Every finding on record at Avir at Adams

Based on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 (MC #1) of 1 MC reviewed for medication storage. The facility failed to ensure that MC #1 was secured while staff were not present. This failure could place residents at risk of getting access to medication that do not belong to them, resulting in potential harm from ingesting.Findings included: An observation was conducted on 07/21/2026 at 1:00PM which revealed MC #1 was unattended and unlocked near the nurse's station. During the observation no residents were around the MC.An observation was conducted on 07/21/2026 at 1:05PM which revealed MC #1 was still unattended and unlocked. During the observation, the MC drawer was opened and medications were observed inside the drawer. An interview was conducted on 07/21/2026 at 1:07PM with an unknown staff member revealed MC #1 belonged to MA A.An interview was conducted on 07/21/2026 at 1:35PM with the DON who stated they had received training on MCs. The DON stated the training included that staff should make sure that all medications were locked and secured, including narcotic and regular medications, should be locked at all times. The DON stated that her expectation for medication storage was to ensure staff are all trained, the medication cart should be locked at all times, and all staff should lock the cart if they saw it unlocked. She stated that the medication cart should be locked once they are not actively using it, or if the cart is not being used for any reason. She stated residents could touch the medication and/or go into the medication cart, if it was left unlocked. The DON stated the staff assigned to the MC would be responsible for locking up MC. The DON stated she did not see the MC unlocked.An interview was conducted on 07/21/2026 at 1:56PM with the ADM who stated their policy regarding MCs, was that they should be locked at all times. The ADM stated every time the nurse or med aid was not at the cart, if they walk away, they should lock it up. He stated that drug diversion could occur or residents could get the medications that don't belong to them, if the MC was left unlocked.An interview was conducted on 07/21/2026 at 2:39PM with MA A who stated she received training on medication storage She stated the training included that they were to lock the MC any time they leave the cart. MA A stated if the MC was left unlocked, residents could get access to the medications. She stated that the MA would be responsible to lock the MC. She stated that she had forgot to lock the MC while she walked away from it, it was an honest mistake.Record review of the facility's policy titled Medication Labeling and Storage dated February 2023 indicated the following: The facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only authorized personnel have access to keys.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use

Based on observations, interviews and record reviews, the facility failed to maintain an effective pest control program so that the facility was free from pests for 1 of 1 kitchen rooms and 3 (Resident #2, Resident #4, and Resident #5) of 10 Resident rooms reviewed for environment.The facility failed to ensure the kitchen and dining room was free of cockroaches.The facility failed to ensure Resident #2, Resident #4, and Resident #5's room were free of cockroaches. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.Findings included:Observation on 06/29/2026 at 11:01 AM revealed two Catchmaster Mouse and Insect Super Glue Traps in the kitchen on the floor located by a trashcan. Observed one Catchmaster box filled with dead cockroaches and a second box with two dead cockroaches. Observation on 06/28/2026 at 2:02 PM revealed a live cockroach in the right corner of Resident #2's room by the door stopper. During an interview on 06/29/2026 at 11:35 AM with Resident #3 she said she has been at the facility for about 4 months and the cockroaches were horrible. Resident #3 said she did not see them in her room, but on the walls in the kitchen. She said she had seen them when she was eating in the dining room. Resident #3 said the cockroaches made her feel dirty.During an interview on 06/29/2026 at 1:39 PM with the DC she said she saw three live cockroaches today. The DC said she saw two in the kitchen and one in the dining room. She said she told the DM when she saw them. She said a negative effect of residents having cockroaches where they live could be the spread of infection. She said she had seen an average of 3 cockroaches a day for about 1 year. During an interview on 06/29/2026 at 1:50 PM the MD said residents had complained about the cockroaches, but they are beginning to get ahead of them. The MD said Residents #4 and #5 had told him about the cockroaches. The MD said a negative effect of having bugs in the facility was germs and the overall negative appearance of the cockroaches. The MD said he heard a couple of days ago that there were cockroaches in the kitchen. He said the bugs are mostly water bugs, giant cockroaches, that come in from the drains. He said it was the responsibility of all staff to keep bugs out of the facility. The MD said he told the Administrator about the cockroaches and the Administrator approved him to get the pest control company to work specifically on the cock roach situation.During an interview on 06/29/2026 at 2:45 PM with Resident #4 she said she had seen cockroaches for about a month. She said she has seen 1 or 2 cockroaches a day in her room. She said she told the MD, but she feels the staff knew about the bugs. She said she tried to kill them when she saw them. Resident #4 said she did not like the cockroaches in her room. During an interview on 06/29/26 at 3:38 PM with the DM she said there were large water cockroaches in the kitchen on the ground mainly, in the storeroom, and by the back door. The DM said the water cockroaches had been bad during the big rains in the past months. The DM said pest control sprayed good last week, and it had gotten a lot better. The DM said the negative effect of having bugs in your kitchen was that bugs were nasty. The DM said they were always on the floor and she had not seen them on anything else. During an interview on 06/29/2026 at 4:43 PM with Resident #5 she said gosh yes, she had seen cockroaches in the facility. She said the MD knew about them. She said she saw a roach yesterday in her room. Resident #5 said she felt scared when she saw bugs. She said those big old water cockroaches scared her. During an interview on 06/29/2026 at 4:50 PM the Administrator said there were cockroaches in the facility but from one week to the next there was a massive decline in the number of bugs in the facility. The Administrator said things were getting better. The Administrator said the negative effect of having bugs in a building was infection from the bugs. During an interview on 06/29/2026 at 5:18 PM the DON said the facility had water bugs. The DON said the water bugs look like cockroaches. She said it makes the facility appear dirty because no one wants to see bugs. The DON said it was almost impossible to prevent. The DON said the facility was actively trying to eliminate the water bugs. She said the possible negative effect of having bugs in the facility was they might be carrying some kind of infection. The DON said the MD was responsible for making sure there was pest control at the facility and for the facility to be bug free.Record review of Facility Pest Control Policy Statement dated May 2007 reflected Policy StatementOur facility shall maintain an effective pest control program.Policy Interpretation and ImplementationThis facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.Pest control services are provided by a licensed pest control exterminator.Windows are screened at all times.Only approved FDA and EPA insecticides and rodenticides are permitted in the facility, and all supplies are stored in areas away from food storage areas.Garbage and trash are not permitted to accumulate and are removed from the facility daily.Maintenance services assist, when appropriate and necessary, in providing pest control services.

Based on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning.The facility failed to notify Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/10/2026 in a facility-initiated discharge to another skilled nursing facility. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 06/10/2026. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.Findings included:Record review of Resident #1's face sheet, dated 06/28/2026, revealed a sixty four year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, cognitive abilities, and the capacity to perform simple tasks), bipolar disorder (a lifelong mental health condition that causes extreme shifts in mood, energy, activity levels, and concentration), and metabolic encephalopathy (a broad term for brain dysfunction caused by chemical, hormonal, or systemic problems in the body).Record review of Resident #1's care plan revealed care plan closed dated 06/19/2026 had a focus of Resident #1 had a behavioral problem of verbal aggression towards staff and residents related to Alzheimer's Disease dated 03/18/2026 has combative, physical aggression, fluctuating calm to aggressive mood swings, wheels her wheelchair very fast and rams into walls/furniture, restless, impulsive behaviors, unclothes self in public spaces, throws water on others initiated 03/13/2026 and revised on 04/01/2026 with interventions administer medications as ordered, monitor/document for side effects and effectiveness dated 03/13/2026, anticipate and meet Resident #1's needs dated 03/13/2026, monitor and document behaviors every shift dated 04/01/2026, psychiatric referral, evaluation, and treatment 04/01/2026, and staff to redirect behaviors and remove resident to a safe location until behavior deescalates 04/01/2026.Record review of Resident #1's MDS (clinical assessment to determine resident's strength and needs) dated 03/27/2026 reflected:Nursing Home Comprehensive Section C - Cognitive Patterns revealed a BIMS score of 3 indicating severe cognitive impairment. E0100 Section E - Behavior Potential Indicators of Psychosis - Delusions (misconceptions or beliefs that are firmly held, contrary to reality), behavioral SymptomsE0200. - Behavioral Symptom - Presence and Frequency Behavior of this type occurred 1 to 3 days - physical behavioral symptoms directed toward others (e.g., hitting, kicking pushing, scratching, grabbing, abusing others sexually), verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others), other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds).Record review of Resident #1's progress notes dated 03/12/2026 by nursing staff reflected Resident #1 placed on secure unit for safety. Record review of Resident #1's progress notes dated 04/07/2026 by SW reflected spoke with Resident #1's RP regarding the possibility of transferring of Resident #1 to another facility due to difficulty managing behaviors on the secured unit. RP asked if Resident #1 was being the aggressor and SW confirmed this. SW informed RP that referrals were sent to 2 different facilities. Resident #1's RP stated, Well, do what you got to do. Record review of email dated 04/08/2026 at 8:51 AM from the former facility Administrator to the Ombudsman reflected we are planning to transfer Resident #1 to a facility that can better manage her behaviors. We contacted Resident #1's RP and he agreed to the transfer. Record review of Resident #1's progress notes dated 04/22/2026 by nursing staff reflected Resident #1 came up behind a staff member and started choking her. Resident #1's RP notified and he stated, okay let me know if she leaves. Record review of Resident #1's progress notes dated 05/07/2026 by SW reflected Resident #1 required new nursing home placement due to increased negative behaviors. Resident #1's clinical records faxed to other nursing facilities for potential transfer. Record review of email dated 05/12/2026 at 4:46 PM from the former facility Administrator to the DD of SS reflected the former Administrator was referred to the DD of SS for assistance with a difficult discharge/transfer. She has assaulted several staff members, attempted sexual contact with another male resident. We have had no luck getting her accepted at other facilities. Record review of email dated 05/12/2026 at 5:28 PM from the DD of SS to the former facility Administrator reflected the DD of SS asked if the Ombudsman was involved and had a 30-day discharge letter been issued. Record review of email dated 05/12/2026 at 6:03 PM from the RNC to the DD of SS reflected the facility had a full time SW and she did not believe a 30-day had been issued by the facility. The RNC stated she was unsure of the Ombudsman involvement, but the Ombudsman would not be of assistance. The Ombudsman would fight their efforts in relocating Resident #1. Record review of email dated 05/13/2026 at 2:51 PM from the DD of SS to the former facility Administrator. Is [Resident#1's RP] open to her moving to a different town?Record review of email dated 05/13/2026 at 3:26 PM from the former facility Administrator to the DD of SS reflected, [Resident#1's RP] is ok with her being moved. He is not actively in her life but had been notified of her behavior and has no objections to moving her elsewhere.Record review of Resident #1's progress notes dated 06/08/2026 by the SW reflected that she attempted to call Resident #1's RP but received no answer. SW left a voicemail reminding RP of the continued search for alternative and safe placement for resident. SW left a callback number for any questions or concerns. SW added on voicemail that resident had not yet been accepted and there was no generalized location of where resident may be accepted. Record review of Resident #1's progress dated 06/10/2026 reflected Resident #1 discharged from the facility; all paperwork and personal items sent with her. Resident #1 unable make needs know unless prompted. During an interview on 06/28/2026 at 3:21 PM with the Administrator he said he did not know anything about Resident #1's transfer to another facility, the SW had that information. During an interview by phone on 06/28/2026 at 4:21 PM with Resident #1's RP he said he was not informed about Resident #1's discharge to another facility. Resident #1's RP said the facility had discussed transferring her, but he did not know when it happened or where she was transferred. The RP said Resident #1 was moved about 2.5 hours away from him to a new facility. The RP said the first he learned that Resident #1 was sent to another facility was when the new facility called him. He said the SW did not call him and tell him the name of the facility Resident #1 was transferred to or when she was transferred. The RP said he could not take care of her because of her past drug addiction, but he loved her. During an interview on 06/29/2026 at 10:37 AM with the SW she said Resident #1 had difficult behaviors and a decision was made by the previous Administrator and the corporate office to transfer Resident #1 to another facility. The SW said the facility was looking for another facility that could manage her behavior and keep her safe. The SW said when Resident #1 was transferred she did call the RP and inform him that Resident #1 was going to be discharged and where she was going to be discharged , but she did not chart that she did so. The SW said it was a rookie foul on her part that she did not chart the conversation with Resident #1's RP. During an interview on 06/29/2026 at 12:04 PM the SW said she did not believe she had read the facility policy on facility initiated resident discharges. The SW said she did not give a thirty (30)-day advance written notice of an impending transfer or discharge from this facility to the RP in writing and did not give the specific reason for the transfer or discharge, the effective date of the transfer or discharge, the specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident was being transferred or discharged , an explanation of the resident's rights to appeal the transfer or discharge. During an interview on 06/29/2026 by phone at 1:06 PM with the DON of the facility Resident #1's was transferred to, the DON said that Resident #1 was doing well and had not had any issues at the facility. The DON at Resident #1's current facility said they recently had a care plan meeting for Resident #1's RP and he commented that he wanted Resident #1 to be moved closer to where he was located. During an interview by phone on 06/29/2026 at 1:10 PM with the PNP she said that the facility asked her about transferring Resident #1 to another facility because of her behaviors and she did not have any objections to Resident #1's transfer but said that the facility needed to follow their facility discharge policy. During an interview by phone on 06/29/2026 at 2:06 PM with the Ombudsman he said he did not have any official notice that Resident #1 was being discharged . The Ombudsman said he did not receive a 30-day discharge notice the included the reason for Resident #1's discharge, the effective date of Resident #1's discharge, or the location where Resident #1 was being discharged .During an interview by phone on 06/29/2026 at 3:02 PM with the DD of SS she said she oversaw the corporate office social work programs. The DD of SS said for a facility initiated discharge the facility would want to have a meeting with the RP to work through whatever might be going on with the resident. The DD of SS said the facility wanted to find the best placement for the resident and said it involved care planning and involvement with the facility Ombudsman. She said if the RP was not involved, then the facility should issue a written 30-day discharge notice. The DD of SS said the facility should document conversations with the RP about discharges. The DD of SS said the facility should specifically document conversation with the RP about the resident transferring to a different area. The DD of SS said if they do not have documentation of conversations with the RP about discharge and where the resident was going, no documentation of a 30-day discharge notice to the RP or the Ombudsman then the facility SW did not follow the discharge policy. During an interview on 06/29/2026 at 3:46 PM with the DON she said the SW was responsible for facility-initiated discharges. The DON said there was no written 30-day notice to the RP or the Ombudsman and the Resident, through her RP, was not notified of her right to appeal. The DON said the SW should follow the discharge policy. She said there was a discharge summary that was created but not completed and the facility did not follow their discharge policy which was made to ensure a safe discharge of residents. The DON said a possible negative effect of not notifying the Ombudsman or the RP as outlined in the facility procedures was family members not knowing where the resident was in case of an emergency. The DON said it was a resident rights issue to not follow the facility discharge procedure. Resident #1, through her RP, did not receive the information about their right to make an appeal. The DON said it was the responsibility of the interdisciplinary team that included the Administrator, the DON, SW, and PNP to make sure residents were properly discharged . The DON said in the future she would make sure residents, RPs, and Ombudsman were notified of discharges and given the required 30-day notice.During an interview on 06/29/2026 at 4:50 PM with the Administrator he said he was minimally involved with Resident #1' discharge. The Administrator said her discharge was in the works when he got there and he was aware they were looking for a place for her. The Administrator said the SW was the person who was responsible for facility discharges and he expected her to follow the facility policy. The Administrator said if the SW did not know the facility policy she needed to pull it and review it. The Administrator said a negative effect of not following the discharge procedure was a resident right issue. The Administrator said if the RP did not receive the proper notice of a discharge, the Resident was not informed of their rights. Review of Facility Policy Transfer or discharged , Facility Initiated dated May 2026 reflected once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy. Facility-Initiated Transfer or Discharge means a transfer or discharge which the resident objects to or did not originate through a resident's verbal or written request, and/or is not in alignment with the resident's stated goals for care and preferences. Notice of Transfer or Discharge (Planned)Except as specified below, the resident and his or her representative are given a thirty (30)-day advance written notice of an impending transfer or discharge from this facility.The resident and representative are notified in writing of the following information:The specific reason for the transfer or discharge, including the basis under S483.15(c)(1)(i)(A)-(F);The effective date of the transfer or discharge;The specific location (such as the name of the new provider or description and/or address if the location is a residence) to which the resident is being transferred or discharged ;An explanation of the resident's rights to appeal the transfer or discharge to the state, including:the name, address, email and telephone number of the entity which receives such appeal hearing requests;information about how to obtain an appeal form; andhow to get assistance in completing and submitting the appeal hearing request;The Notice of Facility Bed-Hold and policies;The name, address, and telephone number of the Office of the State Long-term Care Ombudsman;The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with intellectual and developmental (or related) disabilities (as applies);The name, address, email and telephone number of the agency responsible for the protection and advocacy of residents with a mental disorder or related disabilities (as applies); andThe name, address, and telephone number of the state health department agency that has been designated to handle appeals of transfers and discharge notices.A copy of the notice is sent to the Office of the State Long-Term Care Ombudsman at the same time the notice of transfer or discharge is provided to the resident and representative.If information in the notice changes, the facility will update the recipients of the notice as soon as practicable with the new information to ensure that residents and their representatives are aware of and can respond appropriately.For significant changes, such as a change in the transfer or discharge destination, a new notice will be given that clearly describes the change(s) and resets the transfer or discharge date in order to provide 30-day advance notification and permit adequate time for discharge planning.

Based on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 3 (Res#3, Res#4, and Res#5) of 3 residents reviewed. The facility failed to take residents who smoked out on a scheduled smoke break timely at 10:30 A.M. This failure could result in significant physical, emotional, and behavioral disruptions.Findings included: Record review on 06/05/26 of the smoking break schedule for the residents revealed they were scheduled to go to the designated area for a smoke break at 10:30 A.M. daily. It also revealed the following break times:8:30 AM, 10:30 AM, 1:30 PM, 3:30 PM, 6:30 PM, 8:30 PM. Record review on 06/05/26 of a list of smokers emailed by the RNC on 06/05/26 at 1:08 PM revealed 15 residents were included on the list. There was no printed list provided. A smoking policy was also requested but not provided prior to exit. During an observation on 06/05/26 at 10:50 A.M., the residents who smoked had not gone on the scheduled smoke break. Observation on 06/05/26 at 10:52 AM revealed the smoke break area was located outside at the end of hall B. Observation revealed that there was no one outside in the smoking area between 10:30 AM - 10:55 AM. During an interview on 06/05/26 with Res#3 at 10:53 a.m. revealed that she was supposed to go outside for a supervised smoking break at 10:30 AM with CNA A. Res#3 stated CNA A was often late taking the residents on their scheduled smoking breaks. Interview on 06/05/26 with Res#4 at 11:10 AM revealed she was supposed to go outside for a supervised smoking break at 10:30 AM with CNA A. Res#4 stated CNA A took the residents who smoked on their scheduled smoking break late a lot of times. Interview on 06/05/26 with Res#5 at 11:16 AM revealed he did not smoke but stated the residents who smoked were supposed to go on a scheduled smoke break at 10:30 AM. He stated they went on their smoke breaks later than scheduled several times a week. Interview on 06/05/26 with SS at 11:22 AM revealed she created the schedule for the residents who smoked. She stated that CNA A normally took them on their supervised scheduled break. She stated the facility had two staff members who called in and CNA A received another directive during that time and was unable to adhere to the smokers' schedule. The SS stated CNA B did not find out until almost 11:00 AM that he was supposed to supervise the scheduled smoke break at 10:30 AM. The SS stated that the nurses were responsible to ensure residents who smoked went to their scheduled breaks on time. She stated that residents normally knew when the break time was. She stated that the schedule was not changed until around 11:00 AM to reflect who would supervise the smoking break and she was responsible for that. She stated she and the nurses at the nurse's station were responsible to ensure the smoking break schedules were adhered to. She stated that at that time the nurse that was at the nurse's station may have overlooked the schedule because she oversaw two halls due to a nurse calling out. The SS stated she was not aware that the smoking breaks were late often. She stated the smoke break times were 8:30 AM, 10:30 AM, 1:30 PM, 3:30 PM, 6:30 PM, and 8:30 PM. Interview on 06/05/26 at 1:40 PM with CNA B who revealed he did not know he was supposed to take the residents who smoke on their scheduled break at 10:30 AM because it was not on the schedule when he arrived at work that morning. CNA B said he was scheduled to take them on break at 1:30 PM and 3:30 PM. He stated he was not notified that there was a change in who would take the residents out for their scheduled smoke break. He stated that smoke breaks were especially important to residents because this was their home. CNA B said it could affect their attitudes and their demeanor if they were denied their smoking breaks. He stated that the SS and the LVN B were responsible to ensure that the smoke schedule was adhered to. He stated that the smoke break times were 8:30, 10:30 AM, 1:30 PM, 3:30 PM and 6:30 PM, and 8:30 PM. Interview on 06/05/26 at 2:02 PM, LVN B stated the SS made the break schedule for the residents who smoke, but it was off today due to several staff members being out. She stated that CNA B was assigned a different task at that time by the SS and did not take the residents out for break. LVN B stated that the SS was supposed to ensure that someone was in place if there was a change in the schedule and to also ensure the nurses were aware of the changes. LVN B stated that the entire staff was supposed to make sure that residents went to the smoke breaks on time. She stated that residents were upset when they did not go on smoke breaks on time, which she stated happened often. Interview on 06//05/26 at 2:16 PM, CNA B revealed she was scheduled to supervise the smoking break at 10:30 AM but the SS changed the schedule because some staff members called in for the day. She said she was assigned to another task around 8:00 AM for her shift duration. She stated that the SS should have let the nurses know that the schedule changed. CNA B stated normally if there was a change in the smoking schedule, the SS would let everyone know. CNA B stated it was important for the smokers to go on their scheduled breaks because it could affect their attitudes and daily routines. She stated the smoke break times were 8:30 AM, 10:30 AM, 1:30 PM, 3:30 PM, 6:30 PM, and 8:30 PM. Interview on 06/05/26 on 5:01 PM, the VPO revealed the SS was responsible to ensure that smoke breaks were taken timely and to advise if there was a schedule change in time or a change in who would supervise the break. The VPO stated that this could affect their behaviors and their daily routines. The VPO stated it could violate their rights if there was not an emergency. The VPO stated the facility should have at least two or more backups to ensure that residents who smoked went on breaks in a timely fashion.

Based on observation, interview, and record review the facility failed to update two residents care plans (Res#1 and Res#2) of 7 residents reviewed to reflect interventions in place because of an incident that happened between them. The facility failed to update Res#1's and Res#2's care plans to reflect interventions in place because of an incident that happened on 05/03/26 at 6:26 PM. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.Finding included: Record review on 06/04/26 of Res#1's face sheet, dated 06/04/26, revealed an [AGE] year-old male, admitted [DATE]. His diagnoses included Vascular Dementia (a decline in thinking and memory skills caused by conditions that block or reduce blood flow to the brain, depriving brain tissue of vital oxygen and nutrients), Hyperlipidemia (high amounts of fats (lipids), such as cholesterol and triglycerides, circulating in your bloodstream), Type 2 Diabetes Mellitus (chronic metabolic disorder characterized by persistently high blood sugar levels, and major depression disorder). Res#1's BIMS score was 04, indicating severe cognitive impairment (problems with thinking, learning, memory, judgement, and concentration). Record review on 06/04/26 of Resident #2's face sheet, dated 06/04/26, revealed a [AGE] year-old female admitted [DATE]. Her diagnoses included Alzheimer's disease (a progressive brain disorder that slowly destroys memory, thinking skills, and the ability to carry out daily tasks), Hypokalemia (lower than normal level of potassium in the blood stream), Metabolic Encephalopathy (altered brain function caused by an underling systemic, chemical, or metabolic problem in the body rather than a direct head injury), and Hypertension (where the force of blood against your artery walls is consistently too high). Res#2's BIMS score was 03, indicating severe cognitive impairment. Record review on 06/05/26 of the incident reports, dated 03/05/26 through 06/04/26, revealed there was an incident that happened between Res#1 and Res#2 on 05/03/26. Record review on 06/05/25 of LVN A's risk management notes, dated 05/03/26, revealed the following for Res#1: This resident was observed with his disposable underwear pulled down standing up in his room trying to get in his bed. Upon further investigation it was observed by this writer that a female resident was laying on her back on the bed that he was trying to get into. Female resident immediately removed from the room. Female resident believes that he was her husband.Immediate Action: Both residents were separated and Q/15-minute monitoring started. MD, ADM, and IDON notified.Injury type: No injuries observed at time of the incident.Resident location: SU Record review on 06/05/25 of LVN A's risk management notes on 05/03/26 revealed the following for Res#2: This resident was observed laying on her back in the bed of a male resident without any underwear on.Immediate action taken: Both residents immediately separated and Q/15-minute monitoring started. MD, ADM, and DON notified.Injury type: No injuries observed at time of the incident.Resident location: SU Record review on 06/05/26 of Res#1's care plan, dated 04/01/26, revealed the last update to their care plan was 04/01/26. The care plan did not reflect interventions that were in place because of the incident that happened on 05/03/26. Record review on 06/05/26 of Res#2's care plan, dated 04/01/26, revealed that the last update to their care plan was 04/01/26. The care plan did not reflect interventions that were in place because of the incident that happened on 05/03/26 During an interview on 06/05/26 at 12:47 PM, the MD stated she was aware of the incident on 05/03/26 that happened between Res#1 and Res#2. The MD stated that she instructed staff to continue monitoring until discharged . She stated Res #2 was on 1:1 supervision since she appeared to be the initiator since she was laying across the bed without panties on and Res #1 was on Q/15 monitoring. She stated she spoke with the IDON on 05/06/26, who advised the MD verbally discharged the monitoring that day. During an interview on 06/05/26 at 2:47 PM, RNC stated she reviewed Res#1's and Res#2's care plans and saw they did not reflect the incident that happened on 05/03/26. The care plan policy was requested but not provided prior to exit. During an interview on 06/05/26 at 4:09 PM, LVN A stated she saw Res #1 in his room, and it looked as if he tried to crawl in his bed. LVN A walked in and saw Res #2 lying across the bed with only a T-shirt on. She said she did not have panties on. LVN A stated Res #1 appeared to be trying to unzip his pants. LVN A said she immediately separated them and called the IDON for further instructions. LVN A stated the IDON implemented Q 15 monitoring for Res #1 and 1:1 supervision for Res#2 since she was the aggressor. LVN A stated the IDON advised her to document Res#1's and Res#2's behaviors daily for three days. LVN A stated normally the MD would verbally discharge supervision after reporting no behaviors. During an interview on 06/05/26, the IDON stated each resident's care plan was updated when there was a change of condition and in care. She stated she was trained on and was familiar with facility's care plan policy. The IDON said the care plan was developed at admission and updated as new changes were identified or resolved. The IDON stated the importance of updating care plans was to keep track of each resident's condition so staff would be able to know what needs to properly address when there was a change. The IDON stated normally the MDSC was responsible for making sure that each resident's care plan was updated timely. However, the IDON stated at this time she was responsible for making sure each resident's care plan was updated properly. During an interview on 06/05/26, the RVPO stated the facility's former ADM's last day was 05/29/26 and the new ADM would start on 06/08/26. The RVPO stated she did not know that the care plans were not updated correctly. The RVPO stated she believed it was the MDSC's or the IDON's responsibility to ensure that each resident's care plan was updated correctly. The RVPO stated it was important for each care plan to be updated correctly and timely to ensure that each resident received the correct person-centered care. A copy of the care plan policy was requested, but not received During an interview on 06/05/26, the RNC stated , at this time, it was IDON's responsibility to ensure that care plans were updated correctly, since the facility did not have a MDSC. The RNC stated she did not know why the care plans were not updated to reflect the incident that happened on 05/03/26. The RNC said that resident's care plans should have been updated as soon as staff members reported behaviors or changes. The RNC said that it was important to update care plans to ensure that each resident received the correct person-centered care required to maintain the best quality of life possible.

Based on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1(Resident #1) of 6 residents reviewed for resident's rights.The facility failed to provide peri care in a timely matter for Resident #1 thus causing her to be left sitting in a soiled brief for over four hours. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity, leaving the residents feeling helpless, sad and hopeless. Findings included:Record review of Residents #1 face sheet dated 01/14/26 reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, abnormalities of gait and mobility, furuncle of groin, dehydration, anxiety disorder unspecified, and hypocalcemia (a condition of low calcium in blood)Record review of Resident #1's most recent MDS dated [DATE], reflected a BIMS of 15, indicating cognition was intact. MDS reflects that Resident #1 is bowel continent and is not on a toileting program used to manage the resident's bowel continence. Resident #1 requires assistance with toileting transfer and requires supervision or touching assistance with toileting hygiene.Record review of Resident #1's care plan dated 12/30/2025 reflected the resident received Resident #1' care plan did not reflect that she had any adverse reaction due to sitting in wet briefs for a long period of time.During an interview with Resident #1 held on 01/13/2026 at 12:49pm Resident #1 stated that she liked being at the facility and felt safe, however she revealed that she was often left sitting in a wet brief. Resident #1 revealed that when she was left in her brief it made her feel sad, hopeless, helpless. Resident #1 revealed that she mentioned it to the DON and Admin, however nothing had changed. Resident #1 revealed that she had not had a breakdown in skin and that she had been left in a wet brief for hours mostly at night.Record review of Resident #1's skin assessment dated [DATE], did not reflect any skin breakdown.During an interview on 1/14/2026 at 01:15pm with the DON, she revealed that she was unaware of residents being left sitting in soiled briefs for hours at a time. The DON stated that she had no concerns about there being a shortage of staff in the facility. She reported that during the day the facility staffed two nurses, two med aides, and 6 CNAs. She reported that the staff worked 12-hour shifts. The DON reported that at night the facility staffed two nurses, they had two med-aides until 08:45pm, and six CNAs. The DON reported that she expected for staff to be checking residents frequently, and they should be answering call light as soon as possible. The DON reported that staff didn't document how many times with supervision or touching assistance - changed a resident's brief. She reported that it was documented if a resident had complications throughout the night or was exhibiting abnormal behavior. The DON stated that if a resident was kept sitting in a wet brief for a substantial amount of time it could cause skin breakdown.During an interview with the ADMIN on 01/14/2026, at 02:26pm, it was revealed that no residents or staff had approached him with concerns about a shortage of staff. He reflected that no residents had ever approached him to the issues of sitting in a wet brief for hours at a time. He stated that the facility could use more staff and that he was aggressively recruiting new staff, setting up partnerships with CNA schools, and hiring a hospitality staff. The ADMIN reported that he expected for staff so respond to call lights as soon as possible and they should be doing rounds every two hours. The ADMIN stated that not answering a call light in an appropriate time frame could create poor quality and poor resident satisfaction. During an interview with CNA A held on 01/14/2026 at 03:49pm, he revealed that he received an in-service on abuse and neglect last week. CNA A stated staff leaving a resident in a soiled brief and not helping them eat as a form of neglect. He said that he made his rounds every two hours if not more often than that. The CNA reported that he did not document each time he entered a resident room or when he changed their brief. The CNA A stated that residents had come to him with concerns of being kept sitting in a wet brief for too long. CAN A stated that he reported it to the charge nurse and had yet to see an outcome. He reported that when a resident was kept in a solid brief could cause pressure ulcers, skin tears. CNA A reported that Resident #1 had mentioned being left in soiled briefs once or twice.During an interview with CNA B on 01/14/2026 at 04:05pm, she revealed that she received an in-service on resident rights. She stated that a resident had a right to be treated with dignity and respect. CNA B reported that staff should be making rounds every two hours, however she typically did it every hour. CNA B reported that she could document when she provided peri care on a resident through Point Click Care system. Point Clinic Care login refers to the process of accessing the Point Click Care platform, which is used for patient care and management. To log in, you typically need to enter your username and password on the login page. If you encounter issues, you may need to reset your password or contact support for assistanceCNA B reported that it should take no more than 5 minutes for someone to respond to a call light. She reported that she had come into work several times and found a resident sitting in a soiled brief. CNA B stated that this comes from lack of structure because they have plenty of time to check in on residents throughout the night. CNA B stated that residents could obtain rashes, redness, or skin breakdowns when left in a solid brief.During an interview with LVN A on 01/14/2026 at 04:27pm, she reported that her last in-service on abuse and neglect was last week. She said that an example of neglect is if you fix a call light to not work or not feeding a resident. LVN A reported that they did not document everything, just baths, bowel movements, and if they did not eat all their food. LVN A reported that residents have told her that they were often left in wet briefs in the daytime. LVN A stated that she told the DON who stated, t true. I work the day shift. LVN A stated that lack of staffing could be why residents were left sitting in solid brieReview of Accommodation of Need policy statement dated March 2021 reflected:Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being.Policy Interpretation and Implementation 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents' right to:a. a dignified existence.b. be treated with respect, kindness, and dignity.

Based on interviews and record reviews, the facility failed to protect the resident's(s') right to be free from abuse, neglect, misappropriation of property, and exploitation for 2 of 6 residents (R#1 and R#2). The facility failed to ensure R#1 was not sexually assaulted by R#2 on 12/27/25. An IJ was identified on 12/31/25. The IJ template was provided to the facility on [DATE] at 9:04 p.m. While the IJ was removed on 01/02/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of further abuse, neglect, harm, injury, or death.Findings include:R#1Review of R#1's admission record, dated 12/31/25, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had medical diagnoses that included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, causing stroke-like symptoms that resolve within 24 hours, usually much sooner), noninflammatory vagina disorders (conditions affecting the vagina often due to hormonal changes, anatomical issues or irritation), unsteadiness on feet, gait and mobility abnormalities, need for assistance with personal care, anxiety disorder, pain disorder, major depressive disorder and dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of R#1's quarterly MDS assessment, dated 11/19/25, reflected the cognitive patterns section showed she had no BIMS score, which indicated she was unable to complete her BIMS interview. Staff assessment for her mental status also showed she had short- and long-term memory problems, was normally able to recall the location of her own room and was moderately impaired when making daily life decisions. The behavior section showed she did not exhibit physical, verbal and other behavioral symptoms and wandering behaviors. The functional abilities section showed she required supervision or touching assistance with lower body dressing, transfers and bed mobility. Review of R#1's care plan, revised on 12/31/25, reflected she had a behavior problem of wandering throughout the secure unit, often into other residents' rooms, and sometimes lying down in other residents' beds. Staff were required to implement interventions, which included administering medications as ordered, anticipating and meeting her needs, intervening as necessary to protect other residents' rights and safety, divert her attention and remove her from a situation and take her to an alternate location as needed. Staff were also required to redirect her to her room or another common area when she was observed wandering into other residents' rooms. Review of R#1's task care record for December 2025 reflected staff documented observing her on 12/27/25 at 3:00 p.m. Review of R#1's change in condition evaluation note created by LVN A on 12/27/25 at 4:04 p.m. reflected, Resident found in bed with another resident; staff intervened and separated both without incident. Resident is non-verbal (BIMS 99) and was calm and cooperative. Full physical and skin assessment completed with no injuries or signs of penetration noted. Psychosocial assessment showed no acute distress. DON, responsible party, and abuse coordinator notified. Resident remains ongoing monitoring and care plan review. Review of R#1's skin check note created by LVN A on 12/27/25 at 4:09 p.m. reflected, No skin issues noted upon assessment, nurse and staff observed dried feces on resident's pubic hair. Resident's [family member] was present and gave her a shower. Review of R#1's BIMS evaluation note created by the DON on 12/27/25 at 4:46 p.m. reflected, Resident is nonverbal and unable to participate meaningfully in the assessment. When verbalizations occur, resident repeats words spoken by staff (echolalia), laughs inappropriately, and/or begins dancing. Resident is unable to comprehend, respond appropriately, or follow directions required to complete the BIMS assessment due to severe cognitive/mental impairment. Review of R#1's psychosocial note created by LVN B on 12/27/25 at 5:04 p.m. reflected, Resident observed in male resident's room in bed with male on top of her gyrating his hips. Residents immediately separated. Full body assessment completed with no apparent injuries observed. No c/o pain/discomfort. VS obtained and WNL. DON, Admin, family member, and MD all notified and aware. Review of R#1's incident note created by LVN A on 12/27/25 at 5:56 p.m. reflected, The female resident was found in bed with another resident during routine rounds, and staff intervened immediately, separating both residents without incident. The resident's BIMS score is documented as 99 (unable to assess) and she is non-verbal. At the time of assessment, the resident was observed to be calm, with non-verbal cues including facial expressions, body posture, eye contact, or lack thereof, and was cooperative with care. A thorough head-to-toe physical assessment, including a comprehensive skin check, was completed, with no penetration reported or observed and no bruising, bleeding, or signs of injury noted to the genital, groin, or buttocks areas. A psychosocial assessment was conducted using observation of non-verbal behaviors, with no signs of acute distress noted at the time. The Director of Nursing, responsible party, and facility abuse coordinator were notified per facility protocol. The resident remains on 1:1 supervision to ensure safety, with continued monitoring and interdisciplinary review for psychosocial support and care plan updates. Review of R#1's 15 minute check monitoring form, dated 12/27/25, reflected she was monitored as follows:the DON from 12/27/25 at 3:30 p.m. through 12/27/25 at 5:15 p.m. and CNA F from 12/27/25 at 5:30 p.m. through 12/27/25 at 6:30 p.m.Further review revealed there were no other entries. Review of R#1's physician progress note created by the MD on 12/27/25 at 6:21 p.m. reflected, Resident has been on 1:1 supervision for her safety. She is stable at this time and no longer needs to be on 1:1 supervision. Will D/C the 1:1 supervision. Review of R#1's nurse's note created by LVN A on 12/29/25 at 4:33 p.m. reflected, Female resident involved in a recent incident, family requested transfer to the emergency room for further medical assessment. Resident assessed by nursing staff and medical provider, and based on family request, 911 was initiated for hospital transfer. Nurse called report to Emergency Department and provided pertinent resident information. MD and Director of Nursing were notified and are aware of the transfer. Emergency Medical Services are currently in route to the facility. Resident remains under nursing supervision pending EMS arrival. Review of R#1's hospital after visit summary, dated 12/29/25, reflected she arrived at the hospital by EMS on 12/29/25 at 5:12 p.m. Her visit was due to medical clearance for diagnosis regarding possible STI exposure. Her right knee and right femur were x-rayed due to tenderness on exam due to possible recent abuse. The history and physical information reflected, [R#1] presenting for medical clearance. Presents with family for recent history of possible abuse per the family member. She is currently at her neurological baseline, unable to answer questioning or respond to instructions. Family states that 3 days ago a co-resident at her memory care facility was found on top of her in bed. Both the patient and the other individual appeared to be naked, but no known injuries occurred. Since that time, she has not complained of any pain, has been ambulatory, eating and drinking per normal. Final diagnosis as of 12/30/25 at 12:50 a.m. was possible STI exposure. Review of R#1's nurse's note created by LVN C on 12/30/25 at 3:28 a.m. reflected, Res returned from ED with an order for Flagyl 500mg BID x 7 days; order placed in EMAR and placed to pharmacy. Res appears in good spirits. No s/s of pain. Resps even and unlabored. No skin issues noted. Res. smiling at this writer. MD notified and clarified Vaginitis. Review of R#1 nurse's note created by LVN B on 12/30/25 at 11:48 a.m. reflected, After review of AVS from Xrays show no fxs or abnormalities. No STI test results included in AVS. New order for Flagyl 500mg BID X 7 days prophylactically for possible STI exposure. Initial dose to be administered 12/30/25 at HS. R#2Review of R#2's admission record, dated 12/31/25, reflected he was admitted to the facility on [DATE]. He had medical diagnoses that included intermittent angle-closure bilateral glaucoma (temporary, repeated episodes where the eye's drainage angle closes, causing brief pressure spikes and symptoms like headaches, blurry vision or halos), vascular dementia, schizophrenia and auditory and visual hallucinations. He was discharged to the hospital on [DATE]. Review of R#2's quarterly MDS assessment, dated 11/06/25, reflected the cognitive patterns section showed he had a 15/15 BIMS, which indicated he was cognitively intact. The behavior section showed he did not exhibit psychosis, physical, verbal, or other behavioral symptoms and wandering behaviors. The functional abilities section showed he was independent with lower body dressing, transfers and bed mobility. Review of R#2's care plan, dated 10/27/25, reflected he resided in the secure unit due to his wandering and poor safety awareness. Staff were required to implement interventions, which included providing him with activities, assistance where he need to be going, and monitor and report changes in behaviors to the ADM, DON, MD, and RP. Review of R#2's task care record for December 2025 reflected staff documented observing him on 12/27/25 at 2:57 p.m. Review of R#2's change in condition evaluation note created by LVN A on 12/27/25 at 4:23 p.m. reflected, Resident was observed by staff lying in bed next to a female resident when staff intervened. Review of R#2's struck out incident note created by LVN A on 12/27/25 at 5:29 p.m. reflected, The resident was found in bed with a female resident during routine rounds, and staff intervened immediately, separating both residents without incident. The resident has diagnoses of schizophrenia, unspecified, and dementia, unspecified, with a BIMS score of 6, indicating severe cognitive impairment. At the time of redirection, the resident appeared confused and disorganized, demonstrated impaired judgment and poor personal boundaries, and showed limited insight into the inappropriateness of the behavior, consistent with psychiatric and cognitive conditions. The resident was able to follow simple directions with repeated prompting and was escorted back to the room, no injuries were observed. A full head-to-toe physical assessment and psychosocial assessment were completed with no acute issues noted. A 1:1 supervision was initiated for safety. MD and responsible party was notified, and the VA ED was contacted and provided with report. Due to the severity of the incident, 911 was called, and emergency services responded with police presence. The resident is being transferred to the VA Emergency Department for further medical and psychiatric evaluation. Review of R#2's psychosocial note created by LVN A on 12/27/25 at 9:05 p.m. reflected, Resident assessed following aggressive behavior. BIMS score is 6, indicating severe cognitive impairment. Resident observed to be withdrawn with periods of agitation, evidenced by tense body posture, limited eye contact, and restlessness. Verbal interaction was minimal with delayed and inconsistent responses. Affect appeared constricted. No signs of acute distress noted at time of assessment. Resident was redirectable with staff intervention and is currently in his room on one-to-one supervision with every 15-minute checks for safety. Continued monitoring recommended, with interdisciplinary team involvement for behavior management and psychosocial support. Review of R#2's 15 minute check monitoring form, dated 12/27/25, reflected he was monitored as follows: *the DON from 12/27/25 at 3:15 p.m. through 12/27/25 at 3:45 p.m.*CNA F from 12/27/25 at 4:00 p.m. through 12/27/25 at 5:00 p.m.Further review revealed there were no other entries. Review of R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. reflected, While passing meds, [MA D] knocked and entered [R#2's] room and found [R#2] in bed with [R#1]. [R#2] found with pants down with genitalia exposed. [R#1] pants down but brief up and intact. [MA D] verbalized, stop. [R#2] rolled to his side and witness observed an nonerect penis and intact brief on [R#1]. [MA D] separated immediately by ushering [R#1] out the room. Administration/Abuse coordinator notified. No penetration noted by witness and no evidence noted on either physical examination of alleged victim or alleged perpetrator. [R#2] immediately placed on 1:1 monitoring and 15 min observation. Physical assessment completed on both individuals. [R#1] noted to have no evidence of penetration but found to have liquid stool in brief. Upon being notified writer/administrator physically went to building to investigate in person. Writer inspected [R#2] genitals and no evidence of penetration or pelvic contact. Unable to interview [R#1], but when [R#2] interviewed, he verbalized incomprehensible speech and shook head and body. Witness statement obtained from [MA D]. Responsible parties notified along with psych NP, MD, EMS and VA. [R#2] subsequently sent out to VA by EMS for psych evaluation. [NAME] notified and onsite officer: PO. Psychosocial assessments completed on both, Safe surveys completed. [R#2] BIMS noted to be 6, and PM noted to be 99. When interviewing witness she state that there appeared to be no struggle. Abuse coordinator interviewed: [MA D], [CNA E], and [LVN A]. In-services being conducted: abuse and neglect, resident to resident, frequent rounding, redirection of resident to assigned room or common area. Additionally, all residents on MCU to have full body assessments and [R#1] placed on 1:1 and 15 min observations until cleared by physician.Review of R#2's administration note created by the ADM on 12/29/25 at 8:51 a.m. reflected, Called [R#2's] RP and rediscussed [R#2] recent incident with another resident. I notified her that [R#2] incident makes himsubject to immediate discharged based up on signed admissions agreement regarding safety and that this notification serves as notice of discharge. Writer on site and investigated event in person. Licensed nurse called report to VA and received acceptance. EMS on site with PD to transport [R#2]. Review of R#2's administration note created by the ADM on 12/29/25 at 8:58 a.m. reflected, Called multiple times by Case managers regarding [R#2]. I repeatedly stated that EMS were instructed to take [R#2] toVA Hospital and that report had been call for acceptance. The VA hospital has resources for [R#2] as PD had no intervention other than EMS escort. I also notified CM, that I personally contacted [R#2's] RP regarding incident and that he is subject to immediatetransfer/discharge and the conversation serves as notification. Review of R#2's nurse's note created by the DON on 12/31/25 at 11:40 a.m. reflected, Responsible parties were notified, including the psychiatric NP, attending MD, EMS, and the VA. Due to ongoing psychiatricconcerns, [R#2] was assessed and subsequently transported by EMS to the VA for further psychiatric evaluation and monitoring. Police Department was notified per protocol, and an onsite officer responded (PO). Comprehensive psychosocial assessments were completed on both involved residents. SAFE surveys were also completed in full. [R#2's] BIMS score was assessed and noted to be 6, indicating cognitive impairment. Due to the need for continued psychiatric follow-up and future evaluation, the resident was sent out to the VA for ongoing psychiatric services. A detailed report was called in to the VA by [LVN A] prior to transport to ensure continuity of care. Review of R#2's MD order, dated 12/27/25 at 11:08 a.m., reflected he was okay to discharge to alternative facility/all male facility. The order was confirmed by the DON. There was no MD signature and signed date indicated. Review of the facility's incident report, from 12/01/25 through 12/31/25, reflected R#1's alleged abuse incident occurred on 12/27/25 at 4:21 p.m. R#1's alleged abuse incident occurred on 12/27/25 at 3:15 p.m. Review of the facility's discharge report, dated 12/31/25, reflected R#2 was transferred to the hospital on [DATE] at 3:21 p.m. and there was no return. R#1 was also transferred to the hospital on [DATE] at 5:06 p.m. and returned on 12/30/25 at 3:15 a.m. Review of the facility's self-report reflected the incident that occurred on 12/27/25 at 3:15 p.m. The narrative summary of reportable incident reflected it was identical to R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. Review of MA D's handwritten statement, dated 12/27/25, reflected, On this day I was passing medication at 3:15 and as I entered [R#2's] room I seen [R#2] laying on top of [R#1] and asked him to stop and made sure she was safe and then called for help.There were no other staff statements attached. Review of the facility's resident safety surveys completed by the ADM on unknown dates reflected 6 residents were interviewed. All 6 residents indicated, Yes, when asked did they feel comfortable asking the staff for assistance, did staff treat them with respect and dignity, did they feel safe, did they feel comfortable telling the staff about any concerns and were staff willing to listen and resolve their concerns. All 6 residents indicated, No, when asked if a staff member had physically harmed them, yelled or cursed at them, and if they had any questions for the ADM. Review of the facility's in-services, dated 12/27/25, reflected the DON taught staff about abuse, neglect, resident rights, resident to resident and immediately separating residents to ensure safety, routine checks/frequent rounding, 1:1 observations for safety and supervision of residents, and wandering and redirection. The in-services had attached copies of the abuse, neglect, exploitation and misappropriation prevention program policy, resident rights policy, resident to resident altercations policy, resident checks policy, safety and supervision of residents' policy, and wandering and elopements policy. During an observation of the memory care unit on 12/31/25 at 9:44 a.m., R#1 was sitting in a recliner chair in the living area. The surveyor attempted to interview her, but she was unable to answer any questions. During an interview with CNA G on 12/31/25 at 9:45 a.m., she stated R#1 was nonverbal; she did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and Stop. She stated R#1 wandered, but she would wander into her own room and no other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility, did not know when he was discharged from the facility and did not know why he was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she recalled signing off on in-services, but she could not recall what in-services she received and could not recall what she learned. She stated she did not know who the abuse coordinator was. She stated she knew she would separate, notify staff for help, and notify management if there was a resident-to-resident incident. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to check on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded (checked) on. During an interview with CNA H on 12/31/25 at 9:47 a.m., she stated R#1 did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and stop. She stated R#1 wandered into other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was not at the facility. She stated R#2 was at the facility on 12/26/25. She stated she believed R#2 left the faciity on [DATE]. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by CNA I, LVN A, and the ADON on abuse, neglect, reporting and resident-to-resident altercation on 12/29/25, 12/30/25 and 12/31/25. She stated she learned to report any abuse and neglect observed, separate residents, and notify the ADM, DON and ADON if there was a resident-to-resident incident. She stated the ADM was the abuse and neglect coordinator. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to round on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded on. During an interview with CNA I on 12/31/25 at 10:04 a.m., she stated R#1 communicated in and out. She explained R#1 responded with one words. She stated R#1 will do facial expressions for staff to know how she feels. She stated R#1 did not wander. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility. She last seen R#2 at the facility on 12/24/25. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander and knew where to go from one place to another place. She stated R#1 and R#2 were not cognitively intact. She stated R#1 and R#2 could not give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by the DON and ADON on ensuring resident safety, rounding and checking on residents, shift change, abuse and neglect, resident-to-resident, and 1:1 monitoring. She stated she learned she must immediately report abuse and neglect to the ADM and DON because they were both the abuse and neglect coordinators and investigated abuse and neglect, conduct 1:1 to prevent altercations, ensure resident safety, observe residents every 15 minutes, redirecting residents, alternating in between rounds, helping staff with duties and relieving staff of duties. She stated she would separate the residents, yell for help, notify the charge nurse DON and ADM, keep residents apart, and give a statement if there was a resident-to-resident incident. She stated CNAs checked on residents every 30 minutes in the memory care unit. She stated she knew it was important to round on residents and said, To make sure their breathing, alive, no safety issues, clean, not on the floor, know where they are at, ensure they are not in distress. Residents could be at risk of a lot happening if staff are not conducting rounds. We don't want to not round and find any resident unresponsive, sitting in urine/feces, and on the ground due to a fall. During an interview with ADON on 12/31/25 at 10:25 a.m., she stated R#1 was nonverbal. She stated staff observed facial expressions and behaviors to know how R#1 felt. She stated R#1 was not cognitively intact and could not give consent because she did not have the capacity. She stated R#2 was sent to the hospital and did not know why because she was gone when he was sent out to the hospital. She stated there was an incident that occurred on Saturday (12/27/25) that staff had to send R#2 out to the hospital for. She did not know what the incident was. She did not know why R#2 was discharged from the facility. She last seen R#2 on 12/23/25. She stated R#2 could communicate and understand to an extent. She stated R#2 had a guardian. She stated R#2 was not cognitively intact and did not know if R#2 could give consent. She stated R#2 did not have any wandering behaviors. She stated she did not work on 12/27/25. She stated she last worked on 12/23/25. She stated she did not know any incidents of resident-to-resident sexual abuse. She stated CNA J notified her of the incident on Saturday in the afternoon (12/27/25). She stated CNA J informed her that one of the staff walked in on R#2 on top of another resident and was having sexual intercourse. She stated CNA J told her that the staff separated R#2 and the other resident. She stated she did not know if anyone else was on duty. She stated she did not know if R#2 was placed on 1:1 monitoring. She stated R#2 had no past incidents. She stated she did in-service staff after the incident, but she could not recall what it was about because she was just coming back to work since being off from 12/23/25. She stated she expected staff to separate residents immediately, redirect residents away from each other, ensure resident safety, assess the residents, notify the staff and charge nurse, and ensuring resident community safety. She stated all staff (CNAs and nurses) checked on residents at least every 15-30 minutes in the memory care unit if residents were not within eyesight. She stated she did not know how management ensured CNAs and nurses were rounding. She changed her statement and stated she would walk the hallways to ensure staff were rounding on the floor once every hour. She stated she knew it was important to round on residents and said, For safety and security. Primarily for safety of residents. Residents could be at risk of falling or having a change in condition if staff did not round. During an interview with R#1's family and MPOA on 12/31/25 at 12:03 p.m., they stated R#1 was unable to get up on her own, not a wanderer, and did not wander into any other residents' rooms. They stated an unknown female staff member notified them by phone on 12/27/25 around 8:00pm that a male resident was found on top of R#1, their clothes were off, and R#1's brief was loosened on 12/27/25 at an unknown time in the male resident's room. They stated they did not know who walked in and that a staff member told them that it might have been a medication aide that knocked on the door, walked into the male resident's room, and observed the incident. They stated the ADM told them that R#1's clothes were off and her brief was still on. They stated R#1 was not sent out to the hospital on [DATE], they did not know why R#1 was not sent out to the hospital, learned two days later (12/29/25) that R#1 was not sent to the hospital on [DATE], and had to request the staff to send R#1 to the hospital for further evaluation. They stated they questioned the ADM why R#1 was not sent out to the hospital and he told them because he had staff examine R#1. They stated the male resident was sent out to the hospital on [DATE] and the ADM told them that the male resident would not be able to return from the hospital. During an interview with the SW on 12/31/25 at 1:40 p.m., she stated the ADM notified her on 12/29/25 of R#2's incident. She stated the ADM told them one of the CNAs went to check on R#1 in her room and observed R#2 on top of her. She stated the CNA did not know what R#2 was doing and suspected something inappropriate. She stated R#2 was sent out to the hospital and did not return on unknown date, but she believed the same day as the incident. She stated checked on R#1 on 12/29/25. She stated she did not conduct any assessments on R#1 because R#1 was nonverbal and the new facility owners did not instruct her to. She stated she did not conduct resident safety surveys because she was not there the day of the incident, did not do such on 12/29/25 and was not at the facility on 12/30/25. She stated there was no social services designee for assessments and safety surveys. She stated she knew it was important to assess residents after ANE allegations and said, To see how residents are doing, make sure they still feel safe, make sure there's no psychosocial adverse outcome and need to notify psych services. Residents could start to have other symptoms, such as depression, and not feel comfortable with other residents and staff. She stated the DON in-serviced staff on abuse and neglect policies and procedures and discussed the topics during staff meeting on 12/29/25. She stated the ADM and DON oversee to ensure abuse and neglect procedures were followed. She stated she knew to immediately report ANE to the ADM. She stated the ADM and DON report ANE to the SSA. She stated she did not know the reporting timeframe. She stated the ADM was the abuse and neglect coordinator. She stated she knew it was important to follow ANE procedures and said, To make sure basis was covered and make sure residents were safe. Residents quality of care could be affected and it could put them in more harm. During an interview with R#2's RP on 12/31/25 at 2:10 p.m., they stated R#2 was cognitively in and out, schizophrenic and heard voices. They stated R#2 was at the VA. They stated an unknown female nurse on duty notified them on 12/26/25 that staff caught R#2 sexually assaulting another female resident in her room and they sent him to the ER because he was distraught. They stated the staff did not explain why R#2 was distraught. They stated the staff told them that the female resident was shaken up, okay and out of breath because she was a small person. The staff told them that R#2 was not allowed to come back to the facility and did not explain why he was not allowed to return to the facility. They stated the police have not notified or spoke with them about R#2. The staff told them that this was not the first incident involving R#2 and did not explain what the previous incident was. They stated they recalled R#2 sexually assaulted a female patient at a mental health facility about 30 years ago and served a prison sentence for it. The surveyor attempted to call CNA J on 12/31/25 at 2:29 p.m. and 01/01/26 at 1:49 p.m. and left a voicemail and call back number. CNA J did not return the surveyor's calls. The surveyor attempted to call LVN C on 12/31/25 at 2:31 p.m. and 01/01/26 at 1:50 p.m. and left a voicemail and call back number. LVN C did not return the surveyor's calls. During an interview with MA D on 12/31/25 at 2:53 p.m., she stated she was administering medications on 12/27/25 around 3:00 p.m., R#2'a door was closed, she heard moaning, she entered R#2's room and observed R#2 on top of R#1 in his bed, R#2 and R#1's pants were down, R#1's brief was still on, R#1 was making noises and had A flushed face, and R#2 was thrusting against R#1. She stated she did not believe R#2 penetrated R#1 because R#1's brief was on one of the sides. She stated she told R#2 to stop that, R#2 rolled off of R#1, she got R#2 up and out of the room, R#2 and R#1 were separated, and she called CNA E to help her because R#2 could be aggressive and she wanted CNA E there just in case he got aggressive. She stated she also notified LVN K, who ensured R#2 and R#1 were separated. She stated CNA E and LVN K notified the ADM. She stated she did not know if R#2 and R#1 were assessed. She stated R#2 was sent out to the hospital, did not return from the hospital and she did not know why. She stated she was unsure if R#1 was sent out to the hospital, but she believed R#1 was not. She stated she did not know if R#1's and R#2's families were notified. She stated she did not know if law enforcement came out to the facility. She stated she did not have to give a statement to law enforcement and they had not spoken with her. She stated R#2 was a big man and R#1 was a small woman

Based on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, , investigate any such allegations, and ensure reporting of crimes occurring in federally-funded long-term care facilities for 1 of 6 residents (R#1). The facility failed to implement written policies and procedures in response to the sexual assault of R#1 in that R#1 was not offered emergency transportation services after the abuse incident with R#2 occurred on 12/27/25. An IJ was identified on 01/02/26. The IJ template was provided to the facility on [DATE] at 1:24 p.m. While the IJ was removed on 01/03/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of continued abuse, neglect, harm, injury, or death.Findings include: Review of the facility's abuse, neglect, exploitation and misappropriation prevention program policy, revised April 2021, reflected, Residents have the right to be free from abuse, neglect .1. Protect residents from abuse, neglect, . by anyone including but not necessarily limited to: b. other residents.develop and implement policies and procedures to prevent and identify a. abuse or mistreatment of residents;.5. Establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems.8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, . 9. Investigate and report any allegations within timeframes required by federal requirements. 10. Protect residents from any further harm during investigations. R#1Review of R#1's admission record, dated 12/31/25, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had medical diagnoses that included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, causing stroke-like symptoms that resolve within 24 hours, usually much sooner), noninflammatory vagina disorders (conditions affecting the vagina often due to hormonal changes, anatomical issues or irritation), unsteadiness on feet, gait and mobility abnormalities, need for assistance with personal care, anxiety disorder, pain disorder, major depressive disorder and dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of R#1's quarterly MDS assessment, dated 11/19/25, reflected the cognitive patterns section showed she had no BIMS score, which indicated she was unable to complete her BIMS interview. Staff assessment for her mental status also showed she had short- and long-term memory problems, was normally able to recall the location of her own room and was moderately impaired when making daily life decisions. The behavior section showed she did not exhibit physical, verbal and other behavioral symptoms and wandering behaviors. The functional abilities section showed she required supervision or touching assistance with lower body dressing, transfers and bed mobility. Review of R#1's care plan, revised on 12/31/25, reflected she had a behavior problem of wandering throughout the secure unit, often into other residents' rooms, and sometimes lying down in other residents' beds. Staff were required to implement interventions, which included administering medications as ordered, anticipating and meeting her needs, intervening as necessary to protect other residents' rights and safety, divert her attention and remove her from a situation and take her to an alternate location as needed. Staff were also required to redirect her to her room or another common area when she was observed wandering into other residents' rooms. Review of R#1's task care record for December 2025 reflected staff documented observing her on 12/27/25 at 3:00 p.m. Review of R#1's change in condition evaluation note created by LVN A on 12/27/25 at 4:04 p.m. reflected, Resident found in bed with another resident; staff intervened and separated both without incident. Resident is non-verbal (BIMS 99) and was calm and cooperative. Full physical and skin assessment completed with no injuries or signs of penetration noted. Psychosocial assessment showed no acute distress. DON, responsible party, and abuse coordinator notified. Resident remains ongoing monitoring and care plan review. Review of R#1's skin check note created by LVN A on 12/27/25 at 4:09 p.m. reflected, No skin issues noted upon assessment, nurse and staff observed dried feces on resident's pubic hair. Resident's sister waspresent and gave her a shower. Review of R#1's BIMS evaluation note created by the DON on 12/27/25 at 4:46 p.m. reflected, Resident is nonverbal and unable to participate meaningfully in the assessment. When verbalizations occur, resident repeats words spoken by staff (echolalia), laughs inappropriately, and/or begins dancing. Resident is unable to comprehend, respond appropriately, or follow directions required to complete the BIMS assessment due to severe cognitive/mental impairment. Review of R#1's psychosocial note created by LVN B on 12/27/25 at 5:04 p.m. reflected, Resident observed in male resident's room in bed with male on top of her gyrating his hips. Residents immediately separated. Fullbody assessment completed with no apparent injuries observed. No c/o pain/discomfort. VS obtained and WNL. DON, Admin, sister, and MD all notified and aware. Review of R#1's incident note created by LVN A on 12/27/25 at 5:56 p.m. reflected, The female resident was found in bed with another resident during routine rounds, and staff intervened immediately, separatingboth residents without incident. The resident's BIMS score is documented as 99 (unable to assess) and she is non-verbal. At the time of assessment, the resident was observed to be calm, with non-verbal cues including facial expressions, body posture, eye contact, or lack thereof, and was cooperative with care. A thorough head-to-toe physical assessment, including a comprehensive skin check, was completed, with no penetration reported or observed and no bruising, bleeding, or signs of injury noted to the genital, groin, or buttocks areas. A psychosocial assessment was conducted using observation of non-verbal behaviors, with no signs of acute distress noted at the time. The Director of Nursing, responsible party, and facility abuse coordinator were notified per facility protocol. The resident remains on 1:1 supervision to ensure safety, with continued monitoring and interdisciplinary review for psychosocial support and care plan updates. Review of R#1's 15 minute check monitoring form, dated 12/27/25, reflected she was monitored by the DON from 12/27/25 at 3:30 p.m. through 12/27/25 at 5:15 p.m. and CNA F from 12/27/25 at 5:30 p.m. through 12/27/25 at 6:30 p.m. There were no other entries. Review of R#1's physician progress note created by the MD on 12/27/25 at 6:21 p.m. reflected, Resident has been on 1:1 supervision for her safety. She is stable at this time and no longer needs to be on 1:1 supervision. Will D/C the 1:1 supervision. Review of R#1's nurse's note created by LVN A on 12/29/25 at 4:33 p.m. reflected, Female resident involved in a recent incident, family requested transfer to the emergency room for further medical assessment.Resident assessed by nursing staff and medical provider, and based on family request, 911 was initiated for hospital transfer. Nurse called report to Emergency Department and provided pertinent resident information. MD and Director of Nursing werenotified and are aware of the transfer. Emergency Medical Services are currently in route to the facility. Resident remains under nursing supervision pending EMS arrival. Review of R#1's hospital after visit summary, dated 12/29/25, reflected she arrived at the hospital by EMS on 12/27/25 at 5:12 p.m. Her visit was due to medical clearance for diagnosis regarding possible STI exposure. Her right knee and right femur were x-rayed due to tenderness on exam due to possible recent abuse. The history and physical information reflected, [R#1] presenting for medical clearance. Presents with family for recent history of possible abuse per the family member. She is currently at her neurological baseline, unable to answer questioning or respond to instructions. Family states that 3 days ago a co-resident at her memory care facility was found on top of her in bed. Both the patient and the other individual appeared to be naked, but no known injuries occurred. Since that time, she has not complained of any pain, has been ambulatory, eating and drinking per normal. Final diagnosis as of 12/30/25 at 12:50 a.m. was possible STI exposure. Review of R#1's nurse's note created by LVN C on 12/30/25 at 3:28 a.m. reflected, Res returned from ED with an order for Flagyl 500mg BID x 7 days; order placed in EMAR and placed to pharmacy. Resappears in good spirits. No s/s of pain. Resps even and unlabored. No skin issues noted. Res. smiling at this writer. MD notified and clarified Vaginitis. Review of R#1 nurse's note created by LVN B on 12/30/25 at 11:48 a.m. reflected, After review of AVS from Xrays show no fxs or abnormalities. No STI test results included in AVS. New order for Flagyl500mg BID X 7 days prophylactically for possible STI exposure. Initial dose to be administered 12/30/25 at HS. R#2 Review of R#2's admission record, dated 12/31/25, reflected he was admitted to the facility on [DATE]. He had medical diagnoses that included intermittent angle-closure bilateral glaucoma (temporary, repeated episodes where the eye's drainage angle closes, causing brief pressure spikes and symptoms like headaches, blurry vision or halos), vascular dementia, schizophrenia and auditory and visual hallucinations. He was discharged to the hospital on [DATE]. Review of R#2's quarterly MDS assessment, dated 11/06/25, reflected the cognitive patterns section showed he had a 15/15 BIMS, which indicated he was cognitively intact. The behavior section showed he did not exhibit psychosis, physical, verbal, or other behavioral symptoms and wandering behaviors. The functional abilities section showed he was independent with lower body dressing, transfers and bed mobility. Review of R#2's care plan, dated 10/27/25, reflected he resided in the secure unit due to his wandering and poor safety awareness. Staff were required to implement interventions, which included providing him with activities, assistance where he need to be going, and monitor and report changes in behaviors to the ADM, DON, MD, and RP. Review of R#2's task care record for December 2025 reflected staff documented observing him on 12/27/25 at 2:57 p.m. Review of R#2's change in condition evaluation note created by LVN A on 12/27/25 at 4:23 p.m. reflected, Resident was observed by staff lying in bed next to a female resident when staff intervened. Review of R#2's struck out incident note created by LVN A on 12/27/25 at 5:29 p.m. reflected, The resident was found in bed with a female resident during routine rounds, and staff intervened immediately, separating bothresidents without incident. The resident has diagnoses of schizophrenia, unspecified, and dementia, unspecified, with a BIMS score of 6, indicating severe cognitive impairment. At the time of redirection, the resident appeared confused and disorganized, demonstrated impaired judgment and poor personal boundaries, and showed limited insight into the inappropriateness of the behavior, consistent with psychiatric and cognitive conditions. The resident was able to follow simple directions with repeated prompting and was escorted back to the room, no injuries were observed. A full head-to-toe physical assessment and psychosocial assessment were completed with no acute issues noted. A 1:1 supervision was initiated for safety. MD and responsible party was notified, and the VA ED was contacted and provided with report. Due to the severity of the incident, 911 was called, and emergency services responded with police presence. The resident is being transferred to the VA Emergency Department for further medical and psychiatric evaluation. Review of R#2's psychosocial note created by LVN A on 12/27/25 at 9:05 p.m. reflected, Resident assessed following aggressive behavior. BIMS score is 6, indicating severe cognitive impairment. Resident observed [NAME] withdrawn with periods of agitation, evidenced by tense body posture, limited eye contact, and restlessness. Verbal interaction was minimal with delayed and inconsistent responses. Affect appeared constricted. No signs of acute distress noted at time of assessment. Resident was redirectable with staff intervention and is currently in his room on one-to-one supervision with every 15-minute checks for safety. Continued monitoring recommended, with interdisciplinary team involvement for behavior management and psychosocial support. Review of R#2's 15 minute check monitoring form, dated 12/27/25, reflected he was monitored by the DON from 12/27/25 at 3:15 p.m. through 12/27/25 at 3:45 p.m. and CNA F from 12/27/25 at 4:00 p.m. through 12/27/25 at 5:00 p.m. There were no other entries. Review of R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. reflected, While passing meds, [MA D] knocked and entered [R#2's] room and found [R#2] in bed with [R#1]. [R#2] found with pants downwith genitalia exposed. [R#1] pants down but brief up and intact. [MA D] verbalized, stop. [R#2] rolled to his side and witness observed an nonerect penis and intact brief on [R#1]. [MA D] separated immediately by ushering [R#1] out the room. Administration/Abuse coordinator notified. No penetration noted by witness and no evidence noted on either physical examination of alleged victim or alleged perpetrator. [R#2] immediately placed on 1:1 monitoring and 15 min observation. Physical assessment completed on both individuals. [R#1] noted to have no evidence of penetration but found to have liquid stool in brief. Upon being notified writer/administrator physically went to building to investigate in person. Writer inspected [R#2] genitals and no evidence of penetration or pelvic contact. Unable to interview [R#1], but when [R#2] interviewed, he verbalized incomprehensible speech and shook head and body. Witness statement obtained from [MA D]. Responsible parties notified along with psych NP, MD, EMS and VA. [R#2] subsequently sent out to VA by EMS for psych evaluation. [NAME] notified and onsite officer: PO. Psychosocial assessments completed on both, Safe surveys completed. [R#2] BIMS noted to be 6, and PM noted to be 99. When interviewing witness she state that there appeared to be no struggle. Abuse coordinator interviewed: [MA D], [CNA E], and [LVN A]. In-services being conducted: abuse and neglect, resident to resident, frequent rounding, redirection of resident to assigned room or common area. Additionally, all residents on MCU to have full body assessments and [R#1] placed on 1:1 and 15 min observations until cleared by physician. Review of R#2's administration note created by the ADM on 12/29/25 at 8:51 a.m. reflected, Called [R#2's] RP and rediscussed [R#2] recent incident with another resident. I notified her that [R#2] incident makes himsubject to immediate discharged based up on signed admissions agreement regarding safety and that this notification serves as notice of discharge. Writer on site and investigated event in person. Licensed nurse called report to VA and received acceptance. EMS on site with PD to transport [R#2]. Review of R#2's administration note created by the ADM on 12/29/25 at 8:58 a.m. reflected, Called multiple times by Case managers regarding [R#2]. I repeatedly stated that EMS were instructed to take [R#2] toVA Hospital and that report had been call for acceptance. The VA hospital has resources for [R#2] as PD had no intervention other than EMS escort. I also notified CM, that I personally contacted [R#2's] RP regarding incident and that he is subject to immediatetransfer/discharge and the conversation serves as notification. Review of R#2's nurse's note created by the DON on 12/31/25 at 11:40 a.m. reflected, Responsible parties were notified, including the psychiatric NP, attending MD, EMS, and the VA. Due to ongoing psychiatricconcerns, [R#2] was assessed and subsequently transported by EMS to the VA for further psychiatric evaluation and monitoring. Police Department was notified per protocol, and an onsite officer responded (PO). Comprehensive psychosocial assessments were completed on both involved residents. SAFE surveys were also completed in full. [R#2's] BIMS score was assessed and noted to be 6, indicating cognitive impairment. Due to the need for continued psychiatric follow-up and future evaluation, the resident was sent out to the VA for ongoing psychiatric services. A detailed report was called in to the VA by [LVN A] prior to transport to ensure continuity of care. Review of R#2's MD order, dated 12/27/25 at 11:08 a.m., reflected he was okay to discharge to alternative facility/all male facility. The order was confirmed by the DON. There was no MD signature and signed date indicated. Review of the facility's incident report, from 12/01/25 through 12/31/25, reflected R#1's alleged abuse incident occurred on 12/27/25 at 4:21 p.m. R#1's alleged abuse incident occurred on 12/27/25 at 3:15 p.m. Review of the facility's discharge report, dated 12/31/25, reflected R#2 was transferred to the hospital on [DATE] at 3:21 p.m. and there was no return. R#1 was also transferred to the hospital on [DATE] at 5:06 p.m. and returned on 12/30/25 at 3:15 a.m. Review of the facility's self-report reflected the incident that occurred on 12/27/25 at 3:15 p.m. The narrative summary of reportable incident reflected it was identical to R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. Review of MA D's handwritten statement, dated 12/27/25, reflected, On this day I was passing medication at 3:15 and as I entered [R#2's] room I seen [R#2] laying on top of [R#1] and asked him to stop and made sure she was safe and then called for help.There were no other staff statements attached. Review of the facility's resident safety surveys completed by the ADM on unknown dates reflected 6 residents were interviewed. All 6 residents indicated, Yes, when asked did they feel comfortable asking the staff for assistance, did staff treat them with respect and dignity, did they feel safe, did they feel comfortable telling the staff about any concerns and were staff willing to listen and resolve their concerns. All 6 residents indicated, No, when asked if a staff member had physically harmed them, yelled or cursed at them, and if they had any questions for the ADM. Review of the facility's in-services, dated 12/27/25, reflected the DON taught staff about abuse, neglect, resident rights, resident to resident and immediately separating residents to ensure safety, routine checks/frequent rounding, 1:1 observations for safety and supervision of residents, and wandering and redirection. The in-services had attached copies of the abuse, neglect, exploitation and misappropriation prevention program policy, resident rights policy, resident to resident altercations policy, resident checks policy, safety and supervision of residents policy, and wandering and elopements policy. During an observation of the memory care unit on 12/31/25 at 9:44 a.m., R#1 was sitting in a recliner chair in the living area. The surveyor attempted to interview her, but she was unable to answer any questions. During an interview with CNA G on 12/31/25 at 9:45 a.m., she stated R#1 was nonverbal; she did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and Stop. She stated R#1 wandered, but she would wander into her own room and no other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility, did not know when he was discharged from the facility and did not know why he was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she recalled signing off on in-services, but she could not recall what in-services she received and could not recall what she learned. She stated she did not know who the abuse coordinator was. She stated she knew she would separate, notify staff for help, and notify management if there was a resident-to-resident incident. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to check on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded (checked) on. During an interview with CNA H on 12/31/25 at 9:47 a.m., she stated R#1 did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and stop. She stated R#1 wandered into other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was not at the facility. She stated R#2 was at the facility on 12/26/25. She stated she believed R#2 left the faciity on [DATE]. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by CNA I, LVN A, and the ADON on abuse, neglect, reporting and resident-to-resident altercation on 12/29/25, 12/30/25 and 12/31/25. She stated she learned to report any abuse and neglect observed, separate residents, and notify the ADM, DON and ADON if there was a resident-to-resident incident. She stated the ADM was the abuse and neglect coordinator. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to round on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded on. During an interview with CNA I on 12/31/25 at 10:04 a.m., she stated R#1 communicated in and out. She explained R#1 responded with one words. She stated R#1 will do facial expressions for staff to know how she feels. She stated R#1 did not wander. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility. She last seen R#2 at the facility on 12/24/25. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander and knew where to go from one place to another place. She stated R#1 and R#2 were not cognitively intact. She stated R#1 and R#2 could not give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by the DON and ADON on ensuring resident safety, rounding and checking on residents, shift change, abuse and neglect, resident-to-resident, and 1:1 monitoring. She stated she learned she must immediately report abuse and neglect to the ADM and DON because they were both the abuse and neglect coordinators and investigated abuse and neglect, conduct 1:1 to prevent altercations, ensure resident safety, observe residents every 15 minutes, redirecting residents, alternating in between rounds, helping staff with duties and relieving staff of duties. She stated she would separate the residents, yell for help, notify the charge nurse DON and ADM, keep residents apart, and give a statement if there was a resident-to-resident incident. She stated CNAs checked on residents every 30 minutes in the memory care unit. She stated she knew it was important to round on residents and said, To make sure their breathing, alive, no safety issues, clean, not on the floor, know where they are at, ensure they are not in distress. Residents could be at risk of a lot happening if staff are not conducting rounds. We don't want to not round and find any resident unresponsive, sitting in urine/feces, and on the ground due to a fall. During an interview with ADON on 12/31/25 at 10:25 a.m., she stated R#1 was nonverbal. She stated staff observed facial expressions and behaviors to know how R#1 felt. She stated R#1 was not cognitively intact and could not give consent because she did not have the capacity. She stated R#2 was sent to the hospital and did not know why because she was gone when he was sent out to the hospital. She stated there was an incident that occurred on Saturday (12/27/25) that staff had to send R#2 out to the hospital for. She did not know what the incident was. She did not know why R#2 was discharged from the facility. She last seen R#2 on 12/23/25. She stated R#2 could communicate and understand to an extent. She stated R#2 had a guardian. She stated R#2 was not cognitively intact and did not know if R#2 could give consent. She stated R#2 did not have any wandering behaviors. She stated she did not work on 12/27/25. She stated she last worked on 12/23/25. She stated she did not know any incidents of resident-to-resident sexual abuse. She stated CNA J notified her of the incident on Saturday in the afternoon (12/27/25). She stated CNA J informed her that one of the staff walked in on R#2 on top of another resident and was having sexual intercourse. She stated CNA J told her that the staff separated R#2 and the other resident. She stated she did not know if anyone else was on duty. She stated she did not know if R#2 was placed on 1:1 monitoring. She stated R#2 had no past incidents. She stated she did in-service staff after the incident, but she could not recall what it was about because she was just coming back to work since being off from 12/23/25. She stated she expected staff to separate residents immediately, redirect residents away from each other, ensure resident safety, assess the residents, notify the staff and charge nurse, and ensuring resident community safety. She stated all staff (CNAs and nurses) checked on residents at least every 15-30 minutes in the memory care unit if residents were not within eyesight. She stated she did not know how management ensured CNAs and nurses were rounding. She changed her statement and stated she would walk the hallways to ensure staff were rounding on the floor once every hour. She stated she knew it was important to round on residents and said, For safety and security. Primarily for safety of residents. Residents could be at risk of falling or having a change in condition if staff did not round. During an interview with R#1's family and MPOA on 12/31/25 at 12:03 p.m., they stated R#1 was unable to get up on her own, not a wanderer, and did not wander into any other residents' rooms. They stated an unknown female staff member notified them by phone on 12/27/25 around 8:00pm that a male resident was found on top of R#1, their clothes were off, and R#1's brief was loosened on 12/27/25 at an unknown time in the male resident's room. They stated they did not know who walked in and that a staff member told them that it might have been a medication aide that knocked on the door, walked into the male resident's room, and observed the incident. They stated the ADM told them that R#1's clothes were off and her brief was still on. They stated R#1 was not sent out to the hospital on [DATE], they did not know why R#1 was not sent out to the hospital, learned two days later (12/29/25) that R#1 was not sent to the hospital on [DATE], and had to request the staff to send R#1 to the hospital for further evaluation. They stated they questioned the ADM why R#1 was not sent out to the hospital and he told them because he had staff examine R#1. They stated the male resident was sent out to the hospital on [DATE] and the ADM told them that the male resident would not be able to return from the hospital. During an interview with the SW on 12/31/25 at 1:40 p.m., she stated the ADM notified her on 12/29/25 of R#2's incident. She stated the ADM told them one of the CNAs went to check on R#1 in her room and observed R#2 on top of her. She stated the CNA did not know what R#2 was doing and suspected something inappropriate. She stated R#2 was sent out to the hospital and did not return on unknown date, but she believed the same day as the incident. She stated checked on R#1 on 12/29/25. She stated she did not conduct any assessments on R#1 because R#1 was nonverbal and the new facility owners did not instruct her to. She stated she did not conduct resident safety surveys because she was not there the day of the incident, did not do such on 12/29/25 and was not at the facility on 12/30/25. She stated there was no social services designee for assessments and safety surveys. She stated she knew it was important to assess residents after ANE allegations and said, To see how residents are doing, make sure they still feel safe, make sure there's no psychosocial adverse outcome and need to notify psych services. Residents could start to have other symptoms, such as depression, and not feel comfortable with other residents and staff. She stated the DON in-serviced staff on abuse and neglect policies and procedures and discussed the topics during staff meeting on 12/29/25. She stated the ADM and DON oversee to ensure abuse and neglect procedures were followed. She stated she knew to immediately report ANE to the ADM. She stated the ADM and DON report ANE to the SSA. She stated she did not know the reporting timeframe. She stated the ADM was the abuse and neglect coordinator. She stated she knew it was important to follow ANE procedures and said, To make sure basis was covered and make sure residents were safe. Residents quality of care could be affected and it could put them in more harm. During an interview with R#1's RP on 12/31/25 at 2:10 p.m., they stated R#2 was cognitively in and out, schizophrenic and heard voices. They stated R#2 was at the VA. They stated an unknown female nurse on duty notified them on 12/26/25 that staff caught R#2 sexually assaulting another female resident in her room and they sent him to the ER because he was distraught. They stated the staff did not explain why R#2 was distraught. They stated the staff told them that the female resident was shaken up, okay and out of breath because she was a small person. The staff told them that R#2 was not allowed to come back to the facility and did not explain why he was not allowed to return to the facility. They stated the police have not notified or spoke with them about R#2. The staff told them that this was not the first incident involving R#2 and did not explain what the previous incident was. They stated they recalled R#2 sexually assaulted a female patient at a mental health facility about 30 years ago and served a prison sentence for it. The surveyor attempted to call CNA J on 12/31/25 at 2:29 p.m. and 01/01/26 at 1:49 p.m. and left a voicemail and call back number. CNA J did not return the surveyor's calls. The surveyor attempted to call LVN C on 12/31/25 at 2:31 p.m. and 01/01/26 at 1:50 p.m. and left a voicemail and call back number. LVN C did not return the surveyor's calls. During an interview with MA D on 12/31/25 at 2:53 p.m., she stated she was administering medications on 12/27/25 around 3:00 p.m., R#2'a door was closed, she heard moaning, she entered R#2's room and observed R#2 on top of R#1 in his bed, R#2 and R#1's pants were down, R#1's brief was still on, R#1 was making noises and had A flushed face, and R#2 was thrusting against R#1. She stated she

Based on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, 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 to the administrator of the facility and to other officials for 1 of 6 residents (R#1). The facility failed to report R#1's and R#2's incident to the SSA and law enforcement within 2 hours after the abuse was observed. This failure could place residents at risk of continued abuse, neglect, harm, injury, or death. Findings include: R#1 Review of R#1's admission record, dated 12/31/25, reflected she was initially admitted to the facility on [DATE] and readmitted on [DATE]. She had medical diagnoses that included transient cerebral ischemic attack (a temporary blockage of blood flow to the brain, causing stroke-like symptoms that resolve within 24 hours, usually much sooner), noninflammatory vagina disorders (conditions affecting the vagina often due to hormonal changes, anatomical issues or irritation), unsteadiness on feet, gait and mobility abnormalities, need for assistance with personal care, anxiety disorder, pain disorder, major depressive disorder and dementia (the loss of cognitive functioning to such an extent that it interferes with a person's daily life and activities). Review of R#1's quarterly MDS assessment, dated 11/19/25, reflected the cognitive patterns section showed she had no BIMS score, which indicated she was unable to complete her BIMS interview. Staff assessment for her mental status also showed she had short- and long-term memory problems, was normally able to recall the location of her own room and was moderately impaired when making daily life decisions. The behavior section showed she did not exhibit physical, verbal and other behavioral symptoms and wandering behaviors. The functional abilities section showed she required supervision or touching assistance with lower body dressing, transfers and bed mobility. Review of R#1's care plan, revised on 12/31/25, reflected she had a behavior problem of wandering throughout the secure unit, often into other residents' rooms, and sometimes lying down in other residents' beds. Staff were required to implement interventions, which included administering medications as ordered, anticipating and meeting her needs, intervening as necessary to protect other residents' rights and safety, divert her attention and remove her from a situation and take her to an alternate location as needed. Staff were also required to redirect her to her room or another common area when she was observed wandering into other residents' rooms. Review of R#1's task care record for December 2025 reflected staff documented observing her on 12/27/25 at 3:00 p.m. Review of R#1's change in condition evaluation note created by LVN A on 12/27/25 at 4:04 p.m. reflected, Resident found in bed with another resident; staff intervened and separated both without incident. Resident is non-verbal (BIMS 99) and was calm and cooperative. Full physical and skin assessment completed with no injuries or signs of penetration noted. Psychosocial assessment showed no acute distress. DON, responsible party, and abuse coordinator notified. Resident remains ongoing monitoring and care plan review. Review of R#1's skin check note created by LVN A on 12/27/25 at 4:09 p.m. reflected, No skin issues noted upon assessment, nurse and staff observed dried feces on resident's pubic hair. Resident's sister waspresent and gave her a shower. Review of R#1's BIMS evaluation note created by the DON on 12/27/25 at 4:46 p.m. reflected, Resident is nonverbal and unable to participate meaningfully in the assessment. When verbalizations occur, resident repeats words spoken by staff (echolalia), laughs inappropriately, and/or begins dancing. Resident is unable to comprehend, respond appropriately, or follow directions required to complete the BIMS assessment due to severe cognitive/mental impairment. Review of R#1's psychosocial note created by LVN B on 12/27/25 at 5:04 p.m. reflected, Resident observed in male resident's room in bed with male on top of her gyrating his hips. Residents immediately separated. Fullbody assessment completed with no apparent injuries observed. No c/o pain/discomfort. VS obtained and WNL. DON, Admin, sister, and MD all notified and aware. Review of R#1's incident note created by LVN A on 12/27/25 at 5:56 p.m. reflected, The female resident was found in bed with another resident during routine rounds, and staff intervened immediately, separatingboth residents without incident. The resident's BIMS score is documented as 99 (unable to assess) and she is non-verbal. At the time of assessment, the resident was observed to be calm, with non-verbal cues including facial expressions, body posture, eye contact, or lack thereof, and was cooperative with care. A thorough head-to-toe physical assessment, including a comprehensive skin check, was completed, with no penetration reported or observed and no bruising, bleeding, or signs of injury noted to the genital, groin, or buttocks areas. A psychosocial assessment was conducted using observation of non-verbal behaviors, with no signs of acute distress noted at the time. The Director of Nursing, responsible party, and facility abuse coordinator were notified per facility protocol. The resident remains on 1:1 supervision to ensure safety, with continued monitoring and interdisciplinary review for psychosocial support and care plan updates. Review of R#1's 15 minute check monitoring form, dated 12/27/25, reflected she was monitored by the DON from 12/27/25 at 3:30 p.m. through 12/27/25 at 5:15 p.m. and CNA F from 12/27/25 at 5:30 p.m. through 12/27/25 at 6:30 p.m. There were no other entries. Review of R#1's physician progress note created by the MD on 12/27/25 at 6:21 p.m. reflected, Resident has been on 1:1 supervision for her safety. She is stable at this time and no longer needs to be on 1:1 supervision. WillD/C the 1:1 supervision. Review of R#1's nurse's note created by LVN A on 12/29/25 at 4:33 p.m. reflected, Female resident involved in a recent incident, family requested transfer to the emergency room for further medical assessment.Resident assessed by nursing staff and medical provider, and based on family request, 911 was initiated for hospital transfer. Nurse called report to Emergency Department and provided pertinent resident information. MD and Director of Nursing werenotified and are aware of the transfer. Emergency Medical Services are currently in route to the facility. Resident remains under nursing supervision pending EMS arrival. Review of R#1's hospital after visit summary, dated 12/29/25, reflected she arrived at the hospital by EMS on 12/27/25 at 5:12 p.m. Her visit was due to medical clearance for diagnosis regarding possible STI exposure. Her right knee and right femur were x-rayed due to tenderness on exam due to possible recent abuse. The history and physical information reflected, [R#1] presenting for medical clearance. Presents with family for recent history of possible abuse per the family member. She is currently at her neurological baseline, unable to answer questioning or respond to instructions. Family states that 3 days ago a co-resident at her memory care facility was found on top of her in bed. Both the patient and the other individual appeared to be naked, but no known injuries occurred. Since that time, she has not complained of any pain, has been ambulatory, eating and drinking per normal. Final diagnosis as of 12/30/25 at 12:50 a.m. was possible STI exposure. Review of R#1's nurse's note created by LVN C on 12/30/25 at 3:28 a.m. reflected, Res returned from ED with an order for Flagyl 500mg BID x 7 days; order placed in EMAR and placed to pharmacy. Resappears in good spirits. No s/s of pain. Resps even and unlabored. No skin issues noted. Res. smiling at this writer. MD notified and clarified Vaginitis. Review of R#1 nurse's note created by LVN B on 12/30/25 at 11:48 a.m. reflected, After review of AVS from Xrays show no fxs or abnormalities. No STI test results included in AVS. New order for Flagyl500mg BID X 7 days prophylactically for possible STI exposure. Initial dose to be administered 12/30/25 at HS. R#2 Review of R#2's admission record, dated 12/31/25, reflected he was admitted to the facility on [DATE]. He had medical diagnoses that included intermittent angle-closure bilateral glaucoma (temporary, repeated episodes where the eye's drainage angle closes, causing brief pressure spikes and symptoms like headaches, blurry vision or halos), vascular dementia, schizophrenia and auditory and visual hallucinations. He was discharged to the hospital on [DATE]. Review of R#2's quarterly MDS assessment, dated 11/06/25, reflected the cognitive patterns section showed he had a 15/15 BIMS, which indicated he was cognitively intact. The behavior section showed he did not exhibit psychosis, physical, verbal, or other behavioral symptoms and wandering behaviors. The functional abilities section showed he was independent with lower body dressing, transfers and bed mobility. Review of R#2's care plan, dated 10/27/25, reflected he resided in the secure unit due to his wandering and poor safety awareness. Staff were required to implement interventions, which included providing him with activities, assistance where he need to be going, and monitor and report changes in behaviors to the ADM, DON, MD, and RP. Review of R#2's task care record for December 2025 reflected staff documented observing him on 12/27/25 at 2:57 p.m. Review of R#2's change in condition evaluation note created by LVN A on 12/27/25 at 4:23 p.m. reflected, Resident was observed by staff lying in bed next to a female resident when staff intervened. Review of R#2's struck out incident note created by LVN A on 12/27/25 at 5:29 p.m. reflected, The resident was found in bed with a female resident during routine rounds, and staff intervened immediately, separating bothresidents without incident. The resident has diagnoses of schizophrenia, unspecified, and dementia, unspecified, with a BIMS score of 6, indicating severe cognitive impairment. At the time of redirection, the resident appeared confused and disorganized, demonstrated impaired judgment and poor personal boundaries, and showed limited insight into the inappropriateness of the behavior, consistent with psychiatric and cognitive conditions. The resident was able to follow simple directions with repeated prompting and was escorted back to the room, no injuries were observed. A full head-to-toe physical assessment and psychosocial assessment were completed with no acute issues noted. A 1:1 supervision was initiated for safety. MD and responsible party was notified, and the VA ED was contacted and provided with report. Due to the severity of the incident, 911 was called, and emergency services responded with police presence. The resident is being transferred to the VA Emergency Department for further medical and psychiatric evaluation. Review of R#2's psychosocial note created by LVN A on 12/27/25 at 9:05 p.m. reflected, Resident assessed following aggressive behavior. BIMS score is 6, indicating severe cognitive impairment. Resident observed [NAME] withdrawn with periods of agitation, evidenced by tense body posture, limited eye contact, and restlessness. Verbal interaction was minimal with delayed and inconsistent responses. Affect appeared constricted. No signs of acute distress noted at time of assessment. Resident was redirectable with staff intervention and is currently in his room on one-to-one supervision with every 15-minute checks for safety. Continued monitoring recommended, with interdisciplinary team involvement for behavior management and psychosocial support.Review of R#2's 15 minute check monitoring form, dated 12/27/25, reflected he was monitored by the DON from 12/27/25 at 3:15 p.m. through 12/27/25 at 3:45 p.m. and CNA F from 12/27/25 at 4:00 p.m. through 12/27/25 at 5:00 p.m. There were no other entries. Review of R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. reflected, While passing meds, [MA D] knocked and entered [R#2's] room and found [R#2] in bed with [R#1]. [R#2] found with pants downwith genitalia exposed. [R#1] pants down but brief up and intact. [MA D] verbalized, stop. [R#2] rolled to his side and witness observed an nonerect penis and intact brief on [R#1]. [MA D] separated immediately by ushering [R#1] out the room. Administration/Abuse coordinator notified. No penetration noted by witness and no evidence noted on either physicalexamination of alleged victim or alleged perpetrator. [R#2] immediately placed on 1:1 monitoring and 15 min observation. Physical assessment completed on both individuals. [R#1] noted to have no evidence of penetration but found to have liquid stool in brief. Upon being notified writer/administrator physically went to building to investigate in person. Writer inspected [R#2] genitals and no evidence of penetration or pelvic contact. Unable to interview [R#1], but when [R#2] interviewed, he verbalized incomprehensible speech and shook head and body. Witness statement obtained from [MA D]. Responsible parties notified along with psych NP, MD, EMS and VA. [R#2] subsequently sent out to VA by EMS for psych evaluation. [NAME] notified and onsite officer: PO. Psychosocial assessments completed on both, Safe surveys completed. [R#2] BIMS noted to be 6, and PM noted to be 99. When interviewing witness she state that there appeared to be no struggle. Abuse coordinator interviewed: [MA D], [CNA E], and [LVN A]. In-services being conducted: abuse and neglect, resident to resident, frequent rounding, redirection of resident to assigned room or common area. Additionally, all residents on MCU to have full body assessments and [R#1] placed on 1:1 and 15 min observations until cleared by physician. Review of R#2's administration note created by the ADM on 12/29/25 at 8:51 a.m. reflected, Called [R#2's] RP and rediscussed [R#2] recent incident with another resident. I notified her that [R#2] incident makes himsubject to immediate discharged based up on signed admissions agreement regarding safety and that this notification serves as notice of discharge. Writer on site and investigated event in person. Licensed nurse called report to VA and received acceptance. EMS on site with PD to transport [R#2]. Review of R#2's administration note created by the ADM on 12/29/25 at 8:58 a.m. reflected, Called multiple times by Case managers regarding [R#2]. I repeatedly stated that EMS were instructed to take [R#2] toVA Hospital and that report had been call for acceptance. The VA hospital has resources for [R#2] as PD had no intervention other than EMS escort. I also notified CM, that I personally contacted [R#2's] RP regarding incident and that he is subject to immediatetransfer/discharge and the conversation serves as notification. Review of R#2's nurse's note created by the DON on 12/31/25 at 11:40 a.m. reflected, Responsible parties were notified, including the psychiatric NP, attending MD, EMS, and the VA. Due to ongoing psychiatricconcerns, [R#2] was assessed and subsequently transported by EMS to the VA for further psychiatric evaluation and monitoring. Police Department was notified per protocol, and an onsite officer responded (PO). Comprehensive psychosocial assessments were completed on both involved residents. SAFE surveys were also completed in full. [R#2's] BIMS score was assessed and noted to be 6, indicating cognitive impairment. Due to the need for continued psychiatric follow-up and future evaluation, the resident was sent out to the VA for ongoing psychiatric services. A detailed report was called in to the VA by [LVN A] prior to transport to ensure continuity of care. Review of R#2's MD order, dated 12/27/25 at 11:08 a.m., reflected he was okay to discharge to alternative facility/all male facility. The order was confirmed by the DON. There was no MD signature and signed date indicated. Review of the facility's incident report, from 12/01/25 through 12/31/25, reflected R#1's alleged abuse incident occurred on 12/27/25 at 4:21 p.m. R#1's alleged abuse incident occurred on 12/27/25 at 3:15 p.m. Review of the facility's discharge report, dated 12/31/25, reflected R#2 was transferred to the hospital on [DATE] at 3:21 p.m. and there was no return. R#1 was also transferred to the hospital on [DATE] at 5:06 p.m. and returned on 12/30/25 at 3:15 a.m. Review of the ADM's email correspondence to the SSA on 12/27/25 at 7:09 p.m. reflected, To whom it may concern, website was down and I was unable to submit report directly due to website malfunction. Review of the facility's self-report reflected the incident that occurred on 12/27/25 at 3:15 p.m. The narrative summary of reportable incident reflected it was identical to R#2's administration note created by the ADM on 12/29/25 at 8:23 a.m. Review of MA D's handwritten statement, dated 12/27/25, reflected, On this day I was passing medication at 3:15 and as I entered [R#2's] room I seen [R#2] laying on top of [R#1] and asked him to stop and made sure she was safe and then called for help.There were no other staff statements attached. Review of the facility's resident safety surveys completed by the ADM on unknown dates reflected 6 residents were interviewed. All 6 residents indicated, Yes, when asked did they feel comfortable asking the staff for assistance, did staff treat them with respect and dignity, did they feel safe, did they feel comfortable telling the staff about any concerns and were staff willing to listen and resolve their concerns. All 6 residents indicated, No, when asked if a staff member had physically harmed them, yelled or cursed at them, and if they had any questions for the ADM. Review of the facility's in-services, dated 12/27/25, reflected the DON taught staff about abuse, neglect, resident rights, resident to resident and immediately separating residents to ensure safety, routine checks/frequent rounding, 1:1 observations for safety and supervision of residents, and wandering and redirection. The in-services had attached copies of the abuse, neglect, exploitation and misappropriation prevention program policy, resident rights policy, resident to resident altercations policy, resident checks policy, safety and supervision of residents policy, and wandering and elopements policy. During an observation of the memory care unit on 12/31/25 at 9:44 a.m., R#1 was sitting in a recliner chair in the living area. The surveyor attempted to interview her, but she was unable to answer any questions. During an interview with CNA G on 12/31/25 at 9:45 a.m., she stated R#1 was nonverbal; she did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and Stop. She stated R#1 wandered, but she would wander into her own room and no other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility, did not know when he was discharged from the facility and did not know why he was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she recalled signing off on in-services, but she could not recall what in-services she received and could not recall what she learned. She stated she did not know who the abuse coordinator was. She stated she knew she would separate, notify staff for help, and notify management if there was a resident-to-resident incident. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to check on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded (checked) on. During an interview with CNA H on 12/31/25 at 9:47 a.m., she stated R#1 did not verbally communicate. She stated R#1 sometimes showed facial expressions whenever she was in distress or feeling discomfort and whenever she responded in single words, such as No and stop. She stated R#1 wandered into other residents' rooms. She stated R#1 was not on 1:1. She stated R#2 was not at the facility. She stated R#2 was at the facility on 12/26/25. She stated she believed R#2 left the faciity on [DATE]. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander into other residents' rooms. She stated R#1 and R#2 were not cognitively intact. She stated R#1 could not give consent and she was unsure if R#2 could give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by CNA I, LVN A, and the ADON on abuse, neglect, reporting and resident-to-resident altercation on 12/29/25, 12/30/25 and 12/31/25. She stated she learned to report any abuse and neglect observed, separate residents, and notify the ADM, DON and ADON if there was a resident-to-resident incident. She stated the ADM was the abuse and neglect coordinator. She stated CNAs and nurses checked on residents every less than two hours in the memory care unit. She stated she knew it was important to round on residents and said, Safety. A lot could happen to residents. Any form of accident could happen if they are not frequently rounded on. During an interview with CNA I on 12/31/25 at 10:04 a.m., she stated R#1 communicated in and out. She explained R#1 responded with one words. She stated R#1 will do facial expressions for staff to know how she feels. She stated R#1 did not wander. She stated R#1 was not on 1:1. She stated R#2 was no longer at the facility. She last seen R#2 at the facility on 12/24/25. She did not know why R#2 was discharged from the facility. She stated R#2 was verbal. She stated R#2 did not wander and knew where to go from one place to another place. She stated R#1 and R#2 were not cognitively intact. She stated R#1 and R#2 could not give consent. She stated she did not work on 12/27/25. She stated she did not know any resident-to-resident sexual abuse incidents that occurred at the facility. She stated she was in-serviced by the DON and ADON on ensuring resident safety, rounding and checking on residents, shift change, abuse and neglect, resident-to-resident, and 1:1 monitoring. She stated she learned she must immediately report abuse and neglect to the ADM and DON because they were both the abuse and neglect coordinators and investigated abuse and neglect, conduct 1:1 to prevent altercations, ensure resident safety, observe residents every 15 minutes, redirecting residents, alternating in between rounds, helping staff with duties and relieving staff of duties. She stated she would separate the residents, yell for help, notify the charge nurse DON and ADM, keep residents apart, and give a statement if there was a resident-to-resident incident. She stated CNAs checked on residents every 30 minutes in the memory care unit. She stated she knew it was important to round on residents and said, To make sure their breathing, alive, no safety issues, clean, not on the floor, know where they are at, ensure they are not in distress. Residents could be at risk of a lot happening if staff are not conducting rounds. We don't want to not round and find any resident unresponsive, sitting in urine/feces, and on the ground due to a fall. During an interview with ADON on 12/31/25 at 10:25 a.m., she stated R#1 was nonverbal. She stated staff observed facial expressions and behaviors to know how R#1 felt. She stated R#1 was not cognitively intact and could not give consent because she did not have the capacity. She stated R#2 was sent to the hospital and did not know why because she was gone when he was sent out to the hospital. She stated there was an incident that occurred on Saturday (12/27/25) that staff had to send R#2 out to the hospital for. She did not know what the incident was. She did not know why R#2 was discharged from the facility. She last seen R#2 on 12/23/25. She stated R#2 could communicate and understand to an extent. She stated R#2 had a guardian. She stated R#2 was not cognitively intact and did not know if R#2 could give consent. She stated R#2 did not have any wandering behaviors. She stated she did not work on 12/27/25. She stated she last worked on 12/23/25. She stated she did not know any incidents of resident-to-resident sexual abuse. She stated CNA J notified her of the incident on Saturday in the afternoon (12/27/25). She stated CNA J informed her that one of the staff walked in on R#2 on top of another resident and was having sexual intercourse. She stated CNA J told her that the staff separated R#2 and the other resident. She stated she did not know if anyone else was on duty. She stated she did not know if R#2 was placed on 1:1 monitoring. She stated R#2 had no past incidents. She stated she did in-service staff after the incident, but she could not recall what it was about because she was just coming back to work since being off from 12/23/25. She stated she expected staff to separate residents immediately, redirect residents away from each other, ensure resident safety, assess the residents, notify the staff and charge nurse, and ensuring resident community safety. She stated all staff (CNAs and nurses) checked on residents at least every 15-30 minutes in the memory care unit if residents were not within eyesight. She stated she did not know how management ensured CNAs and nurses were rounding. She changed her statement and stated she would walk the hallways to ensure staff were rounding on the floor once every hour. She stated she knew it was important to round on residents and said, For safety and security. Primarily for safety of residents. Residents could be at risk of falling or having a change in condition if staff did not round. During an interview with R#1's family and MPOA on 12/31/25 at 12:03 p.m., they stated R#1 was unable to get up on her own, not a wanderer, and did not wander into any other residents' rooms. They stated an unknown female staff member notified them by phone on 12/27/25 around 8:00pm that a male resident was found on top of R#1, their clothes were off, and R#1's brief was loosened on 12/27/25 at an unknown time in the male resident's room. They stated they did not know who walked in and that a staff member told them that it might have been a medication aide that knocked on the door, walked into the male resident's room, and observed the incident. They stated the ADM told them that R#1's clothes were off and her brief was still on. They stated R#1 was not sent out to the hospital on [DATE], they did not know why R#1 was not sent out to the hospital, learned two days later (12/29/25) that R#1 was not sent to the hospital on [DATE], and had to request the staff to send R#1 to the hospital for further evaluation. They stated they questioned the ADM why R#1 was not sent out to the hospital and he told them because he had staff examine R#1. They stated the male resident was sent out to the hospital on [DATE] and the ADM told them that the male resident would not be able to return from the hospital. During an interview with the SW on 12/31/25 at 1:40 p.m., she stated the ADM notified her on 12/29/25 of R#2's incident. She stated the ADM told them one of the CNAs went to check on R#1 in her room and observed R#2 on top of her. She stated the CNA did not know what R#2 was doing and suspected something inappropriate. She stated R#2 was sent out to the hospital and did not return on unknown date, but she believed the same day as the incident. She stated checked on R#1 on 12/29/25. She stated she did not conduct any assessments on R#1 because R#1 was nonverbal and the new facility owners did not instruct her to. She stated she did not conduct resident safety surveys because she was not there the day of the incident, did not do such on 12/29/25 and was not at the facility on 12/30/25. She stated there was no social services designee for assessments and safety surveys. She stated she knew it was important to assess residents after ANE allegations and said, To see how residents are doing, make sure they still feel safe, make sure there's no psychosocial adverse outcome and need to notify psych services. Residents could start to have other symptoms, such as depression, and not feel comfortable with other residents and staff. She stated the DON in-serviced staff on abuse and neglect policies and procedures and discussed the topics during staff meeting on 12/29/25. She stated the ADM and DON oversee to ensure abuse and neglect procedures were followed. She stated she knew to immediately report ANE to the ADM. She stated the ADM and DON report ANE to the SSA. She stated she did not know the reporting timeframe. She stated the ADM was the abuse and neglect coordinator. She stated she knew it was important to follow ANE procedures and said, To make sure basis was covered and make sure residents were safe. Residents quality of care could be affected and it could put them in more harm. During an interview with R#1's RP on 12/31/25 at 2:10 p.m., they stated R#2 was cognitively in and out, schizophrenic and heard voices. They stated R#2 was at the VA. They stated an unknown female nurse on duty notified them on 12/26/25 that staff caught R#2 sexually assaulting another female resident in her room and they sent him to the ER because he was distraught. They stated the staff did not explain why R#2 was distraught. They stated the staff told them that the female resident was shaken up, okay and out of breath because she was a small person. The staff told them that R#2 was not allowed to come back to the facility and did not explain why he was not allowed to return to the facility. They stated the police have not notified or spoke with them about R#2. The staff told them that this was not the first incident involving R#2 and did not explain what the previous incident was. They stated they recalled R#2 sexually assaulted a female patient at a mental health facility about 30 years ago and served a prison sentence for it. The surveyor attempted to call CNA J on 12/31/25 at 2:29 p.m. and 01/01/26 at 1:49 p.m. and left a voicemail and call back number. CNA J did not return the surveyor's calls. The surveyor attempted to call LVN C on 12/31/25 at 2:31 p.m. and 01/01/26 at 1:50 p.m. and left a voicemail and call back number. LVN C did not return the surveyor's calls. During an interview with MA D on 12/31/25 at 2:53 p.m., she stated she was administering medications on 12/27/25 around 3:00 p.m., R#2'a door was closed, she heard moaning, she entered R#2's room and observed R#2 on top of R#1 in his bed, R#2 and R#1's pants were down, R#1's brief was still on, R#1 was making noises and had A flushed face, and R#2 was thrusting against R#1. She stated she did not believe R#2 penetrated R#1 because R#1's brief was on one of the sides. She stated she told R#2 to stop that, R#2 rolled off of R#1, she got R#2 up and out of the room, R#2 and R#1 were separated, and she called CNA E to help her because R#2 could be aggressive and she wanted CNA E there just in case he got aggressive. She stated she also notified LVN K, who ensured R#2 and R#1 were separated. She stated CNA E and LVN K notified the ADM. She stated she did not know if R#2 and R#1 were assessed. She stated R#2 was sent out to the hospital, did not return from the hospital and she did not know why. She stated she was unsure if R#1 was sent out to the hospital, but she believed R#1 was not. She stated she did not know if R#1's and R#2's families were notified. She stated she did not know if law enforcement came out to the facility. She stated she did not have to give a statement to law enforcement and they had not spoken with her. She stated R

Based on interview, observation, and record review, the facility failed , to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 10 and Resident # 59 ) reviewed for activities. The facility failed to provide Resident # 10 in room activities during the months of April, May, and June of 2025. The facility failed to provide Resident # 59 in room activities twice per week during the months of April, May, and June 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. Finding included: Review of Resident #10's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses unspecified dementia, unspecified severity, with agitation ( a group of symptoms affecting memory, thinking, and social abilities- its exact severity not determined- with state of restlessness), cognitive communication deficit ( memory loss and trouble concentrating, completing tasks, understanding, remembering, following instructions, and solving problems), and reduced mobility ( limitation in a person's ability to move around independently, either due to physical disabilities, age, or other factors). Review of Resident #10's Significant Change MDS, dated [DATE], reflected Resident #10 had a BIMS score of a 2 indicating her cognition was severely impaired. Resident #10's activity preference was not completed by staff. Review of Resident #10's Quarterly MDS Assessment, dated 05/13/2025, reflected Resident #10 had a BIMS score of a 2 indicating her cognition was severely impaired. ( Activities does not fill out section F on the Quarterly MDS) Review of Resident #10's Comprehensive Care Plan, dated 04/10/2025, reflected Resident #10 was not at ease in joining other residents in activities. Resident #10 will yell and hit the table during group activities. Intervention: Activity Director will provide 1:1 activity session as needed. Place resident in position of almost certain success in an activity. Encourage resident to verbalize feelings and fears. Review of Resident #10's Activity Assessments revealed a Initial Activity Assessment was not completed. Review of Resident #10's Activity Participation Record during the months of April, May, and June from 06/01/2025 to 06/16/2025 reflected Resident #10 did not refuse one-on-one activities or receive one-on-one activities. Observation and Interview on 06/17/2025 at 1:16 PM, revealed Resident #10 was in her geri-chair sitting in the common area near the 200 hall. She was staring toward the wall. Resident #10 said hello. Resident #10 did not respond to any questions or conversation. She was not interview able. Observation and Interview on 06/17/2025 at 3:30 PM, revealed Resident #10 was sitting in her geri-chair in her room. There was no stimulation in the room, and she would not respond to any conversation or questions. Resident #10 was not interviewable. Review of Resident # 59's face sheet, dated 06/18/2025, reflected a [AGE] year-old male admitted on [DATE] with diagnoses which included depression, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest), vascular dementia, moderate, with anxiety (significant decline in memory, thinking, and behavior. Anxiety- unease, worry or fear, often about things that might happen in the future), and insomnia, unspecified (a sleep disorder characterized by difficulty initiating or maintaining sleep, or waking up too early, without a specific underlying cause). Review of Resident #59's admission MDS Assessment, dated 03/04/2025, reflected Resident #59 had a BIMS score of 11 indicating his cognition was moderately impaired. Resident #59's activity preferences were the following: going outside to get fresh air when the weather permitted. Participating in religious services or practices, listening to music, and being around animals such as pets. Review of Resident #59's Comprehensive Care Plan, revised on 05/14/2025, reflected Resident #59 was in pain. Intervention: Offer non-drug interventions for my pain such as activities- conversation (since I love to talk). The care plan did not include any other activities. In an interview with the Activity Director on 06/18/2025 at 8:40 AM, requested Resident #59's Initial Activity Assessment and this was not provided at the time of exit. Review of Resident #59's Activity Quarterly Progress Note, dated 06/09/2025, reflected Resident #59 enjoyed one on one visits. He participated in two one-on-one activities per week. Resident #59 chose not to participate in group activities. He prefers to stay in his room. Resident #59 was alert and oriented to person, place, and time. He was assessed to need one to one interaction, intellectual stimulation, and sensory stimulation (did not specify what type of sensory stimulation). Resident #59's focus of programming was one-to one- activities, intellectually stimulating activities, outdoor activities, and relaxation activities (did not specify his preferences). Resident plan of care will be continued. Resident #59's activity assessment signed by the Activity Director. Review of Resident #59's one-on-one schedule on 06/17/2025, not dated, reflected Resident #59 was to receive one-on-one visits two times per week. Review of Resident #59's one-on-one activity records, on 06/18/2025, from the electronic medical records reflected the following: 1. Resident #59 received one-on-one visits on the following dates during the month of April: a. 04/15/2025 b. 04/16/2025 c. 04/28/2025 2. Resident # 59 received one-on-one visits on the following dates during the month of May: a. 05/07/2025 b. 05/08/2025 c. 05/19/2025 d. 05/30/2025 3. Resident #59 received one-on-one visits on the following dates between 06/01/2025 to 06/16/2025: a. 06/09/2025 b. 06/10/2025 Observation and interview on 06/17/2025 at 9:15 AM, revealed Resident # 59 was in his room lying in bed. He was staring at the wall in front of him. There was not any stimulation in his room. Resident #59 stated he wanted someone to come to his room and talk to him approximately four times a week. He stated he did become lonely especially in the late afternoons. Resident #59 stated no one asked him if he wanted someone to visit with him. He stated some lady comes to his room and asks him to go to activities and will bring him some food from parties sometimes, however, he stated he wanted someone to sit with him and talk to him about different things. He stated he preferred to talk about whatever was on his mind at the time of the visit. Resident #59 stated he did not want to talk about his feelings he wanted to talk about happy things. In an interview on 06/18/2025 at 8:30 AM The Activity Director stated Resident #10 and Resident #59 were on the in-room activity program. She stated Resident #10 did not attend group activities and would sit in the common area near the 200 hall sometimes. She stated Resident #10 would refuse in room activities at least three times a month. The Activity Director stated she did not document when Resident #10 refused in room activities. She stated Resident #10 did not enjoy being in any size group. She stated Resident #59 preferred visits in his room. The Activity Director stated he was to receive in room activities two times per week. She stated she was not aware he wanted more in room visits. The Activity Director stated according to her documentation Resident #10 had not received in room activities for the months of April and May in 2025. She stated Resident #10 did not receive in room activities during the dates of June 1st to June 16th, 2025. She stated Resident #59 did not receive in room activities two times a week during April, May, and June 2025. She stated she did not have an explanation why Resident #59 did not receive the in room visits he needed to prevent him from becoming lonely. The Activity Director stated she had difficulty interacting with Resident #10 during in room activities. She did not elaborate when asked why she had difficulty interacting with Resident #10. She stated Resident #10 did not interact with other residents or watch television. The Activity Director stated she was expected to ensure all residents received activities based on their preferences and their physical abilities. She stated if a resident was not receiving any type of activities there was a possibility a resident may become bored, depressed or have a decline in their quality of life. She stated she did not know Resident #10's activity preferences. The Activity Director stated Resident #10 did not have any family, however, she did have a care giver. She stated the care giver may know Resident #10's activity preferences. She stated she did not interview the caregiver to determine Resident #10's activity preferences. In an interview on 06/19/25 at 09:04 AM, CNA C stated Resident #10 enjoyed sitting in the common area and sometimes covered her head with a blanket. She stated Resident #10 did not interact with other residents. CNA C stated Resident #10 enjoyed drinking coffee and would talk to staff when she was drinking coffee. She stated when she was in her room or in the common area if country music was playing, she would talk about country music with staff. She stated Resident #10 did not enjoy interacting with others for a very long period. In an interview on 06/19/2025 at 12:57 PM The Director of Nurses stated Resident #10 enjoyed drinking coffee and talking to staff. She stated she had observed Resident #10 enjoying music in the common area and in her room. She stated Resident #10 enjoyed talking about music. The Director of Nurses stated Resident #10 did not enjoy group activities and did respond more to one-on-one activities. In an interview on 06/19/2025 at 2:40 PM the Administrator stated he expected in room activities be provided to the residents needing these types of activities. He stated if a resident was not receiving in room activities there was a possibility a resident may become depressed, bored, and isolated. The Administrator stated the Activity Director was responsible for the activity programs and he was responsible to monitor the Activity Director. Review of the facility policy for Activity Programs, dated 11/2021, reflected Activity programs designed to meet the needs of each resident are available on a daily basis. Our activity programs are designed to encourage maximum individual participation and are geared to the individual resident's needs. Activities participation for each resident is based on information in the resident's comprehensive assessment. Review of the facility policy for Activity Documentation, dated 01/2020, reflected The Activity Director is responsible for maintaining appropriate departmental documentation. Recordkeeping is a vital part of the activity program. The following records, at a minimum, are maintained by the Activity Department personnel: 1. Activities evaluation 2. Attendance records 3. Activity progress notes 4. Individualized Activities Care Plan or activities portion of the Comprehensive Care Plan.

Based on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (Resident #7) of two residents reviewed for pressure ulcers. 1. The facility failed to ensure that dressing changes were completed for Resident #7's pressure ulcer on 06/11/2025, 06/13/2025, and 06/16/2025. This failure could place residents with pressure ulcers at risk for infection, pain, and worsening of the wound. Findings included: Review of Resident #7's Face sheet reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included: Schizoaffective Disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Vascular Dementia with anxiety (dementia related to blood flow to the brain that includes feelings of intense and excessive worry and fear), Pain, and Functional quadriplegia (inability to move all four limbs). Review of Resident #7's MDS dated [DATE] reflected that the resident had a BIMS score of 14 (no cognitive impairment). Section M for Skin Condition reflected a 0 for M0210 (Unhealed Pressure Ulcers/Injuries), indicating that she did not have any unhealed pressure ulcers/injuries. The assessment was signed by RCMDS Q. Review of Resident #7's Care Plan reflected a Problem Area stating, Problem Start Date: 01/15/2025 Category: Pressure Ulcer/Injury Resident #7 has a pressure ulcer to sacrum (area of skin above the triangular bone at the base of the spine). Edited: 06/16/2025. There was a related Approach intervention stating, Provide treatment as ordered. Review of Resident #7's orders reflected an order for Wound Treatment Order: Location: mid-back/sacral area-Clean with Normal Saline/Wound Cleanser Apply: Collagen powder and cover with Primary Dressing: Border Gauze Secure with Tape Once a Day: Mon, Wed, Fri 06:00AM-06:00PM started on 06/18/2025.There was an order for, Wound Treatment Order: Location: mid back/sacral area Clean with Normal Saline/Wound Cleanser Apply: Collagen powder and hydrocolloid sheet Cover with Primary Dressing: Bordered gauze Secure with tape Once a day on Mon, Wed, Fri. with a start date of 04/02/2025 and a discontinue date of 06/18/2025. Review of Resident #7's Wound Evaluation and Management Summary dated 05/15/2025 reflected a stage 3 pressure wound to the resident's sacrum with a Duration as greater than 164 days. Review of Resident #7's TAR reflected there was no treatment recorded for Monday, 06/09/2025; the treatment recorded for Wednesday, 06/11/2025 was signed off on by LVN K; the treatment recorded for Friday, 06/13/2025 was signed off on by LVN M; and no treatment was recorded for Monday, 06/16/2025. The TAR reflected a Wound Treatment, Pain Evaluation to be done, Mon, Wed, Fri; Set Frequency to match Treatment Administration Order. The sign offs reflected the same dates and persons indicated for the 06/09/2025, 06/11/2025, and 06/13/2025 treatments. There was a sign off on Monday, 06/16/2025, from LVN K, indicating she assessed pain during wound care that day. Observation of wound care with LVN M, CNA G, and CNA O for Resident #7 on 06/18/2025 at 10:30 AM revealed that the resident had a pressure wound to her sacrum with a diameter of approximately 0.2 cm and a depth of approximately 0.1 cm. The dressing removed from the patient revealed the date, 06/09/25 with the initials for LVN M. In an interview on 06/18/2025 at 03:00PM with LVN M, she stated that she did a full skin assessment on Resident #7 that on the morning of 06/18/2025 she and had not noticed the dressing from Resident #7's sacral wound during the assessment or during wound care performed on 06/18/2025 was dated 06/09/25 with her initials. She stated that she always records the dressing changes on the TAR. She stated that she did sign off on the wound care for Resident #7 on 06/13/25. She stated, I thought I did the wound care that day, but I must not have done it. She stated that she should not have documented that the treatment was done if it was not done. She stated that not doing a dressing change as ordered could place Resident #7 at risk for infection and worsening of the wound. In an interview on 06/19/2025 at 03:37PM with DON, she stated that it is her expectation that if staff document wound care that, it should be done. She stated that wound care should be performed per the orders. She stated that if staff are unable to finish a scheduled task on their shift that it should be passed on to the next shift, to herself, or the ADON, so that it can be completed. She stated that refusals of care should be documented after several attempts to the MD, herself, and the RP in addition to documenting the refusal. She stated the impact to the resident of not receiving care that was ordered could contribute to the worsening of the wound. Attempted an interview with LVN K on 06/19/2025 at 04:53PM. No call was returned prior to exit. In an interview with the ADM on 06/19/2025 at 06:30PM, he stated that he expected that dressing changes be performed per the physician orders and per policy. He stated that the potential impact to the resident of not doing wound care per the orders and policy standards could lead to worsening of the wound or ostomy site. Review of the facility's policy dated April 2024 for Pressure Injury/Skin Breakdown-Clinical Protocol failed to include guidance for facility expectations regarding following wound care orders.

Based on observations, interviews, and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 4 (ADON, RN, LVN M, and LVN J) of 5 staff reviewed for nephrostomy care for Resident #21. The staff were not aware that the nephrostomy policy for the facility indicated that Resident #21 should have sterile dressing changes per the facility policy. This failure could potentially affect the residents by placing them at risk for infection and deterioration of the stoma site due to staff who lack the appropriate skills and competencies to minimize infections. Findings: Review of Resident #21's Face sheet revealed a [AGE] year-old, female admitted on [DATE]. Diagnoses included: Hydronephrosis (swelling of the kidneys from blockage of the flow of urine), Urinary Tract Infection, Chronic Kidney Disease, and Type 2 Diabetes (chronic disorder of abnormal blood sugar levels). Review of Resident #21's Quarterly MDS dated [DATE] reflected a BIMS score of 15 (no cognitive impairment). For Section H-Bowel and Bladder it reflected a 9 for Urinary Continence, indicating Not Rated, resident had a catheter (indwelling or condom), urinary ostomy, or no urine output for the entire 7 days. For Section M-Skin Conditions it was indicated that the Resident has a Surgical Wound with Surgical Wound Care. Review of Resident #21's Care Plan reflected a Problem Area indicating, Problem Start Date: 05/23/2023 Category: Indwelling Catheter has nephrostomy tube [a catheter placed into the kidney through an incision in the back to drain urine] in place d/t Chronic cystitis [inflammation of the bladder wall], Hydronephrosis [swelling of the kidneys from blockage of the flow of urine], CKD [chronic kidney disease], and obstructive uropathy [blockage of the urinary tract]. There was an Approach intervention reflecting, Care for tubes/drains: nephrostomy site care per order Created: 05/23/2023. Review of Resident #21's Orders reflected an order to, Clean nephrostomy site with NS and pat dry. Apply split bandage and secure with tape. Twice A Day Morning 07:00AM -10:00AM, Bedtime: 07:00PM-10:00PM with a start date of 04/09/2025. Review of Physician Progress Note for Resident #21 dated 06/16/2025 reflected a note stating, Resident is currently being treated for a UTI (urinary tract infection)-gentamycin 80 mg inj. Other chronic conditions stable at this time. Review of Resident #21's TAR reflected an order for, Clean nephrostomy site with NS and pat dry. Apply split bandage and secure with tape. Twice a Day. There were sign offs on the dressing changes for LVN M for 06/18/2025 and 06/19/2025 indicating that the dressing change was done. In an interview on 06/17/2025 at 10:45AM, Resident #21 stated that she had nephrostomy tubes to both kidneys. She stated that the staff monitored and cared for the tubing. She denied any concerns. Observation on 06/18/2025 at 10:10AM of Resident #21 revealed that there was no dressing to either nephrostomy site. They were open to air. No redness or drainage was noted to the insertion sites for the nephrostomy tubes. In an interview with Resident #21 on 06/18/2025 at 10:10AM, she stated that the staff check the site every day, but they do not change a dressing to the site. She stated, they just put cream on my back. Observation on 06/19/2025 at 01:15PM revealed that there was no dressing to either nephrostomy site. They were open to air. No redness or drainage was noted to the insertion sites for the nephrostomy tubes. In an interview with Resident #21 on 06/19/2025 at 01:15PM, she stated all they have done is put some lotion on her back. She denied having any dressing added or changed to the nephrostomy sites. In an interview with LVN M on 06/19/2025 at 01:58PM, she was knowledgeable of the ordered dressing change but stated that she did not know that the dressing change should be done with sterile technique per the facility policy. She stated that she does not use sterile equipment or sterile technique for dressing changes for the resident. She stated that she had been doing regular dressing changes for the resident prior to the last two days when she worked. She stated after reading the policy that she should be doing sterile dressing changes. She stated, I did not know any of this. She stated that the resident has had the nephrostomy since she was admitted . She stated that the facility did have supplies for sterile dressing changes. In an interview on 06/19/2025 at 02:05PM, the ADON stated that she had worked at the facility for 30 days. She stated that she had not done any dressing changes for Resident #21. She stated that her role was to oversee education and some audits, including urinary catheters. She stated that the nurses are responsible for direct care to the residents. She stated that Resident #21 is the only resident in the facility with nephrostomy tubes. She stated that she was not aware of the facility policy on nephrostomy tubes. She stated she had not received any training on any special care considerations for the insertion sites or on how to perform the dressing changes for the insertion sites. She stated that if she had been aware of the policy regarding sterile dressing changes, she would audit for different criteria and categorize it differently than the audits for urinary catheter care. She stated that her responsibility is to ensure orders are transcribed and put in place, as well as to monitor progress of the residents. She stated that the facility did have supplies to perform the dressing changes. In an interview with the RN on 06/19/2025 at 02:44PM, she stated that she has worked at the facility since October of last year. She stated that she does not perform the dressing change to Resident #21's nephrostomy site with sterile gloves, supplies, and technique per the policy. She stated that she was unaware that the policy indicated that dressing change was sterile. She stated that based on the policy she should be doing sterile dressing changes for Resident #21. She stated that she did not recall any in-services regarding the nephrostomy policy. She stated that the impact to the resident of not performing dressing changes per the policy could lead to increased risk of infection. She stated that the resident has chronic UTIs. She denies any hospitalizations with UTI to her recollection. In an interview on 06/19/2025 at 03:37PM with the DON, she stated that it was her expectation that staff used sterile technique for the dressing changes to Resident #21's nephrostomy sites. She demonstrated knowledge of the facility policy. She stated that when she did the skin assessment for the resident that morning, she noted that there was no dressing to the site. She stated that she told LVN M to dress the site, but stated she had not gone back to ensure that it was done. She stated that she had not done any recent in-services on the policy for nephrostomy tubes or the related care considerations. She stated that staff were not trained on hire to perform nephrostomy care or dressing changes. She stated that she, the ADON, and the RN were responsible to ensure that the dressing changes were done for Resident #21. She stated that the potential risk to the resident was increased risk of infection. She stated that the resident has had a recent UTI but was not hospitalized . She stated that if the resident was removing the dressing herself that the nurses should be documenting it. She stated that the staff should not be signing off that they performed the care when they did not. In an interview on 06/19/2025 at 04:23PM, LVN J stated that she changed the dressing for Resident #21 every day that she works with her. She could not recall the ordered dressing change. She could not clearly indicate if she used sterile or clean gloves and supplies for dressing changes to Resident #21. She stated that she used sterile gloves for all dressing changes. In an interview with the MD at 05:52PM on 06/19/2025, she stated that if the policy stated that dressing should be changed with sterile technique, then it should be done with sterile technique. She stated that the site is already contaminated and not a sterile site. She stated that the resident has chronic UTIs. She stated that if the nephrostomy care is not performed per the policy that it would lead to an increased risk of infection. She stated that she was not aware that there was no dressing to the site and that it was her expectation that the site have a dressing. In an interview on 06/19/2025 at 06:30PM the ADM stated that he expected that dressing changes be performed per the physician orders and per policy. He stated that the potential impact to the resident of not doing wound care per the orders and policy standards could lead to worsening of the wound or ostomy site. Review of facility in-services for the last six months reflected there were no in-services regarding the nephrostomy care policy for the facility. Review of facility policy dated October 2010 for Nephrostomy Tube, Care of reflected, General Guidelines . 8. Change dressings every 1-3 days, or as ordered. 9. Use sterile technique during dressing changes.

Based on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 4 medication carts (MA B's Medication Cart #1 and Medication Cart #2) and 4 of 6 residents (Resident #5, Resident #7, Resident #10, and Resident #19) reviewed for pharmacy services. 1. The facility failed to ensure MA B accurately reconciled Resident #5's narcotic medication log for Medication Cart #1 when she administered Resident #5's tramadol (controlled medication used for pain) 1 tablet two doses and Codeine/Acetaminophen (controlled medication used for pain) 1 tablets two doses on 6/18/25. 2. The facility failed to ensure MA B accurately reconciled Resident #7's narcotic medication log for Medication Cart #1 when she administered Resident #7's oxycodone (controlled medication used for pain) 1.5 tablets and lorazepam (controlled medication used to treat anxiety) 1 tablet on 6/18/25. 3. The facility failed to ensure MA B accurately reconciled Resident #19's narcotic medication log for Medication Cart #1 when she administered Resident #19's methylphenidate (controlled medication used to treat bipolar disorder) 1 tablet and Hydrocodone-Acetaminophen (controlled medication for pain) 1 tablets two doses on 6/18/25. 4. The facility failed to ensure MA B accurately reconciled and recorded Resident #10's narcotic medication log Medication Cart for Clonazepam 2 mg (Controlled medication used to treat anxiety) tablets. These failures could place residents at risk for loss of prescribed medications, potential for not receiving their prescribed medications, and risk of drug diversion. Findings included: 1. Record review of Resident #5's face sheet, indicated Resident #5, was a [AGE] year-old female, who was admitted to the facility on [DATE] with diagnoses which included acute pain due to trauma, cerebral infarction (stroke, condition when blood flow to parts of the brain is blocked), unspecified intellectual disabilities, hemiplegia (paralysis or weakness) affecting left nondominant side, cellulitis (bacterial skin infection) of left toe, pain in left lower leg, chronic combined systolic (congestive) and diastolic (congestive) heart failure (chronic condition of the heart that affects heart's ability to pump blood well). Record review of Resident #5's quarterly MDS assessment dated [DATE], indicated Resident #5 was able to make herself understood and usually understood others. The MDS assessment indicated Resident #5 had a BIMS score of 10, indicating her cognition was moderately impaired. The MDS assessment indicated Resident #5 received scheduled pain medication and had received an opioid (narcotic) medication within the 5-day look back period with pain intensity of 4/10 on numeric pain scale. Record review of Resident #5's comprehensive care plan revised on 05/08/25, indicated Resident #5 had the potential for pain related to impaired mobility, right shoulder pain with history of left femur fracture. The care plan interventions were to anticipate the resident's need for pain relief and respond immediately to any complaints of pain to make her as comfortable as possible through repositioning and administration of pain medications as ordered. Record review of Resident #5's order summary report indicated she had an order for acetaminophen-codeine-Schedule III tablet, 300-30mg give one tablet by mouth three times a day for pain with an order start date of 07/30/2021 and an order for tramadol -schedule IV tablets, 50mg give one tablet by mouth three times a day for pain with an order start date of 9/18/2023. Record review of Resident #5's medication administration record for 06/01/25-06/30/25, indicated Resident #5 received acetaminophen-codeine tablets, 300-30mg three times a day and tramadol one-tab 50mg three times a day including 6/18/25. Review of Resident #5's narcotic log records reflected the count for tramadol 50 mg tablets was 12 tablets and the count for acetaminophen/codeine 300mg/30mg tablets was 77 tablets. Review of the medication cards for Resident #5 reflected the Tramadol 50 mg had 10 tablets and the acetaminophen/codeine 300/30mg tablets had 75 tablets. During the medication cart reconciliation and interview on 06/18/25 at 05:45pm, MA B stated she administered two doses of tramadol and two doses of acetaminophen-codeine on 06/18/2025 to Resident #5 but failed to document the medications at the time of the administration of two acetaminophen-codeine 300/30mg tablets and two tramadol 50mg tablets on Resident #5's narcotic record. During an interview on 06/18/25 at 05:45 PM, MA B said she was responsible for documenting on the resident's narcotic record when a narcotic medication was administered but had not since she was very busy all day. MA B said not documenting the narcotic medication was administered could cause a discrepancy or a medication error, since someone will not know the resident had already received the narcotic medication. 2. Record review of Resident #7's face sheet dated 6/19/25, indicated a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included left acute respiratory failure with hypoxia (low levels of oxygen in body tissue), chronic obstructive pulmonary disease (lung condition caused by damage to the airways), schizoaffective disorder (mental disorder with unstable mood affecting behavior), bipolar type, Non-Alzheimer's vascular dementia (group of symptoms affecting memory and thinking), mild with anxiety, quadriplegia (symptom of paralysis that affects all limbs and body from neck down), seizure disorder, hypothyroidism (condition where the thyroid gland does not produce enough hormones), pain. Record review of Resident #7's quarterly MDS assessment dated [DATE] indicated Resident #7 was able to make herself understood and understood others. The MDS assessment indicated Resident #7 had a BIMS score of 14, which indicated her cognition was intact. The MDS assessment indicated Resident #7 was not present with behavioral symptoms and received scheduled pain medication. Record review of Resident #7's comprehensive care plan dated from 5/22/2025 indicated Resident #7 had chronic pain related to disc herniation and contractures. The care plan interventions included to anticipate the residents need for pain relief and respond immediately to any complaint of pain through administration routine and PRN pain medication. Record review of Resident #7's comprehensive care plan dated from 5/22/2025 indicated Resident #7 had a diagnosis of bipolar disorder and can have mood swings from euphoria to depression. The care plan interventions included to encourage activities of choice and administer medication per MD order. Record review of Resident #7's order summary report indicated Resident #7 had an order for lorazepam 1mg give one tablet by mouth two times a day for anxiety with a start date of 04/01/2025 and oxycodone 7.5mg four times a day for pain with a start date of 03/06/2025. Record review of Resident #7's medication administration record dated 06/01/25-06/30/25, indicated Resident #7 received lorazepam 1mg in the morning of 6/18/25 and oxycodone 7.5mg at midnight, morning, and mid-day of 6/18/2025. Review of Resident #7's narcotic log records for lorazepam 1 mg tablets reflected that the count for the medication was 30 pills. Review of the medication card for lorazepam 1 mg for Resident revealed there were 29 tablets. Review of Resident #7's narcotic log records for oxycodone 5 mg tablets revealed the count was 40 prefilled cells of prepared tablets. One card had whole tablets of 5 mg and the second card had pre-cut half tablets of oxycodone 2.5mg. The instructions indicated to give one of each card per dose. Review of the medication cards reflected there were 38 prefilled cells of prepared tablets. During the medication cart reconciliation and interview on 06/18/25 at 5:45pm, MA B stated she administered one dose of lorazepam 1 mg and one dose of oxycodone 7.5 mg on 06/18/2025 to Resident #7 but failed to document the administration of one tablet of lorazepam 1mg and 1.5 tablets of oxycodone to achieve a dose of 7.5mg on Resident #7's narcotic record. 3. Record review of Resident #19's face sheet dated from 06/19/2025 indicated a [AGE] year-old female who initially admitted to the facility on [DATE] with diagnoses which included transient cerebral ischemic attack (stroke, condition when blood flow to parts of the brain is blocked), non-pressure chronic ulcer of other part of left lower leg with fat layer exposed, chronic pain, bipolar disorder, Type 2 diabetes, obstructive sleep apnea, and depression. Record review of Resident #19's quarterly MDS assessment dated [DATE], indicated Resident #19 was able to make herself understood and usually understood others. The MDS assessment reflected Resident #19 had a BIMS score of 14, indicating her cognition was intact. The MDS assessment indicated Resident #19 received scheduled pain medication during the 5-day look back period. Record review of Resident #19's comprehensive care plan dated 02/06/25, indicated Resident #19's need for accessing service to promote adjustment to new living environment. The care plan interventions indicated to evaluate the pain routinely to address pain management needs. Pain medications will be administered per physician orders. Pain medication effectiveness will be documented and reported as needed. Record review of Resident #19's nursing medication administrator record for 06/01/25-06/30/25, indicated Resident #19 received hydrocodone-APAP 10-325mg tablets in the morning and mid-day of 6/18/25 and methylphenidate 10mg on 06/18/2025. Record review of Resident #19's order summary report indicated Resident #19 had an order had an order for hydrocodone-APAP 10-325mg tablets give one tablet three times a day for pain with a start date of 06/07/25 and methylphenidate 10mg one tablet once every morning for symptoms of bipolar with a start date of 01/04/2025. Review of Resident #19's narcotic log records reflected there was 27 tablets of methylphenidate 10mg and 81 tablets of Hydrocodone-APAP 10mg-325mg. Review of the medication cards for Resident #19 reflected the methylphenidate 10 mg card had 26 tablets present and the Hydrocodone-APAP 10mg-325mg card had 79 tablets present. During the medication cart reconciliation and interview on 06/18/25 at 5:45pm, MA B stated she administered two doses of Hydrocodone-APAP 10mg-325mg tablets and one dose of methylphenidate 10mg tablets to Resident #19 but failed to document the administration of two tablets of hydrocodone-APAP 10-325mg and one tablet of methylphenidate 10mg on Resident #19's narcotic record. 4. Review of Resident #10's Face sheet reflected a [AGE] year-old, female admitted on [DATE]. Diagnoses included: Dementia, with agitation (loss of thinking, memory, or reasoning), Paranoid Schizophrenia (serious mental illness involving hallucinations, delusion, and disorganized thinking), Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit), and Generalized Anxiety disorder (intense and excessive worry and fear). Review of Resident #10's Quarterly MDS dated [DATE] reflected a BIMS score of 2 (severe cognitive impairment). It reflected that she was able to sometimes understand others and was usually able to make her needs known. The MDS reflected that the resident had received antianxiety medications for the look back period for that assessment. Review of Resident #10's Care Plan reflected a Problem stating, Problem Start Date: 03/08/2024 Category: Psychosocial Well-Being [Resident #10] is at risk for increased behavioral symptoms and changes in mood related to schizophrenia, bipolar disorder, MDD, and anxiety. Edited: 04/18/2025 and an approach intervention stating, Approach Start Date: 03/08/2024 Administer medications as ordered. Monitor and record effectiveness. Monitor and report any adverse side effects. Review of Resident #10's orders reflected, clonazepam - Schedule IV tablet; 2 mg; amt: 1 tablet; oral Special Instructions: Give Two 1mg tablets PO four times a day. Four Times A Day Morning 07:00 AM - 10:00 AM, Mid-Day 11:00 AM - 02:00 PM, Late Afternoon 03:00 PM - 06:00 PM, Bedtime 07:00 PM - 10:00 PM During an observation and interview on 06/18/25 at 05:45 PM, MA B's Medication Cart #2 reflected the clonazepam 2 mg count for Resident #10 was logged as 96 pills. There were 95 tablets present for the count. There was one card of 6 pills, two cards with 30 pills, and one card with 29 pills. MA B stated that she had counted the carts at shift change with no discrepancies noted. She stated that she did not see the one pill removed from the middle of a full card of medication for Resident #10. MA B stated that when a medication discrepancy is found, the DON should be notified immediately. Observation and interview on 06/18/2025 at 05:50 PM revealed the DON was notified of narcotic count discrepancies with MA B. The DON and MA B walked directly to the medication carts to start an audit. In an interview with DON on 06/19/2025 at 08:20 AM, she stated that the narcotic administration logs for Resident #5, Resident #7, and Resident #19 reflected the same amount of medication administration records for the residents for the time periods that MA B was responsible for the medication carts that day. She stated that MA B stated that she gave the medications but failed to log them in the narcotic log records. She stated that she expected those who were administering narcotics to log each administration of narcotic medications. She stated that all staff were drug tested on [DATE]. She stated all drug tests came back negative. She stated that Resident #5, Resident #7, Resident #10, and Resident #19 stated they had received their medications on 06/18/2025. She stated that she concluded that the medication discrepancies related to Resident #5, Resident #7, and Resident #10 were documentation errors. She stated that the facility had not had any narcotic discrepancies to her knowledge. In an interview with Resident #7 on 06/19/2025 at 09:02 AM, she denied any concerns with receiving her medications on 06/18/2025. She stated she does not recall how many doses of pain or anxiety medications she received. In an interview with LVN L on 06/19/25 at 06:03PM she stated that she counted the cart with LVN M and all medications counts were correct and all cards were counted. She denied any discrepancies in narcotics in the building to her recollection. She stated that she had no concerns for any suspicious staff behaviors or reports from residents or other staff regarding such. In an interview with LVN M on 06/19/25 at 06:07pm she stated that she counted the cart off to MA B. She denied any discrepancies in narcotics in the building to her recollection. She stated that she had no concerns for any suspicious staff behaviors or reports from residents or other staff regarding such. In an interview with CNA D on 06/19/25 at 06:08PM she stated that she did count the cart off to MA B the morning of 06/18/2025. She stated all medications counts were correct and all cards were counted. She denied any discrepancies in narcotics in the building to her recollection. She stated that she had no concerns for any suspicious staff behaviors or reports from residents or other staff regarding such. She stated that she thought it could have been an accidental dislodgement from the card when the cards are being manipulated. She denied observing any loose pills in the medication drawer. In an interview on 06/19/25 at 06:30PM with the ADM and DON, the DON stated that regarding the narcotic discrepancies that were found on 06/18/2025 and submitted to the state for intake. She stated that she concluded that there was no diversion. She stated that interviews with the residents stated that they all received their medications. She stated that she interviewed all staff on shift and those who worked with the cart on 06/17/2025. She stated that she inspected the card with the one pill removed from the middle that could not be explained by the MA. She stated that the plastic covering was not compressed and appeared to have been an accidental snag. She stated that all employees were drug tested and were negative. She denied any history of suspicious behavior from staff regarding medications or any history of narcotic discrepancies. She stated that she removed everything from the drawer with the one pill in the middle removed, and stated that she found a small, round, white pill. She stated that she did not check the lettering on the pill. She stated that she immediately destroyed the pill with the drug buster solution. She stated that it was found under the front of the drawer before the medication cards. The ADM stated he deferred to the DON for the investigation findings and impact. The DON stated there was no harm or impact to the residents regarding the incorrect counts. Review of Drug Test results for all staff on shift on 06/18/2025 reflected that all staff tested negative on a ten-panel drug test. Record review of the facility's policy Controlled Substances indicated . Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift 10. Upon administration a. the nurse administering the medication is responsible for recording: 1. Name of the resident receiving the medication; 2. Name, strength, and dose of medication; 3. Time of administration; 4. Method administration; 5. Quantity of the medication remaining; and 6. Signature of nurse administering medication .

Based on observation, interviews, and record reviews the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. 1.The facility failed to maintain proper kitchen sanitation when the [NAME] did not follow proper hand hygiene protocols. 2.The facility failed to ensure residents were safe from potentially contaminated food when staff did not sanitize their hands between giving residents food. The deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings Include: 1. Observation on 6/18/2025, at 9:30 AM, revealed that the Cook, after donning sanitized gloves, continued to prepare pureed noodles. While still wearing the same pair of gloves, she used three different kitchen utensils, a spatula, a serving spoon, and a whisk. She also touched the puree menu book, made notations using a pen, and opened the top of the puree machine to add liquid to the noodles, all without changing her gloves or sanitizing her hands. Furthermore, the [NAME] was observed washing her hands while still wearing the gloves and continued to prepare the puree without replacing them. In an interview on 6/19/2025, at 1:05 PM, DM, stated that the facility ensured staff washed their hands before serving food to residents through in-service training. Dietary aides actively monitored compliance to reinforce proper hand hygiene practices. The DM emphasized that all staff members must sanitize or wash their hands immediately after touching personal items, such as hair or their face, to uphold hygiene standards. Additionally, the DM stated that staff were aware of the critical role hand hygiene played in preventing foodborne illnesses. The facility has set up a designated handwashing station in the kitchen for staff to use before returning to food preparation. On 6/19/2025, at 1:54 PM, an attempt was made to conduct a telephone interview with the Cook, but there was no response. A voicemail was left requesting a return call. In an interview on 06/19/2025, at 2:20 PM, DW I stated that the facility regularly receives in-service training regarding hand hygiene. Regarding hand hygiene policy, she noted that staff must wash their hands and change gloves between tasks and after handling trash. She emphasized that not using proper hand hygiene could result in cross-contamination, potentially causing residents to become sick. On 6/19/2025, at 2:25 PM, an interview was conducted with DW H. She revealed that she does not recall receiving in-service training on hand hygiene however, she understands the importance of hand washing. DW H acknowledged not washing your hands could result in residents becoming ill. 2. Observation on 6/16/2025 at 12:13 PM during lunch service revealed that lunch trays were handed out to Resident #9 and Resident #69, and staff did not sanitize their hands. Staff began sanitizing their hands after passing Resident #9 and Resident #69's rooms. In an interview on 6/19/2025 at 1:53 p.m., MA A stated that she gets the food off the cart. Then she takes the food and sets it up in their room. If the residents need to be fed or if they need assistance, the resident . She is required to wash her hands or sanitize them before serving food. If she touches a non-clean surface, then she must clean her hands. She said that gloves are not required to serve food to residents. She gets in-service on hand hygiene. If hands are contaminated, the resident could get contaminated food. If she sees a staff member not cleaning their hands, she reminds them to do it. In an interview on 6/19/2025 at 2:03 p.m., MA B stated she is supposed to wash her hands before handling residents' food trays. She said if her hands are not cleaned, a resident could get sick from touching a contaminated item. She mentioned her last hand hygiene in-service was a month ago. She said if she sees someone not cleaning their hands, she will remind them to do so. In an interview on 6/19/2025 at 2:10 p.m., CNA F stated that when passing food to residents, she will sanitize her hands before getting the residents' trays. She said this is done for infection control. She said that if she sees a staff member not clean their hands, she will tell them to do it. She said she has been trained on hand hygiene and infection control. In an interview on 6/19/2025 at 3:18 p.m., the ADM stated that staff are required to sanitize their hands before handling residents' food trays. The ADM said that he has not seen any staff not doing that correctly. The ADM stated that if he sees any staff not cleaning their hands, then he will remind them to do it, and then he will talk with them later about hand hygiene. The ADM said he will then do in service on hand hygiene with all staff. The ADM said that when this is not done, residents are at risk of getting sick. In an interview on 6/19/2025 at 4:18 p.m., the DON stated that when staff are passing out food to residents, either in the hall or the dining room, they are required to sanitize their hands. The DON said she has not seen any staff not sanitizing their hands before grabbing food trays. She said if she sees that happening, she will remind them to clean their hands, and she will do an in-service on hand hygiene. She stated if proper hand hygiene is not taken , that puts residents at risk . Record Review of Facility Policy, Resident Personal Food Policy, REV 9-11-2023, reflected: Always wash your food, hands, counters, and cooking tools. Wash hands in warm soapy water for at least 20 seconds before and after touching food. Wash your cutting boards, dishes, forks, spoons, knives, and counter tops with hot soapy water. Do this after working with each food item. Rinse fruits and veggies. Do not wash meat, poultry, fish, or eggs. If water splashes from the sink in washing, it can spread bacteria. Clean the lids on canned goods before opening.

Based on observation, interview, and record review the facility failed to ensure that the resident medical records for two of six residents reviewed for wound care documentation (Resident #7 and Resident #21) were complete and accurately documented. 1. The facility failed to ensure that documentation of dressing changes provided to Resident #7 was accurate and completed on 06/09/2025, 06/11/2025, 06/13/2025, and 06/16/2025. 2. The facility failed to ensure that documentation of dressing changes provided to Resident #21 was accurate and completed on 06/18/2025 and 06/19/2025. This deficient practice could put the resident at risk of having inaccurate medical records and not receiving the ordered treatments and care. Findings: Review of Resident #7's Face sheet reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included: Schizoaffective Disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Vascular Dementia with anxiety (dementia related to blood flow to the brain that includes feelings of intense and excessive worry and fear), Pain, and Functional quadriplegia (inability to move all four limbs). Review of Resident #7's Significant Change MDS dated [DATE] reflected that the resident had a BIMS score of 14 (no cognitive impairment). Section M for Skin Condition reflected a 0 for M0210 (Unhealed Pressure Ulcers/Injuries), indicating that she did not have any unhealed pressure ulcers/injuries. The assessment was signed by RCMDS Q. Review of Resident #7's Care Plan reflected a Problem Area stating, Problem Start Date: 01/15/2025 Category: Pressure Ulcer/Injury [Resident#7] has a pressure ulcer to sacrum [skin above the triangular bone at the base of the spine]. Edited: 06/16/2025. There was a related Approach intervention stating, Provide treatment as ordered. Review of Resident #7's orders reflected an order for Wound Treatment Order: Location: mid-back/sacral area-Clean with Normal Saline/Wound Cleanser Apply: Collagen powder and cover with Primary Dressing: Border Gauze Secure with Tape Once a Day: Mon, Wed, Fri 06:00AM-06:00PM started on 06/18/2025. There was an order for, Wound Treatment Order: Location: mid back/sacral area Clean with Normal Saline/Wound Cleanser Apply: Collagen powder and hydrocolloid sheet Cover with Primary Dressing: Bordered gauze Secure with tape Once a day on Mon, Wed, Fri. with a start date of 04/02/2025 and a discontinue date of 06/18/2025. Review of Resident #7's Wound Evaluation and Management Summary dated 05/15/2025 reflected a stage 3 pressure wound to the resident's sacrum with a Duration as greater than 164 days. Review of Resident #7's TAR reflected there was no treatment recorded for Monday, 06/09/2025; the treatment recorded for Wednesday, 06/11/2025 was signed off on by LVN K; the treatment recorded for Friday, 06/13/2025 was signed off on by LVN M; and no treatment was recorded for Monday, 06/16/2025. The TAR reflected a Wound Treatment, Pain Evaluation to be done, Mon, Wed, Fri; Set Frequency to match Treatment Administration Order. The sign offs reflected the same dates and persons indicated for the 06/09/2025, 06/11/2025, and 06/13/2025 treatments. There was a sign off on Monday, 06/16/2025, from LVN K, indicating she assessed pain during wound care that day. In an interview on 06/17/2025 at 08:57AM with Resident #7, she stated that she was receiving dressing changes to a wound on her tailbone. She stated that the dressing was being changed by nurses. She denied any concerns. Observation of wound care with LVN M, CNA G, and CNA O for Resident #7 on 06/18/2025 at 10:30 AM revealed that the resident had a pressure wound to her sacrum with a diameter of approximately 0.2 cm and a depth of approximately 0.1 cm. The dressing removed from the patient revealed the date, 06/09/25 with the initials for LVN M. In an interview on 06/18/2025 at 03:00PM with LVN M, she stated that she did a full skin assessment on Resident #7 on 06/18/2025 and had not noticed the date on the dressing from Resident #7's sacral wound during the assessment or during wound care on 06/18/2025 was dated 06/09/25 with her initials. She stated that she always records the dressing changes on the TAR. She stated that she did sign off on the wound care for Resident #7 on 06/13/25. She stated, I thought I did the wound care that day, but I must not have done it. She stated that she should not have documented that the treatment was done if it was not done. She stated that not doing a dressing change as ordered could place the Resident #7 at risk for infection and worsening of the wound. Review of Resident #21's Face sheet revealed a [AGE] year-old, female admitted on [DATE]. Diagnoses included: Hydronephrosis (swelling of the kidneys from blockage of the flow of urine), Urinary Tract Infection, Chronic Kidney Disease, and Type 2 Diabetes (chronic disorder of abnormal blood sugar levels). Review of Resident #21's Quarterly MDS dated [DATE] reflected a BIMS score of 15 (no cognitive impairment). For Section H-Bowel and Bladder it reflected a 9 for Urinary Continence, indicating Not Rated, resident had a catheter (indwelling or condom), urinary ostomy, or no urine output for the entire 7 days. For Section M-Skin Conditions it was indicated that the Resident has a Surgical Wound with Surgical Wound Care. Review of Resident #21's Care Plan reflected a Problem Area indicating, Problem Start Date: 05/23/2023 Category: Indwelling Catheter has nephrostomy tube [a catheter placed into the kidney through an incision in the back to drain urine] in place d/t Chronic cystitis [inflammation of the bladder wall], Hydronephrosis [swelling of the kidneys from blockage of the flow of urine], CKD [chronic kidney disease], and obstructive uropathy [blockage of the urinary tract]. There was an Approach intervention reflecting, Care for tubes/drains: nephrostomy site care per order Created: 05/23/2023. Review of Resident #21's Orders reflected an order to, Clean nephrostomy site with NS and pat dry. Apply split bandage and secure with tape. Twice A Day Morning 07:00AM -10:00AM, Bedtime: 07:00PM-10:00PM with a start date of 04/09/2025. Review of Physician Progress Note for Resident #21 dated 06/16/2025 reflected a note stating, Resident is currently being treated for a UTI (urinary tract infection)-gentamycin 80 mg inj. Other chronic conditions stable at this time. Review of Resident #21's TAR reflected an order for, Clean nephrostomy site with NS and pat dry. Apply split bandage and secure with tape. Twice a Day. There were sign offs on the dressing changes for LVN M for 06/18/2025 and 06/19/2025 indicating that the dressing change was done. In an interview on 06/17/2025 at 10:45AM, Resident #21 stated that she had nephrostomy tubes to both kidneys. She stated that the staff monitored and cared for the tubing. She denied any concerns. In an interview on 06/18/2025 at 09:40 AM with LVN M, she stated that she had not done a dressing change on Resident #21 on 06/18/2025. Observation on 06/18/2025 at 10:10AM of Resident #21 revealed that there was no dressing to either nephrostomy site. They were open to air. No redness or drainage was noted to the insertion sites for the nephrostomy tubes. In an interview with Resident #21 on 06/18/2025 at 10:10AM, she stated that the staff check the site every day, but they do not change a dressing to the site. She stated, they just put cream on my back. Observation on 06/19/2025 at 01:15PM revealed that there was no dressing to either nephrostomy site. They were open to air. No redness or drainage was noted to the insertion sites for the nephrostomy tubes. In an interview with Resident #21 on 06/19/2025 at 01:15PM, she stated all they have done is put some lotion on her back. She denied having any dressing added or changed to the nephrostomy sites. In an interview on 06/19/2025 at 11:53AM, the DON stated that she did a skin assessment on Resident #21 that morning prior to surveyor arrival at 08:00AM. She stated that she noted that there was not a dressing to the nephrostomy sites and she instructed the LVN M to do the do the dressing change and ensure there was a dressing to the nephrostomy sites for Resident #21. In an interview with LVN M on 06/19/2025 at 01:58PM, she stated that the initials charted for 06/18/2025 and 06/19/2025 for the dressing change to the nephrostomy sites for Resident #21 were hers. She stated that she intended to do the dressing change on 06/19/2025, but had not had time to do it yet. She stated that she should not have documented that the dressing changes were done if they were not yet done. She stated that the resident has had the nephrostomy since she was admitted . In an interview on 06/19/2025 at 03:37PM with the DON, she stated that it is her expectation that if staff document something, that it should be done. She stated that if staff are unable to finish a scheduled task on their shift that it should be passed on to the next shift, to herself, or the ADON, so that it can be completed. She stated the impact to the resident of not documenting care accurately is that the resident may not have received the care that was ordered and could contribute to the worsening of the wound. Attempted an interview with LVN K on 06/19/2025 at 04:53PM. No call was returned prior to exit. In an interview with the ADM on 06/19/2025 at 06:30PM, he stated that he expected that dressing changes be performed per the physician orders and per policy and that documentation should be accurate in the medical record. Review of facility policy dated April 2024 for Pressure Injury/Skin Breakdown Clinical Protocol reflected, Assessment and Recognition The licensed nurse or MD/NP/PA will assess and document an individual's significant risk factors for developing pressure injuries; for example, immobility, recent weight loss, and a history of pressure injury(s). 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure injury including location, stage, length, width and depth, presence of exudates [drainage from a wound or other lesion] or necrotic tissue [dead or dying cells and tissue]; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses which may contribute to pressure injury/skin break down. Review of facility policy dated October 2010 for Nephrostomy Tube- Care of reflected, Documentation The following information should be recorded in the resident's medical record. 1. The date and time the procedure was performed. 2. Name and title of the person(s) who performed the procedure. 3. The resident's response to the procedure.

Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pests. 1.The facility failed to ensure the facility was free of gnats, and 2 roaches throughout the facility including resident rooms and resident restrooms 2. The facility failed to ensure the facility was free of bedbugs for Resident # 9. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life. The findings included: Record review of Resident # 9's admission face sheet dated 6/18/25 reflected a [AGE] year old female admitted on [DATE] and readmitted on [DATE] with diagnoses of unspecified dementia (a group of thinking and social symptoms that interferes with daily functioning), anxiety (intense, excessive, and persistent worry and fear about everyday situations), abnormalities of gait and mobility, low back pain, depression (a group of conditions associated with the lowering of a person's mood), restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs), chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), fibromyalgia (a long term condition that involves widespread body pain and tiredness), chronic kidney disease (longstanding disease of the kidneys leading to renal failure), insomnia (difficulty falling and staying asleep), and hypotension (low blood pressure). Review of Resident # 9's Quarterly MDS dated [DATE] reflected a BIMS score of 11 indicating moderate cognitive impairment. Resident # 9 required set up or clean up assistance with eating, oral hygiene, personal hygiene, transfers, and toileting. Resident # 9 required supervision or touching assistance for dressing and bathing. Review of Resident # 9's care plan dated 5/10/25 reflected behavioral symptoms of hoarding items which makes it difficult to maintain a safe and tidy living space with interventions of monitor items collected and brought into facility from community outings. Redirect and educate on putting clothing items away into their proper spaces. To perform room rounding interventions and notification of appropriate department to maintain safe tidy living spaces. Review of Resident # 9's Nursing progress note dated 6/17/25 at 10:46 PM reflected observation of resident bible at nurse station counter with bed bugs crawling out of bible. Nurse and CNA inspected Resident # 9 room for more bed bugs. Additional bed bugs discovered in Resident # 9 purse and bed linens. All linen, clothing, and cloth items were bagged up to be washed in hot water. Skin assessment completed for Resident # 9 with small red area to shoulders and bilateral upper extremity. Appears to have been scratched hydrocortisone cream applied. Staff educated on managing and preventing infestation. Attempt made 3x to notify resident family member and educate on prevention/managing infestations as well. Pest control called to come exterminate. MD and DON notified. Hydrocortisone cream applied to bug bites for itching if needed. Also, complete skin assessment every shift X 3 day. Observation on 6/17/25 at 10:46 AM revealed a half-eaten sandwich unwrapped sitting on the overbed table in room [ROOM NUMBER]A. Further observation at 11:29 AM revealed a half-eaten sandwich still sitting unwrapped on the overbed table in room [ROOM NUMBER]A now with 2 gnats on it and circling around it. Skin observation on 6/17/25 at 11:45 AM of Resident # 9 by nurse surveyor in presence of CNA D who assisted resident in undressing. The clusters of red raised bumps were observed on the left shoulder and middle back and left leg with some skin break down due to skin itching and resident scratching those areas. Per CNA D the resident received a shower last night and the resident was moved to another room. Observation on 6/18/25 at 12:05 PM revealed 2 different roaches crawling across the floor of room [ROOM NUMBER]A in the secure unit. Observation on 6/19/25 at 3:47 PM revealed gnats on resident's bed linen in the secure unit room [ROOM NUMBER]A. In an interview on 6/18/25 at 10:26 AM the ADM stated he was aware of Resident # 9's room being found to have bed bugs. The ADM stated all of Resident # 9's belongings were bagged and taken to housekeeping for cleaning. The ADM stated the exterminator was called to come out and that the MS had completed the bed bug pre-treatment protocol and that the DON had been notified. In an interview on 6/18/25 at 10:33 AM the DON stated she had been made aware of Resident # 9's room having bed bugs. The DON stated the following steps occurred: all the resident belongings were bagged and sent to laundry, skin assessment was completed on the resident, the resident was showered and given new clothes, the resident was moved rooms, pest control was called, the room was fumigated and sealed for 48 hours, the resident's family member was notified and educated, staff education was started and is still ongoing. The DON stated the facility followed their policy and she did not feel anything different could have been done. In an interview on 6/18/25 at 10:42 AM the MS stated he was notified about the bed bugs on 6/17/25 late in the evening. The MS stated the next morning he came and prepared the room for the exterminator to come. The MS stated he inspected the common areas and surrounding rooms and did not find any bed bugs in these areas. The MS stated pest control was contacted around 8:00 am on 6/18/25 and came to the facility at 9:00 am and treated the room. The MS stated he would be monitoring the affected room and the surrounding areas. In an interview on 6/19/25 at 2:28 PM LVN M stated she had observed pests around the building. LVN M stated she has documented these sightings in the pest control log and communicated her concerns to the ADM to ensure appropriate action was taken. In an interview on 6/19/25 at 2:30 PM the MS stated pest control services are conducted once a month at the facility by the pest control company the facility is contracted with. The MS emphasized the importance of proper pest control management, noting that inadequate handling could potentially lead to infections within the facility. The MS confirmed that he had received training related to pest control and understood the protocols necessary for maintaining a safe environment. The MS stated he would schedule follow up training sessions to reinforce protocols related to both pest management and safety reporting. In an interview on 6/19/25 at 3:22 PM the ADM stated that staff are frequently in-serviced on pest control. The ADM stated the staff should report any pest issues to him, the DON, and MS and put it in the pest control logbook as well as inform housekeeping. The ADM stated a possible negative outcome of pests in the building could be anywhere from nothing to injury, widespread infestation, or requiring medical interventions. The ADM stated he is aware of a recent pest control issue that bed bugs were located within the facility this week. The ADM stated he believes the facility handled the situation properly and that the bed bugs came from the outside community. In an interview on 6/19/25 at 3:30 PM the DON stated she was aware of the recent bed bug issue within the building and is actively implementing the necessary precautions to inform residents and ensure their safety. The DON stated she understood the benefits of a proactive measures regarding pest management. Record review of facility Pest Control policy undated reflected policy statement: Our facility shall maintain an effective pest control program. Under policy Interpretation and Implementation: 1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. 2. Pest control services are provided by contracted company. 3. Windows are always screened. 4. Only approved Food and Drug Administration and Environmental Protection Agency insecticides and rodenticides are permitted in the facility and all such supplies are stored in the areas away from food storage area. 5. Garbage and trash are not permitted to accumulate and are removed from the facility daily. 6. Maintenance services assist, when appropriate and necessary, in providing pest control services. Record review of Bed Bugs, Preventing and Managing Infestations of undated reflected under heading purpose: Staff will employ infection control strategies to prevent and manage infestation of bed bugs. Under heading preparation: Staff should be trained to recognize bed bugs and bed bug infestations and know what their specific roles will be should an infestation occur. Under heading Monitoring and Inspection: 1. Maintain vigilance if there is an outbreak reported in the geographic region. 2. Thoroughly screen newly admitted residents, as well as those returning from a stay away from the facility. a. Assess skin for papules (small raised tender bump on the skin), vesicles (small blisters on the skin), wheals (a raised often itchy, swelling on the skin), or bullae (an area of skin covered by a raised fluid filled bubble). b. Ask the resident if they have been exposed to bed bugs or have experienced pruritus (itching). c. Check medication orders for any medication used to treat pruritic rash. 3. Remain alert to complaints of pruritus. Pay particular attention to unusual development in skin appearances in any resident. 4. Regularly inspect mattresses, box springs, bed frames and headboards following current published guidelines for inspection and identification. Under heading Treatment: 1. Effective treatment included the following components: a. Staff and resident education b. Recordkeeping and reporting c. Pre-treatment d. Treatment of resident symptoms e. Treatment of infestation f. Evaluation of treatment effectiveness and continued monitoring Record review of pest control log reflected roaches had been documented being seen 20 times throughout the facility since January of 2025, nonspecific bugs had been sighted 2 times in April 2025, bug bites had been sighted on resident in room [ROOM NUMBER] in June 2025, flies and gnats had been sighted 2 times once in February 2025 and once in March 2025. Further review reflected pest control company documented regular monthly service calls on 1/2/25, 2/7/25, 3/6/25, 4/3/25, 5/2/25, and 6/18/25. Follow up service completed 6/12/25 no further follow up services documented from any of the insect sightings. Record review of pest control service contract reflected services performed were to be perform monthly pest control service including coordinating with client's staff to implement an integrated pest management plan, monitor and track pest issues inside and outside of facility, addressing site issues both reported and observed, recording actions taken and observations to staff to be kept on record. Pest control each month consists of inspecting and treating exterior pest issues including all exits, potential entry points, and grounds. Inspecting and treating interior pest issues including kitchen, laundry, exits, and closets. Monitoring and maintain any equipment used to bait and or eliminate pests inside and outside. When requested treat specific areas that are experiencing a particular problem, which may include the removal of persons in affected area for varying time periods. Providing suggestions and advice to the staff that would help alleviate any existing pest issues and prevent future issues. Pest included in the agreement are roaches, bed bugs, spiders, scorpions, crickets, silverfish, beetles, rodents, flies, gnats, fruit flies, wasps, bees, ants, and termites.

Based on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 residents (Resident #1 and Resident #2) of 28 residents observed for a clean environment. The facility failed to ensure Resident #1 and Resident #2 had a homelike environment . These deficient practices could place residents at risk of a decreased quality of life. Findings included: Observations on 06/17/25 at 10:19 a.m., in Resident #1's room. Resident #1 was not in the room at the time. There were several pieces of trash on the floor. The bed sheets were dirty with several stains. It appeared the sheets had not been changed in several days. The bathroom had several pieces of trash on the floor. The toilet had fecal stains on the seat. The toilet appeared not to have been cleaned in a while. Observations on 06/17/25 at 10:19 a.m., in Resident #2's room. The armoire in the room looked old, with paint peeling off and holes in it. Resident #2 said it has been like that for a while. Resident #2 said he has not asked for anyone to replace it. Observations on 06/17/25 at 1:58 a.m ., in Resident #1's room. Resident #1 was in the room, lying in bed. The room and the bathroom had been cleaned. The sheets on the bed had not been changed. Resident #1 said he cannot depend on the staff at the facility . Resident #1 said he did not want to talk anymore because he was going to sleep. In an interview on 6/19/2025 at 1:42 p.m., the HK said rooms are cleaned once a day. The HK said if the room needs to be cleaned more, she will do it. The HK stated Resident #1 is difficult and does not let people clean his room. The HK said she cleans the room when he is not in there. The HK said if a room is not cleaned, it will be unsanitary for the residents. In an interview on 6/19/2025 at 1:52 p.m., MA A stated rooms are cleaned once a day. MA A said if there is a spill, she will clean it up. MA A said if it's a bigger spill, she will get housekeeping to clean up the mess. CNA said sheets are changed on shower days. MA A feels there is enough staff to keep the residents' room cleaned. In an interview on 6/19/2025 at 2:03 PM, MA B stated that if a room is dirty, she tells housekeeping. MA B said housekeeping is fast cleaning rooms when there is a mess. MA B stated that Resident #1 can be difficult when it's time to get his room cleaned. MA B said Resident #1 gets his room cleaned when he is not in the room. CNA said sheets are changed on shower days . MA B feels there are enough staff to keep the rooms cleaned. MA B said Resident #1's room is cleaned when he is not in there. In an interview on 6/19/2025 at 2:10 p.m., CNA F stated that if she sees a dirty room, she will call for housekeeping, so they can clean it up. She stated if it is a small spill then she will clean it up. She said sheets are changed on shower days. She stated that when a room is not clean, it is not sanitary for the resident. She said Resident #1's room is cleaned when he is not in the room. In an interview on 6/19/2025 at 3:18 p.m., the ADM said staff have a difficult time getting Resident #1's room cleaned and the sheets changed because of his behavior. The ADM stated that Resident #1's room sheets are changed when he is not in the room. The ADM said it happens when Resident #1 is outside smoking. The ADM did not know why Resident #1's room was not being cleaned when Resident #1 was not in the room. The ADM said residents' sheets are changed on shower days. In an interview on 6/19/2025 at 4:18 p.m., the DON said residents' rooms are cleaned daily and sheets are changed when a resident takes their shower. The DON said that Resident #1 can be difficult when staff go in there to change his sheets or clean his room. Resident #1 will often curse and yell at the staff who come in and try to help him. Resident #1 usually gets his sheets changed and his room cleaned when he goes out to smoke cigarettes. The DON said Resident #1's room should have been cleaned if the resident was not in the room at the time. Record Review of the facility's Policy Statement , Residents are provided with a safe, clean, comfortable, and homelike environment and encouraged to use their personal belongings to the extent possible. Policy Interpretation and Implementation 1. Staff provides person-centered care that emphasizes the residents' comfort, independence and personal needs and preferences. Needs and preferences. 2. The facility staff and management maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. clean, sanitary and orderly environment. e. clean bed and bath linens that are in good condition.

Based on observation, interviews, and record reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 28 residents . The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen, so the resident's information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life. Findings included: Observation on 6/16/2025 at 12:05 PM during lunch service revealed that the tablet on the medication cart was open and the screen had the resident's information on the laptop screen. The surveyor was watching lunch service and walked around the corner, and the laptop was open. The surveyor waited five minutes, and the staff member did not return to the medication cart. The laptop screen timed out, and the screen went dark after five minutes. In an interview on 6/19/2025 at 1:53 p.m., MA A stated you cannot leave the laptop screen open with residents' information on it. MA A stated this is a HIPAA violation. MA A stated anyone walking by would be able to see the residents' medical information if the laptop were open. MA A said she has not seen any co-workers leaving their laptops open with resident information on the screen. MA A stated if she sees a laptop open showing resident information, then she closes the laptop and reminds the person they need to close the laptop. MA A said she has been in-serviced on resident rights and privacy. In an interview on 6/19/2025 at 2:03 p.m., MA B stated she is aware of the facility's policy on resident rights and privacy. MA B said when you walk away from the cart, you need to lock the laptop screen so that residents' information is not showing. MA B said if a resident's information is showing, then anyone would be able to get the resident's medical records. MA B said if she sees a lap open, she will close it and let the person know that it was open. MA B said she has not seen anyone leave their laptop open with resident information showing. MA B said if she saw an open tablet, then she would close it and remind the worker that they cannot leave the laptop open so anyone can see. MA B said it is a violation of HIPAA and resident rights to leave resident information visible for people walking by to see. In an interview on 6/19/2025 at 3:18 p.m., the ADM stated staff are trained on HIPAA laws. The ADM stated when staff walk away from the medication cart the laptop screen should be locked or minimized. He stated if the screen is left open then someone passing by could get the resident's information. The ADM said he has never seen any staff leave the laptop open with the resident's information on the screen. The ADM said that if staff leave the laptop opened, then he would shut it, talk to the staff. The whole facility would be inserviced on resident rights and privacy. In an interview on 6/19/2025 at 4:18 p.m., with DON said that staff should not walk away from the medication cart with the laptop open that has a resident's information on it. Staff are in serviced on HIPAA law and residents' privacy rights. The DON said that she has not seen any staff leave the laptops open with residents' info on the laptop. The DON stated that if she sees an open laptop then she would close it and talk to the staff member. The DON stated that she would do Inservice. Review of the Job description (undated) revealed staff were to follow their Job Description - Understand, comply with, and promote all rules regarding residents' rights.

Based on interviews, and record review the facility failed to ensure the resident assessments accurately reflected the resident's status for 2 (Resident # 10 and Resident #7) of 8 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #10's Significant Change MDS assessment, dated 12/31/2024, completed Resident #10's preferences for customary routine and activities. 2. The facility failed to ensure that Resident #7's Significant Change in Status MDS assessment on 05/21/2025 accurately reflected that she had an unhealed pressure ulcer at the time of the assessment. This deficient practice could have placed the residents at risk for inadequate care and diminish quality of life due to inaccurate assessments. Findings included: 1. Review of Resident #10's Face Sheet, dated 06/18/2025, reflected a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with the diagnoses unspecified dementia, unspecified severity, with agitation ( a group of symptoms affecting memory, thinking, and social abilities- its exact severity not determined- with state of restlessness), cognitive communication deficit ( memory loss and trouble concentrating, completing tasks, understanding, remembering, following instructions, and solving problems), and reduced mobility ( limitation in a person's ability to move around independently, due to physical disabilities, age, or other factors). Review of Resident #10's Significant Change MDS, dated [DATE], reflected Resident #10 had a BIMS score of a 2 indicating her cognition was severely impaired. Resident #10's staff assessment for activity preference had dashes. (Section F of the MDS indicated section F was not completed). It was certified by the RRN. Review of Resident #10's Comprehensive Care Plan, dated 04/10/2025, reflected Resident #10 was not at ease in joining other residents in activities. Resident #10 will yell and hit the table during group activities. Intervention: Activity Director will provide 1:1 activity session as needed. Place resident in position of almost certain success in an activity. Encourage resident to verbalize feelings and fears. Review of Resident #10's electronic medical record on 06/16/2025 reflected activity staff did not assess Resident #10's activity preferences for the MDS Assessment, dated 12/31/2024. Interview on 06/19/2025 at 8:00 AM requested the RRN's phone number from the Director of Nurses and it was not provided at time of exit. In an interview on 06/19/2025 at 8:30 AM The Activity Director stated she did not complete section F staff assessment (Activity Preferences of Resident #10). She stated Resident #10 was not interview able. She stated Resident #10 did not have family; however, she had a caregiver. The Activity Director stated she did not contact the care giver to obtain information about Resident #1's activity preferences. She stated she forgot to complete the staff assessment of Resident #10's activity preferences on the significant change MDS section, dated 12/31/2024. The Activity Director stated Resident #10's activity preferences were not documented anywhere in the electronic medical record. In an interview on 06/19/2025 at 9:27 AM The Regional MDS Consultant P stated she was responsible for monitoring MDS. She stated if there were dashes on the MDS, this indicated the MDS was not a completed assessment. The Regional MDS Consultant stated the Activity Director was expected to complete section F (Activity Preferences) of the significant change MDS of Resident #10. She stated if the resident was not capable of answering the questions, the Activity Director was required to answer the staff assessment. She stated it was very important for all sections of the MDS to be completed. The Regional MDS Consultant stated the care plan would be difficult to develop if a resident was not assessed on the MDS. In an interview on 06/19/2025 at 12:57 PM The Director of Nurses stated all sections of the MDS were expected to be completed by the appropriate staff. She stated all information was obtained prior to completing the MDS. The DON stated the Activity Director was expected to contact anyone with information on Resident #10 including the care giver. She also stated the staff also could have been interviewed to obtain information when the staff interacted with Resident #10. The DON stated Resident #10 enjoyed drinking coffee and talking to staff. She stated she had observed Resident #10 enjoying music in the common area and in her room. The Director of Nurses stated Resident #10 did not enjoy group activities and did respond more to one-on-one activities. She stated if the MDS assessment was not completely documented, there was a potential the resident's care plan may not be accurate and the resident's quality of life and quality of care may diminish. In an interview on 06/19/2025 at 1:30 PM requested the RRN's phone number from the Director of Nurses and it was not provided at time of exit. Review of Resident #7's Face sheet reflected a [AGE] year-old, female admitted to the facility on [DATE]. Diagnoses included: Schizoaffective Disorder, bipolar type (a mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), Vascular Dementia with anxiety (dementia related to blood flow to the brain that includes feelings of intense and excessive worry and fear), Pain, and Functional quadriplegia (inability to move all four limbs). Review of Resident #7's Significant Change MDS dated [DATE] reflected that the resident had a BIMS score of 14 (no cognitive impairment). Section M for Skin Condition reflected a 0 for M0210 (Unhealed Pressure Ulcers/Injuries), indicating that she did not have any unhealed pressure ulcers/injuries. The assessment was signed by RCMDS Q. Review of Resident #7's orders reflected an order for Wound Treatment Order: Location: mid-back/sacral area [region of skin between the mid-back and the bottom of the spine]-Clean with Normal Saline/Wound Cleanser Apply: Collagen powder and cover with Primary Dressing: Border Gauze Secure with Tape Once a Day: Mon, Wed, Fri 06:00AM-06:00PM started on 04/02/2025. Review of Resident #7's Wound Evaluation and Management Summary from Wound Care Physician dated 05/15/2025 reflected a stage 3 pressure wound to the resident's sacrum with a Duration as greater than 164 days. Review of Resident #7's Care Plan reflected a Problem Area stating, Problem Start Date: 01/15/2025 Category: Pressure Ulcer/Injury Resident #7 has a pressure ulcer to sacrum. Edited: 06/16/2025. There was a related Approach intervention stating, Provide treatment as ordered. Observation of wound care with LVN M, CNA G, and CNA H for Resident #7 on 06/18/2025 at 10:30 AM revealed that the resident had a pressure wound to her sacrum with a diameter of approximately 0.2 cm and a depth of approximately 0.1 cm. In an interview with RCMDS P on 06/19/2025 at 06:20 PM, she stated that the significant change MDS dated [DATE] stated that Resident #7 was coded as having no pressure ulcers. She stated that she was responsible for overseeing the MDS assessments for the building. She stated that she does quarterly score cards with a random audit of residents in the facility to review for accuracy and timeliness. She stated that she had not audited Resident #7. She stated that the resident had wound care notes from the wound doctor at the time of the assessment stating that the resident had a pressure ulcer. She stated coding her as having no pressure ulcers was an error. She stated that the impact to the resident was that it could affect the care planning process and possibly the wound management or payment depending on the wound type. In an interview on 06/19/2025 at 06:30 PM with the ADM and DON, they both stated that they expected the MDS assessments to be accurate. They stated that the person responsible for the MDS assessments in May 2025 was RCMDS P. They stated that she was responsible for the oversight in the absence of a full time MDS staff. He stated that there was no impact to the resident regarding the MDS error because the supplies are paid for by Hospice services, not the reimbursements from the MDS. Review of a staff roster from 06/17/2025 reflected that RCMDS Q was not a current staff member for the facility. Review of the Facility's Policy on Certifying Accuracy of the Resident Assessment, dated November 2019, reflected Any person completing a portion of the Minimum Data Set/ MDS (Resident Assessment Instrument) must sign and certify the accuracy of that portion of the assessment. Any health care professional who participates in the assessment process is qualified to assess the medical, functional and/or psychosocial status of the resident that is relevant to the professional's qualifications and knowledge. Any person who completes any portion of the MDS assessment, tracking form, or correction request form is required to sign the assessment certifying the accuracy of that portion of that assessment. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Each assessment is coordinated and certified as complete by the Resident Assessment Coordinator, who is a registered nurse.

Based on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 46, and Resident #59) reviewed for ADL care. The facility failed to ensure Resident #46's and Resident # 59's nails were cleaned, and did not have any rough edges. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem. Findings included: Review of Resident #46's face sheet, dated, 06/18/2025, reflected a [AGE] year-old male who was admitted on [DATE]. Resident #46 had diagnoses which included need for assistance with personal care ( helping individuals with activities of daily living like bathing, dressing, toileting, grooming, and eating), personal history of traumatic brain injury (occurs when external force impacts the head, causing damage to the brain), presbyopia (gradual loss of the ability to focus on nearby objects), and seizures ( a sudden, temporary surge in the brain that can cause changes in behavior, movement, awareness, or sensation). Review of Resident #46's Quarterly MDS, dated [DATE], reflected the resident had a BIMS score of 9, which indicated his cognition was moderately impaired. Resident #46 required partial/moderate assistance (helper does less than half the effort) with personal hygiene, lower body dressing, transfers, bed mobility, and toileting hygiene. He was dependent on staff for showers. Review of Resident #46's Comprehensive Care Plan, with revision date of 06/07/2025 reflected Resident # 46 required one staff assistance with bathing, dressing, grooming and hygiene. Observation and interview on 06/17/2025 at 8:45 AM, revealed Resident #46 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle and ring fingernails on his right hand. Resident #46's middle fingernail on his right hand was uneven around the edges. Resident #46 did not respond to questions or conversation about his nails. Resident #46 stated yes when asked if he requested for his nails to be cleaned or trimmed. He did not elaborate on who or when he asked for assistance with his fingernails. Review of Resident # 59's face sheet, dated 06/18/2025, reflected a [AGE] year-old male admitted on [DATE] with diagnoses which included need for assistance with personal care ( providing support for individuals who need help with personal hygiene, dressing, or toileting, etc.), depression, unspecified (a mood disorder that causes a persistent feeling of sadness and loss of interest), and scoliosis ( a condition where the spine curves sideways, forming an S or C shape, rather than a straight line- can lead to back pain and difficulty with breathing). Review of Resident #59's Quarterly MDS Assessment, dated 06/09/2025, reflected Resident #59 had a BIMS score of 14 indicating his cognitive status was intact. Resident #59 was dependent on staff for eating, oral hygiene, toileting hygiene, dressing, personal hygiene, transfers, bed mobility and showers. Review of Resident #59's Comprehensive Care Plan, dated 06/09/2025 reflected Resident #59 required assistance with all ADLs to include: transfers, feeding, dressing, bathing, and toileting, etc. Observation and interview on 6/17/2025 at 8:45 AM, revealed Resident #59 was in his room lying in bed. He had a blackish/ brownish substance underneath the middle ring and fore fingernails on his right hand. Resident #59's ring and middle fingernail on his right hand were uneven around the edges. He stated on Saturday (06/14/2025) he asked a nurse if she would clean his nails. Resident #59 did not recall the nurse's name and the nurse stated his nails would be cleaned and trimmed on Sunday (06/15/2025). He stated he was going to ask someone this week to clean and trim his nails. In an interview on 06/19/2025 at 9:00 AM, LVN L stated the nurses were responsible for residents with diagnosis of diabetes with nail care such as trimming, cleaning, filing. She stated the CNAs were responsible for all other residents' nail care. LVN L stated if a resident had brownish/blackish substance underneath their nails and if a resident swallowed the substance there was a possibility a resident may become ill such as stomach problems nausea and vomiting. LVN L stated if a resident refused any type of care, the nurse would document the refusal in the nurse's notes. She stated Resident #59 and Resident #46 did not refuse care. She stated no one had reported to her Resident #46 or Resident #59 refused nail care. LVN L stated she had worked with Resident #46 and Resident #59 for several weeks. She stated she had been in- serviced on nail care, however, she did not recall the date. In an interview on 06/19/2025 at 9:20 AM, CNA E stated the CNAs were responsible for cleaning, trimming, and filing all residents' nails except for the residents with a diagnosis of diabetes. He stated the nurses were responsible for all the residents' nails with a diagnosis of diabetes. CNA E stated the residents' nails were usually cleaned on Sundays, their shower days and as needed. He stated if there was a blackish substance on the residents' fingertips or underneath their nails and the resident swallowed the blackish substance there was a possibility a resident may become ill such as vomiting and diarrhea. He stated a resident may cause a skin tear if their fingernails were not smooth. CNA E stated he was in-serviced on cleaning, filing, and trimming residents' nails but he did not recall the date. He stated he had given care to Resident # 59 and Resident #46, and they did not refuse nail care. CNA E stated he did not know the last time these residents' nails were trimmed or cleaned. He stated if any resident refused care it was reported to the nurse and the nurse would document the refusal in the nurses note. He stated he was in-serviced on nail care. CNA E stated he did not recall the date of the nail care in-service. In an interview on 06/19/25 at 10:30 AM, CNA C stated the nurses, and the CNAs were responsible for nail care. She stated the nurses were responsible to trim and clean all resident's nails with a diagnosis of diabetes. She stated it was the CNAs' responsibility to clean and trim all other residents' nails during showers or as needed. She stated if there was a blackish substance underneath the resident's nails, there was a possibility the substance had bacteria. CNA C stated if a resident swallowed the bacteria there was a possibility a resident may become ill with stomach problems such as vomiting. CNA C stated she was in-serviced on nail care; however, she did not recall the date. She stated she had given care to Resident #59 and Resident #46. She stated she was not aware of Resident #59 or Resident #46 refusing nail care. In an interview on 06/19/25 at 09:36 AM, the Director of Nurses stated if a resident ingested the blackish substance on their fingers or underneath their fingernails, there was a possibility the substance may be some type of bacteria, however it would be difficult to determine if the blackish/ brownish substance was bacteria. She stated it was a possibility a resident may become ill with stomach issues such as vomiting and diarrhea if they ingested the blackish/ brownish substance. She stated the CNAs were responsible for all residents' nails such as cleaning, trimming, and filing except for the residents with diabetes (a disease that occurs when your blood sugar, is too high) . She stated for any resident with a diagnosis of diabetes the nurse was responsible for these residents' fingernails. The Director of Nurses stated the nurse supervisor was responsible for monitoring CNAs giving ADL care including nail care and she was responsible for monitoring the nurse supervisors. Review of the Facility's Policy on Activities of Daily Living, dated 03/2018, reflected Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Interventions to improve or minimize a resident's functional abilities will be in accordance with the resident's assessed needs, preferences, stated goals and recognized standards of practice. The resident's response to interventions will be monitored, evaluated, and revised as appropriate.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for general sanitation. 1. The facility failed to ensure that wastewater from the toilet in the kitchen bathroom did not leak into the kitchen. 2. The facility failed to ensure that a bucket of waste material in the facility kitchen was disposed of properly. 3. The facility failed to ensure that the area around the ice machine was free of wastewater. An IJ was identified on 09/21/23. The IJ template was provided to the facility on [DATE] at 05:25 PM. While the IJ was removed on 09/23/23, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because of the facility's need to continue staff training, disinfection, and monitoring for signs/symptoms of food borne illness. These failures placed residents at risk of food borne illness. Findings included: Review of the maintenance log from June 2023 to September 2023 reflected an empty binder. Review of invoices from the plumbing company reflected the following: 09/08/23 camera drain line at back right of kitchen, unclogged line, pipe is cracked causing toilet itself is clogged, has something lodged inside recommend replacing toilet (diagnosis of toilet issue). 09/12/23-It was determined that the tubular on the 3-comp sink in the kitchen was broken and leaking, reworked the tubular to stop the leaking underneath the middle comp and the comp to the right of the middle. 09/21/23 Replaced toilet in kitchen restroom with new water supply line and wall gasket. During an interview on 09/21/23 at 02:08 PM, CK A stated the toilet had been leaking in the kitchen's bathroom for weeks. She stated the water had come out and into the main part of the kitchen from under the bathroom door, and the toilet did not work in the bathroom, so she had heard staff had been urinating in a five-gallon bucket. She denied any further knowledge of the circumstances, how they had become that way, or who she had spoken to about it. When asked if it had been reported to administration or maintenance, she stated they all knew but did not elaborate. Observation on 09/21/23 at 02:15 PM revealed a closet with an open door six feet down a vestibule toward the back door. At the threshold of the door were two towels rolled up, damp, with black/grey stains on the top of them. There were patches of damp, standing water on the outside of the towels from the Within the closet was a handwashing sink and toilet as well as shelves of chemicals and cleaning supplies. The floor was damp and dirty with patches of standing water and areas where the standing water was black in color. The walls, floors, and sink were extremely dirty with thick black substance stuck in many of the corners and crevices. The toilet was very clean and looked brand new. There was a five-gallon bucket under the handwashing sink a third of the way full of brown liquid, saturated paper, and clumps of brown solid floating inside it. During observation and interview on 09/21/23 at 02:26 PM, the MAINT and the RMAINT looked into the five-gallon bucket and stated they could not be sure what was in the bucket, but it did look like it might be human waste. Both of them stated they had not been in the bathroom, had no idea this was in there, and denied that it had been reported to them. They stated there had been plumbing work done in the bathroom that morning, because the toilet had been broken and overflowing for quite some time, and the plumber had replaced the toilet. The MAINT asked the RMAINT if the plumber might have left the bucket into the bathroom, and the RMAINT stated he did not believe that was possible. During observation and interview on 09/21/23 at 02:28 AM, the ADON leaned closer to the content of the five-gallon bucket and stated it smelled terrible. When getting closer to the bucket, the odor was not strong but was similar to the smell of a portable or vault toilet (such as one used on a construction site). The ADON stated she was not aware of any leaking from the toilet as no one had spoken to her about it. She stated she was new at the facility and had only been there a month. She stated the bathroom was disgusting, and it worried her that it was in the kitchen of the facility. Observation on 09/21/23 at 03:15 PM revealed a pool of standing water around the ice machine in the facility dining room. Water drip stains covered the sides of the machine. The standing water contained dirt and trash, including wet tissue paper. The inside of the ice machine was clean. Facility staff were observed retrieving ice from the machine and serving it to residents on the halls. On 09/2/23 at 05:20 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided. During an interview on 09/22/23 at 12:48 pm, CK B stated he had been working in the kitchen during this episode of his employment only for a couple of weeks. He stated it was his understanding that the toilet had been broken for a year. He stated he had never seen it leak, but he had seen standing water in there. He stated he had only been in the bathroom twice to retrieve chemicals and supplies. CK B stated the way it was once somebody went in that bathroom; they did not want to go back. He stated it was filthy and the toilet was backed up and clogged up. He stated the toilet did not have anything except water in it, but the water was all the way up to the top, and it could not be utilized. CK B stated he saw the five-gallon bucket, and he did not look in it. He stated he had thought there was just water in the bucket. CK B stated everybody in the kitchen knew how bad the bathroom was. He stated he had not spoken to the ADM about anything. CK B stated he had a hand in cleaning the kitchen, such as washing pots and pans and cleaning off equipment. He stated he had told them they would get shut down for the conditions in the kitchen bathroom. He stated the problems remaining in the kitchen made no sense to him. CK B stated he had received training on the computer about kitchen sanitation when he first started. He stated he had worked in food service for a long time and knew the regulations. During an interview on 09/22/23 at 01:18 pm, the MAINT stated he had started the position the Monday prior, on 09/18/23. He stated he had not been into the bathroom to look at it but was told about the problem of the toilet not working and being clogged, and he got permission to get it fixed. The MAINT stated the problem with the toilet was there was something stuck in it. He stated what he was told was the toilet was clogged and overflowed. He stated when this happened the first time, he went in, cleaned up the water spill, and sanitized the bathroom. The MAINT stated that was before he took his current position, but he was the floor technician before that, so it was within his job description to clean the floors. He stated that occurred around a week ago. The MAINT stated he did not know if anyone used the bathroom again and overflowed it after that. He stated they told them to not use the bathroom until the toilet was fixed. When asked who they was, he said it was thee RMAINT and the ADM. He stated he spoke with the assistant dietary manager and notified her not to use the toilet. The MAINT stated he did notice the towels when he observed the bathroom the day before on 09/21/23 and did notice they were damp. He stated he thought the towels had been placed there to stop water from the toilet from seeping out. He stated he did not know if the kitchen staff had placed them there or the plumber. The MAINT stated the facility had just had the plumber in the kitchen to fix a leak in the pipe under the dishwasher and just before that a leak in the pot-washing skin. The MAINT stated there were so many leaks in the kitchen that it was hard to know what was, what. The MAINT stated he had not been in the kitchen or the kitchen bathroom after the plumber came in to replace the toilet, so he had not seen the state of the bathroom until the surveyor asked him to come view it. The MAINT stated education will be part of his role, and he will train staff to use the maintenance log and to communicate with him if things are not working. The MAINT stated the ice machine had a leak, and they had it repaired last night on 09/21/23. He stated the standing water around the ice was most likely water that drained off from a leak from the drainage tube and didn't flow into the drain under the machine. The MAINT stated the ADM was aware of the leaking ice machine, and it was on his agenda to repair, but he had not gotten to it until last night. The MAINT stated the facility was without a maintenance director for a few months, and no work orders had been generated or completed. During an interview on 09/22/23 at 02:40 PM, the DM stated he had just started the Monday before, which was 09/18/23. He stated he started to detail cleaning the kitchen that day, because there were a lot of sanitation issues. The DM stated he delimed the dish machine, cleaned the deep fryer, and began pressure washing the floors. Since then, he dealt with all the product to make sure everything was rotated, labeled, and dated. He stated he had a family emergency the day before and had to leave the facility just as the investigation was underway. He stated he had just discovered the bathroom issue. He stated the bathroom was not being cleaned, and the toilet was not working. The DM stated he was not sure if the toilet had overflowed recently, but the floor back there was wet sometimes. He stated he had not seen the toilet actively leaking. When asked if he was aware of the five-gallon bucket, he asked if it was the one with grease from the grease trap. He stated while cleaning the deep fryer and the grease trap, he had dumped the contents into a five-gallon bucket and set it by the back door for disposal. He stated he had used paper towels to wipe out the grease trap and had dropped them into the bucket. When showed a photograph of the bucket that had been observed on 09/21/23, he stated that was definitely the bucket with the grease trap contents in it. He stated he did not know how it got in the bathroom, but the solid matter in it was the crumbs from cooking, the paper was the paper towels, and the brown liquid was the grease. He stated the presence of water on the floor in the kitchen from the toilet was a health hazard and could cause contamination of the residents' food and thus food borne illness. During an interview on 09/22/23 at 03:00 PM, the ADM stated she did not know the material in the five-gallon bucket was from the grease trap but that was reassuring. She stated she did not see how the broken toilet could have cause water to leak into the kitchen, because she never got any word that it was leaking. She stated she had tried to convince her staff to report issues to her and had an open-door policy. She stated they called her all day and night and sometimes staff walked into her door without knocking half the time, so she did not understand why no one would tell her if there was a problem in the kitchen. She stated she did go in the kitchen and check on it, but she had not gone in the bathroom. She stated the toilet had been fixed the morning of the investigation and was probably messy from the repair, and they had not been in there to fix it when it was observed by the surveyor. She stated she had an invoice for the repair, but it did not seem realistic that they should have been able to already get it cleaned up in a couple hours after the repair was completed. She stated she understood that it was hazardous if toilet water had been leaking all over the kitchen, but she did not believe that had happened. She stated she was aware of the ice machine leak, and that was legitimate, but they had since fixed it. She stated it could cause food borne illness if the kitchen were not properly sanitized. Review of facility policy dated 2018 and titled General Kitchen Sanitation reflected the following: The facility recognizes that foodborne illness has the potential to harm elderly and frail residents. All nutrition and food service employees will maintain clean, sanitary, kitchen facilities in accordance with the state and US food codes in order to minimize the risk of infection and foodborne illness. 11. Check restrooms regularly throughout the shift, and be sure they are stocked with soap, toilet paper, and paper towels. Review of the FDA Food Code dated 2022 reflected the following: Establishment Drainage System. FOOD ESTABLISHMENT drainage systems, including grease traps, that convey SEWAGE shall be designed and installed as specified under 5-202.11(A). 5-402.13 Conveying Sewage. SEWAGE shall be conveyed to the point of disposal through an APPROVED sanitary SEWAGE system or other system, including use of SEWAGE transport vehicles, waste retention tanks, pumps, pipes, hoses, and connections that are constructed, maintained, and operated according to LAW. 5-403.11 Approved Sewage Disposal System. SEWAGE shall be disposed through an APPROVED facility that is: (A) A public SEWAGE treatment plant; P or (B) An individual SEWAGE disposal system that is sized, constructed, maintained, and operated according to LAW. 5-402.13 Conveying Sewage. SEWAGE shall be conveyed to the point of disposal through an APPROVED sanitary SEWAGE system or other system, including use of SEWAGE transport vehicles, waste retention tanks, pumps, pipes, hoses, and connections that are constructed, maintained, and operated according to LAW. The facility's POR was accepted on 09/22/23 at 11:55 AM and included: Plan of Removal: Impact Statement: On, 09/21/2023, an abbreviated survey was initiated at. On 9/21/2023 the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety and was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy. All residents could be affected by this deficient practice/immediate jeopardy. Action: The bucket containing dark brown water, clumps of wet toilet tissue, and clumps of sticky brown substance floating in the water as well as the soiled wet towels have been disposed of. Person(s) Responsible: Maintenance Director Date: 9/21/2023 by 5PM Action: Disinfecting has occurred in the kitchen bathroom and the kitchen, utilizing appropriate disinfectant. The facility's administrator, dietary manager, and housekeeping supervisor have ensured the chemical was safe to utilize in the kitchen yet will clean effectively. Disinfecting will occur immediately to ensure kitchen is sanitary to prepare and serve food. Disinfecting will reoccur if water leaks from restroom, again. An attestation for this action will be kept in the facility records and will be available for review. Kitchen staff will check to ensure there is no backup of sewage water, from the bathroom, on the kitchen floor as well as no buckets containing dark brown water, clumps of wet toilet tissue, and clumps of sticky brown substance floating in the water as well as the soiled wet towels in the kitchen bathroom/in the kitchen. This will be documented in the AM and PM on a tracking sheet by the dietary staff (Cook or Aide), daily. The Cooks/Dietary Aides will be educated on their new daily tracking form prior to working their next shift. Person(s) Responsible: Housekeeping Supervisor, Dietary Manager, Administrator, Dietary Staff (Cooks and Dietary Aides) and/or Designee Date: 9/22/2023 by 1PM Action: A vendor has been contracted to fix the plumbing concern in the kitchen bathroom and the cracked pipe and several of the areas containing running water connections leaked and have continued leaking. There will be a lock placed on the door and an out of order sign placed on the bathroom until it has been fixed. Any leaking items were corrected on 9/21/2023 by 8PM by Corporate Maintenance Director and the vendor. Person(s) Responsible: Administrator, Maintenance Director, and/or Corporate Maintenance Director Date: 9/21/2023 by 8PM Action: All residents will be assessed for signs and symptoms of food borne illness and will the facility's charge nurses will continue to monitor for 72-hours. This documentation will reflect in the MAR. If any residents show signs and symptoms the charge nurse will immediately notify the resident's doctor, Assistant Director of Nurses, and the Administrator. Nurses will know to notify through education provided by facility's administrator and assistant director of nursing. All current staff will be educated over assessing for signs and symptoms of food borne illness and will the facility's charge nurses will continue to monitor for 72-hours. This documentation will reflect in the MAR on prior to working the floor. All temporary and new staff will be educated prior to working the floor. Charge Nurse, Assistant Director of Nursing will be educated by Administrator and/or Clinical Resource Nurse (Regional Nurse). Person(s) Responsible: Charge Nurses, Assistant Director of Nursing, and/or Designee Date: 9/21/2023 by 11PM Action: Educate all staff in reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. All staff can be defined as everyone working in the center- department heads, nursing, housekeeping, dietary. Person(s) Responsible: Administrator and/or Designee Date: 9/22/2023 by 12PM Action: Educate the Dietary Department (all), on serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. The Dietary Manager and Administrator will be educated regarding the sanitary manner of the kitchen by the Clinical Resource Nurse (Regional Nurse) and/or The Clinical Company Leader (Regional [NAME] President of Clinical Services) Person(s) Responsible: Dietary Manager and Administrator Date: 9/22/2023 by 12PM Action: The Dietary Manager and/or the Administrator will complete a weekly and as needed kitchen sanitation round x4 weeks post Plan of Removal acceptance/lifting. This will be documented on a rounding sheet and kept in records that will be readily available for surveyor review. Person(s) Responsible: Dietary Manager and/or Administrator Date: 9/22/2023 by 12PM Action: Maintenance Director will know what the maintenance log is, its location, and to check it daily x5 days through education provided by Administrator and/or Corporate Maintenance Director. Person(s) Responsible: Administrator and/or Corporate Maintenance Director Date: 9/22/2023 by 12PM Action: All direct care staff (charge nurse, cna/tna, cma {sic}) will be educated regarding recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. Person(s) Responsible: Assistant (sic) Director of Nursing and/or Administrator Date: 9/22/2023 by 12PM Action: Ad Hoc QAPI performed with Medical Director regarding the templates received and the facility's plan of removal. Person(s) Responsible: Administrator Date: 9/22/2023 by 10AM Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/21/2023, for F812. The POR was monitored in the following ways: Observation on 09/22/23 at 12:45 PM revealed the ADM, ADON, and MDSN training and discussing the following with the nursing staff: 1) reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log, and 2) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. During interviews between 12:57 PM and 01:25 PM, seven interviewable residents denied any gastrointestinal distress, nausea, vomiting, or any other signs or symptoms of food borne illness. Review on 09/22/23 of a sample of 15 residents, both verbal and nonverbal, reflected they had each received assessments for signs and symptoms of food borne illness and were being tracked for three days in their nursing progress notes to ensure no signs or symptoms arose. Observation on 09/22/23 at 01:33 PM revealed the ADM, ADON, and MDSN training and discussing the following with the dietary staff: 1) serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately and 2) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. The staff were reading an 18-page power point printout on the topic of kitchen sanitation and food borne illness and had copies of a pre/post-test next to them. Observation on 09/22/23 at 1:52 PM revealed the kitchen was clean and organized. The door to the bathroom was locked with a sign that read Out of Order on the door. The floor around the bathroom door was clean and dry. Observation on 09/23/23 from 12:00 PM to 12:20 PM revealed the kitchen being cleaned with no observation of noncompliance in the kitchen area. The bathroom closet was locked with a sign on the door that read Out of Order, and the DM unlocked it. The bathroom was clean, the floor dry, and there were no foul odors. During interviews on 09/23/23 from 01:14 PM to 02:55 PM, two LVNS, five CNAs, and two dietary staff reported they had received training and in-servicing on 1) reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log, and 2) serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately and 3) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. The staff were reading an 18-page power point printout on the topic of kitchen sanitation and food borne illness and had copies of a pre/posttest next to them. Review of in-services dated 09/22/23 reflected that all staff who had worked from 09/21/23 to 09/23/23 had signed the following in-services: Maintenance Request Food Safety 101/Reporting/Logging Leaking Pipes/Sewage Work Orders Food-Borne Illness The IJ was lifted, and the ADM notified on 09/23/23 at 04:45 PM. However, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility's need to continue training, disinfection, and monitoring for signs/symptoms of food borne illness.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one kitchen reviewed for infection control. 1. The facility failed to ensure that wastewater from the toilet in the kitchen bathroom did not leak into the kitchen. 2. The facility failed to ensure that a bucket of waste material in the facility kitchen was disposed of properly. 3. The facility failed to ensure that the area around the ice machine was free of wastewater. An IJ was identified on 09/21/23. The IJ template was provided to the facility on [DATE] at 05:25 PM. While the IJ was removed on 09/23/23, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm because of the facility's need to continue staff training, disinfection, and monitoring for signs/symptoms of food borne illness. These failures placed residents at risk of food borne illness. Findings included: Review of the maintenance log from June 2023 to September 2023 reflected an empty binder. Review of invoices from the plumbing company reflected the following: 09/08/23 camera drain line at back right of kitchen, unclogged line, pipe is cracked causing toilet itself is clogged, has something lodged inside recommend replacing toilet (diagnosis of toilet issue) 09/12/23-It was determined that the tubular on the 3 comp sink in the kitchen was broken and leaking, reworked the tubular to stop the leaking underneath the middle comp and the comp to the right of the middle 09/21/23 Replaced toilet in kitchen restroom with new water supply line and wall gasket During an interview on 09/21/23 at 02:08 PM, CK A stated the toilet had been leaking in the kitchen's bathroom for weeks. She stated the water had come out and into the main part of the kitchen from under the bathroom door, and the toilet did not work in the bathroom, so she had heard staff had been urinating in a five-gallon bucket. She denied any further knowledge of the circumstances, how they had become that way, or who she had spoken to about it. When asked if it had been reported to administration or maintenance, she stated they all knew but did not elaborate. Observation on 09/21/23 at 02:15 PM revealed a closet with an open door six feet down a vestibule toward the back door. At the threshold of the door were two towels rolled up, damp, with black/grey stains on the top of them. There were patches of damp, standing water on the outside of the towels from the Within the closet was a handwashing sink and toilet as well as shelves of chemicals and cleaning supplies. The floor was damp and dirty with patches of standing water and areas where the standing water was black in color. The walls, floors, and sink were extremely dirty with thick black substance stuck in many of the corners and crevices. The toilet was very clean and looked brand new. There was a five-gallon bucket under the handwashing sink a third of the way full of brown liquid, saturated paper, and clumps of brown solid floating inside it. During observation and interview on 09/21/23 at 02:26 PM, the MAINT and the RMAINT looked into the five-gallon bucket and stated they could not be sure what was in the bucket, but it did look like it might be human waste. Both of them stated they had not been in the bathroom, had no idea this was in there, and denied that it had been reported to them. They stated there had been plumbing work done in the bathroom that morning, because the toilet had been broken and overflowing for quite some time, and the plumber had replaced the toilet. The MAINT asked the RMAINT if the plumber might have left the bucket into the bathroom, and the RMAINT stated he did not believe that was possible. During observation and interview on 09/21/23 at 02:28 AM, the ADON leaned closer to the content of the five-gallon bucket and stated it smelled terrible. When getting closer to the bucket, the odor was not strong but was similar to the smell of a portable or vault toilet (such as one used on a construction site). The ADON stated she was not aware of any leaking from the toilet as no one had spoken to her about it. She stated she was new at the facility and had only been there a month. She stated the bathroom was disgusting, and it worried her that it was in the kitchen of the facility. Observation on 09/21/23 at 03:15 PM revealed a pool of standing water around the ice machine in the facility dining room. Water drip stains covered the sides of the machine. The standing water contained dirt and trash, including wet tissue paper. The inside of the ice machine was clean. Facility staff were observed retrieving ice from the machine and serving it to residents on the halls. On 09/2/23 at 05:20 PM, the ADM was notified of an IJ due to above listed failures and an IJ Template was provided. During an interview on 09/22/23 at 12:48 pm, CK B stated he had been working in the kitchen during this episode of his employment only for a couple of weeks. He stated it was his understanding that the toilet had been broken for a year. He stated he had never seen it leak, but he had seen standing water in there. He stated he had only been in the bathroom twice to retrieve chemicals and supplies. CK B stated the way it was once somebody went in that bathroom, they did not want to go back. He stated it was filthy and the toilet was backed up and clogged up. He stated the toilet did not have anything except water in it, but the water was all the way up to the top, and it could not be utilized. CK B stated he saw the five-gallon bucket, and he did not look in it. He stated he had thought there was just water in the bucket. CK B stated everybody in the kitchen knew how bad the bathroom was. He stated he had not spoken to the ADM about anything. CK B stated he had a hand in cleaning the kitchen, such as washing pots and pans and cleaning off equipment. He stated he had told them they would get shut down for the conditions in the kitchen bathroom. He stated the problems remaining in the kitchen made no sense to him. CK B stated he had received training on the computer about kitchen sanitation when he first started. He stated he had worked in food service for a long time and knew the regulations. During an interview on 09/22/23 at 01:18 pm, the MAINT stated he had started the position the Monday prior, on 09/18/23. He stated he had not been into the bathroom to look at it but was told about the problem of the toilet not working and being clogged, and he got permission to get it fixed. The MAINT stated the problem with the toilet was there was something stuck in it. He stated what he was told was the toilet was clogged and overflowed. He stated when this happened the first time, he went in, cleaned up the water spill, and sanitized the bathroom. The MAINT stated that was before he took his current position, but he was the floor technician before that, so it was within his job description to clean the floors. He stated that occurred around a week ago. The MAINT stated he did not know if anyone used the bathroom again and overflowed it after that. He stated they told them to not use the bathroom until the toilet was fixed. When asked who they was, he said it was thee RMAINT and the ADM. He stated he spoke with the assistant dietary manager and notified her not to use the toilet. The MAINT stated he did notice the towels when he observed the bathroom the day before on 09/21/23 and did notice they were damp. He stated he thought the towels had been placed there to stop water from the toilet from seeping out. He stated he did not know if the kitchen staff had placed them there or the plumber. The MAINT stated the facility had just had the plumber in the kitchen to fix a leak in the pipe under the dishwasher and just before that a leak in the pot-washing skin. The MAINT stated there were so many leaks in the kitchen that it was hard to know what, was what. The MAINT stated he had not been in the kitchen or the kitchen bathroom after the plumber came in to replace the toilet, so he had not seen the state of the bathroom until the surveyor asked him to come view it. The MAINT stated education will be part of his role, and he will train staff to use the maintenance log and to communicate with him if things are not working. The MAINT stated the ice machine had a leak, and they had it repaired last night on 09/21/23. He stated the standing water around the ice was most likely water that drained off from a leak from the drainage tube and didn't flow into the drain under the machine. The MAINT stated the ADM was aware of the leaking ice machine, and it was on his agenda to repair, but he had not gotten to it until last night. The MAINT stated the facility was without a maintenance director for a few months, and no work orders had been generated or completed. During an interview on 09/22/23 at 02:40 PM, the DM stated he had just started the Monday before, which was 09/18/23. He stated he started detail cleaning the kitchen that day, because there were a lot of sanitation issues. The DM stated he delimed the dish machine, cleaned the deep fryer, and began pressure washing the floors. Since then, he dealt with all the product to make sure everything was rotated, labeled, and dated. He stated he had a family emergency the day before and had to leave the facility just as the investigation was underway. He stated he had just discovered the bathroom issue. He stated the bathroom was not being cleaned, and the toilet was not working. The DM stated he was not sure if the toilet had overflowed recently, but the floor back there was wet sometimes. He stated he had not seen the toilet actively leaking. When asked if he was aware of the five-gallon bucket, he asked if it was the one with grease from the grease trap. He stated while cleaning the deep fryer and the grease trap, he had dumped the contents into a five-gallon bucket and set it by the back door for disposal. He stated he had used paper towels to wipe out the grease trap and had dropped them into the bucket. When showed a photograph of the bucket that had been observed on 09/21/23, he stated that was definitely the bucket with the grease trap contents in it. He stated he did not know how it got in the bathroom, but the solid matter in it was the crumbs from cooking, the paper was the paper towels, and the brown liquid was the grease. He stated the presence of water on the floor in the kitchen from the toilet was a health hazard and could cause contamination of the residents' food and thus food borne illness. During an interview on 09/22/23 at 03:00 PM, the ADM stated she did not know the material in the five-gallon bucket was from the grease trap but that was reassuring. She stated she did not see how the broken toilet could have cause water to leak into the kitchen, because she never got any word that it was leaking. She stated she had tried to convince her staff to report issues to her and had an open-door policy. She stated they called her all day and night sometimes and walked into her door without knocking half the time, so she did not understand why no one would tell her if there was a problem in the kitchen. She stated she did go in the kitchen and check on it, but she had not gone in the bathroom. She stated the toilet had been fixed the morning of the investigation and was probably messy from the repair, and they had not been in there to fix it when it was observed by the surveyor. She stated she had an invoice for the repair, but it did not seem realistic that they should have been able to already get it cleaned up in a couple hours after the repair was completed. She stated she understood that it was hazardous if toilet water had been leaking all over the kitchen, but she did not believe that had happened. She stated she was aware of the ice machine leak, and that was legitimate, but they had since fixed it. She stated it could cause food borne illness if the kitchen were not properly sanitized. Review of facility policy dated February 2022 and titled Infection Control and Prevention Committee reflected the following: The facility has an infection prevention and control program. The objectives may be attained as a component of the quality assurance and performance improvement committee, or by having a separate infection prevention and control committee. 1. The objectives of the IPCC are to: a. assist in development and implementation of written policies, and procedures for the prevention and control of and personnel; b. provide facility guidelines for a safe and sanitary environment; c. review, establish, and monitor, environmental infection, prevention, and control practices in accordance with CDC/HICPAC/OSHA guidelines and local or state requirements; e. Identify situation is that may result in employees, exposure to blood, bodily fluids, or other, potentially infectious materials. Review of the FDA Food Code dated 2022 reflected the following: Establishment Drainage System. FOOD ESTABLISHMENT drainage systems, including grease traps, that convey SEWAGE shall be designed and installed as specified under 5-202.11(A). 5-402.13 Conveying Sewage. SEWAGE shall be conveyed to the point of disposal through an APPROVED sanitary SEWAGE system or other system, including use of SEWAGE transport vehicles, waste retention tanks, pumps, pipes, hoses, and connections that are constructed, maintained, and operated according to LAW. 5-403.11 Approved Sewage Disposal System. SEWAGE shall be disposed through an APPROVED facility that is: (A) A public SEWAGE treatment plant; P or (B) An individual SEWAGE disposal system that is sized, constructed, maintained, and operated according to LAW. 5-402.13 Conveying Sewage. SEWAGE shall be conveyed to the point of disposal through an APPROVED sanitary SEWAGE system or other system, including use of SEWAGE transport vehicles, waste retention tanks, pumps, pipes, hoses, and connections that are constructed, maintained, and operated according to LAW. The facility's POR was accepted on 09/22/23 at 11:55 AM and included: Plan of Removal: F880 Impact Statement: On, 09/21/2023, an abbreviated survey was initiated at (facility name and address). On 9/21/2023 the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and was provided notification that the Survey Agency has determined that the conditions at the center constitute Immediate Jeopardy for F880. All residents could be affected by this deficient practice/immediate jeopardy Action: The bucket containing dark brown water, clumps of wet toilet tissue, and clumps of sticky brown substance floating in the water as well as the soiled wet towels have been disposed of. Person(s) Responsible: Maintenance Director Date: 9/21/2023 by 5PM Action: Disinfecting has occurred in the kitchen bathroom and the kitchen, utilizing appropriate disinfectant. The facility's administrator, dietary manager, and housekeeping supervisor have ensured the chemical is safe to utilize in the kitchen yet will clean effectively. Disinfecting will occur immediately to ensure kitchen is sanitary to prepare and serve food. Disinfecting will reoccur if water leaks from restroom, again. An attestation for this action will be kept in the facility records and will be available for review. Kitchen staff will check to ensure there is no backup of sewage water, from the bathroom, on the kitchen floor as well as no buckets containing dark brown water, clumps of wet toilet tissue, and clumps of sticky brown substance floating in the water as well as the soiled wet towels in the kitchen bathroom/in the kitchen. This will be documented in the AM and PM on a tracking sheet by the dietary staff (Cook or Aide), daily. The Cooks/Dietary Aides will be educated on their new daily tracking form prior to working their next shift. Person(s) Responsible: Housekeeping Supervisor, Dietary Manager, Administrator, Dietary Staff (Cooks and Dietary Aides) and/or Designee Date: 9/22/2023 by 1PM Action: A vendor has been contracted to fix the plumbing concern in the kitchen bathroom and the cracked pipe and several of the areas containing running water connections leaked and have continued leaking. There will be a lock placed on the door and an out of order sign placed on the bathroom until it has been fixed. Any leaking items were corrected on 9/21/2023 by 8PM by Corporate Maintenance Director and the vendor. Person(s) Responsible: Administrator, Maintenance Director, and/or Corporate Maintenance Director Date: 9/21/2023 by 8PM Action: All residents will be assessed for signs and symptoms of food borne illness and will the facility's charge nurses will continue to monitor for 72-hours. This documentation will reflect in the MAR. If any residents show signs and symptoms the charge nurse will immediately notify the resident's doctor, Assistant Director of Nurses, and the Administrator. Nurses will know to notify through education provided by facility's administrator and assistant director of nursing. All current staff will be educated over assessing for signs and symptoms of food borne illness and will the facility's charge nurses will continue to monitor for 72-hours. This documentation will reflect in the MAR on prior to working the floor. All temporary and new staff will be educated prior to working the floor. Charge Nurse, Assistant Director of Nursing will be educated by Administrator and/or Clinical Resource Nurse (Regional Nurse). Person(s) Responsible: Charge Nurses, Assistant Director of Nursing, and/or Designee Date: 9/21/2023 by 11PM Action: All residents will be assessed for signs and symptoms of food borne illness and will the facility's charge nurses will continue to monitor for 72-hours. If any residents show signs and symptoms the charge nurse will immediately notify the resident's doctor, Assistant Director of Nurses, and the Administrator. Nurses will know to notify through education provided by facility's administrator and assistant director of nursing. Person(s) Responsible: Charge Nurses, Assistant Director, and/or Designee Date: 9/21/2023 by 11PM Action: Educate all staff in reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. All staff can be defined as everyone working in the center- department heads, nursing, housekeeping, dietary. Person(s) Responsible: Administrator and/or Designee Date: 9/22/2023 by 12PM Action: Educate the Dietary Department (all), on serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. The Dietary Manager and Administrator will be educated regarding the sanitary manner of the kitchen by the Clinical Resource Nurse (Regional Nurse) and/or The Clinical Company Leader (Regional [NAME] President of Clinical Services) Person(s) Responsible: Dietary Manager and Administrator Date: 9/22/2023 by 12PM Action: The Dietary Manager and/or the Administrator will complete a weekly and as needed kitchen sanitation round x4 weeks post Plan of Removal acceptance/lifting. This will be documented on a rounding sheet and kept in records that will be readily available for surveyor review. Person(s) Responsible: Dietary Manager and/or Administrator Date: 9/22/2023 by 12PM Action: Maintenance Director will know what the maintenance log is, its location, and to check it daily x5 days through education provided by Administrator and/or Corporate Maintenance Director. Person(s) Responsible: Administrator and/or Corporate Maintenance Director Date: 9/22/2023 by 12PM Action: All direct care staff (charge nurse, can/tna, cma {sic}) will be educated regarding recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. All current staff will be educated prior to working the floor. All temporary and new staff will be educated prior to working the floor. Person(s) Responsible: Assistant Director of Nursing and/or Administrator Date: 9/22/2023 by 12PM Action: Ad Hoc QAPI performed with Medical Director regarding the templates received and the facility's plan of removal. Person(s) Responsible: Administrator Date: 9/22/2023 by 10AM Please accept this Plan of Removal as a credible allegation of compliance for immediate jeopardy initiated on 9/21/2023, for F880. The POR was monitored in the following ways: Observation on 09/22/23 at 12:45 PM revealed the ADM, ADON, and MDS training and discussing the following with the nursing staff: 1) reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log, and 2) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. During interviews between 12:57 PM and 01:25 PM, seven interviewable residents denied any gastrointestinal distress, nausea, vomiting, or any other signs or symptoms of food borne illness. Review on 09/22/23 of a sample of 15 residents, both verbal and nonverbal, reflected they had each received assessments for signs and symptoms of food borne illness and were being tracked for three days in their nursing progress notes to ensure no signs or symptoms arose. Observation on 09/22/23 at 01:33 PM revealed the ADM, ADON, and MDS training and discussing the following with the dietary staff: 1) serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately and 2) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. The staff were reading an 18-page power point printout on the topic of kitchen sanitation and food borne illness and had copies of a pre/post test next to them. Observation on 09/22/23 at 1:52 PM revealed the kitchen was clean and organized. The door to the bathroom was locked with a sign that read Out of Order on the door. The floor around the bathroom door was clean and dry. Observation on 09/23/23 from 12:00 PM to 12:20 PM revealed the kitchen being cleaned with no observation of noncompliance in the kitchen area. The bathroom closet was locked with a sign on the door that read Out of Order, and the DM unlocked it. The bathroom was clean, the floor dry, and there were no foul odors. During interviews on 09/23/23 from 01:14 PM to 02:55 PM, two LVNS, five CNAs, and two dietary staff reported they had received training and in-servicing on 1) reporting sewer/plumbing concerns immediately to maintenance director and facility administrator and filling out the maintenance log, and 2) serving food/beverages in a sanitary manner and reporting sanitation concerns to the Dietary Manager and the Administrator immediately and 3) recognizing signs of symptoms and reporting food borne illness to the doctor, administrator, and assistant director of nursing. The staff were reading an 18-page power point printout on the topic of kitchen sanitation and food borne illness and had copies of a pre/posttest next to them. Review of in-services dated 09/22/23 reflected that all staff who had worked from 09/21/23 to 09/23/23 had signed the following in-services: Maintenance Request Food Safety 101/Reporting/Logging Leaking Pipes/Sewage Work Orders Food-Borne Illness The IJ was lifted, and the ADM notified on 09/23/23 at 04:45 PM. However, the facility remained out of compliance at a scope of widespread and a severity level of potential for more than minimal harm due to the facility's need to continue training, disinfection, and monitoring for signs/symptoms of food borne illness.

Based on interview and record review, The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand for 1 of 9 (Resident #1) reviewed for discharges. The facility did not complete the process for home health services for Resident #1 to receive continued care prior to discharge. 5/22/2023 Resident # 1 discharged from the facility to a motel in the community. Resident # 1called 911 and admitted to the hospital on [DATE] for cellulites and abscess to his left foot that required debriding a surgical procedure. An IJ was identified on 7/6/2023. The IJ began on 5/22/2023 and removed on 5/25/2032. While the IJ was removed on 5/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because (e.g.) all staff had not been trained on 5/25/2023. The failure could place residents at risk of worsened health conditions and hospitalizations. Findings included: Record review of hospital records dated 5/24/2023, reflected Resident #1 admitted to the hospital on [DATE]. The records reflected Resident #1had an amputation of the third middle toe on the left foot on 4/26/2023 with a delayed closure. The medical records reflect Resident #1 was seen for cellulites and abscess to his left foot. The records reflected that the abscess was debrided through a surgical procedure. Resident #1 discharged from the hospital on 6/6/2023 to the community. Record review of a face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old male admitted on [DATE]. He had diagnoses of acute osteomyelitis, left ankle and foot (infection of the bone), Tachycardia unspecified ( a rapid heartbeat that may be regular or irregular but is out of proportion to age and level of exertion), acquired absence of other left toe (code classification of medical billing), type 2 diabetes mellitus with hyperglycemia ( when a person living with [NAME][e 2 diabetes has high blood sugar levels), bipolar disorder ( a disorder associated with mood swings ranging from depressive lows to manic highs), and Cutaneous abscess ( a localized collection of pus in the skin and may occur on any skin surface). Record review of the MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15, which indicated cognitively intact. Section G Functional status of the MDS reflected Resident # 1 required one person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of a care plan dated 4/30/2023 reflected Resident #1 had a short- term goal with a discharge plan to return back to the community. The care plan reflected, ADL function status/Rehabilitation potential interventions included: Ambulation/Transfers, bathing, hygiene, dressing and grooming required one person assist, OT/PT/ST as needed Record reviewed of doctor's order dated 5/22/2023, reflected Resident # 1 was at baseline and to be discharged with all medications except controlled medications. Record review of community referral for home health care services dated 5/22/2023, reflected Resident # 1 would be picked up for services in the community once a PCP was assigned. Record review of nursing note dated 5/22/2023 written by the ADON, indicated Resident #1 was discharged per doctor's order, Resident # 1 signed for all medications given to him. Resident # 1 was instructed on all medications and how to take medications. Resident # 1 was given 20.00 cash for food. An phone interview at 9:30a.m. with Resident # 1, revealed he was discharged from the facility to a motel. Resident # 1 stated the facility paid for a few days at the motel and gave him 20.00 cash for food. Resident # 1 stated asked the facility how he was going to get the continued care and to his appointments that were scheduled. Resident # 1 stated the facility did not provide him with any follow-up information for continued care services. Resident # 1 stated he called 911 to go back into the hospital so that he could get continued medical care. Resident # 1 had been in the motel for 2 days. An interview on 5/22/2023 at 12:30p.m. with the SOWK, revealed Resident #1 was discharged from the facility on 5/22/2023. She stated she completed a referral for Home health services on 5/22/2023. The SOWK stated the application for services for Resident # 1 was accepted pending the resident had a PCP in place. The SOWK stated she was not aware of who Resident # 1 PCP would be since he had discharged from the facility. An interview at 12:45 p.m. on 5/25/2023 with the DON, revealed the facility received an order from the doctor for the discharge that indicated Resident # 1 was at his baseline and no longer required this level of treatment. The DON stated Resident # 1 was discharge with his medications and all his belongings. The DON stated the SOWK set up continued care services in the community for Resident # 1 through home health care. An interview at 1:41p.m. on 5/25/2023 with other state agency staff, revealed Resident # 1 was discharged on 5/22/2023 and he was made aware of the discharge by Resident # 1. The other state agency staff stated Resident # 1 did not have services set up in the community for continued treatment services. The other state agency staff revealed Resident # 1 was convinced to go back to the hospital to get the services he needed. An interview at 4:30p.m. on 5/25/2023 with the Regional ADM, revealed that Resident # 1 was covered by the current PCP at the facility once he discharged from the facility so that he could start his services in the community. The Regional ADM revealed this information should have been provided to the home health provider and Resident #1 so that services in the community could have continued. The Regional ADM revealed the SOWK should have provided this information and would be in-serviced on the process to set up continued services for any resident. An interview at 4:09pm on 7/5/2023 with the NP revealed, she believed that the PCP would follow the resident until another PCP has been chosen. The NP stated the SOWK worker would need to ensure that the resident was set up for continued treatment services in the community. The NP stated Resident #1 was stable to discharge from the facility. She stated they would write a prescription or see the resident at one of their community clinics, however the SOWK would set these services up when the resident discharged from the facility and make them aware when it has been set up so that Resident # 1 could have been seen at one of their community clinics until another PCP had been selected. Record review of the facility's policy titled, Transfer and Discharge Policy, dated March 2021, revealed Policy: In determining the transfer location for a resident, the decisions to transfer to a particular location is determined by the needs, choices and best interests of the resident. The Regional ADM. was notified on 7/6/2023 at 3:30pm., an IJ had been identified due to the above failures. It was determined their failures placed Resident # 1 in an IJ situation on 5/22/2023. The facility implemented the following interventions: An interview at 4:09pm on 7/5/2023 with the Regional ADM. revealed, that they implemented as part of their discharge process was to identify all discharges coming up and discuss with the IDT steps to take to ensure the process was completed timely to ensure residents have a safe discharge in place with continued services set up. The ADM was able to show the current list of residents seeking discharge to other facilities and those seeking discharge to the community. An interview at 4:30pm on 7/5/2023 with SOWK revealed, she had been in-serviced on the admission/discharge policy and procedure. The SOWK was able to discuss the process in which they take when discharging for homeless residents and setting up services in the community. She stated she was advised that the facility PCP would provide services to residents after they discharging to the community for continued services at one of their facilities in the community until a new PCP has been obtained. The SOWK stated she was familiar and has worked with some of the community facilities that accept homeless people to assist the resident to transition back into the facility. Records review of in-service and sign-in sheets regarding Admissions and Discharges policy and procedure dated 5/25/2023 conducted by the traveling ADM, reflected the SOWK and other IDT members had been in-serviced on this process. Records reviewed of QAPI meetings dated 6/28/2023, reflected the IDT members and admissions and discharges were discussed as part of this meeting.

Based on interview and record review, The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand for 1 of 9 (Resident #1) reviewed for discharges. The facility did not complete the process for home health services for Resident #1 to receive continued care prior to discharge. 5/22/2023 Resident # 1 discharged from the facility to a motel in the community. Resident # 1called 911 and admitted to the hospital on 5/24/2023 for cellulites and abscess to his left foot that required debriding a surgical procedure. An IJ was identified on 7/6/2023. The IJ began on 5/22/2023 and removed on 5/25/2032. While the IJ was removed on 5/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because (e.g.) all staff had not been trained on 5/25/2023. The failure could place residents at risk of worsened health conditions and hospitalization s. Findings included: Record review of hospital records dated 5/24/2023, reflected Resident #1 admitted to the hospital on 5/24/2023. The records reflected Resident #1had an amputation of the third middle toe on the left foot on 4/26/2023 with a delayed closure. The medical records reflect Resident #1 was seen for cellulites and abscess to his left foot. The records reflected that the abscess was debrided through a surgical procedure. Resident #1 discharged from the hospital on 6/6/2023 to the community. Record review of a face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old male admitted on [DATE]. He had diagnoses of acute osteomyelitis, left ankle and foot (infection of the bone), Tachycardia unspecified ( a rapid heartbeat that may be regular or irregular but is out of proportion to age and level of exertion), acquired absence of other left toe (code classification of medical billing), type 2 diabetes mellitus with hyperglycemia ( when a person living with [NAME][e 2 diabetes has high blood sugar levels), bipolar disorder ( a disorder associated with mood swings ranging from depressive lows to manic highs), and Cutaneous abscess ( a localized collection of pus in the skin and may occur on any skin surface). Record review of the MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15, which indicated cognitively intact. Section G Functional status of the MDS reflected Resident # 1 required one person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of a care plan dated 4/30/2023 reflected Resident #1 had a short- term goal with a discharge plan to return back to the community. The care plan reflected, ADL function status/Rehabilitation potential interventions included: Ambulation/Transfers, bathing, hygiene, dressing and grooming required one person assist, OT/PT/ST as needed Record reviewed of doctor's order dated 5/22/2023, reflected Resident # 1 was at baseline and to be discharged with all medications except controlled medications. Record review of community referral for home health care services dated 5/22/2023, reflected Resident # 1 would be picked up for services in the community once a PCP was assigned. Record review of nursing note dated 5/22/2023 written by the ADON, indicated Resident #1 was discharged per doctor's order, Resident # 1 signed for all medications given to him. Resident # 1 was instructed on all medications and how to take medications. Resident # 1 was given 20.00 cash for food. An phone interview at 9:30a.m. with Resident # 1, revealed he was discharged from the facility to a motel. Resident # 1 stated the facility paid for a few days at the motel and gave him 20.00 cash for food. Resident # 1 stated asked the facility how he was going to get the continued care and to his appointments that were scheduled. Resident # 1 stated the facility did not provide him with any follow-up information for continued care services. Resident # 1 stated he called 911 to go back into the hospital so that he could get continued medical care. Resident # 1 had been in the motel for 2 days. An interview on 5/22/2023 at 12:30p.m. with the SOWK, revealed Resident #1 was discharged from the facility on 5/22/2023. She stated she completed a referral for Home health services on 5/22/2023. The SOWK stated the application for services for Resident # 1 was accepted pending the resident had a PCP in place. The SOWK stated she was not aware of who Resident # 1 PCP would be since he had discharged from the facility. An interview at 12:45 p.m. on 5/25/2023 with the DON, revealed the facility received an order from the doctor for the discharge that indicated Resident # 1 was at his baseline and no longer required this level of treatment. The DON stated Resident # 1 was discharge with his medications and all his belongings. The DON stated the SOWK set up continued care services in the community for Resident # 1 through home health care. An interview at 1:41p.m. on 5/25/2023 with other state agency staff, revealed Resident # 1 was discharged on [DATE] and he was made aware of the discharge by Resident # 1. The other state agency staff stated Resident # 1 did not have services set up in the community for continued treatment services. The other state agency staff revealed Resident # 1 was convinced to go back to the hospital to get the services he needed. An interview at 4:30p.m. on 5/25/2023 with the Regional ADM, revealed that Resident # 1 was covered by the current PCP at the facility once he discharged from the facility so that he could start his services in the community. The Regional ADM revealed this information should have been provided to the home health provider and Resident #1 so that services in the community could have continued. The Regional ADM revealed the SOWK should have provided this information and would be in-serviced on the process to set up continued services for any resident. An interview at 4:09pm on 7/5/2023 with the NP revealed, she believed that the PCP would follow the resident until another PCP has been chosen. The NP stated the SOWK worker would need to ensure that the resident was set up for continued treatment services in the community. The NP stated Resident #1 was stable to discharge from the facility. She stated they would write a prescription or see the resident at one of their community clinics, however the SOWK would set these services up when the resident discharged from the facility and make them aware when it has been set up so that Resident # 1 could have been seen at one of their community clinics until another PCP had been selected. Record review of the facility's policy titled, Transfer and Discharge Policy, dated March 2021, revealed Policy: In determining the transfer location for a resident, the decisions to transfer to a particular location is determined by the needs, choices and best interests of the resident. The Regional ADM. was notified on 7/6/2023 at 3:30pm., an IJ had been identified due to the above failures. It was determined their failures placed Resident # 1 in an IJ situation on 5/22/2023. The facility implemented the following interventions: An interview at 4:09pm on 7/5/2023 with the Regional ADM. revealed, that they implemented as part of their discharge process was to identify all discharges coming up and discuss with the IDT steps to take to ensure the process was completed timely to ensure residents have a safe discharge in place with continued services set up. The ADM was able to show the current list of residents seeking discharge to other facilities and those seeking discharge to the community. An interview at 4:30pm on 7/5/2023 with SOWK revealed, she had been in-serviced on the admission/discharge policy and procedure. The SOWK was able to discuss the process in which they take when discharging for homeless residents and setting up services in the community. She stated she was advised that the facility PCP would provide services to residents after they discharging to the community for continued services at one of their facilities in the community until a new PCP has been obtained. The SOWK stated she was familiar and has worked with some of the community facilities that accept homeless people to assist the resident to transition back into the facility. Records review of in-service and sign-in sheets regarding Admissions and Discharges policy and procedure dated 5/25/2023 conducted by the traveling ADM, reflected the SOWK and other IDT members had been in-serviced on this process. Records reviewed of QAPI meetings dated 6/28/2023, reflected the IDT members and admissions and discharges were discussed as part of this meeting.

Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for 3 (Resident #1, Resident #2, and Resident #3) of 68 residents reviewed for abuse. 1. Resident #1 grabbed Resident #2 by her hair and started punching her. 2. Residents #1 and #3 were pulling on each other's shirts, scratching, and punching the other. An IJ was identified on 4/29/23 at 6:21pm. Although the IJ was removed on 05/02/23 at 5:21pm, the facility remained out of compliance at a severity level of no actual harm and scoped at a pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure place residents at risk for serious injury, emotional distress, and death. Findings included: Resident #2 Review of Resident #2's face sheet dated 4/29/23 revealed she was originally admitted to the facility on [DATE] and returned to the facility on [DATE] from a Behavioral Hospital. Resident #2's primary diagnoses included hypertension, schizophrenia, dementia, hearing loss, Parkinson's disease, cognitive communication deficit, paranoid schizophrenia, recurrent depressive disorders, and insomnia. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS also indicated Resident #2 had no symptom presence and frequency during her mood interview. The MDS indicated Resident #2 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), verbal behavioral symptoms directed towards others 4 to 6 days, rejected evaluations or care daily, and did not wander. The MDS also indicated Resident #2 was received antipsychotic medications for 2 days, on a routine basis, no gradual dose reductions were attempted, and gradual dose reductions were not documented by a physician as clinically contraindicated. The MDS indicated Resident #2 was independent with her bed mobility, transfers, walking between locations in her room and corridor on same floor, and eating and required supervision with walking in corridor on unit, dressing, and personal hygiene. Review of Resident #2's care plan revised on 3/22/23 revealed under one of her problems that started on 9/17/22 and was edited on 3/22/23 by RN A, she had socially inappropriate/disruptive behavioral symptoms as evidenced by having difficulty navigating in social situations and interactions, has conversations with self and others not there, voices paranoid thinking, can become verbally and physically aggressive, refuses care routinely secondary to Paranoid Schizophrenia, Anxiety, and Dementia. The goal for Resident #2's problem that was edited on 3/9/23 by RN A revealed she will not exhibit socially inappropriate/disruptive behavior. Current socially inappropriate/disruptive behavior pattern included difficulty interacting and awareness of other residents and navigating self in social settings. One of the approaches started on 9/17/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 revealed staff must help Resident #2 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Two other approaches started on 9/17/22 revealed staff must Remove resident from other residents' rooms and unsafe situations, When resident becomes socially inappropriate/disruptive, move resident to a quiet, calm environment. Review of Resident #2's progress note dated 9/17/22 at 6:40pm by LVN A revealed at approximately 5:00pm, she observed Resident #2 rolling in the hall in her wheelchair. LVN A heard shouts move, no you move. LVN A saw two residents in the hall side by side in their wheelchairs. The two residents were unable to pass with obstacles in the hall. LVN A got up to attend to the matter before it went too far. Before LVN A could reach Resident #2, Resident #2 was struck in the head repeatedly by Resident #1. A CNA closer to the residents than LVN A broke up the physical altercation. Resident #2 was assessed and had no apparent injuries. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 12:09pm by the SW revealed Resident #2 mentioned pain in one area of her body and denied any other pain. Resident #2 said she was okay, but she wanted to talk to the police. The SW informed the nurse of Resident #2's pain and contacted the police to send a law enforcement office to the facility. Review of Resident #2's progress note dated 3/21/23 at 1:44pm by the ADON revealed Resident #2 had an altercation with another resident around 9:30am. Resident #2 was noted standing in the threshold of the doorway waiting for HL to finish cleaning her room. Resident #2's behavior was to yell. Resident #1 was in the hallway. Resident #1 rolled his wheelchair over to Resident #2, stood up from his wheelchair, grabbed her hair, and punched her. HL witnessed the altercation. Police came to investigate the incident. Residents #1 and #2 were separated. Resident #1 was to be moved from facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Resident #3 Review of Resident #3's face sheet dated 4/29/23 revealed he was originally admitted on [DATE] and returned 2/26/23. Resident #3's primary diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (blood pressure that is higher than normal), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness, and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 11. The MDS indicated Resident #3 had no symptom presence and frequency during his mood interview. The MDS also indicated Resident #3 had no potential indicators of psychosis, did not exhibit any physical, verbal, or other behavioral symptoms toward others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #3 required supervision with bed mobility, moving between locations, and eating, limited assistance with transfers and toilet use, extensive assistance with dressing and personal hygiene, and was independent with moving and returning from off-unit locations. Review of Resident #3's care plan revised on 3/9/23 revealed under one of his problems that started on 7/15/22 and edited on 2/22/23 by RN A, he had a memory/recall problem/severe cognitive deficit. The goal for Resident #3's problem that was edited on 2/22/23 revealed he will not sustain serious injury due to memory/recall deficit. Two of the approaches started on 7/15/22 included ensure resident's areas were free of hazards and redirect resident when entering unsafe areas. Review of Resident #3's progress note dated 11/7/22 at 3:09pm by LVN B revealed Resident #3 was seen in a physical altercation with another resident. Both residents were seen pulling on each other's shirts, scratching, and punching the other. Residents were quickly pulled apart from one another. No injuries were present on Resident #3 at the time and Resident #3 did not complain of any pain. The progress note did not indicate whether Resident #3 was assessed by psychiatry after the incident. Resident #1 Review of Resident #1's face sheet dated 4/28/23 revealed he was admitted to the facility on [DATE] with primary diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), bipolar disorder (disorder associated with episodes of mood swings), schizophrenia (mental disorder in which people interpret reality abnormally), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS indicated Resident #1 did not have any symptoms present during his mood interview. The MDS also indicated Resident #1 did not have any potential indicators of psychosis, did not exhibit any physical, verbal, or other behaviors towards others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #1 required supervision with his bed mobility, was independent with his transfers, walking in room and corridor, moving between locations, and eating, limited assistance with toilet use, and extensive assistance with dressing and personal hygiene. The MDS also indicated Resident #1 received antipsyhotic, antiaxiety, and antidepressant medications for 7 days, received antipsychotics on a routine basis, did not have a physician document a gradual dose reduction as clinically contraindicated, and did not have a gradual dose reduction documented by a physician and clinically contraindicated. Review of Resident #1's care plan revised on 3/22/23 revealed under one of his problems that started on 9/17/22 and was edited on 3/22/23 by the former DON, he had socially inappropriate/disruptive behavioral symptoms as evidenced by physical and verbal aggression towards other residents and staff secondary to Bipolar D/O, TBI, Schizophrenia, Psychotic D/O with Hallucinations, Anxiety, Restlessness & Agitation. The goal for Resident #1's problem that was edited on 3/9/23 by RN A revealed he not harm self or others secondary to socially inappropriate/disruptive behavior. Current behavior pattern included verbal and physical aggression in certain social situations when his needs or demands are not met immediately. One of the approaches started on 9/17/22 and edited on 9/18/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 and edited on 9/18/22 revealed staff must help Resident #1 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Review of Resident #1's psychiatry clinical note dated 9/21/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are improving. His anger is well controlled. Impulsive behaviors are not currently being displayed . The note also stated under the staff report section: [NAME] had an altercation with another resident on 9/17 where he and another female resident got into a verbal dispute that resulted in patient grabbing female resident and punching her several times in the head. Once the incident was broken up he went to his room and no further incidents between the two were noted. When discussing these behaviors with patient he is remorseful and apologizes for his impulsive behaviors when angry. Provider discussed events with patient's mom so she could also address them with him as well. Review of Resident #1's psychiatry clinical note dated 11/11/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are normal. His anger is well controlled. Impulsive behaviors are not currently being displayed . There was no staff report section included in the note regarding Residents #1 and #3's incident on 11/7/22. Review of Resident #1's psychiatry clinical note dated 3/24/23 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. He is socializing less with staff and other residents. [NAME]'s anger is poorly controlled. Impulsive behaviors continue to be a problem. The note also stated under the staff report section: [NAME] had a major altercation on 3/21/23 (provider was not notified until today). His neighbor was out in the hallway yelling and cursing at the housekeeper who was cleaning her room and [NAME] came out to where she was in the hallway and yelled at her to be quiet. This caused her to keep yelling and then turn her anger toward him and they exchanged words until [NAME] got up from his wheelchair and began punching the other resident. [NAME] has since been moved to another hall away from her room and no incidents between the two or any other resident have occurred since then. When provider asks [NAME] about this incident he states, it wasn't my finest moment .I just snapped. He is remorseful today about events that happened. Review of Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's progress note dated 11/07/22 at 2:55pm, written by LVN B revealed Resident #1 was seen in a physical altercation with another resident. Resident #1 and the other resident were pulling on each other's shirts, scratching, and punching. Resident #1 and the other resident were quickly pulled apart by a CNA and CMA. Resident #1 began yelling at the other resident that he would kill him. When Resident #1 was asked what happened, he stated, He wouldn't stop kicking my chair and told me to move, that's why I beat his ass. The progress note did not indicate whether Resident #1 was assessed by psychiatry after the incident. Review of Resident #1's progress note dated 3/21/23 at 1:33pm written by the ADON revealed at approximately 9:30am, she heard shouting on D hall. Residents #1 and #2 were physically fighting in the hall. HL witnessed the altercation that lasted a few seconds. Resident #1 grabbed Resident #2 by her hair and punched her in her head and breast area. Resident #1 stated he snapped when Resident #2 was yelling at HL. The ADON took Resident #1 to her office. Law enforcement was called and arrived at the facility because Resident #2 wanted to press charges on Resident #1. Review of Resident #1's progress note dated 3/21/23 at 2:00pm but recorded as a late entry on 03/22/23 at 10:43am written by RN A revealed it was reported to him that Resident #1 became aggressive with another resident. After review, it appeared Resident #1's triggers were loud noises and verbal outbursts from other sources. Review of Resident #1's progress note dated 3/21/23 at 3:30pm written by SW revealed she visited Resident #1 regarding the incident that took place with another resident. Resident #1 stated his actions and stated understanding of the consequences. Review of Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed there was a resident to resident incident on 3/21/23 at 9:55am in D Hall. Resident #2 was listed as an individual/resident involved. Resident #2's functional ability was listed as total assistance. Resident #2's level of supervision was listed as within hearing. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #2's other pertinent history revealed she had a history of outbursts, but mostly not towards anyone. Resident #1 was also listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, not independently ambulatory, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had both physical and verbal aggression towards staff and other residents and had been involved in other altercations in the past. No alleged perpetrators were listed. HL was listed as a witness. No adverse injury or effect were noted. Description of injury revealed there was no injury on either Residents #1 and #2 at the time and both of them were being monitored for late reactions/injuries. Provider response revealed Resident #1 was kept on one-on-one monitoring, removed from the hall to another, medications were reviewed, and emergency care plan with residents family was initiated to discuss his behaviors and a possible discharge. Investigation findings were inconclusive. Provider action taken post-investigation revealed staff were in-serviced on resident to resident altercation, Resident #1 was relocated to another hall, there was an emergency care plan with his family about resident's aggression and the possible discharge if his behaviors continued, and his medications were reviewed. The report did not indicate whether Resident #2 was assessed by psychiatry after the incident. The ADM signed the report on 3/28/23. Review of statements included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed HL witnessed the incident between Residents #1 and #2. HL wrote a statement on 3/21/23. HL said in her statement that Resident #1 was punching Resident #2's head, kicking Resident #2, and pulling Resident #2's hair. HL also said in her statement that she tried to open Resident #1's fingers to let Resident #2 go, but Resident #1 was so strong and would not let Resident #2 go. HL said in her statement that she kept telling Resident #1 to stop punching, kicking, and pulling Resident #2. HL also said in her statement that she remembers yelling for her boss, HS, to come help her. HL also said in her statement that Resident #1 eventually let Resident #2 go. HL said in her statement she hoped Resident #2 was okay. Statements also revealed SW met with Resident #2 in the front lobby on 3/21/23 and obtained a statement from her. Resident #2 said in her statement that she was in some pain in the chest area and her head. This information was reported to the charge nurse. Resident #2 also said in her statement that when she was asked what took place, she responded, I don't know. He just started hitting and punching me! I didn't do anything to him. Resident #2 added she wanted to call the police. SW confirmed resident #2 wanted to call the police and resident #2 responded, Yes, that's assault and battery, I know my rights! SW contacted the police and resident #2 waited for their arrival in the front lobby. Statements also revealed SW met with Resident #1 in her office on 3/21/23 and obtained a statement from him. Resident #1 said in his statement that he reported Resident #2 had been keeping him up all night for the past four days with constant yelling and cursing. Resident #1 also said in his statement that when he saw Resident #2 yelling at HL, he just had it. Resident #1 said in his statement when proceeding with the events, I just grabbed her by her hair and kept punching her. Resident #1 added in his statement that he knew what he did was wrong, but he had just had enough. Resident #1 said in his statement that he reported no pain and understood he might have to face some consequences to come. Review of an in-service dated 3/22/23 revealed staff were trained by RN A on monitoring Resident #1, identifying signs of overstimulation (i.e., loud noises, screaming, and arguing), and how to approach a resident who was overstimulated. Staff were trained to encourage the resident to move to a calmer area whenever he/she became overstimulated. Policy and procedure for dealing with resident behaviors undated was attached to the in-service. Review of an in-service dated 3/27/23 revealed staff were trained by the ADM and DON on resident-to-resident altercations. Staff were trained to pay attention to agitation, not to ignore residents since they can ultimately make things worse, and types of behavior are forms of communication. Policy and procedure for resident-to-resident altercation dated December 2016 was attached to the in-service. Review of an in-service dated 4/25/23 revealed staff were trained on abuse and neglect. The in-service did not indicate who trained staff. Staff were trained to protect residents and staff, the definitions for abuse and neglect, what to do if abuse and/or neglect was seen or suspected, and who was the abuse coordinator. Review of resident safety surveys dated 3/23/23 and included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of Provider Investigation report submitted to the State Agency on 11/8/22 at 8:15pm revealed there was a resident to resident altercation on 11/7/22 at 2:50pm in the living area. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within hearing. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of engaging in physical and verbal altercations with other residents and staff. Resident #3 was also listed as an individual/resident involved. Resident #3's functional ability was listed as total assistance. Resident #3's level of supervision was listed as within hearing. Resident #3 was listed as interviewable, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident. Resident #3's other pertinent history revealed he was usually quiet and sits with other residents to watch tv in the living area. No alleged perpetrators were listed. A former staff member was listed as a witness. No adverse injury or effect were noted. No description of injury was noted. Description of allegation noted a charge nurse reported and documented Residents #1 and #3 were seen in the living area holding each others' shirts and punching each other. Provider response revealed Residents #1 and #3 were put on one-on-one monitoring, observed for 72 hours for any adverse effects from incidents, and staff were in-serviced on resident-to-resident altercation. Investigation findings were confirmed. Investigation summary noted Residents #1 and #3 were involved in altercation, both residents were doing well during the investigation, and have stated they were not in pain. Provider action taken post-investigation revealed Residents #1 and #3 were monitored for behaviors, injuries, and psychological or emotional distress resulting from the incident and staff were in-serviced on resident-to-resident altercation. The report did not indicate whether Residents #1 and #3 were assessed by psychiatry after the incident. The ADM signed the report on 11/14/22. Review of statements included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed SW met with Resident #3 at bedside on 11/8/22 and obtained a statement from him. Resident #3 said in his statement that Resident #1 kept pushing his chair. Resident #3 also said in his statement that in return, he got ready to hit him. Resident #3 said in his statement that he was okay and just in minor pain from the altercation with Resident #1. Statements also revealed SW met with Resident #1 in her office on 11/8/22. Resident #1 said in his statement that Resident #3 pushed his chair and added, he always does this and I'm tired of it! Resident #1 also said in his statement that in return, he got up and punched him in the face. Resident #1 said in his statement that he was okay now and in better spirits. Review of resident safety surveys dated 11/9/22 and included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed six residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 11/14/22 revealed staff were trained on resident to resident altercation. The in-service did not indicate who trained staff. Staff were trained to redirect residents when they were having an outburst that can lead to an altercation. Policies and procedures for resident-to-resident altercation dated December 2016 and dealing with resident behaviors undated were attached to the in-service. Review of a Provider Investigation Report submitted to the State Agency on 9/17/22 at 6:45pm revealed there was a resident on resident altercation on 9/17/22 at 5:00pm in the hallway. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of aggressive behaviors towards other residents and staff and was unable to control his emotions prior to his cerebral infarction. Resident #2 was also listed as an individual/resident involved. Resident #2's functional ability was listed as minimal. Resident #2's level of supervision was listed as within eyesight. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of verbal aggression. Resident #2's other pertinent history revealed she had a diagnosis of schizophrenia, anxiety disorder due to known physiological condition, wandered to other residents' rooms sometimes as early as 2:00am and some of them were aggravated when she wandered into their room, and prior to incident wandered into Resident #1's room and he woke up from sleep. No alleged perpetrators were listed. No witnesses were listed. No adverse injury or effect was noted. Description of injury noted no injuries sustained by either of the residents. No description of allegation was noted. Provider response revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments of both residents for 3 days, Resident #1's Psych NP was notified and indicated she would review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, and staff were in-serviced on resident on resident altercations. Investigation findings were confirmed. Provider action taken post-investigation revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments for 3 days, Resident #1's Psych NP was notified and indicated she was going to review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, staff were in-serviced on resident on resident altercations and residents had since been okay. The report did not indicate whether Resident #2 was assessed by psychiatry after the incident. The ADM signed the report on 9/24/22. Review of CNA C witness statement dated 9/17/22, indicated CNA C was putting a resident in her geri-chair. CNA C said in her statement Resident #1 started yelling at her to move. CNA C stated she told Resident #1 she was almost done putting the resident in her geri-chair. CNA C stated Resident #1 proceeded through her and the resident she was helping. CNA C stated Resident #1 hit the other resident's feet with his wheelchair as she was going down with the hoyer lift and she told Resident #1 that's rude. CNA C stated Resident #1 told her to move because she was in his way and about time she did her job. CNA C told Resident #1 she always did her job and Resident #1 said Fuck you, you don't do shit. CNA C said she ended all conversation with Resident #1. CNA C indicated Resident #1 was very rude, bullied other residents, and some residents were even scared to go around him. CNA C stated Resident #1 entered another resident's room while the resident was in the hospital and took his personal items, drinks, food, and money and bragged about it. CNA C indicated she witnessed and reported Resident #1 several times running over another resident's feet, telling her to move, calling her names, pushing her chair to where he was trying to move her until she hit the wall, cussing at the nurses, calling the nurses names, and knocking things off the nurse's cart when he was mad. Review of CNA D's witness statement dated 9/17/22, indicated she heard Resident #1 and #2 arguing in the hallway. CNA D indicated Resident #2 was talking, Resident #1 punched her repeatedly in the face until she came running back down the hallway to stop him. Review of Resident #2's statements written by the SW on 9/19/22 indicated Resident #2 did not know what the SW was referring to when she spoke with her regarding the incident. Resident #2 indicated she had no concerns or complaints regarding the weekend. Further review revealed the SW followed up with Resident #2 on 9/20/22 and 9/22/22. Resident #2 asked the SW why she kept asking her about the past weekend and appeared to not recall what the SW was referring to. Review of Resident #1's statement written by the SW dated 9/19/22 revealed Resident #1 said he was not harmed or upset about the event involving Resident #2 on 9/17/22 and had no concerns or complaints regarding the weekend. The SW followed up with Resident #1 on 9/20/22 and 9/22/22. Resident #1 said \he was over it, fine, and had no concerns or complaints regarding the weekend. Resident safety surveys dated 9/19/22 revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 9/18/22 revealed staff were trained on abuse prevention. The in-service did not indicate who trained staff. Review of an in-service dated 9/18/22 revealed staff were trained on dealing with resident behaviors and resident-to-resident altercations. A former DON trained staff. Resident Monitoring 15 Minute Checks Forms dated 9/17/22, 9/18/22, and 9/19/22 revealed Residents #1 and #2 were checked on by staff every 15 minutes. Staff reported time, Resident #2's location, and signed each entry. During an interview on 4/28/23 at 10:36am, the ADM said the incident between Residents #1 and #2 happened on 3/21/23. The ADM said HL was inside Resident #2's bedroom cleaning. The ADM said Resident #2 was standing with her walker outside her bedroom in the hallway and had an outburst. The ADM defined outburst as a sudden release of strong emotion. The ADM said Resident #2 had schizophrenia and was somewhat alert and oriented. The ADM explained Resident #2 would sometimes respond to staff and sometimes would not respond. The ADM said Resident #1 came down the hallway in his wheelchair to Resident #2 and told her tha [TRUNCATED]

Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 68 residents reviewed for incidents. 1. On 9/17/23, a nurse witnessed Resident #1 repeatedly strike Resident #2 in the head. 2. On 11/7/23, staff witnessed Resident #1 and Resident #3 pulling on each other's shirts, scratching, and punching each other. 3. On 3/21/23, HL A witnessed Resident #1 grab Resident #2 by her hair and repeatedly punch her. An IJ was identified on 4/29/23 at 6:21pm. Although the IJ was removed on 05/02/23 at 5:21pm, the facility remained out of compliance at a severity level of no actual harm and scoped at a pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed all residents at risk for accidents, serious injury, emotional distress, and death. Findings included: Resident #2 Review of Resident #2's face sheet dated 4/29/23 revealed she was originally admitted to the facility on [DATE] and returned to the facility on [DATE] from a Behavioral Hospital. Resident #2's primary diagnoses included hypertension, schizophrenia, dementia, hearing loss, Parkinson's disease, cognitive communication deficit, paranoid schizophrenia, recurrent depressive disorders, and insomnia. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS also indicated Resident #2 had no symptom presence and frequency during her mood interview. The MDS indicated Resident #2 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), verbal behavioral symptoms directed towards others 4 to 6 days, rejected evaluations or care daily, and did not wander. The MDS also indicated Resident #2 was received antipsychotic medications for 2 days, on a routine basis, no gradual dose reductions were attempted, and gradual dose reductions were not documented by a physician as clinically contraindicated. The MDS indicated Resident #2 was independent with her bed mobility, transfers, walking between locations in her room and corridor on same floor, and eating and required supervision with walking in corridor on unit, dressing, and personal hygiene. Review of Resident #2's care plan revised on 3/22/23 revealed under one of her problems that started on 9/17/22 and was edited on 3/22/23 by RN A, she had socially inappropriate/disruptive behavioral symptoms as evidenced by having difficulty navigating in social situations and interactions, has conversations with self and others not there, voices paranoid thinking, can become verbally and physically aggressive, refuses care routinely secondary to Paranoid Schizophrenia, Anxiety, and Dementia. The goal for Resident #2's problem that was edited on 3/9/23 by RN A revealed she will not exhibit socially inappropriate/disruptive behavior. Current socially inappropriate/disruptive behavior pattern included difficulty interacting and awareness of other residents and navigating self in social settings. One of the approaches started on 9/17/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 revealed staff must help Resident #2 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Two other approaches started on 9/17/22 revealed staff must Remove resident from other residents' rooms and unsafe situations, When resident becomes socially inappropriate/disruptive, move resident to a quiet, calm environment. Review of Resident #2's progress note dated 9/17/22 at 6:40pm by LVN A revealed at approximately 5:00pm, she observed Resident #2 rolling in the hall in her wheelchair. LVN A heard shouts move, no you move. LVN A saw two residents in the hall side by side in their wheelchairs. The two residents were unable to pass with obstacles in the hall. LVN A got up to attend to the matter before it went too far. Before LVN A could reach Resident #2, Resident #2 was struck in the head repeatedly by Resident #1. A CNA closer to the residents than LVN A broke up the physical altercation. Resident #2 was assessed and had no apparent injuries. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 12:09pm by the SW revealed Resident #2 mentioned pain in one area of her body and denied any other pain. Resident #2 said she was okay, but she wanted to talk to the police. The SW informed the nurse of Resident #2's pain and contacted the police to send a law enforcement office to the facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 1:44pm by the ADON revealed Resident #2 had an altercation with another resident around 9:30am. Resident #2 was noted standing in the threshold of the doorway waiting for HL to finish cleaning her room. Resident #2's behavior was to yell. Resident #1 was in the hallway. Resident #1 rolled his wheelchair over to Resident #2, stood up from his wheelchair, grabbed her hair, and punched her. HL witnessed the altercation. Police came to investigate the incident. Residents #1 and #2 were separated. Resident #1 was to be moved from facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Resident #3 Review of Resident #3's face sheet dated 4/29/23 revealed he was originally admitted on [DATE] and returned 2/26/23. Resident #3's primary diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (blood pressure that is higher than normal), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness, and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 11. The MDS indicated Resident #3 had no symptom presence and frequency during his mood interview. The MDS also indicated Resident #3 had no potential indicators of psychosis, did not exhibit any physical, verbal, or other behavioral symptoms toward others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #3 required supervision with bed mobility, moving between locations, and eating, limited assistance with transfers and toilet use, extensive assistance with dressing and personal hygiene, and was independent with moving and returning from off-unit locations. Review of Resident #3's care plan revised on 3/9/23 revealed under one of his problems that started on 7/15/22 and edited on 2/22/23 by RN A, he had a memory/recall problem/severe cognitive deficit. The goal for Resident #3's problem that was edited on 2/22/23 revealed he will not sustain serious injury due to memory/recall deficit. Two of the approaches started on 7/15/22 included ensure resident's areas were free of hazards and redirect resident when entering unsafe areas. Review of Resident #3's progress note dated 11/7/22 at 3:09pm by LVN B revealed Resident #3 was seen in a physical altercation with another resident. Both residents were seen pulling on each other's shirts, scratching, and punching the other. Residents were quickly pulled apart from one another. No injuries were present on Resident #3 at the time and Resident #3 did not complain of any pain. The progress note did not indicate whether Resident #3 was assessed by psychiatry after the incident. Resident #1 Review of Resident #1's face sheet dated 4/28/23 revealed he was admitted to the facility on [DATE] with primary diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), bipolar disorder (disorder associated with episodes of mood swings), schizophrenia (mental disorder in which people interpret reality abnormally), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS indicated Resident #1 did not have any symptoms present during his mood interview. The MDS also indicated Resident #1 did not have any potential indicators of psychosis, did not exhibit any physical, verbal, or other behaviors towards others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #1 required supervision with his bed mobility, was independent with his transfers, walking in room and corridor, moving between locations, and eating, limited assistance with toilet use, and extensive assistance with dressing and personal hygiene. The MDS also indicated Resident #1 received antipsyhotic, antiaxiety, and antidepressant medications for 7 days, received antipsychotics on a routine basis, did not have a physician document a gradual dose reduction as clinically contraindicated, and did not have a gradual dose reduction documented by a physician and clinically contraindicated. Review of Resident #1's care plan revised on 3/22/23 revealed under one of his problems that started on 9/17/22 and was edited on 3/22/23 by the former DON, he had socially inappropriate/disruptive behavioral symptoms as evidenced by physical and verbal aggression towards other residents and staff secondary to Bipolar D/O, TBI, Schizophrenia, Psychotic D/O with Hallucinations, Anxiety, Restlessness & Agitation. The goal for Resident #1's problem that was edited on 3/9/23 by RN A revealed he not harm self or others secondary to socially inappropriate/disruptive behavior. Current behavior pattern included verbal and physical aggression in certain social situations when his needs or demands are not met immediately. One of the approaches started on 9/17/22 and edited on 9/18/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 and edited on 9/18/22 revealed staff must help Resident #1 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Review of Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's psychiatry clinical note dated 9/21/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are improving. His anger is well controlled. Impulsive behaviors are not currently being displayed . The note also stated under the staff report section: [NAME] had an altercation with another resident on 9/17 where he and another female resident got into a verbal dispute that resulted in patient grabbing female resident and punching her several times in the head. Once the incident was broken up he went to his room and no further incidents between the two were noted. When discussing these behaviors with patient he is remorseful and apologizes for his impulsive behaviors when angry. Provider discussed events with patient's mom so she could also address them with him as well. Review of Resident #1's psychiatry clinical note dated 11/11/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are normal. His anger is well controlled. Impulsive behaviors are not currently being displayed . There was no staff report section included in the note regarding Residents #1 and #3's incident on 11/7/22. Review of Resident #1's psychiatry clinical note dated 3/24/23 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. He is socializing less with staff and other residents. [NAME]'s anger is poorly controlled. Impulsive behaviors continue to be a problem. The note also stated under the staff report section: [NAME] had a major altercation on 3/21/23 (provider was not notified until today). His neighbor was out in the hallway yelling and cursing at the housekeeper who was cleaning her room and [NAME] came out to where she was in the hallway and yelled at her to be quiet. This caused her to keep yelling and then turn her anger toward him and they exchanged words until [NAME] got up from his wheelchair and began punching the other resident. [NAME] has since been moved to another hall away from her room and no incidents between the two or any other resident have occurred since then. When provider asks [NAME] about this incident he states, it wasn't my finest moment .I just snapped. He is remorseful today about events that happened. Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's progress note dated 11/07/22 at 2:55pm, written by LVN B revealed Resident #1 was seen in a physical altercation with another resident. Resident #1 and the other resident were pulling on each other's shirts, scratching, and punching. Resident #1 and the other resident were quickly pulled apart by a CNA and CMA. Resident #1 began yelling at the other resident that he would kill him. When Resident #1 was asked what happened, he stated, He wouldn't stop kicking my chair and told me to move, that's why I beat his ass. The progress note did not indicate whether Resident #1 was assessed by psychiatry after the incident. Review of Resident #1's progress note dated 3/21/23 at 1:33pm written by the ADON revealed at approximately 9:30am, she heard shouting on D hall. Residents #1 and #2 were physically fighting in the hall. HL witnessed the altercation that lasted a few seconds. Resident #1 grabbed Resident #2 by her hair and punched her in her head and breast area. Resident #1 stated he snapped when Resident #2 was yelling at HL. The ADON took Resident #1 to her office. Law enforcement was called and arrived at the facility because Resident #2 wanted to press charges on Resident #1. Review of Resident #1's progress note dated 3/21/23 at 2:00pm but recorded as a late entry on 03/22/23 at 10:43am written by RN A revealed it was reported to him that Resident #1 became aggressive with another resident. After review, it appeared Resident #1's triggers were loud noises and verbal outbursts from other sources. Review of Resident #1's progress note dated 3/21/23 at 3:30pm written by SW revealed she visited Resident #1 regarding the incident that took place with another resident. Resident #1 stated his actions and stated understanding of the consequences. Review of Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed there was a resident to resident incident on 3/21/23 at 9:55am in D Hall. Resident #2 was listed as an individual/resident involved. Resident #2's functional ability was listed as total assistance. Resident #2's level of supervision was listed as within hearing. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #2's other pertinent history revealed she had a history of outbursts, but mostly not towards anyone. Resident #1 was also listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, not independently ambulatory, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had both physical and verbal aggression towards staff and other residents and had been involved in other altercations in the past. No alleged perpetrators were listed. HL was listed as a witness. No adverse injury or effect were noted. Description of injury revealed there was no injury on either Residents #1 and #2 at the time and both of them were being monitored for late reactions/injuries. Provider response revealed Resident #1 was kept on one-on-one monitoring, removed from the hall to another, medications were reviewed, and emergency care plan with residents family was initiated to discuss his behaviors and a possible discharge. Investigation findings were inconclusive. Provider action taken post-investigation revealed staff were in-serviced on resident to resident altercation, Resident #1 was relocated to another hall, there was an emergency care plan with his family about resident's aggression and the possible discharge if his behaviors continued, and his medications were reviewed. The ADM signed the report on 3/28/23. Review of statements included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed HL witnessed the incident between Residents #1 and #2. HL wrote a statement on 3/21/23. HL said in her statement that Resident #1 was punching Resident #2's head, kicking Resident #2, and pulling Resident #2's hair. HL also said in her statement that she tried to open Resident #1's fingers to let Resident #2 go, but Resident #1 was so strong and would not let Resident #2 go. HL said in her statement that she kept telling Resident #1 to stop punching, kicking, and pulling Resident #2. HL also said in her statement that she remembers yelling for her boss, HS, to come help her. HL also said in her statement that Resident #1 eventually let Resident #2 go. HL said in her statement she hoped Resident #2 was okay. Statements also revealed SW met with Resident #2 in the front lobby on 3/21/23 and obtained a statement from her. Resident #2 said in her statement that she was in some pain in the chest area and her head. This information was reported to the charge nurse. Resident #2 also said in her statement that when she was asked what took place, she responded, I don't know. He just started hitting and punching me! I didn't do anything to him. Resident #2 added she wanted to call the police. SW confirmed resident #2 wanted to call the police and resident #2 responded, Yes, that's assault and battery, I know my rights! SW contacted the police and resident #2 waited for their arrival in the front lobby. Statements also revealed SW met with Resident #1 in her office on 3/21/23 and obtained a statement from him. Resident #1 said in his statement that he reported Resident #2 had been keeping him up all night for the past four days with constant yelling and cursing. Resident #1 also said in his statement that when he saw Resident #2 yelling at HL, he just had it. Resident #1 said in his statement when proceeding with the events, I just grabbed her by her hair and kept punching her. Resident #1 added in his statement that he knew what he did was wrong, but he had just had enough. Resident #1 said in his statement that he reported no pain and understood he might have to face some consequences to come. Review of an in-service dated 3/22/23 revealed staff were trained by RN A on monitoring Resident #1, identifying signs of overstimulation (i.e., loud noises, screaming, and arguing), and how to approach a resident who was overstimulated. Staff were trained to encourage the resident to move to a calmer area whenever he/she became overstimulated. Policy and procedure for dealing with resident behaviors undated was attached to the in-service. Review of an in-service dated 3/27/23 revealed staff were trained by the ADM and DON on resident-to-resident altercations. Staff were trained to pay attention to agitation, not to ignore residents since they can ultimately make things worse, and types of behavior are forms of communication. Policy and procedure for resident-to-resident altercation dated December 2016 was attached to the in-service. Review of an in-service dated 4/25/23 revealed staff were trained on abuse and neglect. The in-service did not indicate who trained staff. Staff were trained to protect residents and staff, the definitions for abuse and neglect, what to do if abuse and/or neglect was seen or suspected, and who was the abuse coordinator. Review of resident safety surveys dated 3/23/23 and included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of Provider Investigation report submitted to the State Agency on 11/8/22 at 8:15pm revealed there was a resident to resident altercation on 11/7/22 at 2:50pm in the living area. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within hearing. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of engaging in physical and verbal altercations with other residents and staff. Resident #3 was also listed as an individual/resident involved. Resident #3's functional ability was listed as total assistance. Resident #3's level of supervision was listed as within hearing. Resident #3 was listed as interviewable, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident. Resident #3's other pertinent history revealed he was usually quiet and sits with other residents to watch tv in the living area. No alleged perpetrators were listed. A former staff member was listed as a witness. No adverse injury or effect were noted. No description of injury was noted. Description of allegation noted a charge nurse reported and documented Residents #1 and #3 were seen in the living area holding each others' shirts and punching each other. Provider response revealed Residents #1 and #3 were put on one-on-one monitoring, observed for 72 hours for any adverse effects from incidents, and staff were in-serviced on resident-to-resident altercation. Investigation findings were confirmed. Investigation summary noted Residents #1 and #3 were involved in altercation, both residents were doing well during the investigation, and have stated they were not in pain. Provider action taken post-investigation revealed Residents #1 and #3 were monitored for behaviors, injuries, and psychological or emotional distress resulting from the incident and staff were in-serviced on resident-to-resident altercation. The ADM signed the report on 11/14/22. Review of statements included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed SW met with Resident #3 at bedside on 11/8/22 and obtained a statement from him. Resident #3 said in his statement that Resident #1 kept pushing his chair. Resident #3 also said in his statement that in return, he got ready to hit him. Resident #3 said in his statement that he was okay and just in minor pain from the altercation with Resident #1. Statements also revealed SW met with Resident #1 in her office on 11/8/22. Resident #1 said in his statement that Resident #3 pushed his chair and added, he always does this and I'm tired of it! Resident #1 also said in his statement that in return, he got up and punched him in the face. Resident #1 said in his statement that he was okay now and in better spirits. Review of resident safety surveys dated 11/9/22 and included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed six residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 11/14/22 revealed staff were trained on resident to resident altercation. The in-service did not indicate who trained staff. Staff were trained to redirect residents when they were having an outburst that can lead to an altercation. Policies and procedures for resident-to-resident altercation dated December 2016 and dealing with resident behaviors undated were attached to the in-service. Review of a Provider Investigation Report submitted to the State Agency on 9/17/22 at 6:45pm revealed there was a resident on resident altercation on 9/17/22 at 5:00pm in the hallway. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of aggressive behaviors towards other residents and staff and was unable to control his emotions prior to his cerebral infarction. Resident #2 was also listed as an individual/resident involved. Resident #2's functional ability was listed as minimal. Resident #2's level of supervision was listed as within eyesight. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of verbal aggression. Resident #2's other pertinent history revealed she had a diagnosis of schizophrenia, anxiety disorder due to known physiological condition, wandered to other residents' rooms sometimes as early as 2:00am and some of them were aggravated when she wandered into their room, and prior to incident wandered into Resident #1's room and he woke up from sleep. No alleged perpetrators were listed. No witnesses were listed. No adverse injury or effect was noted. Description of injury noted no injuries sustained by either of the residents. No description of allegation was noted. Provider response revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments of both residents for 3 days, Resident #1's Psych NP was notified and indicated she would review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, and staff were in-serviced on resident on resident altercations. Investigation findings were confirmed. Provider action taken post-investigation revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments for 3 days, Resident #1's Psych NP was notified and indicated she was going to review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, staff were in-serviced on resident on resident altercations and residents had since been okay. The ADM signed the report on 9/24/22. Review of CNA C witness statement dated 9/17/22 indicated CNA C was putting a resident in her geri-chair. CNA C said in her statement Resident #1 started yelling at her to move. CNA C stated she told Resident #1 she was almost done putting the resident in her geri-chair. CNA C stated Resident #1 proceeded through her and the resident she was helping. CNA C stated Resident #1 hit the other resident's feet with his wheelchair as she was going down with the hoyer lift and she told Resident #1 that's rude. CNA C stated Resident #1 told her to move because she was in his way and about time she did her job. CNA C told Resident #1 she always did her job and Resident #1 said Fuck you, you don't do shit. CNA C said she ended all conversation with Resident #1. CNA C indicated Resident #1 was very rude, bullied other residents, and some residents were even scared to go around him. CNA C stated Resident #1 entered another resident's room while the resident was in the hospital and took his personal items, drinks, food, and money and bragged about it. CNA C indicated she witnessed and reported Resident #1 several times running over another resident's feet, telling her to move, calling her names, pushing her chair to where he was trying to move her until she hit the wall, cussing at the nurses, calling the nurses names, and knocking things off the nurse's cart when he was mad. Review of CNA D's witness statement dated 9/17/22 indicated she heard Resident #1 and #2 arguing in the hallway. CNA D indicated Resident #2 was talking, Resident #1 punched her repeatedly in the face until she came running back down the hallway to stop him. Review of Resident #2's statements written by the SW on 9/19/22 indicated Resident #2 did not know what the SW was referring to when she spoke with her regarding the incident. Resident #2 indicated she had no concerns or complaints regarding the weekend. Further review revealed the SW followed up with Resident #2 on 9/20/22 and 9/22/22. Resident #2 asked the SW why she kept asking her about the past weekend and appeared to not recall what the SW was referring to. Review of Resident #1's statement written by the SW dated 9/19/22 revealed Resident #1 said he was not harmed or upset about the event involving Resident #2 on 9/17/22 and had no concerns or complaints regarding the weekend. The SW followed up with Resident #1 on 9/20/22 and 9/22/22. Resident #1 said he was over it, fine, and had no concerns or complaints regarding the weekend. Resident safety surveys dated 9/19/22 revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 9/18/22 revealed staff were trained on abuse prevention. The in-service did not indicate who trained staff. Review of an in-service dated 9/18/22 revealed staff were trained on dealing with resident behaviors and resident-to-resident altercations. A former DON trained staff. Resident Monitoring 15 Minute Checks Forms dated 9/17/22, 9/18/22, and 9/19/22 reveal[TRUNCATED]

Based on observation, interview, record review, and facility policy review, the facility failed to initiate and implement interventions to prevent wounds from developing. This failure affected one (Resident #58) of two residents reviewed for wounds and had the potential to affect the remaining 27 residents identified as at risk for skin breakdown. The deficient practice resulted in Resident #58 developing a Stage IV pressure ulcer to the ischium. Findings included: A review of Resident #58's quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The record also indicated a Brief Interview for Mental Status (BIMS) of 00, which indicated severe cognitive impairment. The MDS indicated Resident #58 had no pressure ulcers or other skin conditions but was at high risk for developing pressure ulcers. The MDS indicated the resident was always incontinent of bladder and bowel. The MDS indicated Resident #58 required extensive assistance of two staff members for transfers and bed mobility and was totally dependent on the assistance of one staff member for mobility throughout the facility. A review of a care area assessment (CAA) for Resident #58, dated 06/24/2021, indicated a care plan decision was made to develop a care plan regarding pressure ulcer injury prevention. However, a care plan regarding pressure ulcer prevention was never developed. A Braden scale for predicting pressure sore risk was completed by the facility on 08/26/2021 and indicated Resident #58 was at high risk for developing pressure ulcers. A review of progress notes for Resident #58, dated 10/09/2021, indicated the resident developed new stage II pressure ulcers (partial-thickness skin loss with exposed dermis) to the left lateral gluteal fold measuring 1.3 centimeters (cm) x 1.6 cm x 0.1 cm, the left medial gluteal fold measuring 2.6 cm x 2.0 cm x 0.1 cm, the right lateral gluteal fold measuring 0.8 cm x 1.0 cm x 0.1 cm, and the right medial gluteal fold measuring 1.0 cm x 0.5 cm x 0.1 cm. A review of Resident #58's care plan, developed on 10/25/2021, indicated a care plan was initiated for a stage IV (full-thickness skin and tissue loss) pressure ulcer to the left ischium, which had evolved from the left medial gluteal fold stage II pressure ulcer. Interventions included the following: - Administer vitamins and minerals. Date created was 10/28/2021. - Apply dressing per MD (medical doctor) order. Date created was 10/25/2021. - Assess the pressure ulcer for stage, size, presence or absence of granulation tissue and condition of surrounding skin weekly. Date created was 10/25/2021. - Conduct a systematic skin inspection weekly. Date created was 10/25/2021. - Clean and dry as possible. Minimize skin exposure to moisture. Date created was 10/25/2021. - Keep linens clean, dry and wrinkle free. Date created was 10/25/2021. - Turn and reposition every two hours and as needed. Date created was 10/25/2021. - Use support surface when resident in bed. Date created was 10/25/2021. A review of wound physician notes revealed the resident was seen by a contracted wound physician weekly from 10/28/2021 through 12/27/2021 for the left ischium. A review of the CAA for Resident #58, dated 12/08/2021, indicated a care plan decision was made to include a care plan regarding pressure ulcer prevention. However, a care plan regarding pressure ulcer prevention was never developed. A review of Resident #58's care plan, with the most recent revision date of 12/23/2021, indicated the facility had not developed a care plan related to skin integrity or prevention of pressure ulcers. Observation of Resident #58, on 12/28/2021 at 9:51 AM, revealed the resident's bed contained an air mattress. The resident was not in the room at the time. During a dining room observation, on 12/28/2021 at 11:58 AM, Resident #58 was seen in a wheelchair, with a thick foam cushion on the wheelchair and a wedge cushion between the knees. Observation of Resident #58 on 12/30/2021 at 10:28 AM, revealed the resident was in bed. There was an air mattress on the bed. The right side of the bed was against the wall. During an interview on 12/30/2021 at 8:37 AM, Certified Nurse Aide (CNA) B was asked how they were made aware of special needs of residents, including pressure sore prevention. CNA B stated they were informed of special needs of residents by the nurses and staff from the previous shift. When asked if there were any special interventions in place for Resident #58 regarding pressure sore prevention, CNA B stated, Just the air mattress. When asked if there was any information on the kiosk (where care plan information was transmitted from care plans and accessed through a care plan tab; also, where CNAs documented the daily care of residents) containing special interventions for Resident #58, CNA B stated, No. During an interview on 12/30/2021 at 8:37 AM, CNA C was asked how they were made aware of special needs of residents, including pressure sore prevention. CNA C stated they were informed by the nurses and noted it was on the 24-hour report. When asked if Resident #58 had any special interventions in place to prevent pressure sores, CNA C stated the resident had an air mattress, and they tried to turn the resident when they could. CNA C stated the resident often refused care interventions, particularly turning and repositioning. When asked if there was any information on the kiosk of special interventions, particularly regarding turning and repositioning, CNA C stated, No. During a wound care observation on 12/30/2021 at 10:28 AM for Resident #58, Licensed Vocational Nurse (LVN) A provided wound care to the left ischium. LVN A followed all wound care orders and infection control standards. LVN A was asked if the resident had any interventions in place to prevent the pressure sore from worsening. LVN A stated the resident received multivitamins and was on an air mattress. LVN A stated the resident did wear soft boots for the heels at one time, but no longer wore them. The resident lacked a care plan directing staff to don soft boots for Resident #58 in order to offload pressure to the heels. When LVN A examined the resident's heels, it was noted there was an area of redness to the right heel, which was blanchable and approximately the size of a half dollar. LVN A placed a pillow under the resident's legs to elevate the resident's heels off the bed. During an interview on 12/30/2021 at 1:13 PM, the Assistant Director of Nursing (ADON) was asked how staff knew what interventions were put in place to prevent skin breakdown for a resident. The ADON stated CNAs received information from the kiosk, which was where they documented the daily care of residents. The ADON stated there was a tab on the computer kiosk titled, Care Plan, which was verified by the surveyor. When asked how the information was transmitted to the care plan tab on the kiosk, the ADON stated it came from the care plans. The ADON stated they were surprised the staff did not know where the care plans were on the kiosk, as they had been trained. When asked if nurses monitored what interventions were to be in place for Resident #58's skin integrity, the ADON stated the corporate office did not allow the facility to write orders which, if allowed, would then be displayed on the treatment administration record (TAR) and signed off each shift that the intervention was in place. When asked how agency nurses or other temporary staff knew where to find interventions for resident care, the ADON stated they had to look in the care plans. When asked if there were any weekly skin assessments for Resident #58, the ADON stated the facility charted by exception and that they only monitored existing pressure ulcers, bad skin tears, surgical wounds, and cuts. When asked what the definition of a bad skin tear was, the ADON stated one where it was hard to approximate the skin edges or flap. During an interview on 12/30/2021 at 1:13 PM, the clinical case manager stated it was their responsibility to develop care plans. When asked if Resident #58 had a pressure-relieving cushion in the chair or a pressure relieving cushion between their knees, the clinical case manager replied in the affirmative. When asked if those interventions were in the care plan, the clinical case manager stated they were not. When asked if the CNA would see those interventions on the kiosk since they were not in the care plans, the clinical case manager stated, No. When asked if the resident had any care plans regarding skin integrity and pressure ulcer prevention or if there were any interventions in place prior to the resident obtaining a stage IV pressure ulcer to the ischium, the clinical case manager stated they were unable to locate one. During an interview on 12/30/2021 at 1:13 PM, the Director of Nursing (DON) was asked if pressure ulcers could have been avoided had interventions been in place for Resident #58. The DON stated it was possible, but with the resident's other medical problems, pressure ulcers may have developed regardless of facility intervention. The DON stated the care plan should have been written. During an interview on 12/30/2021 at 1:13 PM, the Administrator stated care plans were expected to be developed and to include interventions needed to provide care for that resident. The administrator confirmed the interventions that were to be available on the kiosk for the CNAs was generated from the care plan, which was not initiated for Resident #58. During an interview on 12/30/2021 at 5:45 PM, the Medical Director was asked if they were aware there were no interventions put in place to prevent skin breakdown/pressure sores for Resident #58. The Medical Director stated they were not aware of this and would work with the staff regarding this issue. The Medical Director also stated the wounds for Resident #58 may have developed even with prevention interventions but confirmed attempts at preventing the wounds should have been employed. A review of the facility's policy and procedure titled, Prevention of Pressure Injuries, revised 04/2020 indicated, The purpose of this procedure is to provide information regarding identification of pressure injury risk factors and interventions for specific risk factors .Review the resident's care plans and identify the risk factors as well as the interventions designed to reduce or eliminate those considered to be modifiable .Monitoring. 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an on-going basis. Texas Administrative Code (TAC) §554.901(2)(A)(i), Tag 1449. This requirement is not met as evidenced by: For evidence of violation refer to CMS Form 2567 dated 12/30/2021, F686.

Based on observation, interview and record review the facility failed to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident for one of five residents reviewed for range of motion (Resident #2) and four of four halls reviewed for clean and homelike environment. A. The DON failed to ensure policies and procedures were in place to ensure Resident #2 received interventions to prevent decrease in range of motion or the development and/or worsening of contractures. B. The Administrator failed to ensure residents on all four hallways were provided with a clean and homelike environment. 1. Ensure resident bathrooms did not leak water under the door, creating a slippery surface in resident rooms. 2. Ensure the facility was pest free. 3. Ensure the main dining room was a comfortable temperature. 4. Ensure resident room was in good repair, clean and free of dirt, trash and debris. This deficient practice could place 12 residents with contractures at risk for fixation of joints and loss of function which could lead to increased need for ADL assistance, decline in skin health in the contracture and decreased self-esteem. This deficient practice could also place the census of 91 residents at risk of having a poor quality of life and diminished clean, homelike environment. The findings include: A.During an interview on 5/27/16 at 8:05 a.m., the DON stated she had been at the facility for four months and had not provided training related to contractures. The DON further stated staff was monitored for compliance with standards of care by DON and ADON oversight, daily morning meetings to discuss concerns or issues, facility Angel Rounds and competency evaluations. The DON stated a communication deficit contributed to Resident #2 ' s worsening contractures. The DON stated resources for training, policy and procedure development as well as consultations were available through the facility corporate staff, consultants and the facility medical director During an interview on 05/24/16 at 11:04 a.m., CNA D stated Resident #2 was supposed to be placed on Restorative Program due to contractures, but stated she had not heard any additional information related to this. During an additional interview on 05/25/16 at 11:50 a.m., CNA D stated Resident #2 ' s legs have gotten more contracted since he admitted to the facility. CNA D stated Resident #2 could move his arms, but his right hand was contracted. CNA D stated she sometimes stretched his legs when she performed care; CNA D stated if he hurt, she would leave him alone. CNA D again stated that the Restorative Nursing Program was supposed to pick him up. She was unable to say why Resident #2 was not receiving restorative care. During an interview on 05/25/16 at 11:20 a.m., LVN B stated Restorative Care was talking about picking him (Resident #2) up, but I don ' t know where they are on that. LVN B stated she tried to reposition him. I know it ' s not much. During an additional interview on 05/27/16 at 11:53 a.m., LVN B stated Resident #2 ' s contractures have worsened. She stated sometime in either January or February of 2016, someone asked if there were any residents who would benefit from restorative care. LVN B stated she started a list of residents, which included Resident #2. She stated she handed off the list to the nurse who worked the following shift, but she was unable to recall who she gave the list to. LVN B stated she was unsure if the list was ever given to the MDS Coordinator/LVN H, who was over the Restorative Nursing Program. She was unable to say why Resident #2 was not receiving restorative care. During an interview on 05/26/16 at 10:24 a.m., CNA and Restorative Aide F stated residents in the Restorative Nursing Program received range of motion and/or routine splints. She stated Resident #2 was in therapy in the past. CNA/Restorative Aide F stated she never provided Restorative Care to Resident #2. She stated she was never notified to provide restorative care to Resident #2. During an interview on 05/26/16 at 10:30 a.m., CNA and Restorative Aide G stated residents in the Restorative Nursing Program received stretches for range of motion and/or splints for contractures. She stated she never provided Restorative Care to Resident #2. She stated she was never notified to provide restorative care to Resident #2. During an interview on 05/26/16 at 10:37 a.m., DOR/PTA stated after a resident received therapy, they were usually referred to Restorative Care. DOR/PTA stated he was under the impression Resident #2 received Restorative Nursing Care. During an additional interview on 05/26/16 at 11:00 a.m., DOR/PTA stated according to Resident #2 ' s Discharge Summary from therapy services, he was recommended for Restorative Care. DOR/PTA was unable to say why Resident #2 was not receiving Restorative Care or other splinting devices for his contractures. During an interview on 05/26/16 at 11:40 a.m., the DON stated MDS Coordinator/LVN H was responsible for the Restorative Nursing Program. The DON stated if a resident had contractures, they usually received Restorative Care, and she expected contractures to be addressed in the resident's Care Plan. During an additional interview on 05/27/16 at 8:30 a.m., the DON stated the facility did not have a Policy or Procedure for Range of Motion, Contractures or Restorative Care. During an interview on 05/26/16 at 11:55 a.m., DOR/PTA stated if a resident was to be referred to the Restorative Nursing Program, he verbally notified MDS Coordinator/LVN H. DOR/PTA stated he did not document the referral or communication with MDS Coordinator/LVN H to the Restorative Program. He was unable to say why Resident #2 was not referred to the Restorative Nursing Program. During an interview on 05/26/16 at 12:00 p.m., MDS Coordinator/LVN H stated she was responsible for the Restorative Nursing Program. She stated if a resident came off of therapy and needed Restorative Care, RD/PTA notified her, and the resident was then placed on the Restorative Nursing Program. MDS Coordinator/LVN H stated she was not sure why Resident #2 was never placed on the Restorative Nursing Program. She said, He will be picked up now. MDS Coordinator/LVN H stated if a resident had contractures, she tried to incorporate this into their Care Plan. Surveyor reviewed Resident #2 ' s Care Plan with MDS Coordinator/LVN H, and she agreed with surveyor that Resident #2 ' s Care Plan was not specific to the treatment for [REDACTED]. During an interview on 05/27/16 at 10:25 a.m., CNA P stated Resident #2 ' s right and left leg and his right hand was contracted. CNA P stated Resident #2 ' s contractures have worsened since his admission to the facility, Especially his legs. CNA P stated she notified LVN B and another nurse, currently out on maternity leave, that Resident #2 ' s contractures worsened. She was not sure why Resident #2 was not receiving restorative nursing care. During an interview on 05/27/16 at 10:30 a.m., RN/ADON Q stated she was responsible for Hall A, where Resident #2 resided. RN/ADON Q stated she finds out a resident needs restorative care through the MDS Coordinator/LVN H. RN/ADON Q stated Resident #2 ' s legs were more contracted, but his right hand was better. She was unable to say why Resident #2 was not receiving restorative nursing care. During an interview on 05/27/16 at 10:35 a.m., DOR/PTA stated he met with MDS Coordinator/LVN H daily after morning meeting to discuss each resident who received therapy. The DOR/PTA could not remember discussing Resident #2 with the MDS Coordinator. He could not say why Resident #2 was not receiving Restorative Care. During an interview on 05/27/16 at 11:17 a.m., NP R stated Resident #2 continued to decline, and she tried to get social services to place him on palliative care or Hospice. NP R stated Resident #2 would be indicated for Restorative Nursing Program due to his contractures. NP R stated she did not push for restorative care because, I was focusing on his infection. There ' s a lot of things going on (with Resident #2) more than just restorative care. NP R agreed Resident #2 needed restorative care. During an interview on 05/27/16 at 2:52 p.m., the Administrator stated he was under the impression Resident #2 received restorative care. He stated each resident was screened for therapy. The Administrator stated Resident #2 was now added to the Restorative Nursing Program. B. During an interview on 05/27/16 at 2:55 p.m., the Administrator stated the facility had a plan to fix the damaged doors in the bathrooms, and they were going through a renovation. When asked for the plan, or a time frame, the Administrator stated the Maintenance Director had a list of the damaged doors that were identified earlier in the week. The Administrator stated he did not have a timeline for completion of the maintenance. The Administrator also stated, We have some policies and procedures that were not being followed. When asked which policies were not being followed, the Administrator stated some procedures were not being followed, and the staff should document what they were doing. The Administrator was asked a second time, but failed to identify what procedures he meant. During an interview on 5/27/16 at 10:46 a.m., the Maintenance Director stated corporate office had not yet trained him on his job duties, and he was just doing what he thought needed to be done. 1. During an observations on 5/23/16 at 1:35 p.m., Resident #9 ' s room had an overwhelming smell of urine. Resident #9 was observed lying on a low bed. A urinal with yellow liquid was on the floor next to Resident #9, and wet foot prints were observed leading from the bed to the door leading outside the facility. The wood at the bottom of the door to the bathroom was observed to be peeling and splitting. During an interview on 5/23/16 at 1:35 p.m., LVN S stated Resident #9 stays in his room, and he does not allow staff to clean. During an observation and interview on Initial Tour on 05/23/16 at 2:18 p.m., Resident #36 (room [ROOM NUMBER]) stated he normally took his showers in his bathroom in his room. Resident #36 stated he placed a towel under his bathroom door to keep water from leaking under the door, making the floor slippery. The wood to the bottom and inside of Resident #36's bathroom door was splintered, with wood sticking out. During an additional interview on 05/25/16 at 12:23 p.m., Resident #36 stated on one occasion, he walked out of his bathroom and slipped on the water, which leaked from under the door from his shower. He said, I caught myself, before he fell . Resident #36 verbalized fear of slipping on the water and hitting his head. Resident #36 stated he now placed a towel under the door to keep the water from draining onto his bedroom floor. During an interview on 5/24/16 at 11:56 a.m., CNA Y stated that when she bathed the resident in room [ROOM NUMBER], she had to put towels on the floor to stop water from coming out of the restroom during showers and onto the room floor. During an interview on 05/25/16 at 11:50 a.m., CNA D stated the shower in room [ROOM NUMBER] was not draining. She stated water in the bathroom for room [ROOM NUMBER] and room [ROOM NUMBER] would sometimes leak under the bathroom door during showers. CNA D stated she placed a large bath blanket on the floor to keep water from leaking under the door of the bathroom. During an interview on 5/26/16 at 8:45 a.m. of room [ROOM NUMBER], Resident #39 stated staff put a blanket down at the restroom doorway in order to prevent water from coming out in the room during showers. During an interview on 5/26/16 at 9:10 a.m., CNA T stated water does not go under the door when the residents are showering in room [ROOM NUMBER] (B-Hall), but sometimes water will go directly from the bathroom, through the walls in to the hallway when showering in other rooms. CNA T identified the rooms on B-Hall with water going into the hall: room [ROOM NUMBER] and room [ROOM NUMBER]. CNA T also stated water sometimes comes up from the floor when the toilet is flushed in room [ROOM NUMBER], also on B-Hall. During an observation and interview on 5/26/16 at 9:20 a.m. in room [ROOM NUMBER] there was water coming from under the bathroom door while CNA Z was giving a resident a shower. CNA Z stated water usually comes from under the door during showers. CNA Z also stated they have to put towels down in front of the door to stop water from leaking out into the bedrooms. During an interview on 5/27/16 at 10:46 a.m., the Maintenance Director stated he tried to catch up on maintenance issues since he arrived at the facility in 04/2016. He stated he addressed the shower door issues by sanding and refinishing the doors, but some doors were too damaged to repair and needed to be replaced. The Maintenance Director stated the corporate office had not yet trained him on his job duties, so he was just doing what he thought needed to be done. The Maintenance Director stated maintenance requests were written in the Work Order book, which he reviewed throughout the day to see if any new requests were made. He stated he believed it was a design flaw of the restroom that allowed water to escape from the restroom into the room during showers. 2. During an observation on 05/23/16 at 1:47 p.m., gnats were observed in room [ROOM NUMBER]'s bathroom sink. During a confidential group interview on 5/24/16 at 10:15 a.m., nine alert and oriented residents stated the facility had problems with pest. The residents all agreed the biggest problem was gnats, which were bothersome especially around food items and meal times. During an observation on 5/24/16 at 2:26 p.m. of room [ROOM NUMBER] revealed there was a plastic cup located on top of the single restroom light fixture. Upon review of the cup, the cup contained an unidentified brown lump. The cup's opening was covered with plastic wrap, that had one hole punched into the middle. On top of the brown lump inside the cup were numerous small dead maggots. Flying around the cup and in the restroom in general were numerous gnats. Gnats were also observed flying in the room outside of the restroom. During an interview on 5/24/16 at 2:30 p.m., the Administrator stated he had placed a homemade pest control remedy, which he found on the internet, in approximately five to six resident rooms on the D Wing restrooms five to six days ago. He could not recall which rooms he placed them in. The Administrator stated the remedy was placing a banana in the plastic cup, putting the plastic wrap over the cup ' s opening, then putting a small hole in middle of the cup. The idea was the flies would be drawn into the cup through the hole, but would not be able to escape the cup. The Administrator stated he failed to tell anyone he did this and later forgot he put the cups out. The Administrator stated it was his fault for not telling anyone when he put the cups out and then not picking the cups up. The Administrator stated he tried the homemade fly trap method because it was cheaper than buying fly traps from the store. During an interview on 05/25/16 at 11:50 a.m., CNA D stated she observed gnats in multiple resident rooms. During an interview on 05/27/16 at 10: 15 a.m. and 2:52 p.m., the Administrator stated he was aware the facility had a pest problem in regards to gnats. He stated the previous pest control agency was terminated, and the new agency was making progress at ridding the facility of gnats. The Administrator stated the gnats came from resident potted plants. He stated due to the recent rainfall, the gnat issue was still being worked on. The Administrator stated he did not believe the homemade fry traps he used on the D Wing in an unrecalled number of rooms contributed to the gnat problem. He stated he believed the gnats could not escape once they were inside the cup. The Administrator could not explain why the gnats could not fly out the same hole they flew into. The Administrator stated he got the idea for the homemade fly traps from a video on the internet. He stated when he mentioned the idea to an unrecalled pest control company employee, that employee gave him the okay to try it out. Review of pest control contract revealed facility signed a pest control management contract on 01/15/16. Supplement to Commercial-Monthly Service Agreement revealed, .Be sure to treat inside wooden sink varieties in the rooms that have one. (Facility) will continue to work to continue replacing them. During an interview on 5/24/16 at 4:00 p.m., the supervisor with the contracted pest control company stated the company provides pest control treatment to the facility every Monday. The treatment included one wing per visit and whatever else may be needed. The supervisor stated the facility had Drain Flies coming from the piping areas around the ice machine, and the wall void the piping goes into became a micro-environment for the flies. In addition, the water seepage into the walls created an environment conducive to Drain Flies. As a result, all these areas are treated by the pest control company. The supervisor stated neither he, nor the staff, recommended the use of homemade pest traps. He stated it was recommended to avoid these types of traps. The supervisor stated he did not give the facility approval to use a homemade fly trap, and he had no knowledge of any staff doing so either. The supervisor stated that the homemade trap tried at the facility likely contributed to the fly problem. 3. Review of the facility's undated policy on room temperatures revealed that it was a copy of state regulation 19.705 Environment which stated in part that temperature must be maintained between 71-81 degrees Fahrenheit. During an observation on 5/24/16 at 12:10 p.m., Resident 10 sat in the dining room, shaking. When asked if she was cold, Resident 10 stated, Yes. During a confidential group interview on 5/24/16 at 10:15 a.m., nine alert and oriented residents stated it gets very cold in the dining room during meal times. During an interview on 5/24/16 at 12:11 p.m. in the dining room, Resident 37 stated she was cold, but then she put on a jacket and asked the staff to turn off the ceiling fan above her. During an interview on 5/24/16 at 12:13 p.m. in the dining room, Resident 38 stated he was a little cold. During an interview on 5/24/16 at 12:00 p.m. in the dining room, Resident 40 stated he was cold, but he turned off the ceiling fan above him and he was no longer cold. Resident 40 also stated the ceiling fan wobbled. Resident 40 stated he notified the Assistant Maintenance Director a few weeks ago, but was told he could not fix it. During an interview on 5/24/16 at 11:40 a.m., the Maintenance Director, stated he did not have a way to measure air temperatures. The Maintenance Director stated the only complaint he received about the dining room temperature occurred yesterday when a resident, who was in the dining room watching a movie while sitting under a ceiling fan, complained that his table mate was cold. During an interview on 5/25/16 at 10:30 a.m., the Assisitant Maintenance Director stated he was aware of the ceiling fan in the dining room that wobbled. The Assistant Maintenance Director stated the previous Maintenance Director had tried to fix it, but could not. The Assistant Maintenance Director stated he had not told the current Maintenance Director about the problem with the ceiling fan. Record review of the facility's Temp Log form revealed that testing locations should be chosen in three spots for room/hall samplings in order to make the process most effective. The area of the form for the records air temperatures had sections for air temperature at the beginning of the hall, middle of the hall, end of the hall, the dining room and the kitchen. During an interview on 5/25/16 at 5:00 p.m., the Administrator stated temperatures in common areas of the facility are kept within the regulatory requirements, 65 to 85 degrees Fahrenheit. 4. During an observation on 5/24/16 at 3:47 p.m. and 5/26/16 at 8:50 a.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and separating from the door and the under-the-sink wooden cabinet had water damage on its bottom panel. In addition, under the trash bag, the bottom of the resident trash can had dried, colored liquid spills and assorted trash. During an observation on 5/26/16 at 8:51 a.m. of room [ROOM NUMBER], there was assorted trash on the bottom of the resident trash can under the trash bag. During an observation on 5/26/16 at 8:52 a.m. of room [ROOM NUMBER], there was a dried brown substance on the inner sides and the bottom of the resident trash can under the trash bag. During on observation on 5/24/16 at 3:46 p.m. and 5/26/16 at 8:53 a.m. of room [ROOM NUMBER], there was a mold-like substance on the wood at the bottom of the interior side of the restroom door, and the bottom of the wooden under-the-sink cabinet was warped. In addition, there were dried, brown streaks on the bottom of the resident trash under the trash bag. During an observation on 5/24/16 at 2:15 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. There was a wall tile missing from underneath the shower head fixture. There was accumulated dirt and debris along the bottom of the rear sliding glass door frame. During an observation on 5/26/16 at 8:55 a.m. of room [ROOM NUMBER], the resident trash can had a dried brown substance on the inside of the can under the trash bag. During an observation on 5/24/16 at 3:45 p.m. and 5/26/16 at 8:45 am of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and separating from the door. In addition, the wood bottom and wood rear panel of the under the sink cabinet had significant water damage and the wood bottom had collapsed down. The resident trash can, under the trash bag, had dried brown smears on the inside of the can. During an observation on 5/26/16 at 8:55 a.m. of room [ROOM NUMBER], the resident trash can had a dried black substance on the bottom of the can under the trash bag. During an observation on 5/26/16 at 8:56 a.m. of room [ROOM NUMBER], the resident trash can had a sticky, partially-dried black substance on the bottom of the can under the trash bag. During an observation on 5/24/16 at 12:29 p.m. of room [ROOM NUMBER], the wood on the restroom door was splintering. During an observation on 5/24/16 at 12:28 p.m. of room [ROOM NUMBER], there was a dried brown streak on the wall to the left of the toilet and there was a dried dark substance on the top of the geriatric toilet seat that was above the regular toilet. During an observation on 5/24/16 at 10:38 a.m. of room [ROOM NUMBER], the interior bottom of the restroom door wood was splintered and broken. The restroom was in front of the toilet and to the right of the toilet had dried brown spots and streaks on it. During an observation on 5/24/16 at 10:45 a.m. of room [ROOM NUMBER], the restroom wall in front of the toilet had dried brown spots on it. The floor drain under the toilet did not have a drain cover. There was trash and dirt and the floor along the wall behind Bed B. During an observation on 5/24/16 at 12:05 p.m. of room [ROOM NUMBER], there was a plastic, grocery store type bad wrapped around the base of the shower hose in the restroom. There was dirt and debris along the bottom of the rear sliding glass door frame. During an observation on 5/26/16 at 9:45 a.m. of room [ROOM NUMBER], the resident trash can had a dried orange substance and a medication cup on the bottom of the can under the trash bag. During an observation on 5/24/16 at 12:10 p.m. of room [ROOM NUMBER], there was used toilet paper on the restroom floor and dried smears on the restroom walls. During an observation on 5/26/16 at 9:46 a.m. of room [ROOM NUMBER], the resident trash can had dried brown smears on the bottom and inner sides of the can under the trash bag. During an observation on 5/24/16 at 12:15 p.m. of room [ROOM NUMBER], the wood on the bottom of the interior side of the restroom door was splintering and peeling off the door. Behind the plastic wall barrier that ran along the intersection of the floor and the wall underneath the room sink, the wall was moist and there was a significant amount of debris. During an observation on 5/24/16 at 12:26 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. During an observation on 5/24/16 at 12:15 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. During an observation on 5/24/16 at 12:23 p.m. of room [ROOM NUMBER], there was used toilet paper on the restroom floor. During an observation on 5/24/16 at 10:49 a.m. of room [ROOM NUMBER], the restroom floor in front of the toilet and below the wall mounted hold bar had pooled water with dirt and debris in the water. There was dirt and debris on the floor between Bed A and the wall. There was dirt and trash on the floor under Bed B. There was a significant amount of dirt and debris on the bottom of the rear sliding glass door frame. During an observation on 5/24/16 at 2:45 p.m. and 5/26/16 at 8:59 a.m. of room [ROOM NUMBER], there was a dried brown smear on the restroom wall underneath the wall mounted pull bar that was adjacent to the toilet. The wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. In addition, there was a dried brown substance on the bottom of the resident trash can under the trash bag. During an observation on 5/26/16 at 9:00 a.m. of room [ROOM NUMBER], there was a dried brown substance on the inner sides and bottom of the resident trash can under the trash bag. During an observation on 5/24/16 at 11:07 a.m. of room [ROOM NUMBER], the wood on the interior side of the restroom door had significant chipping, gouging and splintering from the bottom of the door and going up approximately three feet. Along the bottom of the rear sliding glass door frame was dirt, debris and one broken floor tile. The corner of the floor that was adjacent to and opposite of the room sink contained a significant amount of dirt and debris along with a spider web During observation on 5/24/16 at 10:30 a.m., room [ROOM NUMBER]'s restroom floor had dried and wet toilet paper on it. The restroom door edge on the latch side from the bottom of the door edge and going up approximately three feet was chipped and splintering. Along the bottom of room [ROOM NUMBER]'s rear sliding glass door frame was a significant amount of dirt and debris. Along the floor-wall intersection behind the headboard of Bed B was dirt and debris. During observation on 5/24/16 at 10:35 a.m. and 5/26/16 at 9:04 a.m., room [ROOM NUMBER]'s restroom door ' s interior side had chipped and splintered wood from the bottom edge and going up approximately two feet. In addition, the resident trash can had a dried, brown substance on the edges and the inner sides of the can under the trash bag. During observation on 5/24/16 at 10:40 a.m., room [ROOM NUMBER]'s floor behind Bed B and under the adjacent dresser had accumulated dirt and debris on it. During an observation on 5/24/16 at 10:58 a.m., the bottom of room [ROOM NUMBER]'s rear sliding glass door frame had a significant amount of dirt and debris along it. The wall-floor intersection behind Bed A and Bed B had food particles and other debris along it. The wood on interior side of the restroom door was chipped and broken from the bottom of the door and going up approximately two feet. During an observation on 5/24/16 at 2:48 p.m. of room [ROOM NUMBER], the wood on the bottom of the interior side of the restroom door was splintering and peeling off the door. There were dried brown spots and smears on the walls of the restroom and on the underside of the toilet. There was mold on the restroom floor underneath the toilet and on the bottom of the interior side of the restroom door. During an observation on 5/26/16 at 9:02 a.m. of room [ROOM NUMBER], the resident trash can had assorted trash on the bottom of the can under the trash bag. During an observation on 5/24/16 at 2:55 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. During observation on 5/24/16 at 10:51 a.m., room [ROOM NUMBER]'s restroom had used gauze and toilet paper on top of the toilet paper dispenser. There was a dried, brown substance on the metal toilet grab bar, on the geriatric toilet seat above the regular toilet seat, on the floor under the toilet, on the wall in front of the toilet at the wall-floor intersection and on the wall to the right of the toilet. The interior side of the restroom door along the latch side had broken and splintered wood from the bottom edge of the door and going up approximately two feet. During observation on 5/24/16 at 10:43 a.m., room [ROOM NUMBER] had trash, debris and a liquid spill between Bed A and the adjacent wall. The floor around Bed B had debris on it and the trash can near Bed B was full. Along the rear sliding glass door frame bottom was a significant amount of dirt and debris. Dried spills were on the floor between the two resident dressers. During an observation on 5/26/16 at 9:43 a.m. of room [ROOM NUMBER], the resident trash can had a used cotton swab on the bottom of the can under the trash bag. During an observation on 5/26/16 at 9:16 a.m. of room [ROOM NUMBER], the resident trash can had dried brown and black substances on the bottom of the can under the trash bag. During an observation on 5/24/16 at 3:49 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. During an observation on 5/26/16 at 9:41 a.m. of room [ROOM NUMBER], the resident trash can had a dried brown substance on the bottom of the can under the trash bag. During an observation on 5/24/16 at 3:50 p.m. of room [ROOM NUMBER], the wood at the bottom of the interior side of the restroom door was splintering and peeling off the door. During an observation on 5/26/16 at 9:38 a.m. of room [ROOM NUMBER], the resident trash can had a dried, orange substance on the inside of the can under the trash bag. During an observation on 5/24/16 at 3:51 p.m. of room [ROOM NUMBER], the wood was broken and chipped on the latch side edge of the restroom door. During and observation on 5/26/16 at 9:31 a.m. of room [ROOM NUMBER], the resident trash can had dried brown specks throughout the inside of the can under the trash bag. During an observation on 5/24/16 at 2:20 p.m. of room [ROOM NUMBER], the wood on the bottom of the interior side of the restroom door was splintering and peeling off the door. During an interview on 5/27/16 at 9:00 a.m., Housekeeper X stated the housekeepers checked resident rooms. Housekeeper X stated they were instructed to take out the trash, sweep and mop the floor and clean the restroom. Housekeeper X stated when cleaning a room, housekeepers must check behind resident beds and furniture. Housekeeper X stated there were no housekeepers on duty during the evening shift. During an interview on 5/24/16 at 3:00 p.m. and 5/26/16 at 10:00 a.m., the Housekeeping Supervisor stated the housekeeping staff should clean in corners and under beds and furniture. The Housekeeping S

Based on observation, interview and record review the facility failed to ensure a resident with a limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion, for one of five residents reviewed for limited range of motion (Resident #2). The facility failed to have interventions in place to address Resident #2's contractures to both legs and his right hand. The contractures worsened since February 2016 and increased pain when staff would have to move his legs during care. This failure could place 12 residents with contractures at risk for fixation of joints and loss of function which could lead to increased need for ADL assistance, decline in skin health in the contracture and decreased self-esteem. Findings include: Review of the Physician order [REDACTED].#2 was a [AGE] year old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician order [REDACTED]. There was no order for Resident #2 to receive Restorative Nursing Care. Review of the Admission MDS assessment dated [DATE] revealed Resident #2 ' s cognition was severely impaired; however, he was able to sometimes make himself understood. Resident #2 demonstrated no impairment in range of motion on his upper extremities and impairment on one side for his lower extremities. He received Occupational, Physical and Speech Therapy. He was not on a Restorative Nursing Program. Review of the Occupational Therapy Discharge Summary for 09/28/15 through 10/16/15 revealed, .Prognosis to Maintain CLOF (Current Level of Function) = Excellent with consistent staff support; excellent with participation in RNP (Restorative Nursing Program) .Discharge Recommendations .RNP and Splint/brace. Review of the Physical Therapy Discharge Summary for 10/29/15 through 11/09/15 revealed, .Prognosis to Maintain CLOF = Good with consistent staff follow-through . Review of the Physical Therapy Evaluation and Plan of Treatment dated 02/25/16 revealed, .Clinical Impressions: Patient is a [AGE] year old male who presented with weakness of BLE, flexion contractures of B (both) knees (R more than the L), inability to sit, and total dependency with bed mobility and transfers, poor static sitting balance in order to prevent bedsores & (and) contractures, improve sitting balance and reduce assistance with bed mobility & transfers .Splint/Orthotic Recommendations: The patient needs an abductor pillow, knee extension soft brace for b/l (bilateral) LE .Reason for Skilled Services: The patient is not an ideal candidate for Skilled PT services as he has developed contractures, is a Hoyer lift for all transfers, doesn ' t ambulate and needed Max (A) (assist) with all his ADLs. He has very limited ROM, and it would be good to have a restorative nursing program to do ROM activities in available range and do splinting for few hours a day to prevent further contractures . Review of the most recent Quarterly MDS assessment dated [DATE] revealed Resident #2 ' s cognition was still severely impaired, but he sometimes was able to make himself understood. Resident #2 demonstrated no impairment in range of motion on his upper extremities but impairment on both sides for his lower extremities. Resident #2 did not receive any Occupational, Physical or Speech Therapy. He was not on a Restorative Nursing Program. Review of the Care Plan dated 04/28/16 revealed Resident #2 had a history of [REDACTED]. Resident #2 had self-care deficit related to a need for assistance with all ADL ' s, transfers, toileting, eating, bed mobility and bathing. Interventions included assisting with transfer as needed, assisting with repositioning as appropriate and encouraging independence. The Care Plan did not address interventions for contractures in his right hand or both knees. During an observation on 05/24/16 at 10:40 a.m., CNA D and CNA E performed incontinent care on Resident #2. Resident #2 yelled out, Yeow, when CNA D or CNA E moved or straightened his legs. Neither CNA D nor CNA E opened Resident #2 ' s right hand, which was closed throughout incontinent care. Resident #2 did not have an abductor pillow, knee extension soft brace, or any other splinting device recommended by therapy. During an observation on 05/25/16 at 11:04 a.m., LVN B and RN C performed wound care to Resident #2 ' s pressure ulcer on his right heel and his right hip. Resident #2 ' s knees were bent and his right hand was closed. Neither LVN B nor RN C opened Resident #2 ' s hands. He did not have any splint or hand roll in his right hand or on his lower extremities. Resident #2 yelled, Yeow, when LVN B and RN C adjusted his legs to turn him over in bed. Resident #2, again, did not have an abductor pillow, knee extension soft brace, or any other splinting device recommended by therapy. During an interview on 05/24/16 at 11:04 a.m., CNA D stated Resident #2 was supposed to be placed on Restorative Program due to contractures, but stated she had not heard any additional information related to this. During an additional interview on 05/25/16 at 11:50 a.m., CNA D stated Resident #2 ' s legs have gotten more contracted since he admitted to the facility. CNA D stated Resident #2 could move his arms, but his right hand was contracted. CNA D stated she sometimes stretched his legs when she performed care; CNA D stated if he hurt, she would leave him alone. CNA D again stated that the Restorative Nursing Program was supposed to pick him up. During an interview on 05/25/16 at 11:20 a.m., LVN B stated Restorative Care was talking about picking him (Resident #2) up, but I don ' t know where they are on that. LVN B stated she tried to reposition him. I know it ' s not much. During an additional interview on 05/27/16 at 11:53 a.m., LVN B stated Resident #2 ' s contractures have worsened. She stated sometime in either January or February of 2016, someone asked if there were any residents who would benefit from restorative care. LVN B stated she started a list of residents, which included Resident #2. She stated she handed off the list to the nurse who worked the following shift, but she was unable to recall who she gave the list to. LVN B stated she was unsure if the list was ever given to the MDS Coordinator/LVN H, who was over the Restorative Nursing Program. During an interview on 05/26/16 at 10:24 a.m., CNA and Restorative Aide F stated residents in the Restorative Nursing Program received range of motion and/or routine splints. She stated Resident #2 was in therapy in the past. CNA/Restorative Aide F stated she never provided Restorative Care to Resident #2. During an interview on 05/26/16 at 10:30 a.m., CNA and Restorative Aide G stated residents in the Restorative Nursing Program received stretches for range of motion and/or splints for contractures. She stated she never provided Restorative Care to Resident #2. During an interview on 05/26/16 at 10:37 a.m., DOR/PTA stated after a resident received therapy, they were usually referred to Restorative Care. DOR/PTA stated he was under the impression Resident #2 received Restorative Nursing Care. During an additional interview on 05/26/16 at 11:00 a.m., DOR/PTA stated according to Resident #2 ' s Discharge Summary from therapy services, he was recommended for Restorative Care. DOR/PTA was unable to say why Resident #2 was not receiving Restorative Care or other splinting devices for his contractures. During an interview on 05/26/16 at 11:40 a.m., the DON stated MDS Coordinator/LVN H was responsible for the Restorative Nursing Program. The DON stated if a resident had contractures, they usually received Restorative Care. She stated she expected contractures to be addressed in the resident's Care Plan. During an interview on 05/26/16 at 11:55 a.m., DOR/PTA stated if a resident was to be referred to the Restorative Nursing Program, he verbally notified MDS Coordinator/LVN H. DOR/PTA stated he did not document the referral or communication with MDS Coordinator/LVN H to the Restorative Program. He was unable to say why Resident #2 was not referred to the Restorative Nursing Program. During an interview on 05/26/16 at 12:00 p.m., MDS Coordinator/LVN H stated she was responsible for the Restorative Nursing Program. She stated if a resident came off of therapy and needed Restorative Care, RD/PTA notified her, and the resident was then placed on the Restorative Nursing Program. MDS Coordinator/LVN H stated she was not sure why Resident #2 was never placed on the Restorative Nursing Program. She said, He will be picked up now. MDS Coordinator/LVN H stated if a resident had contractures, she tried to incorporate this into their Care Plan. Surveyor reviewed Resident #2 ' s Care Plan with MDS Coordinator/LVN H, and she agreed with surveyor that Resident #2 ' s Care Plan was not specific to the treatment for [REDACTED]. During an interview on 05/27/16 at 8:30 a.m., the DON stated the facility did not have a Policy or Procedure for Range of Motion, Contractures or Restorative Care. During an interview on 05/27/16 at 10:25 a.m., CNA P stated Resident #2 ' s right and left leg and his right hand was contracted. CNA P stated Resident #2 ' s contractures have worsened since his admission to the facility, Especially his legs. CNA P stated she notified LVN B and another nurse, currently out on maternity leave, that Resident #2 ' s contractures worsened. During an interview on 05/27/16 at 10:30 a.m., RN/ADON Q stated she was responsible for Hall A, where Resident #2 resided. RN/ADON Q stated she finds out a resident needs restorative care through the MDS Coordinator/LVN H. RN/ADON Q stated Resident #2 ' s legs were more contracted, but his right hand was better. During an interview on 05/27/16 at 10:35 a.m., DOR/PTA stated he met with MDS Coordinator/LVN H daily after morning meeting to discuss each resident who received therapy. The DOR/PTA could not remember discussing Resident #2 with the MDS Coordinator. He could not say why Resident #2 was not receiving Restorative Care. During an interview on 05/27/16 at 11:17 a.m., NP R stated Resident #2 continued to decline, and she tried to get social services to place him on palliative care or Hospice. NP R stated Resident #2 would be indicated for Restorative Nursing Program due to his contractures. NP R stated she did not push for restorative care because, I was focusing on his infection. There ' s a lot of things going on (with Resident #2) more than just restorative care. NP R agreed Resident #2 needed restorative care. During an interview on 05/27/16 at 2:52 p.m., the Administrator stated he was under the impression Resident #2 received restorative care. He stated each resident was screened for therapy. The Administrator stated Resident #2 was now added to the Restorative Nursing Program. Review of CMS 672 dated 05/23/16 revealed 12 residents with contractures.

Based on observation, interview and record review, the facility failed to ensure residents who required reasonable accommodation of needs and preferences received the appropriate treatment and services to ensure their needs and preferences were addressed and skin breakdown did not occur for one of five residents reviewed for appropriate accommodation of individual needs (Resident #1). Resident #1 had impaired range of motion to both upper extremities, was unable to use a television remote control without pushing it around on his abdomen and sustained wounds of the skin of his abdomen. This failure could place five residents, with severe upper extremity impairment, at risk for the development of pressure sores and/or skin shearing injuries and a diminished quality of life. The findings include: Review of the admission face sheet for Resident #1 reflected a [AGE] year old male with an admission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the MDS, dated [DATE], for Resident #1 reflected resident had severe impairment of all extremities. Observation on 5/17/16 at 8:35 a.m. of Resident #1 revealed abrasions to his abdomen. In an interview on 5/17/16 at 8:35 a.m. LVN O stated the abdominal abrasions were from the resident ' s television remote control. Observation on 5/24/16 at 2:10 p.m. revealed Resident #1 lying in his bed with the television remote control device on his abdomen. Further observation revealed Resident #1 using the palms of his hands to maneuver the device, using a control lever, causing the device to slide up and down on his abdomen. Observation on 5/25/16 at 3:50 p.m. of Resident #1 revealed three dime size wounds to the mid-abdominal area. LVN N provided wound care to Resident #1 with the assistance from ADON C and CNA P. In an interview on 5/25/16 at 3:50 p.m. ADON C stated the wounds were from Resident #1 using his television remote control device. ADON C further stated Resident #1 had to lay the remote control on his abdomen and press down on the remote control lever, causing a shearing injury to the skin on his abdomen. When asked by the surveyor, ADON C stated nothing had been implemented to prevent the shearing injury and I guess we should have thought of that. In an interview on 5/25/16 at 4:35 p.m. Resident #1 stated the shearing injury to his stomach was from using the television remote control, but he did not know what he could have done to prevent the rubbing of the device on his abdomen. In an interview on 5/26/16 at 11:00 a.m. the DON stated she was informed of the concerns regarding Resident #1 ' s abdominal wounds by the ADON. The DON further stated she did not know what could have been done to prevent the wound or to keep it from happening in the future. The DON stated she instructed the ADON to put a sheet between Resident #1 and his remote control device. Upon questioning by the surveyor, the DON stated We can have Physical Therapy evaluate Resident #1 and make recommendations regarding potential mechanisms to prevent the remote control device from rubbing on his abdomen. The DON stated the facility did not have a policy or procedure for Resident Accommodation of Needs. In an interview on 5/26/16 at 12:50 p.m. the SW stated he was not aware of any concerns regarding Resident #1 ' s television remote control. In an interview on 5/27/16 at 8:10 a.m. the DOR/PTA stated this morning he had received a consult request to evaluate Resident #1 ' s use of the specialized television remote control device today. DOR/PTA stated he was not aware there were any concerns with Resident #1's specialized television remote control device prior to today. The facility MDS Coordinator provided 5 residents with severe extremity impairment.

Based on observation, interview, and record review the facility failed to immediately inform the resident's physician when a significant change in the resident's physical status that needed altered treatment for one (1) of 11 residents (Resident #1) reviewed for notification of changes. Resident #1 returned from the hospital on [DATE], but the facility failed to notify the physician until 06/11/2015 of Resident #1's decline in pressure sores to his right buttock; and he had developed two new pressure sores to his left buttock since he was discharged from the hospital on [DATE]. The facility failed to perform a skin assessment on Resident #1's readmission to the facility. The facility performed the skin assessment after surveyor intervention on 06/10/2015. Resident #1's physician changed the treatment to his pressure sores when the physician was notified about his pressure sores. This deficient practice affected Resident #1 and could affect one (1) other resident with pressure sores at risk for delay in appropriate medical treatment, the development of new or worsening medical conditions, and diminished quality of life for any resident who may have a new clinical condition. Findings include: Review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Website National Pressure Ulcer Advisory Panel defined pressure sores: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Review of the Significant Change MDS Assessment for Resident #1 dated 05/07/2015 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 had four (4) Stage II pressure sores with the oldest onset dated 01/28/2015. Resident #1's Stage II pressure sores had granulation tissue (pink or red tissue with shiny, moist, granular appearance). Resident #1 had skin treatments of pressure reducing device for chair, pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications, and application of dressings to feet. Review of the Care Plan for Resident #1 dated 05/06/2015 reflected he had Stage II pressure sores to his right outer foot and left posterior calf. Resident #1 had interventions including to assist with turning and repositioning every two hours and pressure relieving devices for his bed and wheelchair. Review of the facility's Pressure Ulcers dated 06/08/2015 reflected Resident #1 had three Stage II pressure ulcers with an onset date of 03/10/2015 on his coccyx, left posterior calf, and right outer foot. Review of the Hospital Inpatient Record dated 06/02/2015-06/05/2015 for Resident #1 reflected a wound assessment on 06/02/2015 at admission. Resident #1 had an Unstageable pressure sore to his right foot lateral to 5th toe with 60% yellow, slough non-healing measured 2.2 cm by 2 cm. His right lateral lower leg had a suspected deep tissue injury measured 2 cm by 1.5 cm. On Resident #1's left lower lateral leg he had a Stage IV with red granulation tissue measured 4.5 cm by 1.5 cm. Resident #1 had a Stage III on his right ischial tuberosity (bone on lower part of buttock) with red granulation tissue measured 4.5 cm by 3.2 cm. He also had a Stage III on his middle, right buttock with white fibrous slough measured 4 cm by 7 cm. Resident #1 also had a Stage I to his left foot measured 0.5 cm by 0.2 cm. Resident #1 was alert and oriented x4 indicating oriented to person, place, time, and pain. Resident #1's discharge instructions for his pressure sores were to cleanse and apply foam dressings. Also to apply a zinc oxide ointment to the other areas of his bottom, not on the wounds. The instructions also reflected to apply an enzymatic debrider ointment to his right lateral to 5th toe Unstageable pressure ulcer to debride the slough. Observation on 06/09/2015 at 4:20 PM revealed Resident #1 provided wound care by LVN A. Resident #1 had an Unstageable pressure sore to his outer right foot below his little toe, with yellow slough in the middle of the wound. Resident #1 had one healing Stage III to his outer left leg on the calf area. Resident #1 had three Stage III pressure sores on his right buttock and one Stage II on his left buttock. LVN A did not measure any of the pressure sores, even though the left buttock was new. After cleansing all the pressure sores, separately, LVN A applied A&D (vitamins A and D) ointment over Resident #1's entire buttock area, including over all the pressure sores. In an interview on 06/10/2015 at 3:05 PM LVN A stated Resident #1 had multiple areas on his bottom for two weeks, ever since LVN A started working at the facility. He stated he had not notified the physician about the pressure sores or any changes in the pressure sores. Observation on 06/10/2015 at 3:10 PM revealed Resident #1's skin assessment by LVN A, DON, and RNC. Resident #1's Unstageable pressure sore on his outer right foot below his little toe measured 2 cm by 2 cm, irregular shape, with one third of the wound bed covered in yellow slough, and undermining under the edge of the wound-not measured by LVN A. The peri-wound was macerated at the top of the wound edge near the little toe. LVN A stated the wound was a Stage III and the RNC agreed. Resident #1's outer left leg calf area healing Stage III pressure sore measured 3 cm by 2 cm with little depth was almost healed. (These preesure sores were present at hospital). Resident #1's right buttock had three areas: the right outer buttock Stage III pressure sore measured 3 cm by 5 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was not present at hospital). The right inner buttock Stage III pressure sore measured 1 cm by 7 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated the pressure sore had 50% slough and called the pressure sore a Stage II. The shiny, yellow wound bed was granulation tissue and was not slough. (This pressure sore was on the hospital assessment). Resident #1 had a Stage III pressure sore on his right lower buttock measured 6 cm by 7 cm with 0.2 cm depth. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was on the hospital records and had deteriorated.) Resident #1 had two Stage II pressure sores on his lower left buttock-the proximal sore measured 1 cm by 1 cm and the distal sore measured 1.5 cm by 1.5 cm, and both were open. LVN A and RNC stated the proximal sore was open and was a Stage II. LVN A and RNC stated the distal area sore was not open and was a Stage I. (These pressure sores were not present when Resident #1 was at the hospital on [DATE]). Review of Resident #1's chart on 06/11/2015 reflected no notification to the physician had been documented in the Nurse's Notes about the findings on 06/10/2015. Also there was not a readmission assessment performed to include a full skin assessment on 06/05/2015. There was no documentation in the nurse's notes about staff notifying the physician since prior to 06/05/2015. Review of the Weekly Skin Documentation for Resident #1 dated June 2015 reflected it was blank, only the Resident's name and date was on the document. Review of the TAR for Resident #1 dated June 2015 reflected the wound care treatments for his left lateral calf, coccyx, and right fifth metatarsal. The treatment for his coccyx reflected to clean the area with a wound care spray and apply a thick amount of the A&D ointment to the coccyx every day. Resident #1 had no pressure sores on his coccyx. In an interview on 06/11/2015 at 9:55 AM LVN A stated he was at the facility this morning because he did not document in the nurse's notes after measuring the pressure sores. He stated he did not contact the physician about the changes in the pressure sores on 06/10/2015, but passed it on in report for the morning nurse to contact the physician. LVN A stated he was not here when Resident #1 returned from the hospital, but the measurements made on 06/10/2015 were the first and only measurements made since Resident #1 returned from the hospital. In an interview on 06/11/2015 at 11:00 AM RNC stated the physician should have been notified immediately of the changes and new pressure sores. The RNC also stated the wounds should have been assessed and measured on readmission and the physician notified of the findings. In an interview on 06/11/2015 at 12:05 PM the NP stated she expected immediate notification of the changes in Resident #1's skin. She stated when she was notified she changed the treatments on the pressure sores on the buttocks because the ointment was not an appropriate treatment and a mode for infection. She stated she ordered dressings to cover the pressure sores. She stated she expected the facility staff to perform full skin assessments immediately when a resident returned from the hospital. She stated she allowed the facility to stage the pressure sores because the facility staff should know how to stage them. In an interview on 06/11/2015 at 3:55 PM the DON stated she expected the staff to notify the physician immediately or as soon as possible when changes occurred in a resident's skin. She also expected the staff to perform a full skin assessment on readmission from the hospital and notify the physician for treatment orders. She also expected the staff to document thoroughly in the nurse's notes. The DON stated she also expected the staff to measure the sores immediately when a change was identified. In an interview on 06/11/2015 at 5:10 PM the Administrator stated he expected the staff to notify the physician as soon as possible when changes in the resident's skin were identified. He stated he also expected the staff to perform a readmission assessment including a full skin assessment and notify the physician of the assessment and obtain treatment orders for skin problems. Review of the facility's policy entitled Nursing Guidelines: Change of Condition Notification not dated reflected the physician should be notified of changes in a resident's condition when the resident had a significant change in physical status like deterioration in health and when a treatment needed significant change. The facility provided a list of two residents who had pressure sores.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of six (6) residents (Resident #1) reviewed for skin condition. Resident #1 had three Stage III pressure sores to his right buttock, two Stage II pressure sores on his left buttock, an Unstageable pressure sore to his outer right foot, and a healing Stage III pressure sore to his left leg posterior calf. The facility only had documentation and treatments for the right foot and left leg. The pressure sores to the bilateral buttocks were not documented, treated appropriately, and the physician was not notified. Also LVN A provided wound care but did not change gloves per policy while providing care. Resident #1 also stated staff were not turning him every two hours. Resident #1's pressure sores declined after re-admission to the facility on [DATE]. This deficient practice affected Resident #1 and could affect one other resident with pressure sores at risk for the development of new pressure sores, infection and worsening of current pressure sores. Findings include: Review of the facility's policy entitled Reporting Abuse to Facility Management not dated reflected .to promptly report any incident or suspected incident of neglect .to the administrator or his/her designee. The policy defined neglect as the .failure to provide goods and services necessary to avoid physical harm . The policy reflected the neglect would be reported to the State agency, the resident or resident's representative, the law enforcement, and the resident's physician. The policy reflected the incident of neglect would also be investigated. Review of the facility's Pressure Ulcer Staging not dated reflected the definitions of Stage I, II, III, IV, and Eschar pressure sores with pictures. A Stage I had intact skin with persistent redness. The Stage II was defined as Partial thickness skin loss .superficial and presents clinically as an abrasion, blister or shallow crater. The Stage III pressure sore involved Full thickness skin loss and presents clinically as a deep crater with or without undermining and could also be necrotic. Review of the facility's Skin System revised 05/20/2014 reflected a weekly skin assessment would be completed upon admission or readmission. The System also reflected when a resident had a pressure sore, daily documentation would be performed on the Daily Pressure Ulcer Documentation Form until healed. The System reflected the definitions of pressure sores: Stage I-Intact skin with non-blanchable redness .; Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; Stage III-Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling .Bone/tendon is not visible or directly palpable; .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. The System reflected Skin Treatments for recommended use for pressure sores. The Treatments listed dressings to cover the pressure sores; none indicated using only an ointment. The System also reflected Wound Documentation Guidelines indicated to measure each wounds length, width, and depth. Also document the amount of drainage or exudate. And describe the tissue type: necrotic or eschar (Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than the surrounding skin), slough (Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps), granulation (Pink or beefy red tissue with a shiny, moist, granular appearance), [MEDICATION NAME] (For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface). The Guidelines also reflected to measure any undermining (separation of wound edges from the subcutaneous tissue). The Guidelines reflected to document this information daily on the appropriate sheet. Review of the facility's policy entitled Nursing Guidelines: Change of Condition Notification not dated reflected the physician should be notified of changes in a resident's condition when the resident had a significant change in physical status like deterioration in health and when a treatment needed significant change. Review of the Website National Pressure Ulcer Advisory Panel defined pressure sores: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Significant Change MDS Assessment for Resident #1 dated 05/07/2015 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 had four (4) Stage II pressure sores with the oldest onset dated 01/28/2015. Resident #1's Stage II pressure sores had granulation tissue (pink or red tissue with shiny, moist, granular appearance). Resident #1 had skin treatments of pressure reducing device for chair, pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications, and application of dressings to feet. Review of the Care Plan for Resident #1 dated 05/06/2015 reflected he had Stage II pressure sores to his right outer foot and left posterior calf. Resident #1 had interventions including to assist with turning and repositioning every two hours and pressure relieving devices for his bed and wheelchair. Review of the facility's Pressure Ulcers dated 06/08/2015 reflected Resident #1 had three Stage II pressure ulcers with an onset date of 03/10/2015 on his coccyx, left posterior calf, and right outer foot. Review of the Hospital Inpatient Record dated 06/02/2015-06/05/2015 for Resident #1 reflected a wound assessment on 06/02/2015 at admission. Resident #1 had an Unstageable pressure sore to his right foot lateral to 5th toe with 60% yellow, slough non-healing measured 2.2 cm by 2 cm. His right lateral lower leg had a suspected deep tissue injury measured 2 cm by 1.5 cm. On Resident #1's left lower lateral leg he had a Stage IV with red granulation tissue measured 4.5 cm by 1.5 cm. Resident #1 had a Stage III on his right ischial tuberosity (bone on lower part of buttock) with red granulation tissue measured 4.5 cm by 3.2 cm. He also had a Stage III on his middle, right buttock with white fibrous slough measured 4 cm by 7 cm. Resident #1 also had a Stage I to his left foot measured 0.5 cm by 0.2 cm. Resident #1 was alert and oriented x4 indicating oriented to person, place, time, and pain. Resident #1's discharge instructions for his pressure sores were to cleanse and apply foam dressings. Also to apply a zinc oxide ointment to the other areas of his bottom, not on the wounds. The instructions also reflected to apply an enzymatic debrider ointment to his right lateral to 5th toe Unstageable pressure ulcer to debride the slough. In an interview on 06/09/2015 at 2:45 PM Resident #1 stated he acquired the pressure sores while in the facility. He stated the staff did not turn him per the Patient Positioning Chart, and he gestured to his wall where the Chart was taped. Resident #1 stated the staff were to sign the sheet when they turned him. Review of the Patient Positioning Chart in Resident #1's room, no name, with a start date of 05/20/2015 reflected the time was not indicated with the date in the first column. There were three entries for 05/20/2015, indicating right or left, and the comment of every two hours and signed by the staff who turned Resident #1. There were two entries for 05/25/2015, three for 05/26/2015, one for 05/27/2015, three for 05/28/2015, and two for 06/09/2015. Observation on 06/09/2015 at 4:20 PM revealed Resident #1 provided wound care by LVN A. Resident #1 had an Unstageable pressure sore to his outer right foot below his little toe, with yellow slough in the middle of the wound. Resident #1 had one healing Stage III to his outer left leg on the calf area. Resident #1 had three Stage III pressure sores on his right buttock and one Stage II on his left buttock. LVN A did not measure any of the pressure sores, even though the left buttock was a new area. LVN A removed the dressing from the outer right foot and placed it on Resident #1's bed by his foot. LVN A did not change his gloves and cleansed the area with wound care cleanser he sprayed on gauze. LVN A again did not change his gloves, then placed the clean dressing on the pressure sore. LVN A then picked up the dirty dressing and threw it in the trash and removed his gloves. LVN A cleansed all areas in this manner, only changing gloves between each pressure sore. After cleansing all the pressure sores on his buttocks, separately, LVN A applied A&D ointment over Resident #1's entire buttock area, including over all the pressure sores. In an interview on 06/09/2015 at 6:07 PM LVN A stated he should have changed his gloves per his policy when cleaning the pressure sores. He stated he should have removed the dirty dressing and then disposed of his gloves. LVN A stated he should have also changed his gloves after cleansing each pressure sore and prior to placing the clean dressing. In an interview on 06/10/2015 at 3:05 PM LVN A stated Resident #1 had multiple areas on his bottom for two weeks, ever since LVN A started working at the facility. He stated he had not notified the physician about the pressure sores or any changes in the pressure sores. Observation on 06/10/2015 at 3:10 PM revealed Resident #1's skin assessment by LVN A, DON, and RNC. Resident #1's Unstageable pressure sore on his outer right foot below his little toe measured 2 cm by 2 cm, irregular shape, with one third of the wound bed covered in yellow slough, and undermining under the edge of the wound-not measured by LVN A. The peri-wound was macerated at the top of the wound edge near the little toe. LVN A stated the wound was a Stage III and the RNC agreed. Resident #1's outer left leg calf area healing Stage III pressure sore measured 3 cm by 2 cm with little depth was almost healed. (These preesure sores were present at hospital). Resident #1's right buttock had three areas: the right outer buttock Stage III pressure sore measured 3 cm by 5 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was not present at hospital). The right inner buttock Stage III pressure sore measured 1 cm by 7 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated the pressure sore had 50% slough and called the pressure sore a Stage II. The shiny, yellow wound bed was granulation tissue and was not slough. (This pressure sore was on the hospital assessment). Resident #1 had a Stage III pressure sore on his right lower buttock measured 6 cm by 7 cm with 0.2 cm depth. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was on the hospital records and had deteriorated.) Resident #1 had two Stage II pressure sores on his lower left buttock-the proximal sore measured 1 cm by 1 cm and the distal sore measured 1.5 cm by 1.5 cm, and both were open. LVN A and RNC stated the proximal sore was open and was a Stage II. LVN A and RNC stated the distal area sore was not open and was a Stage I. (These pressure sores were not present when Resident #1 was at the hospital on [DATE]). In an interview on 06/10/2015 at 4:05 PM the DON and RNC stated Resident #1 needed to be turned and repositioned at least every two hours even though he was on the air mattress. LVN A agreed. Review of Resident #1's chart on 06/11/2015 reflected no notification to the physician had been documented in the Nurse's Notes about the findings on 06/10/2015. Also there was not a readmission assessment performed to include a full skin assessment when he returned from the hospital on [DATE]. There was no documentation in the nurse's notes about staff notifying the physician since prior to 06/05/2015. Review of the Weekly Skin Documentation for Resident #1 dated June 2015 reflected it was blank, only the Resident's name and date was on the document. Review of the TAR for Resident #1 dated June 2015 reflected the wound care treatments for his left lateral calf, coccyx, and right fifth metatarsal. The treatment for [REDACTED]. Resident #1 had no pressure sores on his coccyx. In an interview on 06/11/2015 at 9:55 AM LVN A stated he was at the facility this morning because he did not document in the nurse's notes after measuring the pressure sores. He stated he did not contact the physician about the changes in the pressure sores on 06/10/2015, but passed it on in report for the morning nurse to contact the physician. LVN A stated he was not here when Resident #1 returned from the hospital, but the measurements made on 06/10/2015 were the first and only measurements made since Resident #1 returned from the hospital on [DATE]. LVN A stated Resident #1 should be repositioned every two hours even though he was on the air mattress. LVN A stated Resident #1 had not ever refused to be repositioned. In an interview on 06/11/2015 at 11:00 AM RNC stated the physician should have been notified immediately of the changes and new pressure sores. The RNC also stated the wounds should have been assessed and measured on readmission and the physician notified of the findings. In an interview on 06/11/2015 at 12:05 PM the NP stated she expected immediate notification of the changes in Resident #1's skin. She stated when she was notified she changed the treatments on the pressure sores on the buttocks because the ointment was not an appropriate treatment and was a mode for infection. She stated she ordered dressings to cover the pressure sores. She stated she expected the facility staff to perform full skin assessments immediately when a resident returned from the hospital. She stated she allowed the facility to stage the pressure sores because the facility staff should know how to stage them. The NP also stated the LVN performing the treatments should have changed his gloves while cleaning the pressure sores per the policy, it's common sense to change gloves. In an interview on 06/11/2015 at 3:55 PM the DON stated she expected the staff to notify the physician immediately or as soon as possible when changes occurred in a resident's skin. She also expected the staff to perform a full skin assessment on readmission from the hospital and notify the physician for treatment orders. She also expected the staff to document thoroughly in the nurse's notes. The DON stated she also expected the staff to measure the pressure sores immediately when a change was identified. She also stated the A&D ointment was not an appropriate treatment for [REDACTED].#1's bilateral buttocks. The DON expected LVN A to change his gloves before he touched something clean. In an interview on 06/11/2015 at 5:10 PM the Administrator stated he expected the staff to notify the physician as soon as possible when changes in the resident's skin were identified. He stated he also expected the staff to perform a readmission assessment including a full skin assessment and notify the physician of the assessment and obtain treatment orders for skin problems. The facility provided a list of two residents who had pressure sores.

Based on observation, interview, and record review the facility failed to meet professional standards of quality for one (1) of one (1) LVN (LVN A) on one (1) of six (6) residents (Resident #1) reviewed for skin condition. Resident #1 had three Stage III pressure sores to his right buttock, two Stage II pressure sores on his left buttock, an Unstageable pressure sore to his outer right foot, and a healing Stage III pressure sore to his left leg posterior calf. The facility only had documentation and treatments for the right foot and left leg. The pressure sores to the bilateral buttocks were not documented, treated appropriately, and the physician was not notified. Also LVN A provided wound care but did not change gloves per policy while providing care. Resident #1 also stated staff were not turning him every two hours. Resident #1's pressure sores declined after re-admission to the facility on [DATE]. This deficient practice affected Resident #1 and could affect one other resident with pressure sores at risk for the development of new pressure sores, infection and worsening of current pressure sores. Findings include: Review of the Texas Administrative Code Title 22 Examining Boards Part 11 Texas Board of Nursing Chapter 217 Licensure, Peer Assistance and Practice Rule §217.11 Standards of Nursing Practice: The Texas Board of Nursing is responsible for regulating the practice of nursing within the State of Texas for Vocational Nurses, Registered Nurses, and Registered Nurses with advanced practice authorization. The standards of practice establish a minimum acceptable level of nursing practice in any setting for each level of nursing licensure or advanced practice authorization. Failure to meet these standards may result in action against the nurse's license even if no actual patient injury resulted. (1) Standards Applicable to All Nurses. All vocational nurses, registered nurses and registered nurses with advanced practice authorization shall: (A) Know and conform to the Texas Nursing Practice Act and the board's rules and regulations as well as all federal, state, or local laws, rules or regulations affecting the nurse's current area of nursing practice; (B) Implement measures to promote a safe environment for clients and others; (C) Know the rationale for and the effects of medications and treatments and shall correctly administer the same; (D) Accurately and completely report and document: (i) the client's status including signs and symptoms; (ii) nursing care rendered; (iii) physician, dentist or podiatrist orders; (iv) administration of medications and treatments; (v) client response(s); and (vi) contacts with other health care team members concerning significant events regarding client's status; (G) Obtain instruction and supervision as necessary when implementing nursing procedures or practices; (H) Make a reasonable effort to obtain orientation/training for competency when encountering new equipment and technology or unfamiliar care situations; (M) Institute appropriate nursing interventions that might be required to stabilize a client's condition and/or prevent complications; (N) Clarify any order or treatment regimen that the nurse has reason to believe is inaccurate, non-efficacious or contraindicated by consulting with the appropriate licensed practitioner and notifying the ordering practitioner when the nurse makes the decision not to administer the medication or treatment; (U) Supervise nursing care provided by others for whom the nurse is professionally responsible; and (2) Standards Specific to Vocational Nurses. The licensed vocational nurse practice is a directed scope of nursing practice under the supervision of a registered nurse, advanced practice registered nurse, physician's assistant, physician, podiatrist, or dentist. Supervision is the process of directing, guiding, and influencing the outcome of an individual's performance of an activity. The licensed vocational nurse shall assist in the determination of predictable healthcare needs of clients within healthcare settings and: (A) Shall utilize a systematic approach to provide individualized, goal-directed nursing care by: (i) collecting data and performing focused nursing assessments; and (v) assisting in the evaluation of the client's responses to nursing interventions and the identification of client needs; (B) Shall assign specific tasks, activities and functions to unlicensed personnel commensurate with the educational preparation, experience, knowledge, and physical and emotional ability of the person to whom the assignments are made and shall maintain appropriate supervision of unlicensed personnel. (C) May perform other acts that require education and training as prescribed by board rules and policies, commensurate with the licensed vocational nurse's experience, continuing education, and demonstrated licensed vocational nurse competencies. Review of the facility's Pressure Ulcer Staging not dated reflected the definitions of Stage I, II, III, IV, and Eschar pressure sores with pictures. A Stage I had intact skin with persistent redness. The Stage II was defined as Partial thickness skin loss .superficial and presents clinically as an abrasion, blister or shallow crater. The Stage III pressure sore involved Full thickness skin loss and presents clinically as a deep crater with or without undermining and could also be necrotic. Review of the facility's Skin System revised 05/20/2014 reflected a weekly skin assessment would be completed upon admission or readmission. The System also reflected when a resident had a pressure sore, daily documentation would be performed on the Daily Pressure Ulcer Documentation Form until healed. The System reflected the definitions of pressure sores: Stage I-Intact skin with non-blanchable redness .; Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; Stage III-Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling .Bone/tendon is not visible or directly palpable; .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. The System reflected Skin Treatments for recommended use for pressure sores. The Treatments listed dressings to cover the pressure sores; none indicated using only an ointment. The System also reflected Wound Documentation Guidelines indicated to measure each wounds length, width, and depth. Also document the amount of drainage or exudate. And describe the tissue type: necrotic or eschar (Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than the surrounding skin), slough (Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps), granulation (Pink or beefy red tissue with a shiny, moist, granular appearance), [MEDICATION NAME] (For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface). The Guidelines also reflected to measure any undermining (separation of wound edges from the subcutaneous tissue). The Guidelines reflected to document this information daily on the appropriate sheet. Review of the facility's policy entitled Nursing Guidelines: Change of Condition Notification not dated reflected the physician should be notified of changes in a resident's condition when the resident had a significant change in physical status like deterioration in health and when a treatment needed significant change. Review of the Website National Pressure Ulcer Advisory Panel defined pressure sores: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Significant Change MDS Assessment for Resident #1 dated 05/07/2015 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 had four (4) Stage II pressure sores with the oldest onset dated 01/28/2015. Resident #1's Stage II pressure sores had granulation tissue (pink or red tissue with shiny, moist, granular appearance). Resident #1 had skin treatments of pressure reducing device for chair, pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications, and application of dressings to feet. Review of the Care Plan for Resident #1 dated 05/06/2015 reflected he had Stage II pressure sores to his right outer foot and left posterior calf. Resident #1 had interventions including to assist with turning and repositioning every two hours and pressure relieving devices for his bed and wheelchair. Review of the facility's Pressure Ulcers dated 06/08/2015 reflected Resident #1 had three Stage II pressure ulcers with an onset date of 03/10/2015 on his coccyx, left posterior calf, and right outer foot. Review of the Hospital Inpatient Record dated 06/02/2015-06/05/2015 for Resident #1 reflected a wound assessment on 06/02/2015 at admission. Resident #1 had an Unstageable pressure sore to his right foot lateral to 5th toe with 60% yellow, slough non-healing measured 2.2 cm by 2 cm. His right lateral lower leg had a suspected deep tissue injury measured 2 cm by 1.5 cm. On Resident #1's left lower lateral leg he had a Stage IV with red granulation tissue measured 4.5 cm by 1.5 cm. Resident #1 had a Stage III on his right ischial tuberosity (bone on lower part of buttock) with red granulation tissue measured 4.5 cm by 3.2 cm. He also had a Stage III on his middle, right buttock with white fibrous slough measured 4 cm by 7 cm. Resident #1 also had a Stage I to his left foot measured 0.5 cm by 0.2 cm. Resident #1 was alert and oriented x4 indicating oriented to person, place, time, and pain. Resident #1's discharge instructions for his pressure sores were to cleanse and apply foam dressings. Also to apply a zinc oxide ointment to the other areas of his bottom, not on the wounds. The instructions also reflected to apply an enzymatic debrider ointment to his right lateral to 5th toe Unstageable pressure ulcer to debride the slough. In an interview on 06/09/2015 at 2:45 PM Resident #1 stated he acquired the pressure sores while in the facility. He stated the staff did not turn him per the Patient Positioning Chart, and he gestured to his wall where the Chart was taped. Resident #1 stated the staff were to sign the sheet when they turned him. Review of the Patient Positioning Chart in Resident #1's room, no name, with a start date of 05/20/2015 reflected the time was not indicated with the date in the first column. There were three entries for 05/20/2015, indicating right or left, and the comment of every two hours and signed by the staff who turned Resident #1. There were two entries for 05/25/2015, three for 05/26/2015, one for 05/27/2015, three for 05/28/2015, and two for 06/09/2015. Observation on 06/09/2015 at 4:20 PM revealed Resident #1 provided wound care by LVN A. Resident #1 had an Unstageable pressure sore to his outer right foot below his little toe, with yellow slough in the middle of the wound. Resident #1 had one healing Stage III to his outer left leg on the calf area. Resident #1 had three Stage III pressure sores on his right buttock and one Stage II on his left buttock. LVN A did not measure any of the pressure sores, even though the left buttock was a new area. LVN A removed the dressing from the outer right foot and placed it on Resident #1's bed by his foot. LVN A did not change his gloves and cleansed the area with wound care cleanser he sprayed on gauze. LVN A again did not change his gloves, then placed the clean dressing on the pressure sore. LVN A then picked up the dirty dressing and threw it in the trash and removed his gloves. LVN A cleansed all areas in this manner, only changing gloves between each pressure sore. After cleansing all the pressure sores on his buttocks, separately, LVN A applied A&D ointment over Resident #1's entire buttock area, including over all the pressure sores. In an interview on 06/09/2015 at 6:07 PM LVN A stated he should have changed his gloves per his policy when cleaning the pressure sores. He stated he should have removed the dirty dressing and then disposed of his gloves. LVN A stated he should have also changed his gloves after cleansing each pressure sore and prior to placing the clean dressing. In an interview on 06/10/2015 at 3:05 PM LVN A stated Resident #1 had multiple areas on his bottom for two weeks, ever since LVN A started working at the facility. He stated he had not notified the physician about the pressure sores or any changes in the pressure sores. Observation on 06/10/2015 at 3:10 PM revealed Resident #1's skin assessment by LVN A, DON, and RNC. Resident #1's Unstageable pressure sore on his outer right foot below his little toe measured 2 cm by 2 cm, irregular shape, with one third of the wound bed covered in yellow slough, and undermining under the edge of the wound-not measured by LVN A. The peri-wound was macerated at the top of the wound edge near the little toe. LVN A stated the wound was a Stage III and the RNC agreed. Resident #1's outer left leg calf area healing Stage III pressure sore measured 3 cm by 2 cm with little depth was almost healed. (These preesure sores were present at hospital). Resident #1's right buttock had three areas: the right outer buttock Stage III pressure sore measured 3 cm by 5 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was not present at hospital). The right inner buttock Stage III pressure sore measured 1 cm by 7 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated the pressure sore had 50% slough and called the pressure sore a Stage II. The shiny, yellow wound bed was granulation tissue and was not slough. (This pressure sore was on the hospital assessment). Resident #1 had a Stage III pressure sore on his right lower buttock measured 6 cm by 7 cm with 0.2 cm depth. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was on the hospital records and had deteriorated.) Resident #1 had two Stage II pressure sores on his lower left buttock-the proximal sore measured 1 cm by 1 cm and the distal sore measured 1.5 cm by 1.5 cm, and both were open. LVN A and RNC stated the proximal sore was open and was a Stage II. LVN A and RNC stated the distal area sore was not open and was a Stage I. (These pressure sores were not present when Resident #1 was at the hospital on [DATE]). In an interview on 06/10/2015 at 4:05 PM the DON and RNC stated Resident #1 needed to be turned and repositioned at least every two hours even though he was on the air mattress. LVN A agreed. Review of Resident #1's chart on 06/11/2015 reflected no notification to the physician had been documented in the Nurse's Notes about the findings on 06/10/2015. Also there was not a readmission assessment performed to include a full skin assessment when he returned from the hospital on [DATE]. There was no documentation in the nurse's notes about staff notifying the physician since prior to 06/05/2015. Review of the Weekly Skin Documentation for Resident #1 dated June 2015 reflected it was blank, only the Resident's name and date was on the document. Review of the TAR for Resident #1 dated June 2015 reflected the wound care treatments for his left lateral calf, coccyx, and right fifth metatarsal. The treatment for [REDACTED]. Resident #1 had no pressure sores on his coccyx. In an interview on 06/11/2015 at 9:55 AM LVN A stated he was at the facility this morning because he did not document in the nurse's notes after measuring the pressure sores. He stated he did not contact the physician about the changes in the pressure sores on 06/10/2015, but passed it on in report for the morning nurse to contact the physician. LVN A stated he was not here when Resident #1 returned from the hospital, but the measurements made on 06/10/2015 were the first and only measurements made since Resident #1 returned from the hospital on [DATE]. LVN A stated Resident #1 should be repositioned every two hours even though he was on the air mattress. LVN A stated Resident #1 had not ever refused to be repositioned. In an interview on 06/11/2015 at 11:00 AM RNC stated the physician should have been notified immediately of the changes and new pressure sores. The RNC also stated the wounds should have been assessed and measured on readmission and the physician notified of the findings. In an interview on 06/11/2015 at 12:05 PM the NP stated she expected immediate notification of the changes in Resident #1's skin. She stated when she was notified she changed the treatments on the pressure sores on the buttocks because the ointment was not an appropriate treatment and was a mode for infection. She stated she ordered dressings to cover the pressure sores. She stated she expected the facility staff to perform full skin assessments immediately when a resident returned from the hospital. She stated she allowed the facility to stage the pressure sores because the facility staff should know how to stage them. The NP also stated the LVN performing the treatments should have changed his gloves while cleaning the pressure sores per the policy, it's common sense to change gloves. In an interview on 06/11/2015 at 3:55 PM the DON stated she expected the staff to notify the physician immediately or as soon as possible when changes occurred in a resident's skin. She also expected the staff to perform a full skin assessment on readmission from the hospital and notify the physician for treatment orders. She also expected the staff to document thoroughly in the nurse's notes. The DON stated she also expected the staff to measure the pressure sores immediately when a change was identified. She also stated the A&D ointment was not an appropriate treatment for [REDACTED].#1's bilateral buttocks. The DON expected LVN A to change his gloves before he touched something clean. In an interview on 06/11/2015 at 5:10 PM the Administrator stated he expected the staff to notify the physician as soon as possible when changes in the resident's skin were identified. He stated he also expected the staff to perform a readmission assessment including a full skin assessment and notify the physician of the assessment and obtain treatment orders for skin problems. The facility provided a list of two residents who had pressure sores.

Based on observation, interview, and record review the facility failed to ensure that a resident who entered the facility without pressure sores did not develop pressure sores and a resident having pressure sores received necessary treatment and services to promote healing and prevent new sores from developing for one (1) of six (6) residents (Resident #1) reviewed for skin condition. Resident #1 had three Stage III pressure sores to his right buttock, two Stage II pressure sores on his left buttock, an Unstageable pressure sore to his outer right foot, and a healing Stage III pressure sore to his left leg posterior calf. The facility only had documentation and treatments for the right foot and left leg. The pressure sores to the bilateral buttocks were not documented, treated appropriately, and the physician was not notified. Also LVN A provided wound care but did not change gloves per policy while providing care. Resident #1 also stated staff were not turning him every two hours. Resident #1's pressure sores declined after re-admission to the facility on [DATE]. This deficient practice affected Resident #1 and could affect one other resident with pressure sores at risk for the development of new pressure sores, infection and worsening of current pressure sores. Findings include: Review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Website National Pressure Ulcer Advisory Panel defined pressure sores: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Review of the Significant Change MDS Assessment for Resident #1 dated 05/07/2015 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 had four (4) Stage II pressure sores with the oldest onset dated 01/28/2015. Resident #1's Stage II pressure sores had granulation tissue (pink or red tissue with shiny, moist, granular appearance). Resident #1 had skin treatments of pressure reducing device for chair, pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications, and application of dressings to feet. Review of the Care Plan for Resident #1 dated 05/06/2015 reflected he had Stage II pressure sores to his right outer foot and left posterior calf. Resident #1 had interventions including to assist with turning and repositioning every two hours and pressure relieving devices for his bed and wheelchair. Review of the facility's Pressure Ulcers dated 06/08/2015 reflected Resident #1 had three Stage II pressure ulcers with an onset date of 03/10/2015 on his coccyx, left posterior calf, and right outer foot. Review of the Hospital Inpatient Record dated 06/02/2015-06/05/2015 for Resident #1 reflected a wound assessment on 06/02/2015 at admission. Resident #1 had an Unstageable pressure sore to his right foot lateral to 5th toe with 60% yellow, slough non-healing measured 2.2 cm by 2 cm. His right lateral lower leg had a suspected deep tissue injury measured 2 cm by 1.5 cm. On Resident #1's left lower lateral leg he had a Stage IV with red granulation tissue measured 4.5 cm by 1.5 cm. Resident #1 had a Stage III on his right ischial tuberosity (bone on lower part of buttock) with red granulation tissue measured 4.5 cm by 3.2 cm. He also had a Stage III on his middle, right buttock with white fibrous slough measured 4 cm by 7 cm. Resident #1 also had a Stage I to his left foot measured 0.5 cm by 0.2 cm. Resident #1 was alert and oriented x4 indicating oriented to person, place, time, and pain. Resident #1's discharge instructions for his pressure sores were to cleanse and apply foam dressings. Also to apply a zinc oxide ointment to the other areas of his bottom, not on the wounds. The instructions also reflected to apply an enzymatic debrider ointment to his right lateral to 5th toe Unstageable pressure ulcer to debride the slough. In an interview on 06/09/2015 at 2:45 PM Resident #1 stated he acquired the pressure sores while in the facility. He stated the staff did not turn him per the Patient Positioning Chart, and he gestured to his wall where the Chart was taped. Resident #1 stated the staff were to sign the sheet when they turned him. Review of the Patient Positioning Chart in Resident #1's room, no name, with a start date of 05/20/2015 reflected the time was not indicated with the date in the first column. There were three entries for 05/20/2015, indicating right or left, and the comment of every two hours and signed by the staff who turned Resident #1. There were two entries for 05/25/2015, three for 05/26/2015, one for 05/27/2015, three for 05/28/2015, and two for 06/09/2015. Observation on 06/09/2015 at 4:20 PM revealed Resident #1 provided wound care by LVN A. Resident #1 had an Unstageable pressure sore to his outer right foot below his little toe, with yellow slough in the middle of the wound. Resident #1 had one healing Stage III to his outer left leg on the calf area. Resident #1 had three Stage III pressure sores on his right buttock and one Stage II on his left buttock. LVN A did not measure any of the pressure sores, even though the left buttock was a new area. LVN A removed the dressing from the outer right foot and placed it on Resident #1's bed by his foot. LVN A did not change his gloves and cleansed the area with wound care cleanser he sprayed on gauze. LVN A again did not change his gloves, then placed the clean dressing on the pressure sore. LVN A then picked up the dirty dressing and threw it in the trash and removed his gloves. LVN A cleansed all areas in this manner, only changing gloves between each pressure sore. After cleansing all the pressure sores on his buttocks, separately, LVN A applied A&D ointment over Resident #1's entire buttock area, including over all the pressure sores. In an interview on 06/09/2015 at 6:07 PM LVN A stated he should have changed his gloves per his policy when cleaning the pressure sores. He stated he should have removed the dirty dressing and then disposed of his gloves. LVN A stated he should have also changed his gloves after cleansing each pressure sore and prior to placing the clean dressing. In an interview on 06/10/2015 at 3:05 PM LVN A stated Resident #1 had multiple areas on his bottom for two weeks, ever since LVN A started working at the facility. He stated he had not notified the physician about the pressure sores or any changes in the pressure sores. Observation on 06/10/2015 at 3:10 PM revealed Resident #1's skin assessment by LVN A, DON, and RNC. Resident #1's Unstageable pressure sore on his outer right foot below his little toe measured 2 cm by 2 cm, irregular shape, with one third of the wound bed covered in yellow slough, and undermining under the edge of the wound-not measured by LVN A. The peri-wound was macerated at the top of the wound edge near the little toe. LVN A stated the wound was a Stage III and the RNC agreed. Resident #1's outer left leg calf area healing Stage III pressure sore measured 3 cm by 2 cm with little depth was almost healed. (These preesure sores were present at hospital). Resident #1's right buttock had three areas: the right outer buttock Stage III pressure sore measured 3 cm by 5 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was not present at hospital). The right inner buttock Stage III pressure sore measured 1 cm by 7 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated the pressure sore had 50% slough and called the pressure sore a Stage II. The shiny, yellow wound bed was granulation tissue and was not slough. (This pressure sore was on the hospital assessment). Resident #1 had a Stage III pressure sore on his right lower buttock measured 6 cm by 7 cm with 0.2 cm depth. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was on the hospital records and had deteriorated.) Resident #1 had two Stage II pressure sores on his lower left buttock-the proximal sore measured 1 cm by 1 cm and the distal sore measured 1.5 cm by 1.5 cm, and both were open. LVN A and RNC stated the proximal sore was open and was a Stage II. LVN A and RNC stated the distal area sore was not open and was a Stage I. (These pressure sores were not present when Resident #1 was at the hospital on [DATE]). In an interview on 06/10/2015 at 4:05 PM the DON and RNC stated Resident #1 needed to be turned and repositioned at least every two hours even though he was on the air mattress. LVN A agreed. Review of Resident #1's chart on 06/11/2015 reflected no notification to the physician had been documented in the Nurse's Notes about the findings on 06/10/2015. Also there was not a readmission assessment performed to include a full skin assessment when he returned from the hospital on [DATE]. There was no documentation in the nurse's notes about staff notifying the physician since prior to 06/05/2015. Review of the Weekly Skin Documentation for Resident #1 dated June 2015 reflected it was blank, only the Resident's name and date was on the document. Review of the TAR for Resident #1 dated June 2015 reflected the wound care treatments for his left lateral calf, coccyx, and right fifth metatarsal. The treatment for [REDACTED]. Resident #1 had no pressure sores on his coccyx. In an interview on 06/11/2015 at 9:55 AM LVN A stated he was at the facility this morning because he did not document in the nurse's notes after measuring the pressure sores. He stated he did not contact the physician about the changes in the pressure sores on 06/10/2015, but passed it on in report for the morning nurse to contact the physician. LVN A stated he was not here when Resident #1 returned from the hospital, but the measurements made on 06/10/2015 were the first and only measurements made since Resident #1 returned from the hospital on [DATE]. LVN A stated Resident #1 should be repositioned every two hours even though he was on the air mattress. LVN A stated Resident #1 had not ever refused to be repositioned. In an interview on 06/11/2015 at 11:00 AM RNC stated the physician should have been notified immediately of the changes and new pressure sores. The RNC also stated the wounds should have been assessed and measured on readmission and the physician notified of the findings. In an interview on 06/11/2015 at 12:05 PM the NP stated she expected immediate notification of the changes in Resident #1's skin. She stated when she was notified she changed the treatments on the pressure sores on the buttocks because the ointment was not an appropriate treatment and was a mode for infection. She stated she ordered dressings to cover the pressure sores. She stated she expected the facility staff to perform full skin assessments immediately when a resident returned from the hospital. She stated she allowed the facility to stage the pressure sores because the facility staff should know how to stage them. The NP also stated the LVN performing the treatments should have changed his gloves while cleaning the pressure sores per the policy, it's common sense to change gloves. In an interview on 06/11/2015 at 3:55 PM the DON stated she expected the staff to notify the physician immediately or as soon as possible when changes occurred in a resident's skin. She also expected the staff to perform a full skin assessment on readmission from the hospital and notify the physician for treatment orders. She also expected the staff to document thoroughly in the nurse's notes. The DON stated she also expected the staff to measure the pressure sores immediately when a change was identified. She also stated the A&D ointment was not an appropriate treatment for [REDACTED].#1's bilateral buttocks. The DON expected LVN A to change his gloves before he touched something clean. In an interview on 06/11/2015 at 5:10 PM the Administrator stated he expected the staff to notify the physician as soon as possible when changes in the resident's skin were identified. He stated he also expected the staff to perform a readmission assessment including a full skin assessment and notify the physician of the assessment and obtain treatment orders for skin problems. Review of the facility's Pressure Ulcer Staging not dated reflected the definitions of Stage I, II, III, IV, and Eschar pressure sores with pictures. A Stage I had intact skin with persistent redness. The Stage II was defined as Partial thickness skin loss .superficial and presents clinically as an abrasion, blister or shallow crater. The Stage III pressure sore involved Full thickness skin loss and presents clinically as a deep crater with or without undermining and could also be necrotic. Review of the facility's Skin System revised 05/20/2014 reflected a weekly skin assessment would be completed upon admission or readmission. The System also reflected when a resident had a pressure sore, daily documentation would be performed on the Daily Pressure Ulcer Documentation Form until healed. The System reflected the definitions of pressure sores: Stage I-Intact skin with non-blanchable redness .; Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; Stage III-Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling .Bone/tendon is not visible or directly palpable; .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. The System reflected Skin Treatments for recommended use for pressure sores. The Treatments listed dressings to cover the pressure sores; none indicated using only an ointment. The System also reflected Wound Documentation Guidelines indicated to measure each wounds length, width, and depth. Also document the amount of drainage or exudate. And describe the tissue type: necrotic or eschar (Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than the surrounding skin), slough (Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps), granulation (Pink or beefy red tissue with a shiny, moist, granular appearance), [MEDICATION NAME] (For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface). The Guidelines also reflected to measure any undermining (separation of wound edges from the subcutaneous tissue). The Guidelines reflected to document this information daily on the appropriate sheet. Review of the facility's policy entitled Nursing Guidelines: Change of Condition Notification not dated reflected the physician should be notified of changes in a resident's condition when the resident had a significant change in physical status like deterioration in health and when a treatment needed significant change. The facility provided a list of two residents who had pressure sores.

Based on observation, interview, and record review the facility failed to implement written policies and procedures that prohibit neglect of residents for one (1) of six (6) residents (Resident #1) reviewed for skin condition. Resident #1 had three Stage III pressure sores to his right buttock, two Stage II pressure sores on his left buttock, an Unstageable pressure sore to his outer right foot, and a healing Stage III pressure sore to his left leg posterior calf. The facility only had documentation and treatments for the right foot and left leg. The pressure sores to the bilateral buttocks were not documented, treated appropriately, and the physician was not notified. Also LVN A provided wound care but did not change gloves per policy while providing care. Resident #1 also stated staff were not turning him every two hours. Resident #1's pressure sores declined after re-admission to the facility on [DATE]. This deficient practice affected Resident #1 and could affect one other resident with pressure sores at risk for the development of new pressure sores, infection and worsening of current pressure sores. Findings include: Review of the Face Sheet for Resident #1 reflected a [AGE] year old male admitted to the facility on [DATE] and readmitted on [DATE] with the following Diagnoses: [REDACTED]. Review of the Website National Pressure Ulcer Advisory Panel defined pressure sores: http://www.npuap.org/resources/educational-and-clinical-resources/npuap-pressure-ulcer-stagescategories/ The National Pressure Ulcer Advisory Panel redefined the definition of a pressure ulcer and the stages of pressure ulcers in 2007, including the original 4 stages and adding 2 stages on deep tissue injury and unstageable pressure ulcers. This work was the culmination of over 5 years of work beginning with the identification of deep tissue injury in 2001. The proposed definitions were refined by the NPUAP with input from an on-line evaluation of their face validity, accuracy clarity, succinctness, utility, and discrimination. This process was completed online and provided input to the Panel for continued work. The proposed final definitions were reviewed by a consensus conference and their comments were used to create the final definitions. International NPUAP-EPUAP Pressure Ulcer DefinitionA pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear. A number of contributing or confounding factors are also associated with pressure ulcers; the significance of these factors is yet to be elucidated. Pressure Ulcer Stages/Categories Category/Stage I: Non-blanchable [DIAGNOSES REDACTED]Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones. May indicate at risk persons. Category/Stage II: Partial thicknessPartial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising*. This category should not be used to describe skin tears, tape burns, incontinence associated [MEDICAL CONDITION], maceration or excoriation.*Bruising indicates deep tissue injury. Category/Stage III: Full thickness skin lossFull thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Category/Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Category/Stage IV: Full thickness tissue lossFull thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Category/Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteo[DIAGNOSES REDACTED] or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable. Additional Categories/Stages for the USA Unstageable/Unclassified: Full thickness skin or tissue loss - depth unknownFull thickness tissue loss in which actual depth of the ulcer is completely obscured by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar are removed to expose the base of the wound, the true depth cannot be determined; but it will be either a Category/Stage III or IV. Stable (dry, adherent, intact without [DIAGNOSES REDACTED] or fluctuance) eschar on the heels serves as the body ' s natural (biological) cover and should not be removed. Review of the Significant Change MDS Assessment for Resident #1 dated 05/07/2015 reflected he had a BIMS score of 12 indicating moderate cognitive impairment. Resident #1 had four (4) Stage II pressure sores with the oldest onset dated 01/28/2015. Resident #1's Stage II pressure sores had granulation tissue (pink or red tissue with shiny, moist, granular appearance). Resident #1 had skin treatments of pressure reducing device for chair, pressure reducing device for bed, Nutrition or hydration intervention to manage skin problems, pressure ulcer care, application of nonsurgical dressings, application of ointments/medications, and application of dressings to feet. Review of the Care Plan for Resident #1 dated 05/06/2015 reflected he had Stage II pressure sores to his right outer foot and left posterior calf. Resident #1 had interventions including to assist with turning and repositioning every two hours and pressure relieving devices for his bed and wheelchair. Review of the facility's Pressure Ulcers dated 06/08/2015 reflected Resident #1 had three Stage II pressure ulcers with an onset date of 03/10/2015 on his coccyx, left posterior calf, and right outer foot. Review of the Hospital Inpatient Record dated 06/02/2015-06/05/2015 for Resident #1 reflected a wound assessment on 06/02/2015 at admission. Resident #1 had an Unstageable pressure sore to his right foot lateral to 5th toe with 60% yellow, slough non-healing measured 2.2 cm by 2 cm. His right lateral lower leg had a suspected deep tissue injury measured 2 cm by 1.5 cm. On Resident #1's left lower lateral leg he had a Stage IV with red granulation tissue measured 4.5 cm by 1.5 cm. Resident #1 had a Stage III on his right ischial tuberosity (bone on lower part of buttock) with red granulation tissue measured 4.5 cm by 3.2 cm. He also had a Stage III on his middle, right buttock with white fibrous slough measured 4 cm by 7 cm. Resident #1 also had a Stage I to his left foot measured 0.5 cm by 0.2 cm. Resident #1 was alert and oriented x4 indicating oriented to person, place, time, and pain. Resident #1's discharge instructions for his pressure sores were to cleanse and apply foam dressings. Also to apply a zinc oxide ointment to the other areas of his bottom, not on the wounds. The instructions also reflected to apply an enzymatic debrider ointment to his right lateral to 5th toe Unstageable pressure ulcer to debride the slough. In an interview on 06/09/2015 at 2:45 PM Resident #1 stated he acquired the pressure sores while in the facility. He stated the staff did not turn him per the Patient Positioning Chart, and he gestured to his wall where the Chart was taped. Resident #1 stated the staff were to sign the sheet when they turned him. Review of the Patient Positioning Chart in Resident #1's room, no name, with a start date of 05/20/2015 reflected the time was not indicated with the date in the first column. There were three entries for 05/20/2015, indicating right or left, and the comment of every two hours and signed by the staff who turned Resident #1. There were two entries for 05/25/2015, three for 05/26/2015, one for 05/27/2015, three for 05/28/2015, and two for 06/09/2015. Observation on 06/09/2015 at 4:20 PM revealed Resident #1 provided wound care by LVN A. Resident #1 had an Unstageable pressure sore to his outer right foot below his little toe, with yellow slough in the middle of the wound. Resident #1 had one healing Stage III to his outer left leg on the calf area. Resident #1 had three Stage III pressure sores on his right buttock and one Stage II on his left buttock. LVN A did not measure any of the pressure sores, even though the left buttock was a new area. LVN A removed the dressing from the outer right foot and placed it on Resident #1's bed by his foot. LVN A did not change his gloves and cleansed the area with wound care cleanser he sprayed on gauze. LVN A again did not change his gloves, then placed the clean dressing on the pressure sore. LVN A then picked up the dirty dressing and threw it in the trash and removed his gloves. LVN A cleansed all areas in this manner, only changing gloves between each pressure sore. After cleansing all the pressure sores on his buttocks, separately, LVN A applied A&D ointment over Resident #1's entire buttock area, including over all the pressure sores. In an interview on 06/09/2015 at 6:07 PM LVN A stated he should have changed his gloves per his policy when cleaning the pressure sores. He stated he should have removed the dirty dressing and then disposed of his gloves. LVN A stated he should have also changed his gloves after cleansing each pressure sore and prior to placing the clean dressing. In an interview on 06/10/2015 at 3:05 PM LVN A stated Resident #1 had multiple areas on his bottom for two weeks, ever since LVN A started working at the facility. He stated he had not notified the physician about the pressure sores or any changes in the pressure sores. Observation on 06/10/2015 at 3:10 PM revealed Resident #1's skin assessment by LVN A, DON, and RNC. Resident #1's Unstageable pressure sore on his outer right foot below his little toe measured 2 cm by 2 cm, irregular shape, with one third of the wound bed covered in yellow slough, and undermining under the edge of the wound-not measured by LVN A. The peri-wound was macerated at the top of the wound edge near the little toe. LVN A stated the wound was a Stage III and the RNC agreed. Resident #1's outer left leg calf area healing Stage III pressure sore measured 3 cm by 2 cm with little depth was almost healed. (These preesure sores were present at hospital). Resident #1's right buttock had three areas: the right outer buttock Stage III pressure sore measured 3 cm by 5 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was not present at hospital). The right inner buttock Stage III pressure sore measured 1 cm by 7 cm, but LVN A did not measure the depth. The depth was greater than 0.1 cm. LVN A and RNC stated the pressure sore had 50% slough and called the pressure sore a Stage II. The shiny, yellow wound bed was granulation tissue and was not slough. (This pressure sore was on the hospital assessment). Resident #1 had a Stage III pressure sore on his right lower buttock measured 6 cm by 7 cm with 0.2 cm depth. LVN A and RNC stated this pressure sore was a Stage II. (This pressure sore was on the hospital records and had deteriorated.) Resident #1 had two Stage II pressure sores on his lower left buttock-the proximal sore measured 1 cm by 1 cm and the distal sore measured 1.5 cm by 1.5 cm, and both were open. LVN A and RNC stated the proximal sore was open and was a Stage II. LVN A and RNC stated the distal area sore was not open and was a Stage I. (These pressure sores were not present when Resident #1 was at the hospital on [DATE]). In an interview on 06/10/2015 at 4:05 PM the DON and RNC stated Resident #1 needed to be turned and repositioned at least every two hours even though he was on the air mattress. LVN A agreed. Review of Resident #1's chart on 06/11/2015 reflected no notification to the physician had been documented in the Nurse's Notes about the findings on 06/10/2015. Also there was not a readmission assessment performed to include a full skin assessment when he returned from the hospital on [DATE]. There was no documentation in the nurse's notes about staff notifying the physician since prior to 06/05/2015. Review of the Weekly Skin Documentation for Resident #1 dated June 2015 reflected it was blank, only the Resident's name and date was on the document. Review of the TAR for Resident #1 dated June 2015 reflected the wound care treatments for his left lateral calf, coccyx, and right fifth metatarsal. The treatment for [REDACTED]. Resident #1 had no pressure sores on his coccyx. In an interview on 06/11/2015 at 9:55 AM LVN A stated he was at the facility this morning because he did not document in the nurse's notes after measuring the pressure sores. He stated he did not contact the physician about the changes in the pressure sores on 06/10/2015, but passed it on in report for the morning nurse to contact the physician. LVN A stated he was not here when Resident #1 returned from the hospital, but the measurements made on 06/10/2015 were the first and only measurements made since Resident #1 returned from the hospital on [DATE]. LVN A stated Resident #1 should be repositioned every two hours even though he was on the air mattress. LVN A stated Resident #1 had not ever refused to be repositioned. In an interview on 06/11/2015 at 11:00 AM RNC stated the physician should have been notified immediately of the changes and new pressure sores. The RNC also stated the wounds should have been assessed and measured on readmission and the physician notified of the findings. In an interview on 06/11/2015 at 12:05 PM the NP stated she expected immediate notification of the changes in Resident #1's skin. She stated when she was notified she changed the treatments on the pressure sores on the buttocks because the ointment was not an appropriate treatment and was a mode for infection. She stated she ordered dressings to cover the pressure sores. She stated she expected the facility staff to perform full skin assessments immediately when a resident returned from the hospital. She stated she allowed the facility to stage the pressure sores because the facility staff should know how to stage them. The NP also stated the LVN performing the treatments should have changed his gloves while cleaning the pressure sores per the policy, it's common sense to change gloves. In an interview on 06/11/2015 at 3:55 PM the DON stated she expected the staff to notify the physician immediately or as soon as possible when changes occurred in a resident's skin. She also expected the staff to perform a full skin assessment on readmission from the hospital and notify the physician for treatment orders. She also expected the staff to document thoroughly in the nurse's notes. The DON stated she also expected the staff to measure the pressure sores immediately when a change was identified. She also stated the A&D ointment was not an appropriate treatment for [REDACTED].#1's bilateral buttocks. The DON expected LVN A to change his gloves before he touched something clean. In an interview on 06/11/2015 at 5:10 PM the Administrator stated he expected the staff to notify the physician as soon as possible when changes in the resident's skin were identified. He stated he also expected the staff to perform a readmission assessment including a full skin assessment and notify the physician of the assessment and obtain treatment orders for skin problems. Review of the facility's Pressure Ulcer Staging not dated reflected the definitions of Stage I, II, III, IV, and Eschar pressure sores with pictures. A Stage I had intact skin with persistent redness. The Stage II was defined as Partial thickness skin loss .superficial and presents clinically as an abrasion, blister or shallow crater. The Stage III pressure sore involved Full thickness skin loss and presents clinically as a deep crater with or without undermining and could also be necrotic. Review of the facility's Skin System revised 05/20/2014 reflected a weekly skin assessment would be completed upon admission or readmission. The System also reflected when a resident had a pressure sore, daily documentation would be performed on the Daily Pressure Ulcer Documentation Form until healed. The System reflected the definitions of pressure sores: Stage I-Intact skin with non-blanchable redness .; Stage II-Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister. Presents as a shiny or dry shallow ulcer without slough or bruising; Stage III-Full thickness tissue loss .Slough may be present but does not obscure the depth of tissue loss. May include undermining or tunneling .Bone/tendon is not visible or directly palpable; .Unstageable-Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. The System reflected Skin Treatments for recommended use for pressure sores. The Treatments listed dressings to cover the pressure sores; none indicated using only an ointment. The System also reflected Wound Documentation Guidelines indicated to measure each wounds length, width, and depth. Also document the amount of drainage or exudate. And describe the tissue type: necrotic or eschar (Black, brown, or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either firmer or softer than the surrounding skin), slough (Yellow or white tissue that adheres to the ulcer bed in strings or thick clumps), granulation (Pink or beefy red tissue with a shiny, moist, granular appearance), [MEDICATION NAME] (For superficial ulcers, new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface). The Guidelines also reflected to measure any undermining (separation of wound edges from the subcutaneous tissue). The Guidelines reflected to document this information daily on the appropriate sheet. Review of the facility's policy entitled Nursing Guidelines: Change of Condition Notification not dated reflected the physician should be notified of changes in a resident's condition when the resident had a significant change in physical status like deterioration in health and when a treatment needed significant change. Review of the facility's policy entitled Reporting Abuse to Facility Management not dated reflected .to promptly report any incident or suspected incident of neglect .to the administrator or his/her designee. The policy defined neglect as the .failure to provide goods and services necessary to avoid physical harm . The policy reflected the neglect would be reported to the State agency, the resident or resident's representative, the law enforcement, and the resident's physician. The policy reflected the incident of neglect would also be investigated. The facility provided a list of two residents who had pressure sores.

Based on observation, interview, and record review the facility failed to provide appropriate treatment and services to prevent urinary tract infections for one (1) of three (3) residents (Resident #4) reviewed for catheters when: A) Resident #4's urinary catheter collection bag was filled beyond capacity with urine backing up in the tubing. Urinary catheter bag was too heavy for plastic clip to secure it to the bed causing it to fall to the floor. B) Resident #4 ' s record revealed five (5) confirmed urinary tract infections [MEDICAL CONDITION] in seven months. C) Resident #4 complained of sharp pinching pain related to urine not being able to drain into the collection bag. These deficient practices placed eight (8) residents with indwelling urinary catheters at risk for the development of/or worsening of urinary tract infection,[MEDICAL CONDITION], undue pain and discomfort and possible trauma such as bleeding or accidental removal of the catheters. Findings include: Review of Resident #4's Face Sheet reflected a [AGE] year old female admitted to the facility on [DATE] with the following [DIAGNOSES REDACTED]. resistant to the antibiotics, bacteremia a bacterial infection in the blood, [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of Resident #4's Quarterly Minimum Data Set (MDS) assessment dated [DATE] reflected Resident #4 had a BIMS's of 15 out of 15 indicating Resident #4 to be cognitively intact. Resident #4 was assessed to have an indwelling urinary catheter. Resident #4 was not assessed to have a UTI within the previous 30 days. Review of Resident #4's Comprehensive Care Plan reflected a problem with a start date of 06/04/2014 of " Urinary Incontinence with an indwelling urinary catheter. " The goal reflected: " Resident will have catheter care managed appropriately as evidenced by not exhibiting signs of infection or urethral trauma. " Under approach: " Assess drainage: Record the amount, type, color, odor " , " Provide catheter care every 2 hours and as needed " and " Report UTI. " Resident #4's reflected a problem with a start date of 06/04/14 of " Potential for urinary tract infection related to indwelling catheter use. " The goal reflected: " Resident will not exhibit signs of urinary tract infection. If symptoms occur, they will be addressed and treated properly. " Under approach: " Assess for UTI " , " Monitor and document intake and output and characteristics of urine " and " Perform catheter care per facility policy or MD order. " Review of Resident #4 ' s Lab Reports revealed high counts of bacteria and positive for UTI for urine samples taken on 08/13/14, 09/17/14, 10/09/14, 12/03/14 and 03/06/15. Results revealed five confirmed UTIs in the previous seven months. An interview and observation of Resident #4 in her room lying in bed on 03/10/15 at 12:30 p.m. revealed her urine catheter bag lying on the floor and inflated to past the capacity. Urine was observed backed up in the tubing past visible part of the tubing. Resident #4 said her Foley catheter bag gets full fast since the facility changed her to the smaller collection bag. Resident #4 said the collection bag has been full enough recently to open up and run out onto the floor. Resident #4 said it gets this full a lot of the time. She said when it is this full it is too heavy for the plastic clip to hold it to the bed so it falls to the floor. Resident #4 said when the bag gets this full it is painful because the urine can no longer drain freely and she gets frequent urinary tract infections [MEDICAL CONDITION]. She said it feels like someone is pinching her down there. In an interview Certified Nurse Aide (CNA) A on 03/10/15 at 1:03 p.m. said Resident #4 fills up the urine bag fast. CNA A said the urine bag had fallen to the floor because it had gotten too full and heavy for the plastic clip to hold it up. CNA A stated there had been one time when she had seen urine running out onto the floor when the bag was too full. In an interview the DON on 03/10/15 at 2:25 p.m. stated that the facility had quit using the 4000ml (milliliter) Foley bags for Resident #4 because the overnight staff would not empty the bag and it would get too full and heavy. The DON said Foley bags should be emptied as needed unless there is an order to empty more frequently. The DON stated that Foley bags should not be left until they are overfilled and they should not be on the floor. In an interview the DON on 03/11/15 at 2:15 p.m. said there were no records of Intake/Output for Resident #4. In an interview Licensed Vocational Nurse (LVN) B said that Foley catheter bags should be emptied when they are close to full unless ordered more otherwise. Review of Facility Procedure for Catheter Care, Urinary dated December 2003 by Senior Living Properties reflected, " Maintain an accurate record of the resident ' s daily output, per facility policy and procedure. It also reflects, " Be sure the catheter tubing and drainage bag are kept off the floor. Review of The Lippincott Manual of Nursing Practice, 10th Edition, Chapter 21, page 782, Maintaining a closed drainage system reflected "Urine should not be allowed to collect in the tubing because a free flow of urine must be maintained to prevent infection. Keep the bag off the floor. " The facility provided CMS 672 reflected eight (8) residents with indwelling urinary catheters and a census of 97 total Residents.

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for 2 of 7 residents reviewed for neglect (Residents #1 and #3). A. The facility failed to develop and implement interventions to monitor Resident #1 for behaviors of self harm. Resident #1 attempted suicide in his room by cutting his wrists and throat with a knife on 2/25/15. The resident has a [DIAGNOSES REDACTED]. B. The facility failed to develop and implement interventions to monitor Resident #3 for behaviors of self harm. Resident #3 has a [DIAGNOSES REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 3/2/15. While the IJ was removed on 3/2/15, the facility remained out of compliance at actual harm with a scope identified as a pattern. This deficient practice could place 2 residents, identified with a [DIAGNOSES REDACTED]. The findings include: A. Review of the undated admission face sheet for Resident #1 reflected a [AGE] year old male with an admission date of [DATE] and a readmission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the consolidated physician orders [REDACTED].#1 reflected the following [MEDICAL CONDITION] medication orders: [MEDICATION NAME] (antidepressant) 10 mg by mouth one time a day for a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] a BIMS score of 15, indicating resident was cognitively intact, felt down or depressed and bad about himself for several days (2-6 days). Review of the care plan dated 2/5/15 for Resident #1 reflected no care plan for suicidal ideation or suicide prevention. Further review reflected the following: Problem: [MEDICAL CONDITION] Drug Use, resident is currently taking [MEDICAL CONDITION] medication as evidenced by Depression, Anxiety. Approach: 1) Monitor and record any displayed behavior or mood problems. 3) Monitor effectiveness of [MEDICAL CONDITION] medications. Further review of the nurse's notes dated 1/7/15 thru 2/25/15 for Resident #1 revealed no behavior monitoring for target behavior depression was documented. Review of the clinical record revealed no behavior monitoring sheets were available for Resident #1. Further review of the MARs for January and February 2015 reflected there was not tracking for behavior monitoring documented on the MAR. In an interview on 3/2/15 at 11:25 a.m. LVN G, Charge Nurse, stated she did not know where the behavior monitoring sheets were kept. She further stated any behaviors are documented in the nurse's notes. LVN G stated she did not know about documenting for targeted behaviors for psychoactive medications. Review of the facility's Incident Report dated 2/25/15 reflected Resident #1 was discovered by staff in his room with blood on both wrists and neck and resident had a knife at his neck. Resident #1 had ordered a knife from a television advertisement that came in an unidentified package to him. Facility staff called EMS 911 and resident was sent to the hospital. Resident #1 stated to staff he meant to kill himself as he didn't have anything else to live for. resident had a history of [REDACTED]. Review of a witness statement dated 2/25/15 by LVN D reflected the following: Approximately 11:20 a.m. CNA yelling come to room, ran into Resident #1's room. Resident #1 was lying in bed, shirt bloody, holding pocket knife to his carotid artery. Knife removed from resident's hand.right and left wrist cut, bleeding. cut to neck bleeding. Pressure applied to wrists and neck with towels and gauze. Resident #1 continually saying I have no reason to live, nothing matters, nobody cares. Observation of Resident #1 at the hospital on [DATE] at 3:00 p.m. revealed resident was subdued, would not make eye contact with the investigator and speech was slow and monotone. In an interview on 2/27/15 at 3:00 p.m. at the hospital, Resident #1 stated he did not have anything to live for and wanted to die. He further stated he had ordered a knife with the intent of using it to kill himself. Review of the MDS dated [DATE] for Resident #1 reflected MDS was for reentry to the facility, no change of condition assessment was provided. Review of the nurses notes dated 1/5/15 for Resident #1 reflected the following: 10:45 a.m. - Resident at nurse's station and states that he is going to kill himself. Resident states that he is lonely because his wife doesn't visit and neither do his friends. Reported to SW and ADON, they went and spoke to resident as well. Was told by ADON to send him out 911. 11:35 a.m. - Resident was sent to ER for suicidal ideation. In an interview on 3/2/15 at 1:00 p.m. Psychiatric RNC (a nurse with advanced training/education in a specialty area) stated she was aware of the suicidal threats Resident #1 had made on 1/5/14 which resulted in admission to an in-patient psychiatric unit for evaluation and treatment. She further stated when Resident #1 returned to the facility he should have been monitored, should have had room checked for sharps, over the counter medications and any other potential means of self harm. RNC stated she expected the facility staff to implement basic safety precautions and make sure there was nothing in Resident #1's room he could use to harm himself. In an interview on 3/2/15 at 1:45 p.m. the ADON stated monitoring Resident #1 and checking his room for potential means of self harm was not done when the resident returned to the facility on [DATE]. In an interview on 3/2/15 at 11:40 a.m. MDS Coordinator H stated when a resident goes out to the hospital and returns a significant change of condition MDS should be generated. She further stated suicidal ideation and/or threats would generate development and implementation of a care plan for suicide prevention. MDS H stated no assessment or interventions were developed or implemented for Resident #1 when he returned from the hospital visit for suicidal ideation on 1/5/15 and there should have been. MDS Coordinator H stated residents receiving any [MEDICAL CONDITION] medications should have behavior monitoring conducted for each medication's targeted behavior. In an interview on 3/2/15 at 11:45 a.m. LVN D, Charge Nurse, stated targeted behavior monitoring had not been conducted for several months because it was too difficult and was too time consuming for the nursing staff. In an interview on 3/2/15 at 10:00 a.m. the facility DON stated she expected staff to conduct behavior monitoring. The DON stated she had only been at the facility for one week. Review of the facility's undated Nursing Guidelines, for antipsychotic medication use, submitted by the DON reflected the following: Guidelines: 1. Documenting the Appropriate Specific Conditions for Antipsychotic Medication Use. · Specific behavior(s) exhibited by the resident will be documented on the Behavioral Monitoring section of the MAR. 2. Documenting the Specific Behaviors which the Resident Exhibits. · For resident's receiving an antipsychotic medication for behavioral symptoms related to an organic mental syndrome, all symptoms or behaviors which relate to the specific condition for the drug's use, will be listed on the Behavioral Monitoring portion of the MAR. · At the end of each shift, the nurse will document the number of times each behavior occurred. · Each month, the nursing staff will sum the occurrences of each behavior and record a total, for each one. B. Record review of the admission face sheet dated 5/13/13 for Resident #3 reflected a [AGE] year old male with an admission date of [DATE] and readmission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the MDS dated [DATE] for Resident #3 reflected a BIMS of 15 (indicating resident was cognitively intact) and a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#3 reflected the following [MEDICAL CONDITION] medication orders: Valporic Acid 250 mg, 3 capsules by mouth twice a day for [MEDICAL CONDITION] Disorder [MEDICATION NAME] 20 mg, 2 capsules by mouth once a day for Depression [MEDICATION NAME] 100 mg tablet by mouth at bedtime for [MEDICAL CONDITION] [MEDICATION NAME] 2 mg tablet by mouth once a day for Anxiety Review of the care plan dated 2/12/15 for Resident #3 reflected the following: Problem: Resident is currently taking [MEDICAL CONDITION] medication as evidenced by: Depression, Anxiety and [MEDICAL CONDITION] Disorder. Approach: Monitor and record any displayed behavior or mood problems. Problem: I exhibit signs and symptoms of depression, as evidenced by want to be left alone and history of suicidal ideation. Problem: Resident has [MEDICAL CONDITION] as manifested by: mood swings, delusions. Approach: Monitor resident for increased agitation, anger, verbal and physical aggression. Document episodes and notify MD. Further review of the nurse's notes dated 12/1/14 thru 2/25/14 for Resident #3 revealed no behavior monitoring for target behavior depression was documented. Review of the clinical record revealed no behavior monitoring sheets were available for Resident #1. Further review of the MARs for January and February 2015 reflected there was not tracking for behavior monitoring documented on the MAR. In an interview on 3/2/15 at 12:15 p.m. the ADON stated there were no behavior monitoring sheets found for Resident #1 or Resident #3. She further stated behavior monitoring was not being conducted on any resident on [MEDICAL CONDITION] medications and the facility policy was to conduct behavior monitoring on all residents receiving [MEDICAL CONDITION] medications for targeted behaviors. Review of the facility's Abuse Prevention Program policy dated 5/20/14 reflected the following: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility's RVP, DON and RN Consultant were notified on 3/2/15 at 1:35 p.m. an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the RN Consultant and RVP on 3/2/15 at 4:35 p.m. The final Plan of Removal was accepted by the investigator on 3/2/15 at 5:20 p.m. Plan of Removal Variance to Standard Resident Behavior/Facility Practice: Failure to monitor resident behaviors and develop care plans. Resident #1 with recommendations by psych for more appropriate care settings. Resident #3 was identified as having suicidal ideation. Corrective Action Steps: Communicated to a local hospital that facility is unable to accommodate resident psychiatric needs. Care plan revised to reflect monitoring for signs/symptoms of suicidal ideation. Social Worker completed mood assessment that reveals no alteration in mood. Started behavior monitoring sheet to identify changes in behaviors. Noted behaviors will be reported to MD for further orders and/or direction. Nurse aide point of care electronic flow sheet (POC) with prompt for reporting signs/symptoms of suicidal ideation. In-servicing staff of suicidal ideation care plan and interventions and behavior monitoring. Monitor compliance of documentation (POC) and behavior monitoring sheets every week for 4 weeks and monthly thereafter with report brought to QA&A for review by IDT. Variance to Standard Identification of residents at risk for psychiatric behaviors and/harm to self or others for behavior programing and care planning. Corrective Action Steps All residents with psychiatric [DIAGNOSES REDACTED]. Behavior evaluation worksheet initiated on all residents with psychiatric [DIAGNOSES REDACTED]. Behavior evaluation worksheet initiated on admission and quarterly thereafter on all residents with psychiatric [DIAGNOSES REDACTED]. Behavior monitoring sheet to identify changes in behaviors in those residents with psychiatric [DIAGNOSES REDACTED]. Noted behavior changes will be reported to MD for further orders and/or directions. Residents with psychiatric [DIAGNOSES REDACTED]. Any resident in acute psychiatric crisis will be attended by staff, with one to one care, treatment/first aid as appropriate until EMS arrival. Notification of RP and MD per policy. Monitor compliance of documentation (POC), behavior monitoring sheets every week for four weeks and monthly thereafter to be discussed in QA&A. The investigator monitored the current plan of removal as follows: Observations on 3/2/15 between 5:30 p.m. and 7:30 p.m. revealed staff conducting behavior risk assessments. Observation on 3/2/15 revealed staff conducting risk assessment for Resident #3. Interviews with nurses, CNAs and MAs on 3/2/15 between 5:30 p.m. and 7:30 p.m. revealed staff had received in-service training for behavior monitoring, the facility Behavior Management Program, and maladaptive behaviors including Depression, Dementia and Suicide. In an interview on 3/2/15 at 6:00 p.m. the DON stated each resident was assessed for behaviors, a Behavior Monitoring form for all residents with a [DIAGNOSES REDACTED]. She further stated each resident with a [DIAGNOSES REDACTED]. Review of the facility's Behavior Evaluation Worksheets reflected all residents with a [DIAGNOSES REDACTED]. On 3/2/15 at 7:30 p.m. the RVP, DON and RN Consultant were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of pattern due to requiring additional time to train all staff, implement behavior assessments on all residents and monitor their Plan of Removal. The DON provided a list of 54 residents with a [DIAGNOSES REDACTED].

Based on interview and record review the facility failed to implement policies and procedures that prohibit neglect for 2 of 7 residents reviewed for neglect (Residents #1 and #3). A. The facility failed to develop and implement interventions to monitor Resident #1 for behaviors of self harm. Resident #1 attempted suicide in his room by cutting his wrists and throat with a knife on 2/25/15. The resident has a [DIAGNOSES REDACTED]. B. The facility failed to develop and implement interventions to monitor Resident #3 for behaviors of self harm. Resident #3 has a [DIAGNOSES REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 3/2/15. While the IJ was removed on 3/2/15, the facility remained out of compliance at actual harm with a scope identified as a pattern. This deficient practice could place 2 residents, identified with a [DIAGNOSES REDACTED]. The findings include: Review of the facility's Abuse Prevention Program policy dated 5/20/14 reflected the following: Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. A. Review of the undated admission face sheet for Resident #1 reflected a [AGE] year old male with an admission date of [DATE] and a readmission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the consolidated physician orders [REDACTED].#1 reflected the following [MEDICAL CONDITION] medication orders: [MEDICATION NAME] (antidepressant) 10 mg by mouth one time a day for a [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] a BIMS score of 15, indicating resident was cognitively intact, felt down or depressed and bad about himself for several days (2-6 days). Review of the care plan dated 2/5/15 for Resident #1 reflected no care plan for suicidal ideation or suicide prevention. Further review reflected the following: Problem: [MEDICAL CONDITION] Drug Use, resident is currently taking [MEDICAL CONDITION] medication as evidenced by Depression, Anxiety. Approach: 1) Monitor and record any displayed behavior or mood problems. 3) Monitor effectiveness of [MEDICAL CONDITION] medications. Further review of the nurse's notes dated 1/7/15 thru 2/25/15 for Resident #1 revealed no behavior monitoring for target behavior depression was documented. Review of the clinical record revealed no behavior monitoring sheets were available for Resident #1. Further review of the MARs for January and February 2015 reflected there was not tracking for behavior monitoring documented on the MAR. In an interview on 3/2/15 at 11:25 a.m. LVN G, Charge Nurse, stated she did not know where the behavior monitoring sheets were kept. She further stated any behaviors are documented in the nurse's notes. LVN G stated she did not know about documenting for targeted behaviors for psychoactive medications. Review of the facility's Incident Report dated 2/25/15 reflected Resident #1 was discovered by staff in his room with blood on both wrists and neck and resident had a knife at his neck. Resident #1 had ordered a knife from a television advertisement that came in an unidentified package to him. Facility staff called EMS 911 and resident was sent to the hospital. Resident #1 stated to staff he meant to kill himself as he didn't have anything else to live for. resident had a history of [REDACTED]. Review of a witness statement dated 2/25/15 by LVN D reflected the following: Approximately 11:20 a.m. CNA yelling come to room, ran into Resident #1's room. Resident #1 was lying in bed, shirt bloody, holding pocket knife to his carotid artery. Knife removed from resident's hand.right and left wrist cut, bleeding. cut to neck bleeding. Pressure applied to wrists and neck with towels and gauze. Resident #1 continually saying I have no reason to live, nothing matters, nobody cares. Observation of Resident #1 at the hospital on [DATE] at 3:00 p.m. revealed resident was subdued, would not make eye contact with the investigator and speech was slow and monotone. In an interview on 2/27/15 at 3:00 p.m. at the hospital, Resident #1 stated he did not have anything to live for and wanted to die. He further stated he had ordered a knife with the intent of using it to kill himself. Review of the MDS dated [DATE] for Resident #1 reflected MDS was for reentry to the facility, no change of condition assessment was provided. Review of the nurses notes dated 1/5/15 for Resident #1 reflected the following: 10:45 a.m. - Resident at nurse's station and states that he is going to kill himself. Resident states that he is lonely because his wife doesn't visit and neither do his friends. Reported to SW and ADON, they went and spoke to resident as well. Was told by ADON to send him out 911. 11:35 a.m. - Resident was sent to ER for suicidal ideation. In an interview on 3/2/15 at 1:00 p.m. Psychiatric RNC (a nurse with advanced training/education in a specialty area) stated she was aware of the suicidal threats Resident #1 had made on 1/5/14 which resulted in admission to an in-patient psychiatric unit for evaluation and treatment. She further stated when Resident #1 returned to the facility he should have been monitored, should have had room checked for sharps, over the counter medications and any other potential means of self harm. RNC stated she expected the facility staff to implement basic safety precautions and make sure there was nothing in Resident #1's room he could use to harm himself. In an interview on 3/2/15 at 1:45 p.m. the ADON stated monitoring Resident #1 and checking his room for potential means of self harm was not done when the resident returned to the facility on [DATE]. In an interview on 3/2/15 at 11:40 a.m. MDS Coordinator H stated when a resident goes out to the hospital and returns a significant change of condition MDS should be generated. She further stated suicidal ideation and/or threats would generate development and implementation of a care plan for suicide prevention. MDS H stated no assessment or interventions were developed or implemented for Resident #1 when he returned from the hospital visit for suicidal ideation on 1/5/15 and there should have been. MDS Coordinator H stated residents receiving any [MEDICAL CONDITION] medications should have behavior monitoring conducted for each medication's targeted behavior. In an interview on 3/2/15 at 11:45 a.m. LVN D, Charge Nurse, stated targeted behavior monitoring had not been conducted for several months because it was too difficult and was too time consuming for the nursing staff. In an interview on 3/2/15 at 10:00 a.m. the facility DON stated she expected staff to conduct behavior monitoring. The DON stated she had only been at the facility for one week. Review of the facility's undated Nursing Guidelines, for antipsychotic medication use, submitted by the DON reflected the following: Guidelines: 1. Documenting the Appropriate Specific Conditions for Antipsychotic Medication Use. · Specific behavior(s) exhibited by the resident will be documented on the Behavioral Monitoring section of the MAR. 2. Documenting the Specific Behaviors which the Resident Exhibits. · For resident's receiving an antipsychotic medication for behavioral symptoms related to an organic mental syndrome, all symptoms or behaviors which relate to the specific condition for the drug's use, will be listed on the Behavioral Monitoring portion of the MAR. · At the end of each shift, the nurse will document the number of times each behavior occurred. · Each month, the nursing staff will sum the occurrences of each behavior and record a total, for each one. B. Record review of the admission face sheet dated 5/13/13 for Resident #3 reflected a [AGE] year old male with an admission date of [DATE] and readmission date of [DATE] and the following Diagnoses: [REDACTED]. Review of the MDS dated [DATE] for Resident #3 reflected a BIMS of 15 (indicating resident was cognitively intact) and a [DIAGNOSES REDACTED]. Review of the physician orders [REDACTED].#3 reflected the following [MEDICAL CONDITION] medication orders: Valporic Acid 250 mg, 3 capsules by mouth twice a day for [MEDICAL CONDITION] Disorder [MEDICATION NAME] 20 mg, 2 capsules by mouth once a day for Depression [MEDICATION NAME] 100 mg tablet by mouth at bedtime for [MEDICAL CONDITION] [MEDICATION NAME] 2 mg tablet by mouth once a day for Anxiety Review of the care plan dated 2/12/15 for Resident #3 reflected the following: Problem: Resident is currently taking [MEDICAL CONDITION] medication as evidenced by: Depression, Anxiety and [MEDICAL CONDITION] Disorder. Approach: Monitor and record any displayed behavior or mood problems. Problem: I exhibit signs and symptoms of depression, as evidenced by want to be left alone and history of suicidal ideation. Problem: Resident has [MEDICAL CONDITION] as manifested by: mood swings, delusions. Approach: Monitor resident for increased agitation, anger, verbal and physical aggression. Document episodes and notify MD. Further review of the nurse's notes dated 12/1/14 thru 2/25/14 for Resident #3 revealed no behavior monitoring for target behavior depression was documented. Review of the clinical record revealed no behavior monitoring sheets were available for Resident #1. Further review of the MARs for January and February 2015 reflected there was not tracking for behavior monitoring documented on the MAR. In an interview on 3/2/15 at 12:15 p.m. the ADON stated there were no behavior monitoring sheets found for Resident #1 or Resident #3. She further stated behavior monitoring was not being conducted on any resident on [MEDICAL CONDITION] medications and the facility policy was to conduct behavior monitoring on all residents receiving [MEDICAL CONDITION] medications for targeted behaviors. The facility's RVP, DON and RN Consultant were notified on 3/2/15 at 1:35 p.m. an IJ situation had been identified due to the above failures. The Plan of Removal was submitted by the RN Consultant and RVP on 3/2/15 at 4:35 p.m. The final Plan of Removal was accepted by the investigator on 3/2/15 at 5:20 p.m. Plan of Removal Variance to Standard Resident Behavior/Facility Practice: Failure to monitor resident behaviors and develop care plans. Resident #1 with recommendations by psych for more appropriate care settings. Resident #3 was identified as having suicidal ideation. Corrective Action Steps: Communicated to a local hospital that facility is unable to accommodate resident psychiatric needs. Care plan revised to reflect monitoring for signs/symptoms of suicidal ideation. Social Worker completed mood assessment that reveals no alteration in mood. Started behavior monitoring sheet to identify changes in behaviors. Noted behaviors will be reported to MD for further orders and/or direction. Nurse aide point of care electronic flow sheet (POC) with prompt for reporting signs/symptoms of suicidal ideation. In-servicing staff of suicidal ideation care plan and interventions and behavior monitoring. Monitor compliance of documentation (POC) and behavior monitoring sheets every week for 4 weeks and monthly thereafter with report brought to QA&A for review by IDT. Variance to Standard Identification of residents at risk for psychiatric behaviors and/harm to self or others for behavior programing and care planning. Corrective Action Steps All residents with psychiatric [DIAGNOSES REDACTED]. Behavior evaluation worksheet initiated on all residents with psychiatric [DIAGNOSES REDACTED]. Behavior evaluation worksheet initiated on admission and quarterly thereafter on all residents with psychiatric [DIAGNOSES REDACTED]. Behavior monitoring sheet to identify changes in behaviors in those residents with psychiatric [DIAGNOSES REDACTED]. Noted behavior changes will be reported to MD for further orders and/or directions. Residents with psychiatric [DIAGNOSES REDACTED]. Any resident in acute psychiatric crisis will be attended by staff, with one to one care, treatment/first aid as appropriate until EMS arrival. Notification of RP and MD per policy. Monitor compliance of documentation (POC), behavior monitoring sheets every week for four weeks and monthly thereafter to be discussed in QA&A. The investigator monitored the current plan of removal as follows: Observations on 3/2/15 between 5:30 p.m. and 7:30 p.m. revealed staff conducting behavior risk assessments. Observation on 3/2/15 revealed staff conducting risk assessment for Resident #3. Interviews with nurses, CNAs and MAs on 3/2/15 between 5:30 p.m. and 7:30 p.m. revealed staff had received in-service training for behavior monitoring, the facility Behavior Management Program, and maladaptive behaviors including Depression, Dementia and Suicide. In an interview on 3/2/15 at 6:00 p.m. the DON stated each resident was assessed for behaviors, a Behavior Monitoring form for all residents with a [DIAGNOSES REDACTED]. She further stated each resident with a [DIAGNOSES REDACTED]. Review of the facility's Behavior Evaluation Worksheets reflected all residents with a [DIAGNOSES REDACTED]. On 3/2/15 at 7:30 p.m. the RVP, DON and RN Consultant were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope of pattern due to requiring additional time to train all staff, implement behavior assessments on all residents and monitor their Plan of Removal. The DON provided a list of 54 residents with a [DIAGNOSES REDACTED].

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures to prevent mistreatment and neglect when: A. LVN W failed to assess Resident #1's altered mental status prior to administering a fast acting insulin, repeatedly placed food in his mouth and massaged his throat to make him swallow and administered [MEDICATION NAME] (used in treatment of [REDACTED].<60) without a physician's orders [REDACTED]. B. Licensed Agency staff were not deemed by the facility to be competent to care for residents prior to being assigned to provide care. C. Facility staff, to include the DON, did not report to the Administrator observed mistreatment and neglect for Resident #1, #2 and #5. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity actual harm with a scope identified as pattern. This deficient practice could place all 103 residents at risk of neglect due to lack of identifying and reporting allegations of mistreatment and neglect. Findings include: Review of the facility ' s Abuse Prevention Program reflected: 5) Our facility has developed policies and procedures to aid in preventing abuse, neglect or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; Review of the facility ' s Abuse Prevention Program, section Reporting Abuse to Facility Management: 3. Employees, facility consultants, volunteers, and/or attending physicians must promptly report any suspected abuse or incidents of abuse to the administrator or his/her designee. If such incidents occur or are discovered after normal business hours, the administrator or his/her designee must be called at home or must be paged and informed of such incidents. 8. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to the administrator or his/her designee. 10. When an incident of resident abuse is suspected or determined, such incident must be reported to the administrator or his/her designee regardless of the time lapse since the incident occurred. Review of the facility ' s Abuse Prevention Program, section Recognizing Signs and Symptoms of Abuse/Neglect: b. Signs of or actual physical neglect: improper use/administration of medication; inadequate provision of care; Caregiver indifferent to resident ' s personal care and needs. Review of the facility's Abuse Prevention Program, section Reporting Abuse to Facility Management: 4. When an alleged or suspected case of mistreatment, neglect, is reported, the facility administrator, or his/her designee, will notify .a.) The State licensing/certification agency responsible for surveying/licensing the facility . 5. Notices to the above agencies/individuals shall be made within 24 hours after the occurrence of the incident or when the facility learns of the abuse (neglect). A. Review of a Face Sheet for Resident #1 reflected he was [AGE] years old and originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] reflected Resident #1 required assistance with set up for meals, no swallowing problems; he was independent with ambulation in his electric wheelchair and required supervision only for all other ADLs. Review of a hospital discharge summary for Resident #1 dated 10/16/14 reflected the following Diagnoses: [REDACTED]. Reviews of a care plan for Resident #1 dated 10/13/14 reflected- instruct resident of signs and symptoms of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of admission orders [REDACTED]. Further review of physician orders [REDACTED]. If greater than 400 or less than 60 call the physician. Humalog twice daily before meals and [MEDICATION NAME] 18 units each morning. Review of nurse's notes for Resident #1 dated 10/10/14 reflected the following: 1:15 pm- Resident returned from medical appointment blood sugar 320- gave sliding scale insulin. Took to dining room to be fed about 10 minutes later CNA states he was sluggish. Went to dining room [ROOM NUMBER] health shakes given and fed 15 % of his meal. Still sluggish. Injection of [MEDICATION NAME] given. Report given to on coming nurse. Review of a MAR for Resident #1 reflected in the space for 11:30 am finger stick glucose readings on 10/10/14 (no time) it was 380 and 4 units of insulin was initialed as given by LVN W. In an interview on 10/23/14 at 10:20 am CNA V stated on the morning of 10/10/14 she was told by LVN W to make sure Resident #1 was clean and dressed for a medical appointment. CNA V stated she went to his room and he was slouching in bed, only mumbled when asked a question and he had urinated on himself to the point of soaking the sheets. CNA V stated she asked LVN W to look at Resident #1 because this was not normal for him. He was usually alert and orientated, continent of urine and could operate his electric wheelchair. CNA V went on to say LVN W did not assess Resident #1 and stated he was Ok and to just get him ready for his appointment. CNA V stated she cleaned Resident # 1 and put him in a manual wheelchair with the assistance of CNA U, because he was unable to operate his electric wheelchair in his condition. At 9:45 am Resident #1 left with a transportation service for his appointment. CNA V stated after he returned from his medical appointment it was lunchtime and LVN W brought him to the dining room and instructed CNA V to feed him and stated he needs to eat, I just gave him insulin. CNA V stated she declined to feed him, because he was so lethargic and could not open his mouth when asked. CNA V stated LVN W observed LVN W putting food in his mouth and it was coming back out and then she attempted to give him cranberry juice and it ran out of his mouth. CNA V further stated LVN W was massaging his throat to try to get him to swallow while he remained slumped in the wheelchair. CNA V went on to say that she left the dining room and shortly afterwards LVN W met her in the hallway pushing Resident #1 in a wheelchair and told her to put him bed. CNA V told LVN W she could see food in his mouth and she didn ' want to put him to bed because he might choke. CNA V stated LVN W walked away and she took Resident #1 to his room. When she got to the room CNA V stated she put on gloves and removed approximately a tablespoon of food from his mouth (Resident # 1 is on a mechanical soft diet due to poor dentition). After removing the food from Resident #1 ' s mouth CNA V stated she and CNA U transferred him to bed and left the head of the elevated. CNA V stated she did not report LVN W's actions to the DON or Administrator. In a telephone interview on 10/24/14 at 4:00 pm LVN W stated prior to 10/10/14 she had taken care of Resident #1 a few times prior to 10/10/14, but she knew he was normally alert and oriented, had no swallowing problems and fed himself LVN W stated on the morning of 10/10/14 Resident #1 was alert, but was fed breakfast because he had a poor appetite. LVN W denied that he was lethargic at breakfast and stated the CNA ' s were ' wrong ' about his condition prior to him leaving for his 10:00 am appointment, but also stated she didn't do an assessment or document his status prior to his departure. LVN W stated when Resident #1 returned from his medical appointment his blood glucose level was high , but she could only remember it being in the 300 's. She stated she took him to the dining room for lunch after giving him insulin and told the CNAs to feed him and that he needed food. LVN W stated the CNAs came to her at the nurses ' station shortly after taking him to the dining room and stated they did not want to feed him because he was sluggish LVN W stated when she went back to the dining room Resident #1 was slumped in his wheelchair, but he answered my questions LVN W stated she fed Resident #1 about 10% of his meal, but he would hold the food in his mouth and would not swallow so she massaged his throat to help him swallow. Later in the interview LVN W stated she gave him 2 packets of sugar in milk at lunch, but couldn't state how much of it he was able to consume. LVN W stated she could not remember if Resident #1 had food in his mouth when she instructed the CNAs to take him to his room and had no comment about CNA V stating she was asked to remove it. In a continued interview with LVN W she stated she performed a finger stick glucose check on Resident #1 in his room after feeding him lunch and it was 150 but she did not document the reading. LVN W stated at some point after the 150 glucose finding she called the doctor or nurse practitioner (she couldn't remember which) and received an order for [REDACTED]. LVN W stated she did not recheck Resident #1 ' s blood glucose level after administering the [MEDICATION NAME], and did not document a telephone order for the [MEDICATION NAME]. LVN W stated she did look in on him before she left at the end of her shift at 2:00 pm and he wasn't in a coma or dead, so it was her expectation that the oncoming nurse should have rechecked Resident #1 blood glucose, because she stated in shift report it was given. In an interview on 10/24/14 at 4:00 pm LVN Z stated she received a phone call on 10/10/14 from the physician that saw Resident #1 for a follow up appointment for his admission to the hospital for pneumonia prior to coming to the facility. The physician stated he had not seen Resident #1 prior to his appointment on 10/10/14, so he did not know his baseline, but he seemed very confused and weak. Review of the facility 24 hour shift report for 10/10/14 reflected no entries by LVN W regarding his altered mental status or that she had administered [MEDICATION NAME]. In an interview on 10/23/14 at 2:00 pm Resident #1 stated he did not remember much about the day he went to the hospital. He remembered receiving a shot in the dining room, but was not sure if it was insulin or something else, because he routinely receives his insulin in the dining room. Resident #1 stated by the time he went to the hospital he couldn't even form a sentence. Resident #1 added he had been diabetic since he was 9 years old and immediately learned to give himself the shots He stated he was familiar with how he feels if his glucose levels are not normal, but he just felt too bad the day he went out to tell anyone. In an interview on 10/24/14 at 5:00 pm the nurse practitioner for the facility stated she had not been contacted by LVN W for an order for [REDACTED]. Review of a nurse's note for Resident #1 written by LVN Z on 10/10/14 reflected the following: 4:30 pm- Resident lying in bed blood sugar checked - results 598. Contacted nurse practitioner for orders. New order noted to give 15 units [MEDICATION NAME] now. 15 units given subcutaneous. 6:30 pm Resident lying in bed responds to verbal stimuli, denies pain, speech clear, remains confused. Metaprolol held due to a heart rate of 54. Will continue to monitor. 7:45 pm Went to room to check blood sugar - results 520. Noted facial drooping on one side, slurred speech with right arm weakness noted. Sent to emergency room due to stroke symptoms. In an interview on 10/22/14 at 4:54 pm LVN Z stated LVN W reported to her at change of shift on 10/10/14 that she had given Resident #1 [MEDICATION NAME] during her shift (6 am-2 pm) because he wasn't acting right. When asked if she questioned LVN W further about how Resident # 1 was acting she stated she had not and she assumed the [MEDICATION NAME] had been given in the morning rather than close to shift change. LVN Z also stated she did not assess Resident #1 until 4:30 pm when it was time for his scheduled finger stick glucose and insulin and that is when his glucose level was 598 LVN Z did confirm she did not recheck his glucose level until 7:30 pm when it was the next scheduled time and it was 520; and he had slurred speech, right sided weakness, facial drooping and was sent to the hospital. In an interview with the DON on 10/22/14 at 10:00 am the DON stated it was brought to her attention on 10/10/14 at 5:30 pm by LVN Z that LVN W had given Resident #1 [MEDICATION NAME] per her 1:15 pm nurse's notes and there was no order. The DON stated she had had an encounter earlier in the day with LVN W because a resident complained it was 11:30 pm and she still had not received her 8:00 am medications and when the resident mentioned it to LVN W she gave her half of her [MEDICATION NAME] dose (1 tablet instead of 2). The DON stated after she learned of the [MEDICATION NAME] error she called the staffing agency and informed them LVN W could not return to the facility because of the quality of care she provided. The DON stated it is the expectation licensed staff would not give [MEDICATION NAME] without a physician's orders [REDACTED].> 300). B. In an interview on 10/22/14 at 10:00 AM, the DON stated the facility did not check competencies of agency nurses, but provided Agency Orientation Guidelines. This list included a tour of the facility, locations of supplies, medications and emergency phone numbers, forms to use, some policy and procedures, and identifying residents with special care needs, such as catheters, enteral tube feeding, oxygen and insulin. The DON added there was no buddy system for new agency nurses to follow a licensed staff nurse. The DON stated she has been with ADONs and she has not monitored the care given by agency nurses before or after the incident with LVN W. In an interview on 10/24/14 at 4:00 pm LVN W stated she did not receive any orientation or competency checks prior to providing care for residents at the facility. LVN W stated 3 years ago when she started working for the staffing agency she took a written medication calculation test and a self assessment test of what her clinical strengths and weaknesses were. In an interview on 10/22/14 LVN X stated she had been working for the staffing agency for approximately 3 years and had been given assignments at the facility for the past several months and usually worked there 4 days a week. LVN X stated she did not receive and orientation or competency test prior to providing care for the residents. In an interview on 10/24/14 at 3:00 pm the Director of the staffing agency that employed LVN W and provided temporary staffing needs for the facility stated there is no competency test for licensed staff when they are contracted. The agency gives a written medication test and a written self assessment of skills strengths and weaknesses's. Observations on 10/22/14 during medication passes revealed 2 agency nurses, LVN X and LVN Y, and 1 staff nurse, LVN Z (who until recently was an agency nurse) administered oral medications, performed finger stick glucose tests and administered insulin without once washing their hands or using hand sanitizer throughout the entire process. C. In an interview on 10/23/14 at 2:24 PM, CNA U stated she was assisting CNA V in Resident #1 ' s care on 10/10/14, due to his weakness that day. CNA U stated she had reported this change (weakness, decreased alertness) to LVN W at the beginning of the shift (6 AM), as LVN W arrived. CNA U reported that she could not remember exactly what LVN W said, but gave the impression that she was not going to check on Resident #1 at that time. CNA U stated it was right before breakfast when LVN W checked on Resident #1. CNA U also stated LVN W took her time checking on another resident ' s [MEDICAL CONDITION] when the CNAs asked, delayed giving a resident a laxative when a resident requested and talked in a derogatory manner about another resident. In the same interview, CNA U further stated LVN W refused to care for Resident #2 one morning when the sutures on her forehead were bleeding, saturating an area the size of the palm of your hand on her head with fresh blood. Blood had also gotten on Resident #2 ' s gown, pillow and sheets. CNA U stated that she stayed with Resident #2 when CNA V went to the nurse ' s station to get LVN W to assess and provide treatment. CNA U reported that she heard LVN W say, I don ' care. CNA U stated that she and CNA V dressed Resident #2, transferred her to the wheelchair and wheeled her to the nurses ' station and asked LVN W to please look at the resident. CNA U stated another nurse provided treatment at that time because LVN W did not. CNA U stated that she had talked to another charge nurse about not being comfortable working with LVN W, but had not gone to the DON or ADM. In an interview on 10/23/14 at 3:13 PM, LVN T stated she was at the nurses ' station when CNA U and V brought Resident #2 to LVN W and asked her to provide treatment as the sutures were bleeding. LVN T stated that LVN W ignored the CNAs, and did not answer at all. LVN T stated that she asked LVN W for the keys to the treatment cart, and provided the treatment as ordered for Resident #2. LVN T further stated that she did report this incident to the weekend RN Supervisor, as she was on duty rather than the DON, but did not report to the ADM or DON. In a telephone interview on 10/23/14 at 4:00 PM, the weekend RN Supervisor stated she was on duty the day Resident #5 did not receive his insulin as ordered from the agency LVN assigned to his care, but could not remember the name of that LVN. The RN Supervisor stated she provided care at Resident #5 ' s request, and could not find that agency LVN for the rest of that shift. The RN Supervisor reported this incident to the DON and asked if she should fill out an incident report, but was told no, because he did get care the rest of the shift. The RN Supervisor stated she did work with LVN W, and that she would not listen to what the residents had to say. The RN Supervisor described LVN W as having a bad attitude. The RN Supervisor stated she did not report this to the ADM In an interview on 10/24/14 at 9:38 AM, the DON stated she vaguely remembered when the RN Supervisor reported the incident regarding an agency LVN not giving Resident #5 his insulin. The DON stated she did not instruct the RN Supervisor to report the incident, and she did not contact the staffing agency to inform them of the LVNs behavior and not to send her again. The DON did not inform the ADM of this incident or investigate further. In an interview on 10/24/14 at 12:45 PM, the ADM stated she was first notified of a possible significant medication error on 10/10/14 at 5:30 PM. The ADM stated they started their investigation on 10/11/14, and reported to the State on 10/12/14. When asked why they did not report an allegation of neglect within 24 hours, the ADM continued to focus on the significant medication error and did not confirm that the incident also qualified as neglect. The ADM did state that Resident #5 not receiving his insulin as ordered was new information, and that an incident report should have been completed. The Administrator went on to say she did not think about including all staff in on the inservice given on 10/11/14 and 10/12/14 because she was focusing on licensed staff and the medication errors. Review of the facility ' s report to the State licensing agency, dated 10/12/14, revealed a report of a medication error and irresponsible actions, and did not mention neglect. Review of the facility ' s inservice training log revealed the most recent documented facility wide Abuse/Neglect training was conducted on 8/22/14. The inservice on 10/11-/12/14 was only given to licensed staff. IJ components: The Medical Director was notified on 10/23/14 at 11:30 AM that an IJ situation had been identified due to the above failures. The ADM and DON were notified on 10/23/14 at 11:49 AM, that an IJ situation had been identified. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct an n audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: On 10/24/14 from 4:00 PM to 5:20 PM, interviews with 3 facility LVNs, 1 agency LVN, 4 CNAs, 1 MA, 1 laundry aide, the Assistant Activity Director and the Admission/Marketing Director revealed staff had been in-serviced on the above Plan of Removal. Staff members were able to state when they were to report an allegation of neglect, to whom, including up to the ADM and State regulatory office. Licensed staff were able to state signs and symptoms of hypo- and [MEDICAL CONDITION], when they were to notify the DON and physician on changes of condition, and the procedure to administer [MEDICATION NAME]. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 PM, the ADM and RNC were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm, with a scope as pattern due to the facility requiring time to train all staff, complete Nurse Proficiency Audits on all licensed staff, and monitor their Plan of Removal. The ADM stated the facility census was 103.

Based on observation interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for 6 of 8 residents reviewed for medication administration when they failed to coordinate care provided by licensed agency nurses. (Residents #1,#3, #4, #6, #7, #8) A. LVN W, an agency nurse, failed to assess Resident #1 ' s altered mental status prior to giving him a dose of fast acting insulin at lunchtime then repeatedly placed food in his mouth and when he could not swallow she massaged his throat. LVN W instructed staff to put him to bed with pocketed food in his mouth. LVN W administered a [MEDICATION NAME] injection to Resident #1 ([MEDICATION NAME] is a treatment for [REDACTED].<60) without a physician's order [REDACTED]. Resident #1's finger stick glucose level elevated to 598. LVN Z, a recent former agency nurse who became a full-time facility employee, administered 15 units of fast acting insulin to Resident #1 due to the elevated blood sugar but did not reassess his blood glucose level until 3 hours and 15 minutes later, when it was 520, and Resident #1 was found to have slurred speech and exhibiting signs of a possible stroke. Resident #1 was transferred to hospital and admitted to the intensive care unit for a primary [DIAGNOSES REDACTED]. B. The facility had no policy or procedure in place to train temporary agency nurses or deem agency nurses were competent to provide care for residents, no buddy system prior to working solo as charge nurses, and facility administrative nurses did not monitor care, to include medication administration, provided by agency nurses for competency resulting in a significant medication error, substandard diabetic management and untimely and inaccurate medication administration . These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity of actual harm and a scope of pattern. This deficient practice could place 27 diabetic residents receiving insulin at risk for complications of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to include [MEDICAL CONDITION], coma and death and a facility census of 103 residents receiving physician ordered medications at risk for complications or worsening of medical conditions. The Findings Include: A. Review of a Face Sheet for Resident #1 reflected he was [AGE] years old and originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] reflected Resident #1 required assistance with set up for meals, no swallowing problems; he was independent with ambulation in his electric wheelchair and required supervision only for all other ADLs. Review of a hospital discharge summary for Resident #1 dated 10/16/14 reflected the following Diagnoses: [REDACTED]. Reviews of a care plan for Resident #1 dated 10/13/14 reflected- instruct resident of signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION]. Review of admission orders [REDACTED]. Further review of physician orders [REDACTED]. Review of nurse's notes for Resident #1 dated 10/10/14 reflected the following: 1:15 PM- Resident returned from medical appointment blood sugar 320- gave sliding scale insulin. Took to dining room to be fed about 10 minutes later CNA states he was sluggish. Went to dining room [ROOM NUMBER] health shakes given and fed 15 % of his meal. Still sluggish. Injection of [MEDICATION NAME] given. Report given to on coming nurse. Review of a MAR for Resident #1 reflected in the space for 11:30 am finger stick glucose readings on 10/10/14 (no time) it was 380 and 4 units of insulin was initialed as given by LVN W. In an interview on 10/23/14 at 10:20 am CNA V stated on the morning of 10/10/14 she was told by LVN W to make sure Resident #1 was clean and dressed for a medical appointment. CNA V stated she went to his room and he was slouching in bed, only mumbled when asked a question and he had urinated on himself to the point of soaking the sheets. CNA V stated she asked LVN W to look at Resident #1 because this was not normal for him. He was usually alert and orientated, continent of urine and could operate his electric wheelchair. CNA V went on to say LVN W did not assess Resident #1 and stated he was Ok and to just get him ready for his appointment. CNA V stated she cleaned Resident # 1 and put him in a manual wheelchair with the assistance of CNA U, because he was unable to operate his electric wheelchair in his condition. At 9:45 am Resident #1 left with a transportation service for his appointment. CNA V stated after he returned from his medical appointment it was lunchtime and LVN W brought him to the dining room and instructed CNA V to feed him and stated he needs to eat, I just gave him insulin. CNA V stated she declined to feed him, because he was so lethargic and could not open his mouth when asked. CNA V stated she observed LVN W putting food in his mouth and it was coming back out and then she attempted to give him cranberry juice and it ran out of his mouth. CNA V further stated LVN W was massaging his throat to try to get him to swallow while he remained slumped in the wheelchair. CNA V went on to say that she left the dining room and shortly afterwards LVN W met her in the hallway pushing Resident #1 in a wheelchair and told her to put him bed. CNA V told LVN W she could see food in his mouth and she didn't want to put him to bed because he might choke. CNA V stated LVN W walked away and she took Resident #1 to his room. When she got to the room CNA V stated she put on gloves and removed approximately a tablespoon of food from his mouth (Resident # 1 is on a mechanical soft diet due to poor dentition). After removing the food from Resident #1 ' s mouth CNA V stated she and CNA U transferred him to bed and left the head of the bed elevated. In a telephone interview on 10/24/14 at 4:00 PM LVN W stated prior to 10/10/14 she had taken care of Resident #1 a few times prior to 10/10/14, but she knew he was normally alert and oriented, had no swallowing problems and fed himself LVN W stated on the morning of 10/10/14 Resident #1 was alert, but was fed breakfast because he had a poor appetite. LVN W denied that he was lethargic at breakfast and stated the CNA ' s were ' wrong ' about his condition prior to him leaving for his 10:00 am appointment, but also stated she didn't do an assessment or document his status prior to his departure. LVN W stated when Resident #1 returned from his medical appointment his blood glucose level was high , but she could only remember it being in the 300 's. She stated she took him to the dining room for lunch after giving him insulin and told the CNAs to feed him and that he needed food. LVN W stated the CNAs came to her at the nurses ' station shortly after taking him to the dining room and stated they did not want to feed him because he was sluggish LVN W stated when she went back to the dining room Resident #1 was slumped in his wheelchair, but he answered my questions LVN W stated she fed Resident #1 about 10% of his meal, but he would hold the food in his mouth and would not swallow so she massaged his throat to help him swallow. Later in the interview LVN W stated she gave him 2 packets of sugar in milk at lunch, but couldn't state how much of it he was able to consume. LVN W stated she could not remember if Resident #1 had food in his mouth when she instructed the CNAs to take him to his room and had no comment about CNA V stating she was asked to remove it. In a continued interview with LVN W she stated she performed a finger stick glucose check on Resident #1 in his room after feeding him lunch and it was 150 but she did not document the reading. LVN W stated at some point after the 150 glucose finding she called the doctor or nurse practitioner (she couldn't remember which) and received an order for [REDACTED]. LVN W stated she did not recheck Resident #1 ' s blood glucose level after administering the [MEDICATION NAME], and did not document a telephone order for the [MEDICATION NAME]. LVN W stated she did look in on him before she left at the end of her shift at 2:00 PM and he wasn't in a coma or dead, so it was her expectation that the oncoming nurse should have rechecked Resident #1 blood glucose, because she stated in shift report it was given. In an interview on 10/24/14 at 4:00 PM LVN Z stated she received a phone call on 10/10/14 from the physician that saw Resident #1 for a follow up appointment for his admission to the hospital for pneumonia prior to coming to the facility. The physician stated he had not seen Resident #1 prior to his appointment on 10/10/14, so he did not know his baseline, but he seemed very confused and weak. Review of the facility 24 hour shift report for 10/10/14 reflected no entries by LVN W regarding his altered mental status or that she had administered [MEDICATION NAME]. In an interview on 10/13/14 at 2:00 PM Resident #!, who was alert and oriented x3, stated he did not remember much about the day he went to the hospital. He remembered receiving a shot in the dining room, but was not sure if it was insulin or something else, because he routinely receives his insulin in the dining room. Resident #1 stated by the time he went to the hospital he couldn't even form a sentence. Resident #1 added he had been diabetic since he was 9 years old and immediately learned to give himself the shots He stated he was familiar with how he feels if his glucose levels are not normal, but he just felt too bad the day he went out to tell anyone. In an interview on 10/24/14 at 5:00 PM the nurse practitioner for the facility stated she had not been contacted by LVN W for an order for [REDACTED]. Review of a nurse's note for Resident #1 written by LVN Z on 10/10/14 reflected the following: 4:30 PM- Resident lying in bed blood sugar checked - results 598. Contacted nurse practitioner for orders. New order noted to give 15 units [MEDICATION NAME] now. 15 units given subcutaneous. 6:30 PM Resident lying in bed responds to verbal stimuli, denies pain, speech clear, remains confused. Metaprolol held due to a heart rate of 54. Will continue to monitor. 7:45 PM Went to room to check blood sugar - results 520. Noted facial drooping on one side, slurred speech with right arm weakness noted. Sent to emergency room due to stroke symptoms. In an interview on 10/22/14 at 4:54 PM LVN Z stated LVN W reported to her at change of shift on 10/10/14 that she had given Resident #1 [MEDICATION NAME] during her shift (6 am-2 PM) because he wasn't acting right. When asked if she questioned LVN W further about how Resident # 1 was acting she stated she had not and she assumed the [MEDICATION NAME] had been given in the morning rather than close to shift change. LVN Z also stated she did not assess Resident #1 until 4:30 PM when it was time for his scheduled finger stick glucose and insulin and that is when his glucose level was 598 LVN Z did confirm she did not recheck his glucose level until 7:30 PM when it was the next scheduled time and it was 520; and he had slurred speech, right sided weakness, facial drooping and was sent to the hospital. In an interview with the DON on 10/22/14 at 10:00 am the DON stated it was brought to her attention on 10/10/14 at 5:30 PM by LVN Z that LVN W had given Resident #1 [MEDICATION NAME] per her 1:15 PM nurse's notes and there was no order. The DON stated after she learned of the [MEDICATION NAME] error she called the staffing agency and informed them LVN W could not return to the facility because of the quality of care she provided. The DON stated it is the expectation licensed staff would re-check a residents glucose level initially 15 minutes after administering [MEDICATION NAME] or insulin for an abnormally high glucose level (greater than 300). Review of the Facility ' s Provider Investigation Report dated 10/16/14 reflected the following: LVN W was observed putting food in Resident #1's mouth and stroking his throat to make the food go down. He consumed a diabetic health shake. At 12:45 PM LVN W was observed in the dining room sitting next to Resident #1 with an orange [MEDICATION NAME] container in her hand. No one witnessed her giving the injection. Statements from CNA V and CNA U revealed LVN W told them at about 1:00 PM to put Resident #1 to bed but they told her to they didn ' t 't want to because he had food in his mouth, CNA V stated she put on gloves and removed food from his mouth and they put him to bed. Went to check on him again in 30 minutes and he still didn ' t ' T ' t look well. Asked LVN W again to check on him and she said he is Ok he is probably just sleeping. A Statement from Dietary Aide Q revealed LVN W was repeatedly placing food in Resident #1's mouth without him being able to swallow and she was massaging his throat. Dietary Aide took two diabetic shakes to the table for LVN W to give to try and stop her from placing any more food in his mouth. B. In a continued interview with LVN W on 10/24/14 she stated she had no orientation or competency check from the facility prior to providing resident care. LVN W stated the staffing agency she was contracted with gave her a written medication test in 2010 and she completed a written self assessment of skills strengths and weakness, but no competency exams were given. LVN W added she was slow with giving medications and gave medications late or they were omitted. In an interview on 10/22/14 at 9:15 AM, LVN X- an agency nurse, stated she had not received any orientation, or competency checks at the facility. LVN X stated she just asks questions. In an interview on 10/22/14 at 4:00 PM, LVN Y- an agency nurse, stated she had not received any training or competency checks at the facility, but was given the facility's Agency Orientation Guidelines ( a checklist of where supplies are located, emergency numbers, etc.). In an interview on 10/24/14 at 2:00 PM LVN S stated she was responsible for reporting to the oncoming agency nurse at the end of her shift at 2:00 PM and to make sure the agency nurse knew which residents she was assigned to care for. LVN S stated she failed to inform the agency nurse she was responsible for Resident #3 and this resulted in her not receiving her 4:30 PM scheduled insulin,. In an interview on 10/24/14 at 12:45 PM, the DON stated on 10/10/14, prior the Glugacon error, she had had an encounter with LVN W because a resident complained it was 11:30 PM and she still had not received her 8:00 AM medications and when the resident mentioned it to LVN W she gave her half of her [MEDICATION NAME] dose (1 tablet instead of 2).The DON added she had not monitored any med passes for timeliness, omissions or errors since her investigation regarding the significant medication error on 10/10/14. The DON stated that the agency LVN notified her on 10/19/14 that she had missed Resident #3 and #4's insulin, and that is why she documented the medication errors/omissions. Review of facility Medication Error Reports reflected the following medication and diabetic management errors where made by agency nurses: -On 10/04/14 at 4:30 PM Resident #1's blood glucose was 55 and agency nurse LVN Y did not notify his physician. There is a physician order [REDACTED].<60. -On 10/09/14: -LVN W did not administer Resident # 7 's daily dose of [MEDICATION NAME] 50 mcg (for allergies [REDACTED]. -LVN W did not administer Resident #8 's 8:00 am dose of [MEDICATION NAME] (used for the stiffness, tremors and muscle weakness related to Parkinson ' s disease). It is physician ordered for 3 times a day. Review of facility Medication Error Reports for 10/10/14 revealed the following: -LVN W failed to administer to Resident #1 the 8:00 AM injection of [MEDICATION NAME] 150 mcg (for watery stools). It is physcian ordered for three times a day. -LVN W administered Resident # 4 ' s 7:00 am dose of [MEDICATION NAME] 100 mg. (for nerve pain) at 9:00 am and did not notify the physician. It is physician ordered for three times a day. -LVN W administered Resident #6 's 7:00 am [MEDICATION NAME] (for depression) and [MEDICATION NAME] (for nerve pain) at 11:20 and did not notify the physician; and her [MEDICATION NAME] for hypertension, Cyclobezaprine ( a muscle relaxant) and [MEDICATION NAME] for anxiety scheduled at 8:00 AM was given at 11:20 AM without physician notification. -LVN W did not administer Resident #7 's 8:00 am dose of [MEDICATION NAME] 25-100 mg. 4 tabs. It is physician ordered for twice daily. -On 10/19/14 staff nurse LVN S failed to inform agency an agency nurse of her assigned residents and Resident #3 did not receive her scheduled 8 units of Humalog insulin at 4:30 PM and when her glucose was checked at 8:00 PM it was 364 and she required 10 units and Resident #3 missed her blood glucose check 4:30 PM for sliding scale insulin. At 8:00 PM she received 4 units of insulin for a blood glucose of 260. In an interview on 10/23/14 at 11:30 am the Medical Director stated LVN W should not have given [MEDICATION NAME] without an order and she should have monitored his reaction and rechecked his glucose level 15 minutes after administration. The Medical Director was informed an Immediate Jeopardy had been identified for significant medication errors and neglect. The Medical Director went on to say he just accepted the position as co-medical director and the facility had just been sold; so there were numerous changes with staffing which had caused a heavy reliance on staffing agencies. The Medical Director added there were many challenges ahead for them, but that did not excuse LVN W actions or improper diabetic management or assessment of residents by any licensed staff. The facility Administrator and DON was notified on 10/23/14 at 11:49 that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct a an audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: Ten MARS and TARS were reviewed for accuracy of insulin administration and follow up on abnormal glucose and no concerns were identified. There was one transcription error for a resident ' s insulin to be held all day on the 24th, rather than just the morning dose as physician ordered. Because it was identified prior to the time the insulin would have been withheld, no medication error had occurred and the ADON was notified and corrected the transcription error. Four LVN ' s were interviewed, including 1 agency LVN, and all were knowledgeable about the Management of Diabetic Residents to include insulin and reporting neglect. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 PM, the Administrator, DON and RNC was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential of more than minimal harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 27 residents receiving insulin.

Based on interview and record review the ADM and DON failed to use the facility's resources in an effective and efficient manner in order to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 4 of 6 residents reviewed for diabetic management and neglect. (Residents # 1, 3, 4 & 5) A. The ADM and DON failed to ensure 6 of 6 agency LVNs were oriented and competent to provide care and services to the residents, as stated in the Agreement between the facility and the staffing agency dated 02/14/12. Lack of competency checks resulted in a significant medication error by LVN W, an agency LVN, and Resident #1 being hospitalized for [REDACTED].#3 &4. The DON failed to monitor 12 of 12 facility LVNs and 6 of 6 agency LVNs after providing diabetic management training and timely med-pass training on 10/11/14. B. The DON failed to report, or investigate, an allegation of neglect reported to her by the RN weekend supervisor. An agency LVN refused to give Resident #5 his insulin. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice could place 27 residents receiving insulin at risk for complications regarding diabetic care, including low and high blood glucose levels; and all 103 residents at risk of neglect, due to lack of checking competencies, and timely and accurate medication pass. Findings: A. Review of facility's staffing schedule provided by ADM, revealed 6 out of 9 shifts were covered by agency LVNs on October 19, 2014, before the investigation. At least 1 agency nurse was scheduled every day in October 2014. In an interview on 10/22/14 at 10:00 AM, the DON stated the facility did not check competencies, but provided Agency Orientation Guidelines. This list included a tour of the facility, locations of supplies, medications and emergency phone numbers, forms to use, and identifying residents with special care needs, such as catheters, enteral tube feeding, oxygen and residents that receive insulin. The DON added there was no buddy system for new agency nurses to follow a licensed staff nurse. In an interview on 10/23/14 at 5:15 PM, the RNC stated it was the agency's responsibility to ensure the LVNs they send to work at the facility are competent. Review of the Agreement between the facility and the staffing agency dated 02/14/12 revealed: I. B) Contractee has the final decision as to the qualifications or lack thereof and assignment of Independent Contract Labor Personnel. II. A) Contractee shall provide sufficient information about it's specific needs so that Contractor may attempt to match the skills and experience of its Independent Contract Labor Personnel to those needs. Contractee has final verdict as to the qualifications of lack thereof and assignment of each Independent Contract Labor Personnel. C) Contractee will orient Independent Contract Labor Personnel to the Contractee ' s work environment and its rules and regulations, including but not limited to the physical layout . E) If in the sole discretion of the Contractee, an individual whose services were arranged by Contractor is judged to be incompetent, negligent or has engaged in misconduct, Contractee may require such person to leave its premises and shall inform Contractor of this action immediately. In a telephone interview on 10/24/14 at 1:27 PM, a representative from the staffing agency stated they did not perform a competency skills test, but had the Contract Labor Personnel fill out a Competency Self-Review checklist. The individual puts a check mark in a column to show if they were independent, need review, or never performed the skill. No written test, or return demonstration was observed or required by the staffing agency. Review of the facility's Licensed Nurse Proficiency Audit performed for facility LVNs, but not agency LVNs, revealed the following skills were to be observed: 1. Change of shift report; 2. Walking rounds. In an interview on 10/24/14 at 10:30 AM, LVN S stated on 10/19/14, she gave report to the agency nurse coming on duty for Hall 'A' , but did not give report for Hall 'C' because she did not realize the agency nurse was assigned to half of the residents on Hall 'C.' Resident #3 and #4 both resided on Hall 'C' . Review of two Medication Error reports dated 10/19/14, revealed both residents had orders to receive blood glucose readings and insulin at 4:30 PM. Both Residents, #3 and #4 did not receive their insulin as ordered due to failure of LVN S to give end of shift report to the agency nurse, and failure of the agency nurse to receive, or ask for, report from the previous shift. In an interview on 10/24/14 at 12:45 PM, the DON stated she had not monitored any med passes for timeliness, omissions or errors since her investigation regarding the significant medication error on 10/10/14. The DON stated that the agency LVN notified her that she had missed Resident #3 and #4's insulin, and that is why she documented the medication error. Review of facility Medication Error Reports reflected the following medication and diabetic management errors where made by agency nurses: On 10/04/14 at 4:30 PM Resident #1's blood glucose was 55 and agency nurse LVN Y did not notify his physician. There is a physician order [REDACTED].<60. On 10/19/14 staff nurse LVN S failed to inform agency an agency nurse of her assigned residents and Resident #3 did not receive her scheduled 8 units of Humalog insulin at 4:30 PM and when her glucose was checked at 8:00 PM it was 386 and she required 10 units. On 10/09/14: -LVN W did not administer Resident#1's 8:00 AM [MEDICATION NAME] 150 mcg injection (for watery diarrhea). It is physician ordered for three times daily. -LVN W did not administer Resident # 8 's daily dose of [MEDICATION NAME] 50 mcg (for allergies [REDACTED]. -LVN W did not administer Resident #10 's 8:00 am dose of [MEDICATION NAME] (used for the stiffness, tremors and muscle weakness related to Parkinson ' s disease). It is physician ordered for 3 times a day. Review of facility Medication Error Reports for 10/10/14 revealed the following: -LVN W administered Resident # 4 ' s 7:00 am dose of [MEDICATION NAME] 100 mg. (for nerve pain) at 9:00 am and did not notify the physician. It is physician ordered for three times a day. -LVN W administered Resident #6 's 7:00 am [MEDICATION NAME] (for depression) and [MEDICATION NAME] (for nerve pain) at 11:20 and did not notify the physician; and her [MEDICATION NAME] for hypertension, Cyclobezaprine ( a muscle relaxant) and [MEDICATION NAME] for anxiety scheduled at 8:00 AM was given at 11:20 AM without physician notification. -LVN W did not administer Resident #7 's 8:00 am dose of [MEDICATION NAME] 25-100 mg. 4 tabs. It is physician ordered for twice daily. In an interview on 10/22/14 at 9:15 AM, LVN X stated she had not received any orientation, or competency checks at the facility. LVN X stated she just asks questions. LVN X was an agency nurse. In an interview on 10/22/14 at 4:00 PM, LVN Y stated she had not received any training at the facility, but was given the facility's Agency Orientation Guidelines. LVN Y was an agency nurse. Diabetic management training and timely med pass training was provided on 10/11/14 to facility and agency nursing staff, in response to the incident on 10/10/14 when Resident #1 was given [MEDICATION NAME] by LVN W without an order, without checking blood glucose prior to injection, and without follow-up glucose monitoring. Resident #1 was hospitalized for [REDACTED]. In an interview on 10/22/14 at 10:30 AM, the ADON stated the tool they were going to use to monitor staff regarding the diabetic management training was not yet in place. The tool, Diabetic Audit Flowsheet, tracks correct blood glucose testing procedures and appropriate insulin administration. The ADON stated the facility would begin to monitor staff when the second ADON started next week. In an interview on 10/23/14 at 11:49 AM, the ADM stated no monitoring was in place using their tool for diabetic management training, because the DON had been working without an ADON. The ADM stated she had recently terminated two ADONs for not performing, and hired the current ADON. The second ADON was expected to start soon, and they would be able to put the Diabetic Audit Flowsheet in place at that time. The ADM also stated that the DON had been eye-balling the process up to that point. B. In a telephone interview on 10/23/14 at 4:00 PM, the weekend RN Supervisor stated she was on duty the day Resident #5 did not receive his insulin as ordered from the agency LVN assigned to his care, but could not remember the name of that LVN, or the date of the incident. The RN Supervisor stated she provided care at Resident #5's request, and could not find that agency LVN for the rest of that shift. The RN Supervisor reported this incident to the DON and asked if she should fill out an incident report, but was told no, because he did get care the rest of the shift. In an interview on 10/24/14 at 9:38 AM, the DON stated she vaguely remembered when the RN Supervisor reported the incident regarding an agency LVN not giving Resident #5 his insulin. The DON stated she did not instruct the RN Supervisor to report the incident, and she did not contact the staffing agency to inform them of the LVNs behavior and not to send her again. The DON did not inform the ADM of this incident or investigate further. In an interview on 10/24/14 at 12:45 PM, the ADM stated that Resident #5 not receiving his insulin as ordered was new information to her, and that an incident report should have been completed. Review of the facility's Abuse Prevention Program, section Recognizing Signs and Symptoms of Abuse/Neglect: all personnel are to report any signs and symptoms of abuse/neglect to their supervisor or other designee immediately. · Implementation - 1) b. Signs of or actual physical neglect .Improper use/administration of medication; inadequate provision of care; caregiver indifferent to resident's personal care and needs . Review of the facility's Inservice Training log revealed the most recent documented training on abuse/neglect for all staff was 8/22/14. IJ components: The Medical Director was notified on 10/23/14 at 11:30 AM that an IJ situation had been identified due to the above failures. The ADM and DON were notified on 10/23/14 at 11:49 AM, that an IJ situation had been identified. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct an n audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: On 10/24/14 from 4:00 PM to 5:20 PM, interviews with 3 facility LVNs, 1 agency LVN, 4 CNAs, 1 MA, 1 laundry aide, the Assistant Activity Director and the Admission/Marketing Director revealed staff had been in-serviced on the above Plan of Removal. Staff members were able to state when they were to report an allegation of neglect, to whom, including up to the ADM and State regulatory office. Licensed staff were able to state signs and symptoms of hypo- and [MEDICAL CONDITION], when they were to notify the DON and physician on changes of condition, and the procedure to administer [MEDICATION NAME]. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 PM, the ADM and RNC were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm, with a scope as pattern due to the facility requiring time to train all staff, complete Nurse Proficiency Audits on all licensed staff, and monitor their Plan of Removal. The DON provided a list of 27 residents who received insulin, and the facility census was 103.

Based on observation, interview and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 13 residents reviewed for diabetic management. LVN W, an agency nurse, administered a [MEDICATION NAME] injection to Resident #1 without assessing his altered mental status ([MEDICATION NAME] is a treatment for [REDACTED].<60), without a physician's orders [REDACTED]. Resident # 1 was admitted to the intensive care unit for a primary [DIAGNOSES REDACTED]. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity of potential for harm and a scope of isolation. This deficient practice could place 27 diabetic residents receiving insulin at risk for complications of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to include [MEDICAL CONDITION], coma and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected he was [AGE] years old and originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of a hospital discharge summary for Resident #1 dated 10/16/14 reflected the following Diagnoses: [REDACTED]. Review of an Admission MDS dated [DATE] reflected Resident #1 required assistance with set up for meals, no swallowing problems; he was independent with ambulation in his electric wheelchair and required supervision only for all other ADLs. Reviews of a care plan for Resident #1 dated 10/13/14 reflected- instruct resident of signs and symptoms of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of admission orders [REDACTED]. Further review of physician orders [REDACTED]. If greater than 400 or less than 60 call the physician. Humalog twice daily before meals and [MEDICATION NAME] 18 units each morning. Review of nurse's notes for Resident #1 dated 10/10/14 reflected the following: 1:15 pm- Resident returned from medical appointment blood sugar 320- gave sliding scale insulin. Took to dining room to be fed about 10 minutes later CNA states he was sluggish. Went to dining room [ROOM NUMBER] health shakes given and fed 15 % of his meal. Still sluggish. Injection of [MEDICATION NAME] given. Report given to on coming nurse. Review of a facility Medication Error Report for Resident #1 dated 10/14/14 revealed on 10/10/14 LVN W failed to give Resident #1 his 8:00 am dose of [MEDICATION NAME] 150 mg. In a telephone interview on 10/24/14 at 4:00 pm LVN W stated when Resident #1 returned from his morning appointment it was lunch time and she performed a finger stick glucose that was in the 300 range and she administered insulin prior to taking him to the dining room. After feeding him 10% of his lunch she performed another finger stick glucose check on Resident #1 and it was 150 but she did not document the reading. LVN W stated at some point after the 150 glucose finding she called the doctor or nurse practitioner (she couldn't remember which) and received an order for [REDACTED]. LVN W stated she did not recheck Resident #1 ' s blood glucose level after administering the [MEDICATION NAME], and did not document a telephone order for the [MEDICATION NAME]. LVN W stated she did look in on him before she left at the end of her shift at 2:00 pm and he wasn't in a coma or dead, so it was her expectation that the oncoming nurse should have rechecked Resident #1 blood glucose, because she stated in shift report it was given. In an interview on 10/23/14 at 2:00 pm Resident #1 stated he did not remember much about the day he went to the hospital. He remembered receiving a shot in the dining room, but was not sure if it was insulin or something else, because he routinely receives his insulin in the dining room. Resident #1 stated by the time he went to the hospital he couldn't even form a sentence Resident #1 added he had been diabetic since he was 9 years old and immediately learned to give himself the shots He stated he was familiar with how he feels if his glucose levels are not normal, but he just felt too bad the day he went out to tell anyone. Review of a nurse's note for Resident #1 written by LVN Z on 10/10/14 reflected the following: 4:30 pm- Resident lying in bed blood sugar checked - results 598. Contacted nurse practitioner for orders. New order noted to give 15 units [MEDICATION NAME] now. 15 units given subcutaneous. 6:30 pm Resident lying in bed responds to verbal stimuli, denies pain, speech clear, remains confused. Metaprolol held due to a heart rate of 54. Will continue to monitor. 7:45 pm Went to room to check blood sugar - results 520. Noted facial drooping on one side, slurred speech with right arm weakness noted. Sent to emergency room due to stroke symptoms. In an interview on 10/22/14 at 4:54 pm LVN Z stated LVN W reported to her at change of shift on 10/10/14 that she had given Resident #1 [MEDICATION NAME] during her shift (6 am-2 pm) because he wasn't acting right. When asked if she questioned LVN W further about how Resident # 1 was acting she stated she had not and she assumed the [MEDICATION NAME] had been given in the morning rather than close to shift change. LVN Z also stated she did not assess Resident #1 until 4:30 pm when it was time for his scheduled finger stick glucose and insulin and that is when his glucose level was 598 LVN Z did confirm she did not recheck his glucose level until 7:30 pm when it was the next scheduled time and it was 520; and he had slurred speech, right sided weakness, facial drooping and was sent to the hospital. Review of the facility 24 hour shift report for 10/10/14 reflected no entries by LVN W regarding his altered mental status or that she had administered [MEDICATION NAME]. In an interview on 10/24/14 at 5:00 pm the nurse practitioner for the facility stated she had not been contacted by LVN W for an order for [REDACTED]. In an interview with the DON on 10/22/14 at 10:00 am the DON stated it was brought to her attention on 10/10/14 at 5:30 pm by LVN Z that LVN W had given Resident #1 [MEDICATION NAME] per her 1:15 pm nurse's notes and there was no order. The DON stated after she learned of the [MEDICATION NAME] order she called the staffing agency and informed them LVN W could not return to the facility because of the quality of care she provided. In an interview on 10/23/14 at 11:30 am the Medical Director stated LVN W should not have given [MEDICATION NAME] without an order and she should have monitored his reaction and rechecked his glucose level 15 minutes after administration. The Medical Director was informed an Immediate Jeopardy had been identified for significant medication errors and neglect. The Medical Director went on to say he just accepted the position as co-medical director and the facility had just been sold; so there were numerous changes with staffing which had caused a heavy reliance on staffing agencies. The Medical Director added there were many challenges ahead for them, but that did not excuse LVN W actions or improper diabetic management of residents and medication errors by any licensed staff References: Mayo Clinic - American Diabetes Association- Federal Drug Administration The DON provided a list of 27 residents in the facility that receives insulin. IJ components: The facility Administrator and DON was notified on 10/23/14 at 11:49 that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct a n audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: Ten MARS and TARS were reviewed for accuracy of insulin administration and follow up on abnormal glucose and no concerns were identified. There was one transcription error for a resident 's insulin to be held all day on the 24th, rather than just the morning dose as physician ordered. Because it was identified prior to the time the insulin would have been withheld, no medication error had occurred and the ADON was notified and corrected the transcription error. Four LVN ' s were interviewed, including 1 agency LVN, and all were knowledgeable about the Management of Diabetic Residents to include insulin and reporting neglect. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 pm, the Administrator, DON and RNC was informed the IJ was removed. However, the facility remained out of compliance at a severity of potential of more than minimal harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal The DON provided a list of 27 residents receiving insulin.

Based on observation, interview and record review the facility failed to develop and implement written policies and procedures that prevent mistreatment and neglect when: LVN W, an agency nurse, failed to assess Resident #1's altered mental status prior to administering a fast acting insulin, repeatedly placed food in his mouth and massaged his throat to make him swallow and administered [MEDICATION NAME] (used in treatment of [REDACTED].<60) without a physician's orders [REDACTED]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity of actual harm with a scope identified as pattern. This deficient practice could place 27 diabetic residents receiving insulin at risk for complications of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to include [MEDICAL CONDITION], coma and death. Findings include: Review of a Face Sheet for Resident #1 reflected he was [AGE] years old and originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] reflected Resident #1 required assistance with set up for meals, no swallowing problems; he was independent with ambulation in his electric wheelchair and required supervision only for all other ADLs. Review of a hospital discharge summary for Resident #1 dated 10/16/14 reflected the following Diagnoses: [REDACTED]. Reviews of a care plan for Resident #1 dated 10/13/14 reflected- instruct resident of signs and symptoms of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of admission orders [REDACTED]. Further review of physician orders [REDACTED]. If greater than 400 or less than 60 call the physician. Humalog twice daily before meals and [MEDICATION NAME] 18 units each morning. Review of nurse's notes for Resident #1 dated 10/10/14 reflected the following: 1:15 pm- Resident returned from medical appointment blood sugar 320- gave sliding scale insulin. Took to dining room to be fed about 10 minutes later CNA states he was sluggish. Went to dining room [ROOM NUMBER] health shakes given and fed 15 % of his meal. Still sluggish. Injection of [MEDICATION NAME] given. Report given to on coming nurse. Review of a MAR for Resident #1 reflected in the space for 11:30 am finger stick glucose readings on 10/10/14 (no time) it was 380 and 4 units of insulin was initialed as given by LVN W. In an interview on 10/23/14 at 10:20 am CNA V stated on the morning of 10/10/14 she was told by LVN W to make sure Resident #1 was clean and dressed for a medical appointment. CNA V stated she went to his room and he was slouching in bed, only mumbled when asked a question and he had urinated on himself to the point of soaking the sheets. CNA V stated she asked LVN W to look at Resident #1 because this was not normal for him. He was usually alert and orientated, continent of urine and could operate his electric wheelchair. CNA V went on to say LVN W did not assess Resident #1 and stated he was Ok and to just get him ready for his appointment. CNA V stated she cleaned Resident # 1 and put him in a manual wheelchair with the assistance of CNA U, because he was unable to operate his electric wheelchair in his condition. At 9:45 am Resident #1 left with a transportation service for his appointment. CNA V stated after he returned from his medical appointment it was lunchtime and LVN W brought him to the dining room and instructed CNA V to feed him and stated he needs to eat, I just gave him insulin. CNA V stated she declined to feed him, because he was so lethargic and could not open his mouth when asked. CNA V stated LVN W observed LVN W putting food in his mouth and it was coming back out and then she attempted to give him cranberry juice and it ran out of his mouth. CNA V further stated LVN W was massaging his throat to try to get him to swallow while he remained slumped in the wheelchair. CNA V went on to say that she left the dining room and shortly afterwards LVN W met her in the hallway pushing Resident #1 in a wheelchair and told her to put him bed. CNA V told LVN W she could see food in his mouth and she didn ' t ' want to put him to bed because he might choke. CNA V stated LVN W walked away and she took Resident #1 to his room. When she got to the room CNA V stated she put on gloves and removed approximately a tablespoon of food from his mouth (Resident # 1 is on a mechanical soft diet due to poor dentition). After removing the food from Resident #1 ' s mouth CNA V stated she and CNA U transferred him to bed and left the head of the elevated. CNA V stated she did not report LVN W's actions to the DON or Administrator. In a telephone interview on 10/24/14 at 4:00 pm LVN W stated prior to 10/10/14 she had taken care of Resident #1 a few times prior to 10/10/14, but she knew he was normally alert and oriented, had no swallowing problems and fed himself LVN W stated on the morning of 10/10/14 Resident #1 was alert, but was fed breakfast because he had a poor appetite. LVN W denied that he was lethargic at breakfast and stated the CNA ' s were ' wrong ' about his condition prior to him leaving for his 10:00 am appointment, but also stated she didn't do an assessment or document his status prior to his departure. LVN W stated when Resident #1 returned from his medical appointment his blood glucose level was high , but she could only remember it being in the 300 's. She stated she took him to the dining room for lunch after giving him insulin and told the CNAs to feed him and that he needed food. LVN W stated the CNAs came to her at the nurses ' station shortly after taking him to the dining room and stated they did not want to feed him because he was sluggish LVN W stated when she went back to the dining room Resident #1 was slumped in his wheelchair, but he answered my questions LVN W stated she fed Resident #1 about 10% of his meal, but he would hold the food in his mouth and would not swallow so she massaged his throat to help him swallow. Later in the interview LVN W stated she gave him 2 packets of sugar in milk at lunch, but couldn't state how much of it he was able to consume. LVN W stated she could not remember if Resident #1 had food in his mouth when she instructed the CNAs to take him to his room and had no comment about CNA V stating she was asked to remove it. In a continued interview with LVN W she stated she performed a finger stick glucose check on Resident #1 in his room after feeding him lunch and it was 150 but she did not document the reading. LVN W stated at some point after the 150 glucose finding she called the doctor or nurse practitioner (she couldn't remember which) and received an order for [REDACTED]. LVN W stated she did not recheck Resident #1 ' s blood glucose level after administering the [MEDICATION NAME], and did not document a telephone order for the [MEDICATION NAME]. LVN W stated she did look in on him before she left at the end of her shift at 2:00 pm and he wasn't in a coma or dead, so it was her expectation that the oncoming nurse should have rechecked Resident #1 blood glucose, because she stated in shift report it was given. In an interview on 10/24/14 at 4:00 pm LVN Z stated she received a phone call on 10/10/14 from the physician that saw Resident #1 for a follow up appointment for his admission to the hospital for pneumonia prior to coming to the facility. The physician stated he had not seen Resident #1 prior to his appointment on 10/10/14, so he did not know his baseline, but he seemed very confused and weak. Review of the facility 24 hour shift report for 10/10/14 reflected no entries by LVN W regarding his altered mental status or that she had administered [MEDICATION NAME]. In an interview on 10/23/14 at 2:00 pm Resident #1 stated he did not remember much about the day he went to the hospital. He remembered receiving a shot in the dining room, but was not sure if it was insulin or something else, because he routinely receives his insulin in the dining room. Resident #1 stated by the time he went to the hospital he couldn't even form a sentence. Resident #1 added he had been diabetic since he was 9 years old and immediately learned to give himself the shots He stated he was familiar with how he feels if his glucose levels are not normal, but he just felt too bad the day he went out to tell anyone. In an interview on 10/24/14 at 5:00 pm the nurse practitioner for the facility stated she had not been contacted by LVN W for an order for [REDACTED]. Review of a nurse's note for Resident #1 written by LVN Z on 10/10/14 reflected the following: 4:30 pm- Resident lying in bed blood sugar checked - results 598. Contacted nurse practitioner for orders. New order noted to give 15 units [MEDICATION NAME] now. 15 units given subcutaneous. 6:30 pm Resident lying in bed responds to verbal stimuli, denies pain, speech clear, remains confused. Metaprolol held due to a heart rate of 54. Will continue to monitor. 7:45 pm Went to room to check blood sugar - results 520. Noted facial drooping on one side, slurred speech with right arm weakness noted. Sent to emergency room due to stroke symptoms. In an interview on 10/22/14 at 4:54 pm LVN Z stated LVN W reported to her at change of shift on 10/10/14 that she had given Resident #1 [MEDICATION NAME] during her shift (6 am-2 pm) because he wasn't acting right. When asked if she questioned LVN W further about how Resident # 1 was acting she stated she had not and she assumed the [MEDICATION NAME] had been given in the morning rather than close to shift change. LVN Z also stated she did not assess Resident #1 until 4:30 pm when it was time for his scheduled finger stick glucose and insulin and that is when his glucose level was 598 LVN Z did confirm she did not recheck his glucose level until 7:30 pm when it was the next scheduled time and it was 520; and he had slurred speech, right sided weakness, facial drooping and was sent to the hospital. In an interview with the DON on 10/22/14 at 10:00 am the DON stated it was brought to her attention on 10/10/14 at 5:30 pm by LVN Z that LVN W had given Resident #1 [MEDICATION NAME] per her 1:15 pm nurse's notes and there was no order. The DON stated she had had an encounter earlier in the day with LVN W because a resident complained it was 11:30 pm and she still had not received her 8:00 am medications and when the resident mentioned it to LVN W she gave her half of her [MEDICATION NAME] dose (1 tablet instead of 2). The DON stated after she learned of the [MEDICATION NAME] error she called the staffing agency and informed them LVN W could not return to the facility because of the quality of care she provided. The DON stated it is the expectation licensed staff would not give [MEDICATION NAME] without a physician's orders [REDACTED].> 300). Review of the facility ' s Abuse Prevention Program reflected: 5) Our facility has developed policies and procedures to aid in preventing abuse, neglect or mistreatment of [REDACTED]. c. Identification of occurrences and patterns of potential mistreatment/abuse; Review of the facility ' s Abuse Prevention Program, section Reporting Abuse to Facility Management: 3. Employees, facility consultants, volunteers, and/or attending physicians must promptly report any suspected abuse or incidents of abuse to the administrator or his/her designee. If such incidents occur or are discovered after normal business hours, the administrator or his/her designee must be called at home or must be paged and informed of such incidents. 8. Any individual observing an incident of resident abuse or suspecting resident abuse must promptly report such incident to the administrator or his/her designee. 10. When an incident of resident abuse is suspected or determined, such incident must be reported to the administrator or his/her designee regardless of the time lapse since the incident occurred. Review of the facility ' s Abuse Prevention Program, section Recognizing Signs and Symptoms of Abuse/Neglect: b. Signs of or actual physical neglect: improper use/administration of medication; inadequate provision of care; Caregiver indifferent to resident ' s personal care and needs. Review of the facility ' s report to the State licensing agency, dated 10/12/14, revealed a report of a medication error and irresponsible actions, and did not mention neglect. Review of the facility ' s inservice training log revealed the most recent documented facility wide Abuse/Neglect training was conducted on 8/22/14. The inservice on 10/11-/12/14 was only given to licensed staff. IJ components: The Medical Director was notified on 10/23/14 at 11:30 AM that an IJ situation had been identified due to the above failures. The ADM and DON were notified on 10/23/14 at 11:49 AM, that an IJ situation had been identified. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct an n audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1 has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: On 10/24/14 from 4:00 PM to 5:20 PM, interviews with 3 facility LVNs, 1 agency LVN, 4 CNAs, 1 MA, 1 laundry aide, the Assistant Activity Director and the Admission/Marketing Director revealed staff had been in-serviced on the above Plan of Removal. Staff members were able to state when they were to report an allegation of neglect, to whom, including up to the ADM and State regulatory office. Licensed staff were able to state signs and symptoms of hypo- and [MEDICAL CONDITION], when they were to notify the DON and physician on changes of condition, and the procedure to administer [MEDICATION NAME]. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 PM, the ADM and RNC were informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm, with a scope as pattern due to the facility requiring time to train all staff, complete Nurse Proficiency Audits on all licensed staff, and monitor their Plan of Removal. The DON provided a list of 27 residents receiving insulin.

Based on observation, interview and record review the facility failed to provide services that meet professional standards for 1 of 6 residents reviewed for Diabetic Management (Resident # 1) when on 10/10/14: LVN W failed to assess Resident #1 ' s altered mental status prior to giving him a dose of fast acting insulin at lunchtime then repeatedly placed food in his mouth and when he could not swallow she massaged his throat. LVN W instructed staff to put him to bed with pocketed food in his mouth. LVN W administered a [MEDICATION NAME] injection to Resident #1 ([MEDICATION NAME] is a treatment for [REDACTED].<60) without a physician's order [REDACTED]. LVN Z administered 15 units of fast acting insulin to Resident #1 due to a finger stick glucose level of 598 and did not reassess his blood glucose level until 3 hours and 15 minutes later, when it was 520, and Resident #1 was found to have slurred speech and exhibiting signs of a possible stroke. Resident #1 was transferred to hospital and admitted to the intensive care unit for a primary [DIAGNOSES REDACTED]. . These failures resulted in an identification of an Immediate Jeopardy (IJ) on 10/23/14. While the IJ was removed on 10/24/14, the facility remained out of compliance at a severity of actual harm and a scope of pattern. This deficient practice could place 27 diabetic residents receiving insulin at risk for complications of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] to include [MEDICAL CONDITION], coma and death. The Findings Include: Review of a Face Sheet for Resident #1 reflected he was [AGE] years old and originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of an Admission MDS dated [DATE] reflected Resident #1 required assistance with set up for meals, no swallowing problems; he was independent with ambulation in his electric wheelchair and required supervision only for all other ADLs. Review of a hospital discharge summary for Resident #1 dated 10/16/14 reflected the following Diagnoses: [REDACTED]. Reviews of a care plan for Resident #1 dated 10/13/14 reflected- instruct resident of signs and symptoms of [MEDICAL CONDITION] and [MEDICAL CONDITION]. Review of admission orders [REDACTED]. Review of nurse's notes for Resident #1 dated 10/10/14 reflected the following: 1:15 pm- Resident returned from medical appointment blood sugar 320- gave sliding scale insulin. Took to dining room to be fed about 10 minutes later CNA states he was sluggish. Went to dining room [ROOM NUMBER] health shakes given and fed 15 % of his meal. Still sluggish. Injection of [MEDICATION NAME] given. Report given to on coming nurse. Review of a MAR for Resident #1 reflected in the space for 11:30 am finger stick glucose readings on 10/10/14 (no time) it was 380 and 4 units of insulin was initialed as given by LVN W. In an interview on 10/23/14 at 10:20 am CNA V stated on the morning of 10/10/14 she was told by LVN W to make sure Resident #1 was clean and dressed for a medical appointment. CNA V stated she went to his room and he was slouching in bed, only mumbled when asked a question and he had urinated on himself to the point of soaking the sheets. CNA V stated she asked LVN W to look at Resident #1 because this was not normal for him. He was usually alert and orientated, continent of urine and could operate his electric wheelchair. CNA V went on to say LVN W did not assess Resident #1 and stated he was Ok and to just get him ready for his appointment. CNA V stated she cleaned Resident # 1 and put him in a manual wheelchair with the assistance of CNA U, because he was unable to operate his electric wheelchair in his condition. At 9:45 am Resident #1 left with a transportation service for his appointment. CNA V stated after he returned from his medical appointment it was lunchtime and LVN W brought him to the dining room and instructed CNA V to feed him and stated he needs to eat, I just gave him insulin. CNA V stated she declined to feed him, because he was so lethargic and could not open his mouth when asked. CNA V stated she observed LVN W putting food in his mouth and it was coming back out and then she attempted to give him cranberry juice and it ran out of his mouth. CNA V further stated LVN W was massaging his throat to try to get him to swallow while he remained slumped in the wheelchair. CNA V went on to say that she left the dining room and shortly afterwards LVN W met her in the hallway pushing Resident #1 in a wheelchair and told her to put him bed. CNA V told LVN W she could see food in his mouth and she didn ' t want to put him to bed because he might choke. CNA V stated LVN W walked away and she took Resident #1 to his room. When she got to the room CNA V stated she put on gloves and removed approximately a tablespoon of food from his mouth (Resident # 1 is on a mechanical soft diet due to poor dentition). After removing the food from Resident #1 ' s mouth CNA V stated she and CNA U transferred him to bed and left the head of the bed elevated. In a telephone interview on 10/24/14 at 4:00 pm LVN W stated prior to 10/10/14 she had taken care of Resident #1 a few times prior to 10/10/14, but she knew he was normally alert and oriented, had no swallowing problems and fed himself LVN W stated on the morning of 10/10/14 Resident #1 was alert, but was fed breakfast because he had a poor appetite. LVN W denied that he was lethargic at breakfast and stated the CNA ' s were ' wrong ' about his condition prior to him leaving for his 10:00 am appointment, but also stated she didn't do an assessment or document his status prior to his departure. LVN W stated when Resident #1 returned from his medical appointment his blood glucose level was high , but she could only remember it being in the 300 's. She stated she took him to the dining room for lunch after giving him insulin and told the CNAs to feed him and that he needed food. LVN W stated the CNAs came to her at the nurses ' station shortly after taking him to the dining room and stated they did not want to feed him because he was sluggish LVN W stated when she went back to the dining room Resident #1 was slumped in his wheelchair, but he answered my questions LVN W stated she fed Resident #1 about 10% of his meal, but he would hold the food in his mouth and would not swallow so she massaged his throat to help him swallow. Later in the interview LVN W stated she gave him 2 packets of sugar in milk at lunch, but couldn't state how much of it he was able to consume. LVN W stated she could not remember if Resident #1 had food in his mouth when she instructed the CNAs to take him to his room and had no comment about CNA V stating she was asked to remove it. In a continued interview with LVN W she stated she performed a finger stick glucose check on Resident #1 in his room after feeding him lunch and it was 150 but she did not document the reading. LVN W stated at some point after the 150 glucose finding she called the doctor or nurse practitioner (she couldn't remember which) and received an order for [REDACTED]. LVN W stated she did not recheck Resident #1 ' s blood glucose level after administering the [MEDICATION NAME], and did not document a telephone order for the [MEDICATION NAME]. LVN W stated she did look in on him before she left at the end of her shift at 2:00 pm and he wasn't in a coma or dead, so it was her expectation that the oncoming nurse should have rechecked Resident #1 blood glucose, because she stated in shift report it was given. In an interview on 10/24/14 at 4:00 pm LVN Z stated she received a phone call on 10/10/14 from the physician that saw Resident #1 for a follow up appointment for his admission to the hospital for pneumonia prior to coming to the facility. The physician stated he had not seen Resident #1 prior to his appointment on 10/10/14, so he did not know his baseline, but he seemed very confused and weak. Review of the facility 24 hour shift report for 10/10/14 reflected no entries by LVN W regarding his altered mental status or that she had administered [MEDICATION NAME]. In an interview on 10/23/14 at 2:00 pm Resident #!, who was alert and oriented x3, stated he did not remember much about the day he went to the hospital. He remembered receiving a shot in the dining room, but was not sure if it was insulin or something else, because he routinely receives his insulin in the dining room. Resident #1 stated by the time he went to the hospital he couldn't even form a sentence. Resident #1 added he had been diabetic since he was 9 years old and immediately learned to give himself the shots He stated he was familiar with how he feels if his glucose levels are not normal, but he just felt too bad the day he went out to tell anyone. In an interview on 10/24/14 at 5:00 pm the nurse practitioner for the facility stated she had not been contacted by LVN W for an order for [REDACTED]. Review of a nurse's note for Resident #1 written by LVN Z on 10/10/14 reflected the following: 4:30 pm- Resident lying in bed blood sugar checked - results 598. Contacted nurse practitioner for orders. New order noted to give 15 units [MEDICATION NAME] now. 15 units given subcutaneous. 6:30 pm Resident lying in bed responds to verbal stimuli, denies pain, speech clear, remains confused. Metaprolol held due to a heart rate of 54. Will continue to monitor. 7:45 pm Went to room to check blood sugar - results 520. Noted facial drooping on one side, slurred speech with right arm weakness noted. Sent to emergency room due to stroke symptoms. In an interview on 10/22/14 at 4:54 pm LVN Z stated LVN W reported to her at change of shift on 10/10/14 that she had given Resident #1 [MEDICATION NAME] during her shift (6 am-2 pm) because he wasn't acting right. When asked if she questioned LVN W further about how Resident # 1 was acting she stated she had not and she assumed the [MEDICATION NAME] had been given in the morning rather than close to shift change. LVN Z also stated she did not assess Resident #1 until 4:30 pm when it was time for his scheduled finger stick glucose and insulin and that is when his glucose level was 598 LVN Z did confirm she did not recheck his glucose level until 7:30 pm when it was the next scheduled time and it was 520; and he had slurred speech, right sided weakness, facial drooping and was sent to the hospital. In an interview with the DON on 10/22/14 at 10:00 am the DON stated it was brought to her attention on 10/10/14 at 5:30 pm by LVN Z that LVN W had given Resident #1 [MEDICATION NAME] per her 1:15 pm nurse's notes and there was no order. The DON stated she had had an encounter earlier in the day with LVN W because a resident complained it was 11:30 pm and she still had not received her 8:00 am medications and when the resident mentioned it to LVN W she gave her half of her [MEDICATION NAME] dose (1 tablet instead of 2). The DON stated after she learned of the [MEDICATION NAME] error she called the staffing agency and informed them LVN W could not return to the facility because of the quality of care she provided. The DON stated it is the expectation licensed staff would re-check a residents glucose level intially 15 minutes after administering [MEDICATION NAME] or insulin for an abnormally high glucose level (greater than 300). Review of the Facility ' s Provider Investigation Report dated 10/16/14 reflected the following: LVN W was observed putting food in Resident #1's mouth and stroking his throat to make the food go down. He consumed a diabetic health shake. At 12:45 PM LVN W was observed in the dining room sitting next to Resident #1 with an orange [MEDICATION NAME] container in her hand. No one witnessed her giving the injection. Statements from CNA V and CNA U revealed LVN W told them at about 1:00 pm to put Resident #1 to bed but they told her to they didn 't want to because he had food in his mouth, CNA V stated she put on gloves and removed food from his mouth and they put him to bed. Went to check on him again in 30 minutes and he still didn ' t look well. Asked LVN W again to check on him and she said he is Ok he is probably just sleeping. A Statement from Dietary Aide Q revealed LVN W was repeatedly placing food in Resident #1's mouth without him being able to swallow and she was massaging his throat. Dietary Aide took two diabetic shakes to the table for LVN W to give to try and stop her from placing any more food in his mouth. In an interview on 10/23/14 at 11:30 am the Medical Director stated LVN W should not have given [MEDICATION NAME] without an order and she should have monitored his reaction and rechecked his glucose level 15 minutes after administration. The Medical Director was informed an Immediate Jeopardy had been identified for significant medication errors and neglect. The Medical Director went on to say he just accepted the position as co-medical director and the facility had just been sold; so there were numerous changes with staffing which had caused a heavy reliance on staffing agencies. The Medical Director added there were many challenges ahead for them, but that did not excuse LVN W actions or improper diabetic management or assessement of residents by any licensed staff The facility Administrator and DON was notified on 10/23/14 at 11:49 that an IJ situation had been identified due to the above failures. The following Plan of Removal was submitted by the Administrator on 10/23/14 at 4:45 PM. The final Plan of Removal was accepted by the investigator on 10/24/14 at 11:20 AM. Allegation of neglect: failure to report allegations/observations of neglect: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. Resident #2 received treatment from another nurse on duty at the time and experienced no adverse effects. 3. Staff will be in-serviced regarding Abuse/Neglect policy and procedure, when, how and to who you report to including up the chain of command. 4. Daily the administrator will monitor by randomly interview and observe staff members (including agency) and residents regarding abuse/neglect. 5. Licensed nurse competency evaluation including medication administration and diabetic management will be completed on all licensed nurses including agency nurses. 6. In the event that it is determined that someone is not knowledgeable regarding the abuse/neglect policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 7. The agency staff will be trained regarding the expectations of providing care and services and reporting neglect/abuse. Allegation of neglect: failure to assess/follow protocols: 1. DON in-serviced regarding her role in safe guarding the residents, ensuring competency of staff, and stopping unsafe practices when they occur. 2. Licensed staff will be in-serviced on how to assess a resident change of condition. 3. Licensed staff will be in-serviced on physician notification of change of condition, including but not limited to refusal of medication, medication out of time compliance, omission of medication, omission of treatment, etc. 4. Retrain the staff to alert the director of nursing services and the administrator of resident changes in condition including but not limited to medication passes outside of time parameters, omitted medications, refusal of medications, concerns regarding other staff member performance, etc. 5. Train staff regarding the Stop and Watch tool and notification of the tool to the proper entity. This tool provided a quick overview of any concerns noted regarding the resident. 6. Train licensed staff on end of shift report form which will be verified each morning by nursing management for completion. 7. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of change in treatment plan. 8. Pharmacy consultant will conduct a n audit to ensure facility and agency staff members are within the established parameters for medication pass times, documenting appropriately, no omissions, and notifications. 9. Nursing management will conduct competency audits utilizing the competency tools such as licensed nurse competency, medication pass audit, medication aide competency, nurse aide competency. 10. Agency will be called and explained that prior to any agency staff member working at the facility, they are to go through orientation with competency verification. This orientation will be held once a week with regular staff orientation. This orientation will include competency evaluation. An agency competency book will be maintained in the DON office. 11. Nursing management will conduct competency evaluations weekly x4 weeks, then every two weeks for 1 month, then monthly thereafter. Competencies will be completed during orientation prior to staff member working alone on the floor. 12. In the event that it is determined that someone is not knowledgeable or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. 13. An out of cycle QA&A will be held regarding the allegation of neglect and discussed with the medical director. Allegation of Significant Medication Error: failure to ensure diabetic competency: 1. Affected Resident #1, has been clinically monitored daily by Nursing Administration since his return from the hospital. Administrator has interviewed Resident #1 daily for his well-being and satisfaction. 2. MD was notified regarding each resident blood sugar omitted, blood sugar was taken at 8 PM and blood sugar results were reported to the physician. Regarding Resident #4, was to administer insulin per sliding scale as ordered. Regarding Resident #5, blood sugar was taken and resident refused sliding scale insulin. 3. Train facility staff as well as agency staff on standards of practice involving blood glucose levels and appropriate interventions as indicated by physician orders. 4. Train the facility and agency staff regarding the signs and symptoms of hyper- and hypoglycemic episodes and appropriate interventions. 5. Train the facility staff and agency staff of notification of the physician when interventions are required for episodes of hyper- or hypoglycemic symptoms. 6. Diabetic residents will have parameters determined by their POC for administering [MEDICATION NAME]. 7. Licensed staff will be trained regarding the determined parameters for administering [MEDICATION NAME]. 8. LVN ' s will alert RN of any administration of [MEDICATION NAME] prior to that administration. If the RN is in the facility they will assess the resident. 9. Director of nursing services and/or designee will audit active clinical records if indicated on the 24 hour report of a change in treatment plan. 10. Director of nursing services and/or designee will audit the Medication Administration Record [REDACTED]. 11. The director of nursing services and/or designee will utilize the diabetic audit flow sheet daily to determine compliance with diabetic teaching. 12. In the event that it is determined that someone is not knowledgeable regarding the policy or is in need of retraining, the retraining will be conducted prior to the employee coming back to the floor. The investigators monitored the current plan of removal as follows: Ten MARS and TARS were reviewed for accuracy of insulin administration and follow up on abnormal glucose and no concerns were identified. There was one transcription error for a resident ' s insulin to be held all day on the 24th, rather than just the morning dose as physician ordered. Because it was identified prior to the time the insulin would have been withheld, no medication error had occurred and the ADON was notified and corrected the transcription error. Four LVN ' s were interviewed, including 1 agency LVN, and all were knowledgeable about the Management of Diabetic Residents to include insulin and reporting neglect. Review of the Licensed Nurse Proficiency Audit revealed 9 competencies had been completed at that time, to include 7 facility LVNs and 2 agency LVNs. On 10/24/14 at 5:22 pm, the Administrator, DON and RNC was informed the IJ was removed. However, the facility remained out of compliance at a severity of actual harm with a scope as pattern due to the facility requiring time to train all staff and monitor their Plan of Removal. The DON provided a list of 27 residents receiving insulin.

Based on interview and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for one (1) of 68 residents reviewed for controlled drug prescriptions when (Resident #1): The facility failed to acquire the controlled medication, Vimpat (an anti-seizure medication), for Resident #1 in a timely manner and as a result the resident did not receive four doses of the prescribed medication from the evening dose on 2/25/13, the day of admission through the morning dose on 02/27/13. Resident#1 had seizure activity the morning of 02/27/13. The physician was notified and Ativan was administered intravenously before the resident was transported to the hospital. This deficient practice placed 68 residents who currently have prescriptions for controlled drugs at risk for not receiving their medications according to physician orders [REDACTED]. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Interim Care Plan revealed a blank care plan with only the " Activities " section completed. Review of Resident #1 ' s admission orders Keppra 1250 mg by mouth BID, Metoprolol succ XL (Toprol XL) 100 mg by mouth daily, Simvastatin (Zocor) 5 mg by mouth at night, Aspirin 81 mg by mouth daily, Dexamethasone Sod Phos 4 mg by mouth two times daily, Hydrocodone- acetam 10-325 (Norco 10-325) 1 Tab by mouth every 6 hours PRN Pain, Ativan 0.5 mg one by mouth daily and at night PRN Anxiety, Metformin 500 mg by mouth twice daily, Lacosamide (Vimpat) 100 mg by mouth twice daily, Phenytoin Sodium Extended (Dilantin) 100 mg by mouth three times daily, Doxycycline (Vibramycin) 100 mg by mouth twice daily for 3 days, Enoxaparin Sodium (Lovenox) 60 mg SQ twice daily, Famotidine (Pepcid) 20 mg by mouth daily, Coumadin 5 mg take by mouth every night. " Review of Resident #1 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On the 8 AM dose for 02/26/13 an initial with a circle around it was present indicating that the dose was not given. Review of the facility incident report reflected " (Resident #1) admitted on the 25th with a significant history of [DIAGNOSES REDACTED] and subsequent seizure disorder. Resident was ordered Dilantin, Keppra and Vimpat. Resident missed four doses of Vimpat due to the nurse ' s failure to obtain medicine from the pharmacy. Subsequently, resident was admitted to ICU on 02/27/13 with a [DIAGNOSES REDACTED]. " " Describe corrective or proactive actions being taken: Immediately inservice nurses on how to order medications and specifically educate on seizure medications. Spoke with (Physician) re: resident ' s condition and he stated that she would continue to have seizures due to her history of diagnoses. We will QA&A incident. Pharmacist to give inservice on ordering medications, cut off times and calling after hours and timeliness. Will do a med error report also. Counsel of admitting nurse (LVN M). " Signed by the Director of Nursing (DON). Review of the Medications Error Report dated 02/28/13 reflected " Res emtered facility at 1545 on the 25th- failed to receive Vimpat on 25th, 2 doses on the 26th and 1 dose on the 27th. Res admitted to (hospital) ICU. In-serviced staff: meds; Pharmacist will do in-service on 10th; QAA; Chart Review, Counsel Staff. " Interview on 03/01/13 at 9:20 AM, the DON stated Resident #1 was admitted to the facility on [DATE] at 3:45 PM. The DON stated the resident admitted with medications orders that were faxed to the pharmacy immediately upon admission. The DON stated that the resident had received all medications prior to admission to the facility. The DON stated all of Resident #1 ' s medications except for the controlled drugs (Vimpat, Ativan and Hydrocodone) arrived at the facility by the morning of 02/26/13. The DON stated that Vimpat is a " schedule V controlled drugs " and they had difficulty getting it into place because the doctor has to handwrite the triple script order on one of these medications. The DON stated that the doctor did not fax the triplicate until 9:30 PM on 02/26/13 to the pharmacy. The DON stated that " where we fell down was that my nurses should have been calling to get that medication. " The DON stated that the resident was supposed to receive twice daily doses of Vimpat to control seizures that had recently worsened while in the hospital due to an enlarging [DIAGNOSES REDACTED]. The DON stated that the resident did not receive the PM dose of the Vimpat on 02/25/13, The AM and PM dose of Vimpat on 02/26/13 and the AM dose of Vimpat on 02/27/13. The DON stated that the resident had a seizure on 02/27/13 at 10:15 AM. The DON also stated that the resident was on two other medications for seizures (Dilantin and Keppra) and did receive these medications during the time that she did not receive the doses of Vimpat. Interview on 03/01/13 at 12:25 PM, Licensed Vocational Nurse (LVN) M stated that she was the nurse who admitted Resident #1 on 02/25/13. LVN M stated that after the resident admitted to the facility she verified the medication orders with the Physician, and then she faxed the orders to the pharmacy and called them 30 minutes later to confirm that they had received them. LVN M stated that the first night (2/25/13) none of the medications came in but the granddaughter said she could bring the Dilantin and Keppra from home. LVN M stated that the next morning (2/26/13) when she came on shift (6 AM - 2 PM) she noticed that all of the residents medications were delivered that morning except for the controlled drugs (Vimpat, Ativan and Hydrocodone). She called the pharmacy again and they said they needed a handwritten triplicate order from the Physician for the three controlled drugs. LVN M stated that she called the Physician right away to notify him that the pharmacy needed the triplicates for the Vimpat and other drugs. LVN M stated that the Physician stated that he was not in his office and he would fax the orders later when he could get to a fax machine. LVN M stated that the pharmacy also told her that she was not an agent for the Physician which allows her to order medications under his name. LVN M stated that she notified the DON that she was not an agent for the doctor and the DON told her that she could ask the Administrator to work on that situation. LVN M stated that she " tried and tried to get the medication in " but she was dependent on the doctor to the write the prescription. LVN M stated that she had not received any direct training from the facility on what procedure to follow to order medications and ensure that it arrived in a timely manner. Interview on 03/01/13 at 1:45 PM Medication Aide (Med Aide) C stated that she passed medications for residents on Resident #1 ' s hall on the day shift from 6AM to 2 PM on 02/26/13 and 02/27/13. Med Aide C stated that the nurse passed the medications to Resident #1 on the morning of 02/26/13. Med Aide C stated that when she tried to pass Resident #1 ' s medications on 02/27/13, the Vimpat medication was not in the cart. Med Aide C stated that LVN M had informed her on 02/26/13 that the Vimpat had not been delivered with the rest of the medications. Interview on 03/01/13 at 3:40 PM, Med Aide D stated that she worked the 2PM to 8PM shift on 02/26/13 and passed medications for Resident #1. Med Aide D stated that she noticed the Vimpat was not available on the medication cart and informed the nurse who informed her that she was aware of it and trying to get the medication in. Med Aide D stated that LVN M was on the phone with the pharmacy often that evening trying to get the medication in. Med Aide D stated that she left the Vimpat PM dose on 02/26/13 box blank without her signature on the Medication Administrator Record just in case the medication came in after she left her shift at 8 PM. Interview on 03/01/13 at 1:55 PM LVN N stated she worked the day shift (6 AM- 2PM) on 02/27/13. LVN N stated that Med Aide C passed medications that morning and Med Aide C did not inform LVN N that any medications were missing. LVN N stated that the son of Resident #1 came to get her (LVN N) around 10:50 AM to inform the nurse that Resident #1 was having a seizure. LVN N stated she notified the doctor and intravenous Ativan was administered. LVN N stated that she then sent the resident out to the hospital following the advice of the Physician. LVN N stated that Resident #1 ' s family informed her that she had not been receiving the Vimpat medication since admission because the facility was having difficulty getting the medication in. LVN N stated that she called the pharmacy immediately following addressing the resident ' s symptoms. LVN N stated that the pharmacy informed her that they were out of the medication and were trying to get it in in order to have it delivered but that it was coming today with the afternoon shipment. LVN N stated that she told the pharmacy that " it was not acceptable " that the medication had not arrived yet. LVN N stated that she had not received any direct training from the facility on what procedure to follow to order medications or how to ensure it arrived in a timely manner, but had learned it over time on her own. Interview on 03/01/13 at 2:05 PM, the DON stated that LVN M could have asked one of the other nurses who are agents to assist her with ordering the medication or that she should have notified her (the DON) to ensure it was ordered from another pharmacy who could place the order sooner. The DON stated the " agent " list that the pharmacy uses to know which nurses can order medications under the doctor ' s permission is outdated and that the facility needs to update it. The DON stated she did not know how LVN M would have known which nurses were on the agent list. Interview on 03/01/13 at 2:10 PM, the Administrator stated that he knows the facility was at fault for not having the Vimpat medication there in a timely manner. The Administrator stated that the facility needed to update the " agent " list. The Administrator stated that they have not been keeping the " agent " list updated like they should when new nurses are hired. The Administrator stated that he would educate staff on the procedure for ordering medications and who is an agent. The Administrator stated that LVN M should have been more aggressive in trying to get the medication in and she should have notified administrative staff. Interview on 03/01/13 at 2:40 PM, the Physician stated that he was notified on 02/25/13 that Resident #1 was admitted and he verified the orders with the admitting nurse (LVN M). The Physician stated that he was notified that the facility was having trouble getting the Vimpat on 02/26/13 around noon. The Physician stated that the facility had trouble getting the medication because it was a controlled medication. The Physician stated no one at the facility has prescriptive authority because there has been a lot of turn over since they initiated the agent list back in 2011. The Physician stated he asked the nurse to text him the information of the medication order for Vimpat, the nurse said she couldn ' t because the new DON wouldn ' t allow them to text that information anymore so the nurse had to fax the information. The Physician stated that he could not get to the fax until later in the evening of 02/26/13. The Physician stated that he faxed the pharmacy the triplicate order around 9 PM on 02/26/13. The Physician stated that there is no way to tell if missing the four doses of Vimpat was the cause of the seizure. The Physician stated that Resident #1 does has intractable seizures from her [DIAGNOSES REDACTED]. The Physician stated that the facility needs to have a plan for getting critical medications in timely when he does not have access to a fax machine. Review of the " Designated Agents " List for the consultant pharmacy company dated 02/28/13 compared to the Staffing schedules for 02/25/13- 02/26/13 reflected that one designated agent was working on 02/25/13 during the 2 PM -10 PM shift and one designated agent worked the 10 PM to 6 AM shift. On 02/26/13 one agent worked on the 6 AM- 2 PM shift, one agent worked on the 2 PM- 10 PM shift and one agent worked on the 10 PM- 6 AM shift. Review of a timeline provided by the Consultant Pharmacy for the attempts to order Resident #1 ' s Vimpat medication reflected " 02/25/13: (5:42 PM)- Facility faxed hospital discharge orders for (Resident #1) to pharmacy, 02/26/13: (3:08 AM) - Handwritten physician orders [REDACTED].#1) including two antiepileptic drugs (phenytoin and levetiracetam); (9:28 PM)- (Resident #1) ' s physician faxes valid signed prescriptions for controlled substances Vimpat 100 mg, hydrocodone 10/325, and Ativan 0.5 mg; 02/27/13: (9:10 AM-9:23 AM)- (Physician) refaxes the three (prescriptions) for controlled substances, sent on 1:00 PM run, received by (LVN) at (6:05 PM). Review of the Admission History and Physical from Resident #1 ' s hospital records for the hospital stay beginning 02/27/13 reflected " (Resident #1) is a [AGE] year old Caucasian female recently hospitalized from [DATE]-02/25/13, when she was discharged to (the facility) ... Briefly (Resident #1) was admitted on [DATE] after having 3 seizures. She was observed in the ICU without any observed seizures. She was transferred to the floor just prior to discharge, she went into [DIAGNOSES REDACTED] and was transferred back to the ICU and was put on propofol and Versed to control her seizures and was added Keppra and phenytoin as well as Vimpat. She eventually was weaned off of propofol, Versed and her seizures were controlled. While hospitalized , she did develop an acute deep vein thrombosis in the right peroneal vein. She was discharged on [DATE] to (the facility). The granddaughter is in the room and gives the following history. (Resident #1) has not received Vimpat in the last 2 days because of difficulty obtaining the medication and ' she is bleeds bad ' that is what led to her beginning to seize again. In the ER, she was evaluated and found to be in status, she was evaluated by neurology, who recommended a loading dose of 2 g of Keppra, 1 g of phenytoin, and 200 mg lacosamide with continuing doses 2 g b.i.d of Keppra, 100 mg IV q 8 hours of phenytoin, 200 mg IV of Vimpat b.i.d. She is getting an EEG set up in the ER room at the time of my evaluation and will be admitted to MICU. " Review of the Inpatient Progress Note from Resident #1 ' s hospital records for the hospital stay dated 03/01/13 reflected " ...I have discussed with the neurology service the difficulty in attainting a seizure-free state with the patient having such a large [DIAGNOSES REDACTED]. Feeding tube to be placed today, given that the patient is anticipated to remain in drug-induced coma now for several days ... I feel it would be important that the family members gather and have a discussion as to a plan if the patient cannot remain seizure-free. Overall, I think the intensity of her seizure disorder in conjunction with her multiple disabilities has reached a level of a fatal combination. " " Diagnoses: [REDACTED]. Review of the facility ' s policy on " Ordering and Receiving Non-Controlled Medications " dated 09/2010 reflected " Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. " Review of the facility ' s policy on " Ordering and Receiving Controlled Medications " dated 09/2010 reflected the following " 4. The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. A valid written prescription requires patient name, drug name and strength, quantity to dispense, directions for use, date and signature of prescriber. In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order. If unable to obtain another written prescription and provide the medication prior to the depletion of the current supply, the pharmacy will notify the nursing care center immediately. " Review of the facility ' s policy on " Controlled Substance Medication Orders " dated 09/2010 reflected " Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them. The pharmacy can dispense a schedule III-V controlled substance medication after the receipt of a practitioner signed valid schedule III-V prescription (original and/or fax) or the practitioner (or his agent) speaks directly to the pharmacist providing a verbal authorized controlled substance prescription. " The DON reported 68 residents receive controlled medications.

Based on interview and record review the facility failed to ensure that residents are free of any significant medication errors for one (1) of 68 residents reviewed for controlled drug prescriptions when (Resident #1): The facility failed to acquire the controlled medication, [MEDICATION NAME] (an anti-[MEDICAL CONDITION] medication), for Resident #1 in a timely manner and as a result the resident did not receive four doses of the prescribed medication from the evening dose on 2/25/13, the day of admission through the morning dose on 02/27/13. Resident#1 had [MEDICAL CONDITION] activity the morning of 02/27/13. The physician was notified and [MEDICATION NAME] was administered intravenously before the resident was transported to the hospital. This deficient practice placed 68 residents who currently have prescriptions for controlled drugs at risk for not receiving their medications according to physician orders [REDACTED]. Findings include: Review of Resident #1 ' s Face Sheet reflected a [AGE] year old female admitted on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #1 ' s Interim Care Plan revealed a blank care plan with only the " Activities " section completed. Review of Resident #1 ' s admission orders [MEDICATION NAME] 1250 mg by mouth BID, [MEDICATION NAME] succ XL ([MEDICATION NAME] XL) 100 mg by mouth daily, [MEDICATION NAME] ([MEDICATION NAME]) 5 mg by mouth at night, Aspirin 81 mg by mouth daily, [MEDICATION NAME] Sod Phos 4 mg by mouth two times daily, [MEDICATION NAME]- acetam 10-325 ([MEDICATION NAME] 10-325) 1 Tab by mouth every 6 hours PRN Pain, [MEDICATION NAME] 0.5 mg one by mouth daily and at night PRN Anxiety, [MEDICATION NAME] 500 mg by mouth twice daily, Lacosamide ([MEDICATION NAME]) 100 mg by mouth twice daily, [MEDICATION NAME] Sodium Extended ([MEDICATION NAME]) 100 mg by mouth three times daily, [MEDICATION NAME] ([MEDICATION NAME]) 100 mg by mouth twice daily for 3 days, [MEDICATION NAME] Sodium ([MEDICATION NAME]) 60 mg SQ twice daily, [MEDICATION NAME] ([MEDICATION NAME]) 20 mg by mouth daily, [MEDICATION NAME] 5 mg take by mouth every night. " Review of Resident #1 ' s Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. On the 8 AM dose for 02/26/13 an initial with a circle around it was present indicating that the dose was not given. Review of the facility incident report reflected " (Resident #1) admitted on the 25th with a significant history of [DIAGNOSES REDACTED] and subsequent [MEDICAL CONDITION] disorder. Resident was ordered [MEDICATION NAME] and [MEDICATION NAME]. Resident missed four doses of [MEDICATION NAME] due to the nurse ' s failure to obtain medicine from the pharmacy. Subsequently, resident was admitted to ICU on 02/27/13 with a [DIAGNOSES REDACTED]. " " Describe corrective or proactive actions being taken: Immediately inservice nurses on how to order medications and specifically educate on [MEDICAL CONDITION] medications. Spoke with (Physician) re: resident ' s condition and he stated that she would continue to have [MEDICAL CONDITION] due to her history of diagnoses. We will QA&A incident. Pharmacist to give inservice on ordering medications, cut off times and calling after hours and timeliness. Will do a med error report also. Counsel of admitting nurse (LVN M). " Signed by the Director of Nursing (DON). Review of the Medications Error Report dated 02/28/13 reflected " Res entered facility at 1545 (3:45PM) on the 25th (02/25/13)- failed to receive [MEDICATION NAME] on 25th (02/25/13) , two doses on the 26th (02/26/13) and one dose on the 27th (02/27/13). Res admitted to (hospital) ICU. In-serviced staff: meds; Pharmacist will do in-service on 10th; QAA; Chart Review, Counsel Staff. " Interview on 03/01/13 at 9:20 AM, the DON stated Resident #1 was admitted to the facility on [DATE] at 3:45 PM. The DON stated the resident admitted with medications orders that were faxed to the pharmacy immediately upon admission. The DON stated that the resident had received all medications prior to admission to the facility. The DON stated all of Resident #1 ' s medications except for the controlled drugs ([MEDICATION NAME] and [MEDICATION NAME]) arrived at the facility by the morning of 02/26/13. The DON stated that [MEDICATION NAME] is a " schedule V controlled drugs " and they had difficulty getting it into place because the doctor has to handwrite the triple script order on one of these medications. The DON stated that the doctor did not fax the triplicate until 9:30 PM on 02/26/13 to the pharmacy. The DON stated that " where we fell down was that my nurses should have been calling to get that medication. " The DON stated that the resident was supposed to receive twice daily doses of [MEDICATION NAME] to control [MEDICAL CONDITION] that had recently worsened while in the hospital due to an enlarging [DIAGNOSES REDACTED]. The DON stated that the resident did not receive the PM dose of the [MEDICATION NAME] on 02/25/13, The AM and PM dose of [MEDICATION NAME] on 02/26/13 and the AM dose of [MEDICATION NAME] on 02/27/13. The DON stated that the resident had a [MEDICAL CONDITION] on 02/27/13 at 10:15 AM. The DON also stated that the resident was on two other medications for [MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) and did receive these medications during the time that she did not receive the doses of [MEDICATION NAME]. Interview on 03/01/13 at 12:25 PM, Licensed Vocational Nurse (LVN) M stated that she was the nurse who admitted Resident #1 on 02/25/13. LVN M stated that after the resident admitted to the facility she verified the medication orders with the Physician, and then she faxed the orders to the pharmacy and called them 30 minutes later to confirm that they had received them. LVN M stated that the first night (2/25/13) none of the medications came in but the granddaughter said she could bring the [MEDICATION NAME] and [MEDICATION NAME] from home. LVN M stated that the next morning (2/26/13) when she came on shift (6 AM - 2 PM) she noticed that all of the residents medications were delivered that morning except for the controlled drugs ([MEDICATION NAME] and [MEDICATION NAME]). She called the pharmacy again and they said they needed a handwritten triplicate order from the Physician for the three controlled drugs. LVN M stated that she called the Physician right away to notify him that the pharmacy needed the triplicates for the [MEDICATION NAME] and other drugs. LVN M stated that the Physician stated that he was not in his office and he would fax the orders later when he could get to a fax machine. LVN M stated that the pharmacy also told her that she was not an agent for the Physician which allows her to order medications under his name. LVN M stated that she notified the DON that she was not an agent for the doctor and the DON told her that she could ask the Administrator to work on that situation. LVN M stated that she " tried and tried to get the medication in " but she was dependent on the doctor to the write the prescription. LVN M stated that she had not received any direct training from the facility on what procedure to follow to order medications and ensure that it arrived in a timely manner. Interview on 03/01/13 at 1:45 PM Medication Aide (Med Aide) C stated that she passed medications for residents on Resident #1 ' s hall on the day shift from 6AM to 2 PM on 02/26/13 and 02/27/13. Med Aide C stated that the nurse passed the medications to Resident #1 on the morning of 02/26/13. Med Aide C stated that when she tried to pass Resident #1 ' s medications on 02/27/13, the [MEDICATION NAME] medication was not in the cart. Med Aide C stated that LVN M had informed her on 02/26/13 that the [MEDICATION NAME] had not been delivered with the rest of the medications. Interview on 03/01/13 at 3:40 PM, Med Aide D stated that she worked the 2PM to 8PM shift on 02/26/13 and passed medications for Resident #1. Med Aide D stated that she noticed the [MEDICATION NAME] was not available on the medication cart and informed the nurse who informed her that she was aware of it and trying to get the medication in. Med Aide D stated that LVN M was on the phone with the pharmacy often that evening trying to get the medication in. Med Aide D stated that she left the [MEDICATION NAME] PM dose on 02/26/13 box blank without her signature on the Medication Administrator Record just in case the medication came in after she left her shift at 8 PM. Interview on 03/01/13 at 1:55 PM LVN N stated she worked the day shift (6 AM- 2PM) on 02/27/13. LVN N stated that Med Aide C passed medications that morning and Med Aide C did not inform LVN N that any medications were missing. LVN N stated that the son of Resident #1 came to get her (LVN N) around 10:50 AM to inform the nurse that Resident #1 was having a [MEDICAL CONDITION]. LVN N stated she notified the doctor and intravenous [MEDICATION NAME] was administered. LVN N stated that she then sent the resident out to the hospital following the advice of the Physician. LVN N stated that Resident #1 ' s family informed her that she had not been receiving the [MEDICATION NAME] medication since admission because the facility was having difficulty getting the medication in. LVN N stated that she called the pharmacy immediately following addressing the resident ' s symptoms. LVN N stated that the pharmacy informed her that they were out of the medication and were trying to get it in in order to have it delivered but that it was coming today with the afternoon shipment. LVN N stated that she told the pharmacy that " it was not acceptable " that the medication had not arrived yet. LVN N stated that she had not received any direct training from the facility on what procedure to follow to order medications or how to ensure it arrived in a timely manner, but had learned it over time on her own. Interview on 03/01/13 at 2:05 PM, the DON stated that LVN M could have asked one of the other nurses who are agents to assist her with ordering the medication or that she should have notified her (the DON) to ensure it was ordered from another pharmacy who could place the order sooner. The DON stated the " agent " list that the pharmacy uses to know which nurses can order medications under the doctor ' s permission is outdated and that the facility needs to update it. The DON stated she did not know how LVN M would have known which nurses were on the agent list. Interview on 03/01/13 at 2:10 PM, the Administrator stated that he knows the facility was at fault for not having the [MEDICATION NAME] medication there in a timely manner. The Administrator stated that the facility needed to update the " agent " list. The Administrator stated that they have not been keeping the " agent " list updated like they should when new nurses are hired. The Administrator stated that he would educate staff on the procedure for ordering medications and who is an agent. The Administrator stated that LVN M should have been more aggressive in trying to get the medication in and she should have notified administrative staff. Interview on 03/01/13 at 2:40 PM, the Physician stated that he was notified on 02/25/13 that Resident #1 was admitted and he verified the orders with the admitting nurse (LVN M). The Physician stated that he was notified that the facility was having trouble getting the [MEDICATION NAME] on 02/26/13 around noon. The Physician stated that the facility had trouble getting the medication because it was a controlled medication. The Physician stated no one at the facility has prescriptive authority because there has been a lot of turn over since they initiated the agent list back in 2011. The Physician stated he asked the nurse to text him the information of the medication order for [MEDICATION NAME], the nurse said she couldn ' t because the new DON wouldn ' t allow them to text that information anymore so the nurse had to fax the information. The Physician stated that he could not get to the fax until later in the evening of 02/26/13. The Physician stated that he faxed the pharmacy the triplicate order around 9 PM on 02/26/13. The Physician stated that there is no way to tell if missing the four doses of [MEDICATION NAME] was the cause of the [MEDICAL CONDITION]. The Physician stated that Resident #1 does has intractable [MEDICAL CONDITION] from her [DIAGNOSES REDACTED]. The Physician stated that the facility needs to have a plan for getting critical medications in timely when he does not have access to a fax machine. Review of the " Designated Agents " List for the consultant pharmacy company dated 02/28/13 compared to the Staffing schedules for 02/25/13- 02/26/13 reflected that one designated agent was working on 02/25/13 during the 2 PM -10 PM shift and one designated agent worked the 10 PM to 6 AM shift. On 02/26/13 one agent worked on the 6 AM- 2 PM shift, one agent worked on the 2 PM- 10 PM shift and one agent worked on the 10 PM- 6 AM shift. Review of a timeline provided by the Consultant Pharmacy for the attempts to order Resident #1 ' s [MEDICATION NAME] medication reflected " 02/25/13: (5:42 PM)- Facility faxed hospital discharge orders for (Resident #1) to pharmacy, 02/26/13: (3:08 AM) - Handwritten physician orders [REDACTED].#1) including two antiepileptic drugs ([MEDICATION NAME] and levetiracetam); (9:28 PM)- (Resident #1) ' s physician faxes valid signed prescriptions for controlled substances [MEDICATION NAME] 100 mg, [MEDICATION NAME] 10/325, and [MEDICATION NAME] 0.5 mg; 02/27/13: (9:10 AM-9:23 AM)- (Physician) refaxes the three (prescriptions) for controlled substances, sent on 1:00 PM run, received by (LVN) at (6:05 PM). Review of the Admission History and Physical from Resident #1 ' s hospital records for the hospital stay beginning 02/27/13 reflected " (Resident #1) is a [AGE] year old Caucasian female recently hospitalized from [DATE]-02/25/13, when she was discharged to (the facility) ... Briefly (Resident #1) was admitted on [DATE] after having 3 [MEDICAL CONDITION]. She was observed in the ICU without any observed [MEDICAL CONDITION]. She was transferred to the floor just prior to discharge, she went into [DIAGNOSES REDACTED] and was transferred back to the ICU and was put on propofol and Versed to control her [MEDICAL CONDITION] and was added [MEDICATION NAME] and [MEDICATION NAME] as well as [MEDICATION NAME]. She eventually was weaned off of propofol, Versed and her [MEDICAL CONDITION] were controlled. While hospitalized , she did develop an acute [MEDICAL CONDITION] in the right peroneal vein. She was discharged on [DATE] to (the facility). The granddaughter is in the room and gives the following history. (Resident #1) has not received [MEDICATION NAME] in the last 2 days because of difficulty obtaining the medication and ' she is bleeds bad ' that is what led to her beginning to seize again. In the ER, she was evaluated and found to be in status, she was evaluated by neurology, who recommended a loading dose of 2 g of [MEDICATION NAME], 1 g of [MEDICATION NAME], and 200 mg lacosamide with continuing doses 2 g b.i.d of [MEDICATION NAME], 100 mg IV q 8 hours of [MEDICATION NAME], 200 mg IV of [MEDICATION NAME] b.i.d. She is getting an EEG set up in the ER room at the time of my evaluation and will be admitted to MICU. " Review of the Inpatient Progress Note from Resident #1 ' s hospital records for the hospital stay dated 03/01/13 reflected " ...I have discussed with the neurology service the difficulty in attainting a [MEDICAL CONDITION]-free state with the patient having such a large [DIAGNOSES REDACTED]. Feeding tube to be placed today, given that the patient is anticipated to remain in drug-induced coma now for several days ... I feel it would be important that the family members gather and have a discussion as to a plan if the patient cannot remain [MEDICAL CONDITION]-free. Overall, I think the intensity of her [MEDICAL CONDITION] disorder in conjunction with her multiple disabilities has reached a level of a fatal combination. " " Diagnoses: [REDACTED]. Review of the facility ' s policy on " Ordering and Receiving Non-Controlled Medications " dated 09/2010 reflected " Policy: Medications and related products are received from the provider pharmacy on a timely basis. The nursing care center maintains accurate records of medication order and receipt. " Review of the facility ' s policy on " Ordering and Receiving Controlled Medications " dated 09/2010 reflected the following " 4. The Drug Enforcement Agency (DEA) requires that a pharmacy must have a valid prescriber signed prescription in order to dispense controlled substances. A valid written prescription requires patient name, drug name and strength, quantity to dispense, directions for use, date and signature of prescriber. In an emergency situation, verbal authorization may be given by the prescriber to the pharmacist for a new order. If unable to obtain another written prescription and provide the medication prior to the depletion of the current supply, the pharmacy will notify the nursing care center immediately. " Review of the facility ' s policy on " Controlled Substance Medication Orders " dated 09/2010 reflected " Before a controlled substance medication can be dispensed, the pharmacy must be in receipt of a clear, complete, valid prescription from a person lawfully authorized to prescribe them. The pharmacy can dispense a schedule III-V controlled substance medication after the receipt of a practitioner signed valid schedule III-V prescription (original and/or fax) or the practitioner (or his agent) speaks directly to the pharmacist providing a verbal authorized controlled substance prescription. " The DON reported 68 residents receive controlled medications.

Based on observation, interview and record review, the facility failed to ensure 1 of 9 sampled residents (Resident #4) received the necessary care and services to attain the highest practicable physical well-being. On [DATE] at approximately 6:10 am, Resident #4 was found by Certified Nurse Aide U (CNA U) with clammy skin, short of breath and vomitus on the floor. CNA U reported the residents condition to Licensed Vocational Nurse I (LVN) who administered oxygen several minutes later, but failed to take vital signs, recheck the Resident, call the physician. Resident #4 was found unresponsive at approximately 7:50 AM by the oncoming nurse (LVN G). Resident #4 was transported to a local hospital where he was pronounced dead at 8:34 AM. This resulted in an Immediate Jeopardy. The IJ was removed on [DATE] at 3:00 PM following acceptance of the Plan of Removal and verification interventions were initiated. The facility remained out of compliance at a level of actual harm that is isolated. Failure to immediately notify the physician of residents significant change of condition could result to further declined of the residents' condition due to a lack of medical intervention resulting in serious injury or death and could affect 8 residents in the facility. The findings include: After an administrative review, the surveyor reentered the facility on [DATE] obtain additional information. Review of Resident # 4's clinical record revealed a [AGE] year old male admitted to the facility on [DATE] (Saturday) and transferred to the hospital (Wednesday) [DATE]. His [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:10 PM, the following information was reported by CNA U. CNA U stated on [DATE] at 6:10 AM she checked on Resident # 4 and found him panting (short breaths), with clammy skin and emesis (vomit) on the floor. CNA U stated Resident #4 told her " I can't breathe " . CNA U stated she reported to LVN I (the night shift nurse) Resident #4 did not look good, his skin was an odd color and he could not breathe. CNA U stated, LVN I told her she had a few more residents to give insulin to and then she would check on Resident #4. CNA U stated, she asked CNA V to help her get Resident #4 cleaned up because she thought he would be sent to the hospital. CNA U stated, when they uncovered Resident #4, they saw bloody stool in his bed. CNA U stated Resident #4 told the aides " I feel like I am going to pass out " . CNA U reported, " Resident #4 stopped panting and started trembling. His head fell back and his eyes rolled back in his head. Resident #4 looked afraid and went in and out of consciousness." CNA U stated she went for help. She stated LVN I responded at 7:05 AM and administered oxygen to Resident #4. CNA U stated, she reported the bloody stools to LVN I at that time. CNA U stated LVN I left the room without getting vital signs on Resident #4. CNA U stated she and CNA V stayed in Resident #4's room putting cool rags on his forehead. CNA U stated she tried to get Resident #4's vital signs, but could not get a reading with a digital blood pressure cuff so she used a manual cuff to get a reading. CNA U stated a business office employee came to the room and said to them " are you going to stay in there all day? We need your help " . The two aides went to the dining room to help with breakfast. CNA U stated she went back to Resident #4's room approximately 7:50 AM and found him unresponsive. CNA U went to LVN G (the oncoming dayshift nurse) for help. LVN G assessed Resident #4, took his vitals and called 911. Review of the emergency room discharge summary dated [DATE] revealed Resident #4 expired at 8:34 AM. In an interview on [DATE] at 10:30 AM CNA V reported the same sequence of events as CNA U. CNA V confirmed the statements made by CNA U. In an interview on [DATE] at 6:10 AM, LVN I stated she was called to Resident #4's room by CNA U on the morning of [DATE] sometime after 6:00 AM. LVN I stated she finished what she was doing and went to Resident #4's room. LVN I stated Resident #4's respirations were up and she felt he needed Oxygen. LVN I stated she administered Oxygen without taking vital signs. LVN I stated she left the room and did not see Resident #4 again on her shift. LVN I continued to report she should have responded to CNA U's initial request to check Resident #4, should have taken vital signs when she found Resident #4 in distress and administered Oxygen and should have called the physician about Resident #4's change of condition. LVN I stated she should have given the oncoming nurse more information about Resident #4's change of condition. In an interview on [DATE] at 7:30 AM, the DON stated she expected her nurses to report change of condition to the resident's physician as soon as possible. The DON also stated, she expected her nurses to take vital signs on residents found in distress and accompany the on-coming nurse into the residents' room so both nurses know the status of the resident as they go off shift and take over the shift. In a telephone interview on [DATE] at 3:00 PM, Resident #4's physician stated he relied on the nurses to report changes in condition, such as changes experienced by Resident #4, as soon as possible. He continued to state, Resident #4 should never had been released from the hospital. The physician stated Resident #4 was discharged from the hospital a day later than expected, on a Saturday because he experienced complications after having a pacemaker installed. The physician continued to report Resident #4 was discharged from the hospital with elevated [MEDICATION NAME] levels referred to as PT- INR. (Reference: WebMD ,[DATE]: [MEDICATION NAME] is an anticoagulant medication. This means that it helps prevent clots from forming in the blood. To determine the correct dose of [MEDICATION NAME], it is necessary to have blood tests. The [MEDICATION NAME] time (PT or [MEDICATION NAME]) test is used to calculate your INR to make the appropriate adjustments in your [MEDICATION NAME] therapy.) (Reference: Clot Care.org dated January, 2004 titled, "Understanding the PT-INR test: PT stands for [MEDICATION NAME] time. It is a measure of how quickly blood clots. INR stands for International Normalized Ratio. The higher the INR is, the longer it takes your blood to clot. Your clinician will establish an appropriate target INR range for each patient and adjust your anticoagulation therapy to keep your INR in the target range. The most common INR target range for someone on [MEDICATION NAME] is between 2.0 and 4.0. An individual whose blood clots normally should have an INR of approximately 1.) The Physician stated, Resident #4's PT-INR level on [DATE], the day he was discharged from the hospital, was 23.8 and 2.46 respectively. He reported he discontinued Resident #4's [MEDICATION NAME] and ordered a recheck of the PT-INR in three days ([DATE]). The physician stated he received the rechecked lab results several hours after Resident #4 expired on [DATE] and they were at critical levels. After an administrative review, the surveyor reentered the facility on [DATE] to obtain additional information. On [DATE] at 4:45 PM, the facility Administrator and Director of Nurses (DON) were informed additional information regarding Resident #4's change of condition on [DATE] was required and the survey was extended due to the need for further investigation. On [DATE] at 5:00 PM, the Administrator provided a list of residents sent to the hospital, residents with a change of condition and any training or in-services provided to nursing over the past month. On [DATE] at 10:45 AM, review of the Licensed Vocational Nurse (LVN) I written statement and staff interviews revealed LVN I did not respond to Certified Nurse Aide (CNA) U's request for help in a timely manner, did not do a complete assessment of Resident #4 when she finally went to his room, and if she had assessed him correctly, would have seen the blood on his sheets and known there was internal bleeding. On [DATE] at 11:45 AM, the Administrator, DON and Corporate Nurse were informed of the aforementioned findings, placed the facility in " Immediately Jeopardy "(IJ) . The DON stated she had already started training her nurses on the following areas: change of condition, assessments, physician notification and change of shift reports. The DON stated, not all of the nurses had been through the training, but she would call those nurses in for interviews and training. On [DATE] at 2:00 PM the facility submitted the Plan of Removal. The Plan of Removal as submitted by the facility was as follows: Plan of Removal for Immediate Jeopardy 1. In-service training was provided on [DATE] for nursing staff in regards to notification of changes in residents' condition, assessments, and Policy and Procedure regarding notification of change in condition and assessments. 2. The DON/ADON or designee started proficiency check offs on [DATE] for Licensed Nurses. 10 of 14 staff members have been checked off at this time. The completion date for this process will be [DATE]. 3. Proficiency audits will be conducted yearly and as needed by DON/ADON or designee for nursing staff to ensure that competency is maintained by nursing staff. 4. The Nurse Aides will verbally report and change in condition of residents ' to the charge nurse. If the problem is an emergency the nurse aide will be instructed to follow the chain of command and notify the next supervisor. 5. Policy on Report shift to shift will be implemented. Nursing staff will be in-serviced by the DON/ADON or designee by [DATE]. (See attached) 6. 24 hour reports will be reviewed at stand up meetings every weekday morning. The DON/ADON or designee will review medical records of residents with changes in condition and provide interventions as appropriate. 7. Any problems/concerns will be referred to as the QA committee for review for correction with no less than 30 days. Administrator will determine when substantial compliance has been achieved and maintained. Nursing Guidelines Report Shift to Shift Equipment 1. Report Log 2. Census Report 3. Narcotics form 4. Narcotics check form 5. Narcotics Keys (ONLY TO BE RELEASED TO AND CARRIED BY LICENSED NURSES or CERTIFIED MEDICATION AIDES) NOTE: THIS GUIDELINE IS TO BE COMPLETED AT THE CHANGE OF EACH SHIFT WITHOUT EXCEPTION. 1. Verify that all staff coming on duty are present for report. 2. Report the condition of each resident. 3. List and report and elevated temperatures or abnormal vital signs and the last checked. 4. Report the last dose of any prn medication administered and effectiveness. 5. Report and condition change or follow-up on any condition change of any resident. 6. Report use of oxygen during the past shift, duration used and effectiveness. 7. Report incidents, status of residents, orders to be followed. 8. Report all equipment failure or supplies needed. 9. Report on status of staffing or following shifts(s). 10. Report status of " ALL CALLS TO PHYSICIANS. a) Why call was placed. b) Name of Resident. c) When Last call was placed. 11. Report on all medications not administered as ordered and reason. 12. Report all residents out on pass. 13. Report all physician order [REDACTED]. THE NURSE COMING ON DUTY IS TO GIVE ASSIGNMENTS TO STAFF, INCLUDING ALL SPECIAL CARE REQUIRED BY EACH RESIDENT. NURSE COMING ON DUTY AND NURSE GOING OFF DUTY ARE TO COUNT NARCOTICS AND EXCHANGE KEY WHEN COUNT IS CORRECT. In an interview on [DATE] at 1:40 PM, newly promoted Assistant Director of Nurses, LVN G stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. ADON/LVN G stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded. In an interview on [DATE] at 2:45 PM, LVN K weekend nurse, stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN K stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she now calls the DON when there is a change of condition. In an interview on [DATE] at 3:15 PM, LVN L (weekend nurse) stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN L stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she has been instructed to call the DON. LVN L stated if a resident was in distress at the end of her shift, she would go to the residents room with the on-coming nurse to ensure the new nurse was aware of the residents status. In an interview on [DATE] at 3:45 PM, LVN E (,[DATE] shift) stated she received training in September the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN E stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she has been instructed to call the DON. In an interview on [DATE] at 11:15 AM, the MDS nurse stated she fills as charge nurse sometimes, and she recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. In an interview on [DATE] at 2:00 PM, LVN I stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN I stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. Record review of the In-service training log verified the nurses had received this training on [DATE]. Interviews conducted with random residents on the following days [DATE], [DATE] and [DATE] revealed no complaints or concerns with nursing assessments or not receiving care in an emergency situation. The Administrator, DON and Corporate Nurse were informed the " Immediate Jeopardy " status was lifted at 3:00 PM [DATE]. The facility CMS 672, dated [DATE], documented a resident census of 102.

Based on interviews and record review, the facility failed to immediately consult with the physician for a change of condition for 1 of 9 ( Resident #4) residents reviewed for change of condition. On [DATE] at approximately 6:10 am, Resident #4 was found by Certified Nurse Aide U (CNA U) with clammy skin, short of breath and vomitus on the floor. CNA U reported the residents condition to Licensed Vocational Nurse I (LVN) who administered oxygen several minutes later, but failed to take vital signs, recheck the Resident, call the physician. Resident #4 was found unresponsive at approximately 7:50 AM by the oncoming nurse (LVN G). Resident #4 was transported to a local hospital where he was pronounced dead at 8:34 AM. This resulted in an Immediate Jeopardy. The IJ was removed on [DATE] at 3:00 PM following acceptance of the Plan of Removal and verification interventions were initiated. The facility remained out of compliance at a level of actual harm that is isolated. Failure to immediately notify the physician of residents significant change of condition could result to further declined of the residents' condition due to a lack of medical intervention resulting in serious injury or death and could affect 8 residents in the facility. The findings include: After an administrative review, the surveyor reentered the facility on [DATE] obtain additional information. Review of Resident # 4's clinical record revealed a [AGE] year old male admitted to the facility on [DATE] (Saturday) and transferred to the hospital (Wednesday) [DATE]. His [DIAGNOSES REDACTED]. In an interview on [DATE] at 2:10 PM, the following information was reported by CNA U. CNA U stated on [DATE] at 6:10 AM she checked on Resident # 4 and found him panting (short breaths), with clammy skin and emesis (vomit) on the floor. CNA U stated Resident #4 told her " I can't breathe " . CNA U stated she reported to LVN I (the night shift nurse) Resident #4 did not look good, his skin was an odd color and he could not breathe. CNA U stated, LVN I told her she had a few more residents to give insulin to and then she would check on Resident #4. CNA U stated, she asked CNA V to help her get Resident #4 cleaned up because she thought he would be sent to the hospital. CNA U stated, when they uncovered Resident #4, they saw bloody stool in his bed. CNA U stated Resident #4 told the aides " I feel like I am going to pass out " . CNA U reported, " Resident #4 stopped panting and started trembling. His head fell back and his eyes rolled back in his head. Resident #4 looked afraid and went in and out of consciousness." CNA U stated she went for help. She stated LVN I responded at 7:05 AM and administered oxygen to Resident #4. CNA U stated, she reported the bloody stools to LVN I at that time. CNA U stated LVN I left the room without getting vital signs on Resident #4. CNA U stated she and CNA V stayed in Resident #4's room putting cool rags on his forehead. CNA U stated she tried to get Resident #4's vital signs, but could not get a reading with a digital blood pressure cuff so she used a manual cuff to get a reading. CNA U stated a business office employee came to the room and said to them " are you going to stay in there all day? We need your help " . The two aides went to the dining room to help with breakfast. CNA U stated she went back to Resident #4's room approximately 7:50 AM and found him unresponsive. CNA U went to LVN G (the oncoming dayshift nurse) for help. LVN G assessed Resident #4, took his vitals and called 911. Review of the emergency room discharge summary dated [DATE] revealed Resident #4 expired at 8:34 AM. In an interview on [DATE] at 10:30 AM CNA V reported the same sequence of events as CNA U. CNA V confirmed the statements made by CNA U. In an interview on [DATE] at 6:10 AM, LVN I stated she was called to Resident #4's room by CNA U on the morning of [DATE] sometime after 6:00 AM. LVN I stated she finished what she was doing and went to Resident #4's room. LVN I stated Resident #4's respirations were up and she felt he needed Oxygen. LVN I stated she administered Oxygen without taking vital signs. LVN I stated she left the room and did not see Resident #4 again on her shift. LVN I continued to report she should have responded to CNA U's initial request to check Resident #4, should have taken vital signs when she found Resident #4 in distress and administered Oxygen and should have called the physician about Resident #4's change of condition. LVN I stated she should have given the oncoming nurse more information about Resident #4's change of condition. In an interview on [DATE] at 7:30 AM, the DON stated she expected her nurses to report change of condition to the resident's physician as soon as possible. The DON also stated, she expected her nurses to take vital signs on residents found in distress and accompany the on-coming nurse into the residents' room so both nurses know the status of the resident as they go off shift and take over the shift. In a telephone interview on [DATE] at 3:00 PM, Resident #4's physician stated he relied on the nurses to report changes in condition, such as changes experienced by Resident #4, as soon as possible. He continued to state, Resident #4 should never had been released from the hospital. The physician stated Resident #4 was discharged from the hospital a day later than expected, on a Saturday because he experienced complications after having a pacemaker installed. The physician continued to report Resident #4 was discharged from the hospital with elevated [MEDICATION NAME] levels referred to as PT- INR. (Reference: WebMD ,[DATE]: [MEDICATION NAME] is an anticoagulant medication. This means that it helps prevent clots from forming in the blood. To determine the correct dose of [MEDICATION NAME], it is necessary to have blood tests. The [MEDICATION NAME] time (PT or [MEDICATION NAME]) test is used to calculate your INR to make the appropriate adjustments in your [MEDICATION NAME] therapy.) (Reference: Clot Care.org dated January, 2004 titled, "Understanding the PT-INR test: PT stands for [MEDICATION NAME] time. It is a measure of how quickly blood clots. INR stands for International Normalized Ratio. The higher the INR is, the longer it takes your blood to clot. Your clinician will establish an appropriate target INR range for each patient and adjust your anticoagulation therapy to keep your INR in the target range. The most common INR target range for someone on [MEDICATION NAME] is between 2.0 and 4.0. An individual whose blood clots normally should have an INR of approximately 1.) The Physician stated, Resident #4's PT-INR level on [DATE], the day he was discharged from the hospital, was 23.8 and 2.46 respectively. He reported he discontinued Resident #4's [MEDICATION NAME] and ordered a recheck of the PT-INR in three days ([DATE]). The physician stated he received the rechecked lab results several hours after Resident #4 expired on [DATE] and they were at critical levels. After an administrative review, the surveyor reentered the facility on [DATE] to obtain additional information. On [DATE] at 4:45 PM, the facility Administrator and Director of Nurses (DON) were informed additional information regarding Resident #4's change of condition on [DATE] was required and the survey was extended due to the need for further investigation. On [DATE] at 5:00 PM, the Administrator provided a list of residents sent to the hospital, residents with a change of condition and any training or in-services provided to nursing over the past month. On [DATE] at 10:45 AM, review of the Licensed Vocational Nurse (LVN) I written statement and staff interviews revealed LVN I did not respond to Certified Nurse Aide (CNA) U's request for help in a timely manner, did not do a complete assessment of Resident #4 when she finally went to his room, and if she had assessed him correctly, would have seen the blood on his sheets and known there was internal bleeding. On [DATE] at 11:45 AM, the Administrator, DON and Corporate Nurse were informed of the aforementioned findings, placed the facility in " Immediately Jeopardy "(IJ) . The DON stated she had already started training her nurses on the following areas: change of condition, assessments, physician notification and change of shift reports. The DON stated, not all of the nurses had been through the training, but she would call those nurses in for interviews and training. On [DATE] at 2:00 PM the facility submitted the Plan of Removal. The Plan of Removal as submitted by the facility was as follows: Plan of Removal for Immediate Jeopardy 1. In-service training was provided on [DATE] for nursing staff in regards to notification of changes in residents' condition, assessments, and Policy and Procedure regarding notification of change in condition and assessments. 2. The DON/ADON or designee started proficiency check offs on [DATE] for Licensed Nurses. 10 of 14 staff members have been checked off at this time. The completion date for this process will be [DATE]. 3. Proficiency audits will be conducted yearly and as needed by DON/ADON or designee for nursing staff to ensure that competency is maintained by nursing staff. 4. The Nurse Aides will verbally report and change in condition of residents ' to the charge nurse. If the problem is an emergency the nurse aide will be instructed to follow the chain of command and notify the next supervisor. 5. Policy on Report shift to shift will be implemented. Nursing staff will be in-serviced by the DON/ADON or designee by [DATE]. (See attached) 6. 24 hour reports will be reviewed at stand up meetings every weekday morning. The DON/ADON or designee will review medical records of residents with changes in condition and provide interventions as appropriate. 7. Any problems/concerns will be referred to as the QA committee for review for correction with no less than 30 days. Administrator will determine when substantial compliance has been achieved and maintained. Nursing Guidelines Report Shift to Shift Equipment 1. Report Log 2. Census Report 3. Narcotics form 4. Narcotics check form 5. Narcotics Keys (ONLY TO BE RELEASED TO AND CARRIED BY LICENSED NURSES or CERTIFIED MEDICATION AIDES) NOTE: THIS GUIDELINE IS TO BE COMPLETED AT THE CHANGE OF EACH SHIFT WITHOUT EXCEPTION. 1. Verify that all staff coming on duty are present for report. 2. Report the condition of each resident. 3. List and report and elevated temperatures or abnormal vital signs and the last checked. 4. Report the last dose of any prn medication administered and effectiveness. 5. Report and condition change or follow-up on any condition change of any resident. 6. Report use of oxygen during the past shift, duration used and effectiveness. 7. Report incidents, status of residents, orders to be followed. 8. Report all equipment failure or supplies needed. 9. Report on status of staffing or following shifts(s). 10. Report status of " ALL CALLS TO PHYSICIANS. a) Why call was placed. b) Name of Resident. c) When Last call was placed. 11. Report on all medications not administered as ordered and reason. 12. Report all residents out on pass. 13. Report all physician order [REDACTED]. THE NURSE COMING ON DUTY IS TO GIVE ASSIGNMENTS TO STAFF, INCLUDING ALL SPECIAL CARE REQUIRED BY EACH RESIDENT. NURSE COMING ON DUTY AND NURSE GOING OFF DUTY ARE TO COUNT NARCOTICS AND EXCHANGE KEY WHEN COUNT IS CORRECT. In an interview on [DATE] at 1:40 PM, newly promoted Assistant Director of Nurses, LVN G stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. ADON/LVN G stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded. In an interview on [DATE] at 2:45 PM, LVN K weekend nurse, stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN K stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she now calls the DON when there is a change of condition. In an interview on [DATE] at 3:15 PM, LVN L (weekend nurse) stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN L stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she has been instructed to call the DON. LVN L stated if a resident was in distress at the end of her shift, she would go to the residents room with the on-coming nurse to ensure the new nurse was aware of the residents status. In an interview on [DATE] at 3:45 PM, LVN E (,[DATE] shift) stated she received training in September the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN E stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. She also stated she has been instructed to call the DON. In an interview on [DATE] at 11:15 AM, the MDS nurse stated she fills as charge nurse sometimes, and she recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. In an interview on [DATE] at 2:00 PM, LVN I stated she had recently received training in the following areas: change of condition, assessments, physician notification and change of shift reporting. LVN I stated if a resident has a change, she takes vitals, completes a full assessment, calls the doctor and reports her findings, what she found, what she did and how the resident responded to the treatment. Record review of the In-service training log verified the nurses had received this training on [DATE]. Interviews conducted with random residents on the following days [DATE], [DATE] and [DATE] revealed no complaints or concerns with nursing assessments or not receiving care in an emergency situation. The Administrator, DON and Corporate Nurse were informed the " Immediate Jeopardy " status was lifted at 3:00 PM [DATE]. The facility CMS 672, dated [DATE], documented a resident census of 102.