on 11 a.m. that a CNA was called in for the resident. There was a long period of time after my last contact with the resident where anything could have happened. Like the nurse [Staff J, LPN] had to give the [tube] feeding. Review of timecards revealed Staff H, CNA clocked in at 2:47 p.m. on 10/24/2022 and clocked out at 7:32 a.m. on 10/25/2022. Review of CNA task documentation in Resident #7's medical record revealed eating was charted by Staff H on 10/24/2022 at 6:00 p.m. and toileting was performed by Staff H, CNA on 10/25/2022, charting time 6:59 a.m. On 11/03/2022 at 10:37 a.m., a telephone interview was conducted with Staff J, LPN. She confirmed she worked at the facility through a nursing agency. She confirmed she worked at the facility on the 11:00 p.m. to 7:00 a.m. shift on 10/24/2022 - 10/25/2022 and was the assigned nurse for Resident #7. She stated she started her shift at 10:45 p.m. and left at either 7:25 a.m. or 7:30 a.m. on 10/25/2022. She stated when she started her shift she got report from Staff I, LPN. She stated she performed feeding tube flushes for Resident #7 around 12:00 a.m. and 2:00 a.m. and performed a bolus feeding through Resident #7's feeding tube at 5:00 a.m. in the morning on 10/25/2022. She stated Resident #7 was wearing a shirt, not a gown and said when she performed the bolus feeding, I didn't see her entire body, I only saw just from her stomach area up. Staff J stated Resident #7 was in her bed during the bolus feeding. She said, [Resident #7] had a blanket on, only saw area where the tube was, always try to expose just what I need. Staff J reported she had administered insulin to the resident in the morning on 10/25/2022 and had given the injection in the resident's left arm. She stated the insulin administration was the last care task she provided for Resident #7 during that shift. Staff J reported nothing unusual occurred with Resident #7 during her shift and stated Resident #7 was asleep during the shift and said, the three or four times I saw her, she was sleeping. Staff J stated she never saw a sheet tied across Resident #7's midsection and fastened to the bed and confirmed she never saw any restraint on Resident #7 during her shift. She said, if I had seen that I would have freed her first and then I would have questioned the CNA who had her and then would have called [Staff C, LPN, UM] or, I don't even know who the DON is. Regarding the restraint found on Resident #7, Staff J said, that is a no no, that is abuse. I learned that in school. I don't even agree with stuff like that. I was just shocked, like what, and then I was shocked because I didn't see it. Staff J said, I didn't communicate with the CNA [Staff H] much. I feel like she [Staff H] could have did more rounds especially when it came to me answering most of the lights. [Staff H] had a slight attitude, just body language when I said something to her about one of the male rooms that smelled like pee pee, but she still went and checked on them. Staff J said, I don't know who put the sheet there. I don't know why someone would other than what I said about keeping people from falling, but with that you just have to check on people. There are so many tactics you can use other than restraining people. And it's prohibited. Staff J confirmed she continued working at the facility post-incident and said, they didn't remove me from the schedule or nothing so I picked up some more days after that. Regarding education or training received from the facility she said, we don't do any training at the facility and stated she did not receive any education post-event from the facility. Review of timecards revealed Staff J, LPN clocked in at 10:45 p.m. on 10/24/2022 and clocked out at 7:15 a.m. on 10/25/2022. Review of Resident #7's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] A telephone interview was conducted with Staff I, LPN on 11/02/2022 at 9:27 a.m. He confirmed he had worked at the facility maybe two or three times through a nursing agency. He confirmed he worked at the facility on 10/24/2022 on the 3:00 p.m. to 11:00 p.m. shift and was the assigned nurse for Resident #7. He stated he gave her medications and gave her a bolus feeding through her feeding tube around 5:00 p.m. or 6:00 p.m. He stated he arrived to the unit for his shift at about 2:50 p.m. or 3:00 p.m. and rounded on Resident #7 at that time. He said, she was in the bed at time of my bolus feeding with her. He stated Resident #7 was a little antsy that day but otherwise was her normal self. He said, she's confused, very confused; she can't talk like me and you. Staff I stated he never saw any restraint on Resident #7 during his shift and said, if I would have saw something like that I would definitely untied it and reported it. He confirmed he was asked to provide a written statement and stated, in my written statement I told them everything just like I'm telling you, and also that I refused to work at a facility that tied people to the bed, and I refuse to go back there. I won't work at a facility that would do something like that. Staff I stated the DON had asked him, did two CNAs get into it during his shift and he told the DON no, but that he remembered the 11:00 p.m. to 7:00 a.m. CNA who worked a double was upset. Staff I said that CNA had been upset because the previous CNA had not completed care and had left residents wet and she was upset about working the shift, upset about working in general. Staff I said, I'm not saying she (the CNA) did it, but she definitely didn't feel like working and had an attitude. Staff I said, the lady [Resident #7] was a fall risk, I know that. She was a busy body, moved around a lot. They [the staff] didn't like that about her. If they did tie her to the bed that was probably the reason. Staff I said, the fact that happened was highly upsetting, that's totally abuse. I can't imagine someone would do something like that. I won't work in a place like that. Review of timecards revealed Staff I, LPN clocked in at 2:45 p.m. on 10/24/2022 and clocked out at 11:15 p.m. on 10/24/2022. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA confirmed the discovery first witnessed by Staff E, CNA of Resident #7 with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, LPN] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the unit manager performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H was suspended pending investigation but said Staff I and Staff J were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA said, there was never any indication from [Resident #7's niece] that she thought this was abuse related. The NHA stated the facility's Social Services Director (SSD) did a trauma assessment and said, and I think also a BIMS assessment. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated [TRUNCATED]

Based on record review, interviews with nursing and administrative staff, the resident's physician, the resident's representative, the resident's psychiatric practitioner, and the facility's Medical Director, the facility Administration failed to use its resouces effectively to lead and direct the overall operations of the facility in accordance with resident needs, regulations, and company policies related to abuse for one (Resident #7) of three residents reviewed for abuse. On 10/25/2022, Resident #7, a cognitively and physically impaired resident who had a communication deficit and was dependent on staff for all care and services, was found by a Certified Nursing Assistant (CNA) restrained to her bed by a sheet placed across her midsection and tied to the bedframe. This finding was immediately reported to and witnessed by supervising nursing staff and reported to the Director of Nursing (DON) and the Administrator (NHA), who also served as the facility's Abuse Coordinator. Facility administration determined this was not abuse, did not fully investigate, report, protect, and take corrective action to prevent a similar occurrence. The failure of the Administration to follow CMS guidelines and to implement their abuse policies created a likelihood that placed all residents at risk of a similar occurrence which could lead to serious injury or serious harm such as skin tears or pressure wounds, or serious psychosocial harm (using the psychosocial severity guide), serious impairment or death due to ligature risk. This resulted in the findings of Immediate Jeopardy occurring on 10/25/2022. The immediacy was removed on 11/04/2022 after verification of the implementation of removal actions. The scope and severity was reduced to a D (no actual harm with potential for more that minimal harm). Findings included: Cross Reference to F600, F609, and F610. Review of the facility job description titled, Administrator dated December 2018 revealed: Summary: Lead and direct the overall operations of the facility in accordance with customer needs, government regulations and complany policies, with focus on maintaining excellent care for the residents while achieving the facility's business objectives. Essential Duties and Responsibilites included: Management duties including, but not limited to, hiring, training and developing, coaching and counseling, and terminating department staff, as deemed necessary. Lead the facility management staff and consultants in developing and working from a business plan that focuses on all aspects of facility operations, including setting priorities and job assignments. Monitor each department's activities, communicate policies, evaluate performance, provide feedback and assist, observe, coach, and discipline as needed. Develop an environment that allows for creative thinking, problem solving, and empowerment in the development of a facility management team. Oversee regular rounds to monitor delivery of nursing care, operation of support departments, cleanliness and appearance of the facility; Morale of the staff; And ensure resident needs are being addressed. Responsible for the QA (Quality Assurance) program. Maintain a working knowledge of and confirm compliance with all governmental regulations. Manage turnover and solidify current and future staffing through development of recruiting sources, and through appropriate selection, orientation, training, staff education and development. Consult with department managers concerning the operation of their departments to assist in eliminating\correcting problem areas, and\or improvement of services. Provide guidance and leadership throughout the survey process to ensure state and federal regulations are met and adhered to. Job Requirements included: Strong attention to detail and accuracy, excellent organizational skills with the ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Strong analytical and problem solving skills. Ability to work with minimal supervision, take initiative and make independent decisions. Ability to deal with new tasks without the benefit of written procedures. During an interview on 10/31/2022 at 3:24 p.m., the facility Administrator (NHA) confirmed that she was also the facility's designated Abuse Coordinator. Request for additional facility job descriptions for Abuse Coordinator was requested on 11/03/2022 at 3:15 p.m. The Regional Nurse Consultant (RNC) and the Regional Director of Operations (RDO) reported there was no separate description and that those responsiblities were embedded in the facility NHA job description. Review of the facility's Administrator job description revealed no specifications related to the role or duties of Abuse Coordinator for the facility. Review of the facility's Director of Nursing (DON) job description dated August 2021 revealed: Summary: to manage the overall operations of the Nursing Department in accordance with Company policies, standards of nursing practices, and governmental regulations to maintain excellent care of all residents' needs. Essential Duties & Responsibilities included: Identify and participate in process improvement initiatives that improve the customer experience, enhance workflow, and\or improve the work environment. Management duties including, but not limited to, hiring, training, and developing, coaching, and counseling, and terminating department staff, as deemed necessary. Participate in facility surveys (inspections) made by authorized governmental agencies. Plan, develop, organize, implement, evaluate, and direct the nursing services department, as well as its programs and activities, in accordance with current rules, regulations, policies/procedures and guidelines that govern the long-term care facility. Ensure attainment of staffing requirements based on current needs and State and Federal guidelines. Ensure that the risk portal Is maintained and or completed in a timely manner. Ensure the provision of appropriate departmental in-service education programs and compliance with Corporate, State and Federal guidelines. Direct the performance and delivery of nursing services and resident care services in compliance with Corporate policies and State and Federal regulations. In conjunction with the NHA, inform the state of any reportable incidents within appropriate time frames. Complete investigative analysis as required, and file reports based on state guidelines. Regularly inspect the facility and nursing practices for compliance with federal, state, and local standards and regulations. Review Resident Incident Reports and facilitate corrective action. Comply with, support, and enforce company policies involving all safety . procedures. Review and verify that documentation procedures for nursing are met according to corporate, state, and federal guidelines. Job Requirements: Ability to communicate on all levels of organization and work well within a team environment in support of company objectives. Customer service oriented with the ability to work well under pressure. Strong attention to detail and accuracy, excellent organizational skills with ability to prioritize, coordinate and simultaneously maintain multiple projects with high level of quality and productivity. Strong analytical and problem solving skills. Ability to deal with new tasks, work with minimal supervision, take initiative and make independent decisions. A review of the policy titled Medical Director Responsibilities with a copyright date of 2020 and no implementation/review/or revision date revealed: Policy: The facility retains a physician designated as Medical Director, to a coordinate the medical care provided by attending physicians, and to assist with development and implementation of resident care policies. 4. The Medical Director's responsibilities include participation in: a. Administrative decisions including recommending, developing and approving facility policies related to resident care of physical, mental and psychosocial well-being; b. Issues related to the coordination of medical care identified through the facilities QA committee and other activities related to the coordination of care; c. Organizing and coordinating services provided by other professionals as they relate to resident care; d. Participate in the QA committee. Review of the facility policy titled Abuse, Neglect and Exploitation revised 10/01/2022 revealed: Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Definitions: Abuse means the willful infliction of inury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprevation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facility or enabled through the use of technology. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal requirements related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Mistreatment means inappropriate treatment or exploitation of a resident. Policy Explanation and Compliance Guidelines: The facility will designate an Abuse Prevention Coordinator in the facility who is responsible for reporting allegations or suspected abuse, neglect, or exploitation to the state survey agency and other officials in accordance with state law. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; IV. Identification of Abuse, Neglect and Exploitation A. The facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff to resident abuse . B. Possible indicators of abuse include, but are not limited to: 1. Resident, staff or family report of abuse. 6. Physical abuse of a resident observed. 7. Psychological abuse of a resident observed. 8. Failure to provide care needs such as comfort, safety, feeding, bathing, dressing, turning & positioning. 9. Evidence of photographs or videos of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the resident's cognitive status. 10. Sudden or unexplained changes in behaviors and/or activities such as fear of a person or place, or feelings of guilt or shame. V. Investigation of Alleged Abuse, Neglect and Exploitation A. An immediate investigation is warranted when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur. C. Written procedures for investigations include: 1. Identifying staff responsible for the investigation; 2. Exercising caution in handling evidence that could be used in a criminal investigation (e.g., not tampering or destroying evidence); 3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. Providing complete and thorough documentation of the investigation. VI. Protection of Resident The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation; B. Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed; C. Increased supervision of the alleged victim and residents; D. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator; E. Protection from retaliation; F. Providing emotional support and counseling to the resident during and after the investigation, as needed; VII. Reporting/Response A. The facility will have written procedures that include: 1. Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later that 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or b. Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. 2. Assuring that reporters are free from retaliation or reprisal; 3. Promoting a culture of safety and open communication in the work environment prohibiting retaliation against any employee who reports a suspicion of a crime. This facility will post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if the employee believes the facility has retaliated against him/her for reporting a suspected crime and how to file such a complaint. 5. Taking all necessary actions as a result if the investigation, which may include, but are not limited to, the following: a. Analyzing the occurrence(s) to determine why abuse, neglect, misappropriation of resident property or exploitation occurred, and what changes are needed to prevent further occurrences; b. Defining how care provision will be changed and/or improved to protect residents receiving services; c. Training of staff on changes made and demonstration of staff competency after training is implemented; d. Identification of staff responsible for implementation of corrective actions; e. The expected date for implementation; and f. Identification of staff responsible for monitoring the implementation of the plan. B. The Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. An interview was conducted on 10/31/2022 at 3:24 p.m. with the NHA, DON, Regional Director of Operations (RDO), and Regional Nurse Consultant (RNC). The NHA confirmed she was the facility's designated Abuse Coordinator and the DON was the facility designated Risk Manager. The NHA reported Staff E, CNA was the first witness to observe Resident #7 in bed with a sheet tied across her midsection to the bedframe on 10/25/2022. The NHA said, I'm going to estimate I was made aware around 10:30 a.m. The DON confirmed that timing. The DON said, me and the Unit Manager [Staff C, Licensed Practical Nurse (LPN)] went down to the resident's room. The resident was laying in bed. The sheet had been removed already by the time I got down there. Me and the Unit Manager [Staff C, LPN/UM] performed a skin assessment, there was no redness caused from where the sheet itself was, but we did notice there was a spot on right lateral ankle, pressure area. The DON stated Resident #7's primary care physician (PCP) was notified of the area on the ankle and treatment was put in place. The DON stated the PCP was also informed about the incident with the restraint and that the facility Medical Director was also informed. The NHA said, we did initiate an investigation to try and figure out how this happened and stated interviews were conducted with the 10/24/22 - 10/25/22, 11 p.m. - 7 a.m. shift, and the 3 p.m. - 11 p.m. shift on 10/24/2022. The NHA stated Staff H, CNA had worked both shifts and was assigned to Resident #7 for both shifts. The NHA identified that Staff I, LPN was Resident #7's assigned nurse for the 3:00 p.m. - 11:00 p.m. shift on 10/24/2022 and Staff J, LPN was Resident #7's assigned nurse for the 11:00 p.m. - 7:00 a.m. shift on 10/24/22 to 10/25/2022. The NHA stated Staff H was suspended pending investigation but said Staff I and Staff J were not suspended or removed from resident care because we did not anticipate any issue there. [Staff H] was the last person who cared for the patient. In response to how that was known, the NHA said, the restraint was not identified by [Staff J] at 5 a.m. during tube feeding, during interview with [Staff H] she told us she provided care (to Resident #7) after 5 a.m., she refused to participate further with our investigation, would not provide written statement, ignored requests and walked out the door. The NHA stated, unfortunately she's a disgruntled employee because she failed to cooperate with the investigation and was insubordinate to her supervisor, so we separated employment. Regarding Staff I, the NHA reported he chose not to pick up any further shifts and said, he was scheduled for 10/25 3:00 p.m. to 11:00 p.m., and he gave written communication he was not coming for any scheduled shifts. He didn't want to be involved in any issues of this type. The NHA said, [Staff J] may have worked more shifts. We'll check into that. Regarding other actions that were taken in response to the incident, the NHA stated they informed Resident #7's niece of this event, told her what was done in terms of the resident's skin, and educated the family that, what we found was not acceptable. The NHA said, there was never any indication from [Resident #7's niece] that she thought this was abuse related. The NHA stated the facility's Social Services Director (SSD) did a trauma assessment and said, and I think also a BIMS assessment. The NHA stated the DON started some education with facility nursing staff related to restraint training on 10/26/2022 and said that education was still ongoing. Regarding reporting the incident, the NHA said, we did not report this, did not feel like it met criteria for abuse, neglect or harm, we were not able to identify why it was done and there was nothing in the investigation that gave us any reason to believe that there was negative outcome. We could not identify a purpose. The NHA stated they were not able to identify who had applied the restraint to Resident #7 and said, unfortunately we were unable to get [Staff H] to participate in this investigation. Regarding the lack of documentation in Resident #7's medical record including no evidence of the SSD assessment, the RNC said, we try to keep our charts really clinically focused. We don't restrain people unless it's medically necessary and in her case, it wasn't. It seems like it wasn't an extenuated period of time that it went on because the nurse didn't see it. It was unfortunate that [Staff H] wouldn't come forward to participate with us. The RNC said, we looked at the psychosocial harm of it. I don't know why [the SSD] didn't document it, but it was done. Regarding whether the facility considered Resident #7 being restrained with the sheet tied to the bed as abuse, the RNC responded that they had looked at the restraint component as an involuntary component and that the sheet wasn't so tight that she couldn't freely move. The RNC said, I assume one of your concerns is about reporting. We discussed and ruled out, by definition, willful intent and harm and that's why we didn't report, not that we weren't taking this seriously. All of the staff who were interviewed indicated they had not seen anything like that in the past. Not that it matters, it was an isolated incident because even isolated incidents we would report if there was a willful intent or harm. The RDO said, when we talked about it, we considered it [the restraint] was an inappropriate intervention. Review of the facility nursing staff and assignment schedule revealed Staff I, LPN was not scheduled at the facility after 10/24/2022. Staff J, LPN was scheduled and assigned care for Resident #7 on 10/26/2022 and was scheduled in the facility on 10/28/2022 and 10/29/2022. On 11/01/2022 at 1:28 p.m., a telephone interview with the facility's Medical Director confirmed the facility informed him of the restraint incident with Resident #7. The Medical Director said, I think they notified me afterwards because they didn't think it was a reportable incident. They notified me a few days later in morning meeting. The Medical Director stated the restraint was described to him as loosely tied. He said, we bantered this around, was almost like trying to make an analogy of a person in a wheelchair who was mobile and putting a laptop or safety belt around them, that would impede their mobility and be considered a restraint. But [Resident #7], I looked at her case, someone bedbound, total care, couldn't move, didn't look good but didn't impede mobility in reality. Regarding whether psychosocial impact was discussed he said, I don't think that came up, no, but that's a good point. He then stated, I think someone said her BIMS was basically zero meaning she wasn't alert and aware of her surroundings so because of that I wouldn't have been worried about psychosocial impact but if she had been alert and aware, I would have been concerned about that. The Medical Director stated he was not asked to participate in an investigation. He said, I don't know if they're done with their investigation, I know they were talking to some people, I don't know the outcome. The Medical Director stated there had been no QA process or meeting related to the incident that he was involved in and said, Our QA is coming up this Thursday so I'm sure it will come up. Review of the facility logs titled Incidents By Incident Type and Abuse/Adverse Event Log was conducted on 10/31/2022. Both logs revealed no entries related to Resident #7. On 11/01/2022 at 1:41 p.m., during an interview Staff E, CNA reported she was the first witness who discovered Resident #7 restrained to her bed on 10/25/2022. Staff E stated at the time of the event she was a contract employee through a staffing agency. Staff E revealed on 10/25/2022 she received a late call to pick up the day shift (7:00 a.m. - 3:00 p.m.) and she arrived at the facility at 8:00 a.m. Staff E said her assignment that day included Resident #7. She said when she arrived at the facility, she got a report from another CNA on the unit and, then I began passing breakfast trays . Staff E reported after passing out breakfast, I went down the short hall to feed [Resident #7]. That had to be like 8 something but before 9. Staff E reported that while feeding the resident, She was in bed and covered [with a blanket]. Staff E said she did not see the restraint at that time because the resident was covered. Staff E stated Resident #7 did not eat much, and after assisting her with breakfast, she left to assist another resident. Staff E stated after she finished caring for the other resident, she began providing morning care and toileting to her assigned residents. Staff E said, When I pulled back her [Resident #7's] covers to see if she needed to be changed, I seen the restraint, so I went to the nurse [Staff D] who was on the opposite side and asked her if this was something that was supposed to be there. [Staff D] went to the room and confirmed no, that [restraint] wasn't supposed to be there. Staff E said, it had to be like after 10 [a.m.] that I saw the restraint. Staff E described the restraint as a bed sheet. She stated, like it wasn't in her skin or like pressing on her, it was just over her, over abdomen and tied to the bedframe. Staff E stated she had never seen anything like that before on Resident #7 or any other resident at the facility. Staff E said, [Staff D] got a supervisor who came down [to see the restraint] and after that, I removed it. Staff E confirmed, I removed the restraint and changed her. Staff E reported she did not observe any skin concerns when she was changing the resident after removing the restraint. Staff E indicated she had cared for Resident #7 before. Staff E said, I've never heard her to be very verbal, she really doesn't do much. Staff E reported she was asked to provide a statement to the facility following the event. Staff E reported that when she gave her statement, we did discuss restraints are not to be used. Staff E did not have any other information about any facility investigation or additional staff education. On 10/31/2022 at 1:00 p.m., Staff D, LPN confirmed Resident #7 was found restrained to the bed with a sheet and said, It happened. I believe it was October 25th. Staff D, LPN looked in her cell phone and confirmed that 10/25/2022 was the correct date. Staff D reported she was working on the unit for Resident #7 but was not her assigned nurse for the 7 a.m. - 3 p.m. shift. Staff D recalled Staff E reporting the restraint to her around 10:30ish [a.m.]. Staff D said, [Resident #7] was sleeping through breakfast so when [Staff E] went in after breakfast to get her up and cleaned up was when she noticed the restraint. Staff D stated the restraint was not visible without pulling back the bed linens. Staff D said after Staff E came to her, I went down there, and I witnessed a sheet draped across her [Resident #7's] lower abdomen area, tied to the bedframe. I referred it to [Staff C, LPN/UM] and she referred it to the DON. I've never taken care of the resident. I really didn't hear any more about it. Staff D said, I provided a written statement and did not know any other details about any investigation. Staff D said later that day (10/25/2022) the DON asked everybody to sign an in-service about restraints, that the facility was a no restraint facility. Staff D stated finding Resident #7 restrained in her bed was upsetting. Staff D stated, [Resident #7] is a sweetheart. I mean she does make a lot of noise, calls out and moans. She does have pain that she is treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with Staff C, LPN, UM on 10/31/2022 at 12:21 p.m. She confirmed the incident with Resident #7 and said, it happened last week sometime in the morning, and it was brought to her attention that day at about 9:30 a.m. or 10:00 a.m. in the morning by Staff D, LPN. She said after Staff D reported it to her, I came to the room, I saw the resident lying in the bed and she had a sheet folded into a narrow strip across her hips and tied to the bedframe. She stated Staff D reported it to the DON and then we [Staff C and Staff D] untied the restraints. Staff C said the agency CNA (Staff E) who first saw the restraint was a late call. They didn't have any staff to cover the assignment, which was why it was discovered so late. Staff C, LPN/UM stated she and the DON performed a skin assessment and found a new open area on her right ankle. Staff C stated Resident #7 was cognitively impaired and it was normal for Resident #7 not to communicate or respond. Staff C reported Spanish was the resident's primary language. Staff C stated when performing the skin assessment, Resident #7 could not provide any information related to the restraint. Staff C said following the incident, the DON had us write statements. She said she didn't hear anything about an investigation or the outcome. She said, I've been asked to educate staff about restraints, haven't done it yet, policy here is no restraint use. Staff C stated she had been asked to start the education the day of the event or the day after. Staff C consulted the Electronic Health Record (EHR) for Resident #7 and confirmed the date of the incident was 10/25/2022. She confirmed there was no progress note entered in the record about the incident and said, I didn't write a progress note in here at all. The DON said she would take care of the documentation. On 10/31/2022 at 11:40 a.m., Staff B, LPN revealed she was the assigned nurse for Resident #7 on the 7 a.m. - 3 p.m. shift on 10/25/2022 when the restraint was discovered. She confirmed the restraint was found by Staff E, CNA who reported it to Staff D, LPN. Staff B said, I saw them [Staff E and Staff D] and [Staff C, LPN/Unit Manager (UM)] go to the room so I went down there and saw it [the restraint]. Staff B said, it was around 10:30 a.m. She reported a bed sheet was folded into a narrow width, placed over the resident's waist, and tied underneath the resident to the bedframe. Staff B said, we notified the DON and NHA. Staff B reported Resident #7 was untied from the restraint and stated, I believe [Staff C, LPN/UM] did the skin check with the NHA and the DON. Staff B said, they gathered a statement from me and thought the facility administration did an investigation. She did not know any details of the investigation process or the outcome. Staff B said, I know they did education on restraints and stated the training provided was that we don't use restraints in this facility. Staff B reported Resident #7 did not communicate much but could respond to yes or no questions about pain. Staff B stated, she [Resident #7] cries out a lot. Review of Resident #7's medical record was conducted on 10/31/2022. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating severe cognitive impairment. The MDS revealed no mood disturbance and no behavioral symptoms. The MDS revealed extensive physical assistance by one to two person(s) was required for bed mobility, dressing, eating, toileting, and personal hygiene and total dependence on one to two person(s) for transfers and locomotion on and off the unit. The resident did not walk and used a wheelchair for mobility. The MDS revealed Resident #7 was always incontinent of urine and bowel and received 51% or more of her total calories from a feeding tube. The MDS indicated the resident had a [CONDITION(S)], no pressure ulcers, and no restraints (during the observation period of 10/20/2022 to 10/27/2022). Review of the care plan for Resident #7 revealed: A focus area, initiated on 8/9/2022 and revised on 10/29/22, for exhibiting inappropriate behaviors such as pulling at her feeding tube, disrobing and restlessness while in bed, not easily redirected. Interventions in [TRUNCATED]

Based on observations, interviews and record reviews the facility 1. failed to ensure emergency medications were available for a resident who had a hypoglycemic episode for one Resident (#1) out of 3 diabetic residents reviewed with orders for emergency [MEDICATION NAME], 2. failed to monitor and report trends of unstable glucose readings and to report abnormal results for 4 (#1,#5,#14, #15) out of 25 insulin dependent diabetics in the facility and 3. failed to administer medications, treatments and provide follow up care as ordered for 2 (#1, #2) of 17 residents sampled. Findings included: [DIAGNOSES REDACTED] in Elderly Type 2 Diabetes Patients Diabetes Management (2016) Volume 6, Issue 3 documents: [DIAGNOSES REDACTED] is a condition of reduced blood glucose level below 70 mg/dl (3.9 mmol/l). Hypoglycemic coma is a medical emergency which usually associated with glycemic around 20 mg/dl (1.1 mmol/l). Prolonged severe [DIAGNOSES REDACTED] may result in permanent neurological disorders. [DIAGNOSES REDACTED] also has a negative impact on the cardiovascular system. Severe [DIAGNOSES REDACTED] may induce ventricular arrhythmias. Severe [DIAGNOSES REDACTED] requiring hospitalization in patients with type 2 diabetes occurred mostly in elderly. Low hemoglobin HbA1c level indicates inappropriate intensification of therapy as a main cause of severe [DIAGNOSES REDACTED] in elderly patients .Blood glucose levels below 45 mg/dl (2.5 mmol/l) may cause profound disturbances of Central Nervous System (CNS) with loss of consciousness and generalized convulsions. Hypoglycemic coma is a medical emergency usually associated with blood glucose level around 20 mg/dl (1.1mmol/l). Prolonged severe [DIAGNOSES REDACTED] may result in permanent neurological disorders. Loss of consciousness may be accompanied by bilateral plantar reflex, muscle tension, hypothermia. In the course of severe [DIAGNOSES REDACTED] may also appear unusual symptoms. Recurrent [DIAGNOSES REDACTED] with generalized [MEDICAL CONDITION] may lead to mis[DIAGNOSES REDACTED]. Recurrent severe [DIAGNOSES REDACTED] may lead to the development of brain degeneration with mood disorders and impaired cognitive functions. [DIAGNOSES REDACTED] also has a negative impact on the cardiovascular system. [DIAGNOSES REDACTED] may exacerbate [MEDICAL CONDITION] ischemia. This phenomenon is particularly disadvantageous to patients with diabetes. Severe and moderate [DIAGNOSES REDACTED] may be associated with the induction of ventricular arrhythmias (QT prolongation). [DIAGNOSES REDACTED] can lead to injuries, falls with fractures, traffic accidents. Severe [DIAGNOSES REDACTED] is a complication with psychological and social consequences to the patients and their families. A review of the manufacturer's instructions documented the side effects for [MEDICATION NAME] administered orally or intermuscular are: Nausea and vomiting, gastro-intestinal discomfort to include diarrhea, [MEDICAL CONDITION], and a temporary increase in both blood pressure and pulse rate following the administration of [MEDICATION NAME]. Insulin reacts antagonistically towards [MEDICATION NAME]. A review of the facility policy titled Diabetic Care Protocol with an effective date of [DATE] and a revision date of [DATE], 1. Upon admission, initiate hypoglycemic protocol physician order sheet or obtain specific orders for managing hypoglycemic episodes. 4. Develop care plan to include; 4.1 patient's usual symptoms indicating low or high blood glucose. 4.2 patient's usual or ordered regime for diet, blood glucose monitoring, and exercise. 4.3 daily foot care/skin observations, 4.4 patients and learning needs related to diabetes. 4.5 pain management as indicated. 5. Perform fingerstick blood glucose monitoring as ordered. 6. Administer insulin/oral hypoglycemic medication as ordered. 7. Evaluate for and respond to any change in condition. 8. Treat hypoglycemic episode or cording to [DIAGNOSES REDACTED] protocol or per order. 9. Report blood glucose results to physician/mid-level provider according to order parameters. 9.1.1. Urgent: Notify immediately if blood glucose is greater than 400 or less than 70 (and not corrected with interventions according to [DIAGNOSES REDACTED] Protocol [DIAGNOSES REDACTED] Protocol with no effective date but a revised date of [DATE] documents under the column Presentation Symptoms Asymptomatic: Low blood glucose (less than 70 or ordered low parameter). Treatment: 1. Hold all diabetic medications, including insulin and oral meds 2 3. If blood glucose if equal or below 70 or ordered parameter, administer rapidly absorbed simple, carbohydrates such as 4 oz., juice, or 5 or 6 oz regular soda pop or tube of glucose gel per patients routine. If meal time, have patient eat meal. 4. In 15 minutes, repeat blood glucose measurement 10. Activate emergency medical services . 11. Document; 11.1 insulin/oral hypoglycemic medications; 11.2 blood glucose reading; 11.3 nursing interventions; 11.4 notification of physician/mid-level provider and response, as indicated; 11.5 notification of family, as indicated; 11.6 patient/family education. 1. A review of the medical record for Resident #1 revealed the resident was transferred to the hospital on [DATE], Documented on the transfer form under other relevant information: Patient foaming at the mouth. Not able to speak, diaphoretic, blood sugar 52 unable to get patient to eat or swallow, no [MEDICATION NAME] in the automated medication dispensing system. 911 called. 911 arrived and gave D10 and took the patient to hospital. A review of the nurse's note dated [DATE] at 02:00 written by the unit manager documented, Resident was found unresponsive in her bed by certified nurse's aide (CNA) who then alerted the resident's nurse to her condition. Assessment revealed blood pressure ,[DATE], temp 96 F axillary, O2 99% RA (room air), heart rate 100 bpm and respiration rate (RR) 20. Resident was alert with eyes open but not able to speak. Foaming from her mouth and cold and clammy to touch. Blood sugar was 47. Resident was unable to take anything by mouth at the time and [MEDICATION NAME] was unavailable. 911 was called to the facility and upon their arrival resident's blood sugar was checked again and it was 32. IV started and resident was given [MEDICATION NAME] rapid infusion at which time the resident began to stabilize and she was able to verbalize and make her needs known. However, resident still had elevated BP and lingering confusion, EMT transported her to the hospital for evaluation. A review of the patient information sheet for Resident #1 documented an original admission date of [DATE] from an acute care hospital with a [DIAGNOSES REDACTED]. A re-admission date of [DATE] from an acute care hospital without documentation of a new [DIAGNOSES REDACTED]. An interview was conducted on [DATE] at 12:12 p.m., the unit manager for the North said, I was working the ,[DATE] shift on [DATE] and Resident #1 was my patient. Throughout the shift she sat up at the nurse's station. I did her blood sugar checks as ordered. I did give her coverage at dinner time and then she stayed up in her chair until bedtime she was asymptomatic, then she went to bed. My shift ended at 11p.m. Then the next nurse came in and took over for me Staff B, LPN I was here late doing charting until 2:30 a.m., and right before I was going to go home an aide came up and said, Is she supposed to look like that? Staff B, LPN went down to the room to assess the patient and her sugar was low. I have seen her like this. Staff B, LPN and I went down to the room and she was really pale, diaphoretic and she was foaming at the mouth. Staff B, LPN was still trying to get the glucose gel into her to see if it would have any effect and at that time I got her vitals. Staff B, LPN went to go get [MEDICATION NAME]. When she came back she said she looked everywhere and there was not a kit anywhere. I told her to call 911 since we cannot give her anything by mouth. The first time we checked her sugar level it was 99, then we tried another machine and it was 47. When the Paramedics got here and checked it her sugar was 32. Within 5 minutes after the paramedics started working on her, she was less symptomatic. Staff B, LPN seemed to think she was a little more confused than normal and sent her to the hospital. The next day the hospital called and said she was admitted with pneumonia. Normally we have 2 [MEDICATION NAME] emergency kits in the automated drug dispensing system. I cannot attest to the inventory in the system. I honestly do not know what the process is. I only know that they are supposed to be in the automated drug dispensing system and there were none. I think the stock comes in gray crates and the Assistant Director of Nurses (ADON) and the Director of Nurses (DON) will re-stock. I think it is an electronic thing the automated medication dispensing system communicates somehow with the pharmacy and that's how they know to send stock. An interview was conducted on [DATE] at 1:00 p.m., the DON said, I do not know why there was not a [MEDICATION NAME] emergency kit in the automatic medication dispensing system on [DATE]. We get stock ,[DATE] times a week. If we use the last of something today then we get it on the next delivery. The pharmacy drivers bring out our stock. No the pharmacy does not stock the automatic medication dispensing system and they send someone out that specifically checks out the machine about once a month. No, no one really checks the system. The machine communicates directly with the pharmacy. As far as Resident #1 no we did not start an IV. EMS did a good thing they are right around the corner. We do have an issue with orders that are too long they do not go over to the pharmacy. Like a [MEDICATION NAME] order would be too long. I have told the nurses about the glitch. But by the time we realize the pharmacy never got the order then we have to fax it to them. Our electronic medical record system is to communicate with the pharmacy. I believe there was an order for [REDACTED]. We try to make sure on all admissions all orders are faxed but the nurses will have to remember to fax an order if it is too long. An observation was conducted on [DATE] at 8:40 a.m., Resident #1 was sitting in the small dining room (no other residents) across from the nurse's station with Staff K, Certified Nurse's Aide (CNA) was assisting the resident with her breakfast. Staff K, CNA said, No she eats very well. She always seems hungry. I think she could use more food at meals. A family member was here yesterday and brought her some food and she had a good day. A review of the breakfast meal ticket for [DATE] documented the diet: Consistent Carbohydrate Puree, nectar like liquids. Category Information: Puree All Categories. A review of the physician order summary for [DATE] - [DATE] an active order as of [DATE] for Consistent Carbohydrate diet Dysphagia Puree texture. Thick Liquids-Nectar Like consistency. A Nutrition Assessment was completed on [DATE] at 15:59. A Nutrition Assessment was completed today. The resident's Nutrition Concern Category Score is: No Concerns Identified. There is NO Nutrition Problems. Nutritional Diagnosis (None if Blank) nothing documented. A copy of the nutritional assessments were requested but not provided. On [DATE] the Director of Nurses (DON) provided a copy of the PAR levels and items that are stocked in the automatic medication dispensing machine dated (YEAR). A review of that information with the DON revealed that the emergency drug kit for [MEDICATION NAME] was not on the list. An interview was conducted on [DATE] at 1:05 p.m., the DON confirmed the emergency drug kit for [MEDICATION NAME] was not an item listed as a stock item provided by the pharmacy. This is the most current item list they have. The one I had was dated 2013. I do not know why it is not on that supply list but it is a stock item. On [DATE] at 1:12 p.m., The DON provided a copy of a verbal order she had written dated [DATE] for Resident #1 showing that she ordered a [MEDICATION NAME] emergency kit for the resident. Yes, one should have been ordered just for her after that night. No, that is not the first time she has been hypoglycemic and the nurses needed to use a [MEDICATION NAME] emergency kit. Patient #1 is a critical diabetic and she should have one in her name and available on the medication cart with her other medications. Several requests were made to the DON to speak with the facility pharmacy representative and pharmacist (any) on [DATE], [DATE]. On [DATE] the DON stated that their pharmacy representative was out of town at a conference. On [DATE] at 1:52 p.m a phone message with a call back number was left for Staff A, Licensed Practical Nurse (LPN) and at [DATE] at 1:55 pm for Staff B, LPN. A return phone call was received on [DATE] at 10:43 a.m., Staff A, LPN said, Yes I was working on that night of [DATE]. I was not the nurse caring for Resident #1 but I was working with Staff B, LPN and she asked me to go get an emergency [MEDICATION NAME] kit. I used one on her the last time I worked with her and her glucose level bottomed out. I looked and there was not a [MEDICATION NAME] kit on any of the medication carts. I checked the automatic medication dispensing machine and there were no emergency [MEDICATION NAME] kits in there. I tried to shove a sugar pack in her mouth but she was foaming from her mouth and I could not get anything in. We got a glucose level reading of 32 and the EMS when they arrived got 27. Our machine was even off. I am not sure why they stopped ordering individual [MEDICATION NAME] emergency kits but it was written on the nurse's communication board that we were not to order them. The DON asked me did you go to the other side and check to see if they had a [MEDICATION NAME] kit. Yes, I called over there and they did not have one. There was nothing I could do for that lady it was terrible! One of the nurses from the other side did come over. Also, the unit manager was working that night and she could not believe they keep returning them because management was saying they were too expensive. Maybe on the south unit they do not need them but on the north unit we have several brittle diabetics and we have to use an emergency kit often. About a month or so ago I saw several of the [MEDICATION NAME] emergency kits in the medication room in the Return to Pharmacy bin, and heard that we needed to return any that were on out carts because of the cost. Yes, if they have not been used the pharmacy will take them back. They will take any medications that are not used. I knew stock had come in but the automatic medication dispensing system was empty. The DON said the stock that came in was in my office. Well how was I supposed to know that the stock was in her office? It is hard on the night shift to get a physician to call us back. When I left the physician had not called us back yet for Resident #1. No, we did not try to start an IV. I'm not even sure if there is a protocol for that. Even if were we would need an order and I do not think we have IV supplies. Yes, I remember they told us the [MEDICATION NAME] kits were high cost and we needed to return them. I called Patient #1's responsible party that night and she was getting upset saying they were not feeding her. They put her on some type of mechanical diet, she is hungry need to give her bigger portions. Her diet was changed because keeps aspirating, holding food in. The patient's responsible party will bring food in when she comes to visit. A return phone call was received on [DATE] at 12:53 p.m., Staff B, LPN said, The emergency [MEDICATION NAME] kits were supposed to be in the automatic medication dispensing system. But on [DATE] there were none. I had to call 911 wrote in my note that 911 was called and that there was not an emergency [MEDICATION NAME] kit available in the building. Also, the Nurse called me from the hospital and stated that her temperature was 92 and they had put her on a warming blanket. No other option but to try sugar since there were no kits available. I was in the room when they came in it and her glucose level was 32. Yes she was on a puree diet. We did all we could. Her mouth was clinched shut. There was blood in her mouth. The hospital said her tongue was cut. Yes, she was foaming at the mouth. Our unit manager is new and she told me that the incident was terrifying to her. Yes, I went down to try and get an emergency [MEDICATION NAME] kit out of the machine but it would not take the code. So, I went and got another nurse. Then we realized there were no kits in the machine. Yes, later we were told there was some [MEDICATION NAME] emergency kits in the DON's office. How were we supposed to know that? A review of the facility incident log revealed no documentation of a medication error or any documentation for Resident #1 for [DATE]. An interview was conducted on [DATE] at 10:05 the Assistant Director of Nurses said, If there was a medication error it would be in the incident log. An observation was conducted on [DATE] at 8:17 a.m., Staff F, Licensed Nurse (LPN) who was working from the medication cart she identified as the medication cart for front hall south opened each drawer of her cart and said, No there is not a [MEDICATION NAME] emergency kit in my cart. There is supposed to be some in the automated medication dispensing machine and there is supposed to be one on each medication cart. An observation was conducted on [DATE] at 8:30 a.m., Staff G, LPN who had what she called the front cart, opened all of the drawers to see if there was an emergency [MEDICATION NAME] kit. Staff G, LPN looked and there was not an emergency [MEDICATION NAME] kit on her cart. Staff G, LPN said, Someone must have moved it- There is supposed to be 1 in the front cart. We do not have an emergency drug kit (EDK). We have an automated medication dispensing system. An observation was conducted on [DATE] at 8:43 a.m., Staff C, LPN walked down the hall with the surveyor to the cart she call the back hall cart and said, We do not order kits for every resident receiving insulin because sometimes in an emergency they are expired. An interview was conducted on [DATE] at 9:17 a.m., Staff E, Licensed Practical Nurse (LPN) said, I only have 1 [MEDICATION NAME] emergency kit in my cart and it is for a specific resident. I am not sure why she has one, because they no longer order [MEDICATION NAME] emergency kit's for residents on insulin. About a month ago management told us to bring up any [MEDICATION NAME] emergency kit's we had and they returned them all to the pharmacy. They said each of those kits cost about $250.00 dollars and they were not going to order them for each patient. There is supposed to be one in the automated medication dispensing system but not too long ago on a night we needed one there was not a [MEDICATION NAME] emergency kit in the medication system . I heard that the DON asked the nurses on that night if they went around and checked the other carts. We do not have time to do that. But if I had once even if were for another resident, I would use it in case of an emergency. An observation was conducted on [DATE] at 925 a.m., with Staff C, LPN who identified her cart as the middle cart. Staff C, LPN opened up her cart and said, There is not a glycogen emergency kit in my cart. I know we have one in the front cart. An observation with Staff C, LPN of the medication cart she identified as the back hall cart. Staff C, LPN said, No, there is not a [MEDICATION NAME] emergency kit in this cart. At 9:35 a.m., Staff C, LPN walked the surveyor down to the central supply room located on the front of the North hall and in the central supply room there was an automated medication dispensing system and there were 2 [MEDICATION NAME] emergency kit's observed in the machine verified by the barcode label for the bin the kits were stored in. An interview was conducted on [DATE] at 1:30 p.m., the DON provided a detailed transaction report by date from the pharmacy for the automated medication dispensing system. On [DATE] the ADON stocked the system with 2 [MEDICATION NAME] emergency kits then it shows on [DATE] an emergency [MEDICATION NAME] kit was taken out of the machine at 12:35 a.m., for Resident #1 by Staff B, LPN. Yes, we have had to use the emergency [MEDICATION NAME] kit several times for Resident #1. So, that left 1 [MEDICATION NAME] emergency kit. Then that one was taken out on [DATE] for Resident # 14 at 4:55 p.m., which left no [MEDICATION NAME] emergency kits in the automated medication dispensing system from [DATE] until [DATE] when it was refilled by the ADON. Once or twice a week the ADON and I try to stock the same day but to be honest, sometimes we do not get a chance too. I called the pharmacy and asked him to send a different report because I want to know why there was no replacement for the [MEDICATION NAME] emergency kits for 10 days. An interview was conducted on [DATE] at 3:15 p.m., the physician for Resident #1 was standing at the nurse's station with the surveyor and together the glucose levels for the past 3 months were reviewed with the physician. He said, When I see this yo yo with glucose levels I will go back to the nurse or the CNA to see if she is eating. Yes, I see what you are saying. Back in (MONTH) I believe she was on a short acting insulin and she was super sensitive to it. You could give her only ,[DATE] units and her glucose could be at 240 and it would drop to 40. Last week I changed her to only long acting insulin and for 7 units in the am and 7 units in the pm. I know I have changed her insulin a couple of times since December. Today after reviewing her levels I changed it to 10 units in the morning and 10 units at HS (bed time). We stopped her regular insulin and evening coverage and they are to let her eat. Well when you look at it she bottomed out on [DATE], [DATE] and recently on [DATE]. That's three times- to me it shows less calories in- so she would have needed less insulin. The surveyor then pointed out to the attending physician that the CNA's were documenting under tasks in the medical record that Resident #1 was eating for the most part 100% of all meals. The attending physician shook his head and walked away. A review of the documented glucose levels for Resident #1 (MONTH) 2019, (MONTH) 2019, (MONTH) 2019 and (MONTH) (YEAR) showed that the resident's glucose levels ranged from 32 to 397, the higher readings were generally in the late evening. The readings and documentation regarding abnormal blood sugars included the following: [DATE] at 6:43 am 32; No [MEDICATION NAME] Emergency Kit in the facility Nurses Note [DATE] 6:32 am BS: 162, Sliding Scale Insulin held resident had hypoglycemic episode in the evening. Will continue to monitor. There is no documentation in the medical record for [DATE] or [DATE] documenting the hypoglycemic episode, no documentation that the facility hypoglycemic protocol was implemented or interventions, no documentation that the physician was notified. [DATE] at 18:21 pm 64 [DATE] at 5:37 am 66 There was no documentation in the medical record for [DATE] or [DATE] documenting the hypoglycemic episode, or documentation that the facility initiated their hypoglycemic protocol or any documentation of interventions implemented and there was no documentation that the physician was notified. [DATE] at 7:51 am 42 Nurses note documents emergency [MEDICATION NAME] administered, reassessed and was 94. Waiting on MD to respond at this time. [DATE] at 6:36 am 69 The medical record revealed no documentation or evidence that the physician was notified of of a glucose level below 70 per physician ordered parameters or if the facility initiated their hypoglycemic protocol and what interventions were implemented. [DATE] at 7:10 am 44 The medical record revealed no documentation or evidence that the physician was notified of a glucose level below 70 per physician ordered parameters or if the facility initiated their hypoglycemic protocol and what interventions were implemented. [DATE] at 12:25 pm 60 The medical record revealed no documentation or evidence that the physician was notified of a glucose level below 70 per physician ordered parameters or if the facility initiated their hypoglycemic protocol and what interventions were implemented. [DATE] at 00:58 am Nurses note documented a glucose level of 43. Emergency [MEDICATION NAME] was administered. The documentation revealed no evidence that the physician was notified of a glucose level below 70 per physician ordered parameters. [DATE] at 16:34 pm 69 The medical record revealed there was no documentation that the physician was notified of a glucose level below 70 per physician ordered parameters. A review of the Medication Administration Record [REDACTED] Fingerstick blood glucose notify MD if blood glucose is greater than 400 or below 70 initiate hypoglycemic protocol every 5 minutes as needed Start date [DATE] *[MEDICATION NAME] Emergency Kit 1 mg inject 1 mg IM every 15 minutes as needed for hypoglycemic symptoms difficulty to arouse or unconscious Administer immediately repeat BS in 15 minutes if no response 1st administration., repeat [MEDICATION NAME] if no response to second injection in 15 minutes repeat blood glucose and start IV access if not presently established and go to next step based on results. Start Date of [DATE]. *Glucose Gel 40% Place and dissolve 1 dose [MEDICATION NAME] every 15 minutes as needed for blood glucose less than 70 or ordered parameter symptomatic or asymptomatic but conscious and able to swallow as needed repeat protocol. Start Date of [DATE] *[MEDICATION NAME] R Solution 100 Unit/ML Inject as per Sliding Scale if ,[DATE] =0, If ,[DATE] =3 units, ,[DATE]=5, ,[DATE]=7, ,[DATE]=9 units, ,[DATE]==11 units ,[DATE]=7 units, ,[DATE]=9 units, ,[DATE]=11 units, ,[DATE]=13 units and call MD if less than 80 call MD follow hypoglycemic protocol subcutaneous before meals and at bedtime for DM management. Order Date [DATE]. *Levimir Solution 100 unit/ML Inject 7 units subcutaneous two times a day for DM Start Date [DATE] *Pertinent Medication [MEDICATION NAME] Tablet 5 mg Give 1 tablet by mouth one time a day related to acute [MEDICAL CONDITION] with [MEDICAL CONDITION] Start Date [DATE]. A review of the MAR for (MONTH) 2019: *Fingerstick blood glucose Notify MD if blood sugar greater than 400 If blood glucose is below 70 initiate [DIAGNOSES REDACTED] protocol every 15 minutes as needed Start Date [DATE] at 12:11p.m. PRN *Glucose Gel 40% Place and dissolve 1 dose [MEDICATION NAME] every 15 minutes as needed for blood glucose less than 70 or ordered parameter symptomatic or asymptomatic but conscious and able to swallow as needed repeat protocol PRN Start Date [DATE] *[MEDICATION NAME] Emergency Kit 1 mg inject 1 mg IM every 15 minutes as needed for hypoglycemic symptoms difficulty to arouse or unconscious Administer immediately repeat BS in 15 minutes if no response 1st administration., repeat [MEDICATION NAME] if no response to second injection in 15 minutes repeat blood glucose and start IV access if not presently established and go to next step based on results Start Date of [DATE] PRN *[MEDICATION NAME] R Solution 100 Unit/ML Inject as per Sliding Scale if ,[DATE] =0, If below 80, begin hypoglycemic protocol. Call MD and write a note. ,[DATE] =3 units, ,[DATE]=5 units, 251- 300=7 units, ,[DATE]=9 units, ,[DATE]=11 units, ,[DATE]=13 units. If above 400, give 13 units, call MD and write a note, subcutaneous before meals and at bedtime for DM management. Start Date [DATE] *Levimir Solution 100 unit/ML Inject 15 units subcutaneous two times a day for DM II Do not give if blood glucose is less than 200 with a Start Date [DATE] and D/C date of [DATE]. **Pertinent Medication: [MEDICATION NAME] Tablet 5 mg Give 1 tablet by mouth one time a day related to acute [MEDICAL CONDITION] with [MEDICAL CONDITION] Order Date [DATE]. A review of the MAR for (MONTH) 2019 revealed: *Fingerstick blood glucose Notify MD if blood sugar greater than 400 If blood glucose is below 70 initiate [DIAGNOSES REDACTED] protocol call and four times a day for diabetes mellitus for 7 days Start Date of [DATE]. Hours Blood Sugar (BS): 6:30 am; 11:30 am; 1630 pm and 2100 pm. *[MEDICATION NAME] Emergency Kit 1 mg inject 1 mg IM every 15 minutes as needed for hypoglycemic symptoms difficulty to arouse or unconscious Administer immediately repeat BS in 15 minutes if no response 1st administration., repeat [MEDICATION NAME] if no response to second injection in 15 minutes repeat blood glucose and start IV access if not presently established and go to next step based on results with a Start Date of [DATE] and D/C date of [DATE] ordered PRN. Insulin regular solution 100 Unit/ML Inject as per Sliding Scale if ,[DATE] =0, If below 80, begin hypoglycemic protocol. Call MD and write a note. ,[DATE] =3 units, ,[DATE]=5 units, 251- 300=7 units, ,[DATE]=9 units, ,[DATE]=11 units, ,[DATE]=13 units. If above 450, give 13 units, call MD and write a note, subcutaneous before meals and at bedtime for DM II. Hours Blood Sugar (BS): 6:30 am; 11:30 am; 1630 pm and 2100 pm. Start Date [DATE] Hold Date from [DATE] to [DATE] D/C [DATE]. *Levimir Solution 100 unit/ML Inject 15 units subcutaneous two times a day for DM Start Date [DATE] and D/C date [DATE] Hours 9 am and 2100 pm. *[MEDICATION NAME] ,[DATE] 100 units/ml Give 20 units SQ one time a day a 2100 pm related to Type 2 Diabetes Mellitus without complications Start Date [DATE] and D/C date of [DATE]. *[MEDICATION NAME] ,[DATE] 100 units/ml Give 20 units SQ two times a day 9:00 am and 2000 related to Type 2 Diabetes Mellitus without complications Start Date [DATE] and D/C date of *[MEDICATION NAME] ,[DATE] 100 units/ml Give 26 units SQ one time a day related to Type 2 Diabetes Mellitus without complications Start Date [DATE] and D/C date of [DATE]. 9:00 am *[MEDICATION NAME] ,[DATE] 100 units/ml Give 20 units SQ one time a day 9:00 am related to Type 2 Diabetes Mellitus without complications Start Date [DATE] and D/C date of [DATE]. **Pertinent Medication: [MEDICATION NAME] Tablet 20 mg Give 1 tablet by mouth one time a day 9:00 am for pneumonia (PNA) [DATE] and D/C date of [DATE]. A review of the MAR for (MONTH) (YEAR) revealed: The MAR indicated [REDACTED]. *[MEDICATION NAME] Emergency Kit 1 mg inject 1 mg IM every 15 minutes as needed for hypoglycemic symptoms difficulty to arouse or unconscious Administer immediately repeat BS in 15 minutes if no response 1st administration., repeat [MEDICATION NAME] if no response to second injection in 15 minutes repeat blood glucose and start IV access if not presently established and go to next step based on results with a Start Date of [DATE] and D/C date of [DATE] ordered PRN. *[MEDICATION NAME] R Solution 100 Unit/ML Inject as per Sliding Scale if ,[DATE] =0, ,[DATE] =3 units, ,[DATE]=5 units, 251- 300=7 units, ,[DATE]=9 units, ,[DATE]=11 units, ,[DATE]=13 units. If above 450 call MD and write a note, subcutaneous before meals and at bedtime for DM management. Start Date [DATE] and D/C on [DATE]. Hours Blood Sugar (BS): 6:30 am; 11:30 am; 1630 pm and 2100 pm. *Levimir Solution 100 unit/ML Inject 7 units subcutaneous two times a day for DM Start Date [DATE] Hours 9 am and 2100 pm **Pertinent Medication: [MEDICATION NAME] Tablet 20 mg Give 1 tablet by mouth one time a day for pneumonia (PNA) [DATE] and D/C date of [DATE] 9 am. A review of the TAR (Treatment Administration Record) revealed no orders for a HGBA1C lab test to monitor diabetes. A review of the physician visit note e-signed on [DATE] at 7:34 a.m., This is a follow up visit after recent changes to patient's insulin dosing. Patient is a known insulin dependent diabetic and recently the nursing staff reported patient with frequent low AM blood sugars. Patient's insulin dose was readjusted in an attempt at correcting this, but patient continued to experience severe fluctuations in her blood sugars. A review of the