Every finding on record at Avir at The Meadow

Based on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable for 1 (Resident #1) of 5 resident rooms on the 200 Hall reviewed for safe, clean, and homelike environment.The facility failed to ensure the door handle on Resident #1's room door was working properly on 07/27/26.The facility failed to ensure the outlet cover on the wall in Resident #1's room was not bent on 07/27/26.The facility failed to ensure the hole in the wall between Resident #1's room and bathroom areas was sealed on 07/27/26.The facility failed to ensure the floor threshold between the hallway and the entryway of Resident #1's room was sealed and covered on 07/27/26.These failures place residents at risk for a diminished quality of life, infection, and clean homelike environment.Findings included:Record review of Resident #1's Face Sheet, dated 07/27/26, reflected a [AGE] year old female admitted [DATE] and readmitted on [DATE], with diagnoses including: chronic obstructive pulmonary disease (COPD) (a long-lasting lung condition, mainly including emphysema and chronic bronchitis, that causes swelling and blocks airflow), atelectasis (partial or complete collapse of a lung or a small area of air sacs (alveoli), commonly caused by general anesthesia, blocked airways, or external pressure), candidal cystitis and urethritis (fungal infections or inflammations of the bladder and urethra caused by Candida (yeast) species), PTSD (a mental health condition that can develop after you experience or witness a very scary or harmful event), anxiety (the body's natural response to stress, characterized by feelings of fear, dread, and uneasiness), and dementia (a decline in mental abilities severe enough to interfere with daily life).Record review of Resident #1's Quarterly MDS assessment, dated 06/19/2026, reflected a BIMS score of 15 which indicated no cognitive impairment. In Section GG - Functional Abilities of the MDS Assessment for Resident #1, Section GG0120. Mobility Devices, revealed Resident #1 required a walker for assistance walking. In Section J. Health Conditions, revealed Resident #1 had 1 fall since admission to the facility.Record review of Resident #1's Care Plan, dated 06/15/2026, reflected:Focus: Risk for Injury: Fall Occurred 6/12/26 resident stated she was pushed by spouse.Date Initiated: 06/15/2026Revision on: 06/16/2026Goal: Resident will be free of further Falls.Date Initiated: 06/16/2026Target Date: 09/18/2026Interventions/Tasks: .Assess Resident and identify any injuries from fall.Date Initiated: 06/16/2026 Determine and address causative factors of the fall.Date Initiated: 06/16/2026 Follow facility post-fall policy.Date Initiated: 06/16/2026[Resident #1] impaired cognitive function r/t dementia in other diseases classified elsewhere, moderate, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. During an observation on 07/27/2026 at 10:45 AM, Resident #1 was observed entering her room with a walker. Resident #1 was observed to have some difficulty opening the door to her room due to the lock on the door not working properly. Resident #1 was observed having some difficulty entering her room with her walker due to the floor threshold between the hallway and the entryway of Resident #1's room not being sealed and covered, which caused the floor to be uneven.During an observation of Resident #1's room on 07/27/26 at 10:47 AM, revealed that the door handle was not working properly. There was a hole beside the door handle, which allowed no privacy for Resident #1. The threshold between the hallway and the entryway of Resident #1's room was not sealed, which made the floor uneven in the entryway. The outlet cover on the wall in Resident #1's room was bent with exposed wires. There was a hole in the wall in Resident #1's room in between the room and bathroom areas.During an interview with Resident #1 on 07/27/26 at 10:54 AM, she stated she had been at the facility for 5 years. Resident #1 stated she had requested several times to have the door handle properly fixed on her door. Resident #1 stated she did not have any privacy due to the hole being on her door handle, which allowed anyone who was in the hallway to look into her room. Resident #1 stated she could not use the outlet on the wall to plug anything up because the outlet cover was bent and she did not want to put anything into the outlet because she was scared, she may be electrocuted or shocked. Resident #1 stated she also requested to have the hole in the wall in between her room and bathroom repaired because she did not want any water or anything like pests and bugs to enter or exit her room due to there being a hole in the wall. Resident #1 stated she told staff and maintenance personnel about the door and the bent outlet, but they have not been repaired them. Resident #1 stated it was difficult sometimes to enter her room because the door was not working properly and the threshold in the entryway not being leveled. Resident #1 stated she used a walker for assistance and used oxygen and did not want to have any unnecessary falls due to the door not working properly and the floor being uneven. Resident #1 stated she had not had any falls due to the door not working properly and the floor being uneven. Resident #1 stated she wanted to have the repairs done in her room to prevent any falls and safety. Resident #1 stated she could not recall the first time she spoke with staff and requested the maintenance issues in her room to be repaired. Resident #1 stated she could not recall the last time she spoke with staff and requested the maintenance issues in her room to be repaired but stated it was recently.During an interview on 07/27/26 at 11:54 AM with CNA A, she stated she had been employed at the facility for 3 years. CNA A stated that she was assigned to the 200 Hall on 07/27/26. CNA A stated she had been in Resident #1's room to perform care on the resident on several occasions. CNA A stated she was unaware that the door handle on Resident #1's room was not working properly and there was a hole beside the door handle. CNA A stated she did not notice the outlet cover on the wall in Resident #1's room was bent. CNA A stated she was unaware of the hole in the wall in Resident #1's room on the wall adjacent to the bathroom. CNA A stated she was unaware that the threshold between the hallway and the entry door of Resident #1's room was uneven. CNA A stated she did not know about the hole in the wall between Resident #1's room and bathroom areas. CNA A stated Resident #1 had not mentioned any of the maintenance repair issues needed for her room. CNA A stated if she noticed any of the maintenance issues, she would immediately report the issues to her Nurse. CNA A stated the QRC Code at the Nurses Station was used to make a Maintenance Request to have the issues addressed. CNA A stated the risk of the outlet cover in Resident #1's room not being repaired is the outlet is exposed, which made the wires visible, and someone could be electrocuted if they inserted their hands or an object in the exposed wires. CNA A stated there was a risk of resident safety with there being a hole in Resident #1's door handle. CNA A stated there was a potential of harm to Resident #1 being harmed by there being a hole on her door handle because someone could peek in the hole and look at the resident. CNA A stated there was a risk for Resident #1 to have a fall if the floor was uneven, which could cause her to have a serious fall with injuries. CNA A stated with the hole in Resident #1's wall between the bathroom and room areas was that the open areas there was a potential for pests and rodents to enter or exit the residents room and bathroom areas.During an interview on 07/27/26 at 12:16 PM with LVN B, she stated she was employed at the facility as a PRN Nurse (a licensed nurse who works on an as-needed, flexible schedule rather than a traditional full-time or part-time routine). LVN B stated that she was assigned to the 200 Hall on 07/27/26. LVN B stated she had been in Resident #1's room on several occasions. LVN B stated she was unaware that the door handle on Resident #1's room was not working properly and there was a hole beside the door handle. LVN B stated she did not notice the outlet cover on the wall in Resident #1's room was bent. LVN B stated she was unaware of the hole in the wall in Resident #1's room on the wall adjacent to the bathroom. LVN B stated she was unaware that the threshold between the hallway and the entry door of Resident #1's room was uneven. LVN B stated she did not know about the hole in the wall between Resident #1's room and bathroom areas. LVN B stated Resident #1 had not mentioned any of the maintenance repair issues needed for her room. LVN B stated if she noticed any of the maintenance issues, she would immediately use the QRC Code at the Nurses Station to make a Maintenance Request to have the issues addressed. LVN B stated there were no potential risks or harm associated with any of the maintenance issues reported to her about Resident #1's room.During an interview on 07/27/26 at 12:37 PM, the Maintenance Director stated he had been employed at the facility for 7 months. He stated that the facility did not have Maintenance Repair Logs at the Nurses' Station. He stated all staff utilized TELS for Maintenance Repairs or Requests. He stated if staff needed any repairs to be done in a resident's room, they were to scan the TELS QRC posted at each Nurses' Station and they were to complete the Maintenance Request. He stated he would log into TELS several times a day to check on Maintenance Repair Requests that were submitted by staff. The Maintenance Director stated after he received the Maintenance Request from Staff, he then would mentally add the Maintenance Repair or Request. He stated he did not have any physical Maintenance Repair Logs. He stated he could not recall there being any Maintenance Repair Requests for Resident #1's room in TELS. He stated he was aware of the maintenance issues in Resident #1's room but could not recall how he was made aware of the Maintenance Repairs needed for the resident's room. The Maintenance Director stated he was unaware that the door handle on Resident #1's room was not working properly and there was a hole beside the door handle. He stated on his previous visit to Resident #1's room, he did not notice the outlet cover on the wall in Resident #1's room was bent. He stated he was unaware of the hole in the wall in Resident #1's room on the wall adjacent to the bathroom. He stated he was unaware that the threshold between the hallway and the entry door of Resident #1's room was uneven. The Maintenance Director stated he did not know about the hole in the wall between Resident #1's room and bathroom areas. He stated Resident #1 had not mentioned any of the maintenance repair issues needed for her room. He stated that he would have an In-Service Training with the staff to ensure that all staff were on the same page on completing a Maintenance Request in TELS. He stated that the risk of the hole on Resident #1's door beside her handle was that her or someone else's finger(s) or hand could get stuck in there causing an injury. He stated the risk of the bent outlet cover in Resident #1's room was that the wires were exposed. He stated the exposed wires behind the outlet cover could cause someone to cut and/or electrocute themselves if they touch the wire or get any liquid on the exposed wires. The Maintenance Director stated that the hole in Resident #1's room between the wall and bathroom wires, there was a potential for someone to be curious and put their hands in the hole. He stated with there being a hole in the wall, there was potential for insect activity and anything could come from the toilet and enter the residents room through the hole. The Maintenance Director stated that due to Resident #1 having a walker, there was a potential hazard for her to have a fall with injuries due to the floor being uneven, Record Review of the facility's Grievance Logs for April 2026 - July 2026 revealed no concerns regarding the maintenance repairs needed for Resident #1's room. Record review of the facility's Accident/Incident logs from April 2026 - July 2026 revealed, Resident #1 had a fall on 06/12/2026 without any injuries. Record Review of the facility's policy revised December 2009, for Maintenance Service, revealed: Policy Statement:Maintenance service shall be provided to all areas of the building, grounds, and equipment.Policy Interpretation and Implementation:1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times.2. Functions of maintenance personnel include, but are not limited to: a. maintaining the building in compliance with current federal, state, and local laws, regulations, and guidelines. b. maintaining the building in good repair and free from hazards. d. maintaining the., wiring, etc., in good working order. f. establishing priorities in providing repair service. h. maintaining the grounds, sidewalks, parking lots, etc., in good order. i. providing routinely scheduled maintenance service to all areas. j. others that may become necessary or appropriate.3. The maintenance director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.8. The maintenance director is responsible for maintaining the following records/reports. k. Inspection of building; l. Work order requests; .10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. Record Review of facility's policy revised February 2021, for Resident Rights, revealed: Policy Statement:Employees shall treat all residents with kindness, respect, and dignity.Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: a. a dignified existence; b. be treated with respect, kindness, and dignity; c. be free from abuse, neglect. g. exercise his or her rights as a resident of the facility and as a resident . h. be supported by the facility in exercising his or her rights; i. exercise his or her rights without interference, coercion, discrimination or reprisal from the facility;. u. voice grievances to the facility .without discrimination or reprisal and without fear of discrimination or reprisal; v. have the facility respond to his or her grievances;.

Based on observation, interview, and record review, the facility failed to maintain a homelike environment by ensuring that 2 residents (Resident #2, and Resident #3) bedroom received the housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #2, and Resident #3) of 8 residents reviewed for physical environment.The facility failed on 06/12/26 to remove the food on the floor from the dinner meal served on 06/11/26 in 2 residents room.This failure could place residents at risk for diminished quality of life due to unsafe, unclean, unhealthy, and unhomelike living conditionsFindings included:During an observation on 06/12/26 at 10:42 A.M., there were chicken strips and dried green peas on the floor underneath Resident #2's bed. There were also chicken strips and dried green peas on the floor between Resident #2's and Resident #3's beds. During an observation on 06/12/26 at 11:48 A.M., there were chicken strips and dried green peas on the floor underneath Resident #2's bed. There were also chicken strips and dried green peas on the floor between Resident #2's and Resident #3's beds. During an observation on 06/12/26 at 12:17 P.M., there were chicken strips and dried green peas on the floor underneath Resident #2's bed. There were also chicken strips and dried green peas on the floor between Resident #2's and Resident #3's beds. Record review of Resident #2's Face Sheet, dated 06/12/24, reflected a [AGE] year old female admitted [DATE] with diagnoses including Parkinson's disease without dyskinesia (the early-to-mid stages of the condition or presentations where involuntary writhing movements have not developed), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), dementia (a decline in mental ability severe enough to interfere with daily life), encephalopathy (any disease, damage, or malfunction that affects the brain's structure or function), and anxiety (the body's natural response to stress, characterized by feelings of fear, dread, and uneasiness). Record review of Resident #2's Quarterly MDS assessment, dated 04/30/2026, reflected a BIMS score of 00 which indicated severe cognitive impairment, which suggested Resident #2 was unable to recall simple words, state the current month, year, or day, and may have given nonsensical or no responses. In Section GG - Functional Abilities of the MDS Assessment for Resident #2, Section A. Eating: The ability to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal is placed before the resident, was coded 5. Code 5 stated Resident #2 required ADL assistance with Setup or Clean-Up assistance meals. Setup or Clean-up assistance required Helper to set up and clean up; resident completed activity. Helper assisted only prior to or following the activity. Record review of Resident #2's Care Plan, dated 04/29/2026, reflected:Focus:[Resident #2] has potential nutritional problem r/t impaired cognition.Diet: Regular diet Regular texture, Regular consistency.Date Initiated: 04/29/2026Revision on: 05/14/2026 Focus: [Resident #2] has an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Impaired balanceDate Initiated: 04/29/2026Revision on: 05/14/2026 Goals: [Resident #2] will maintain and or improve current level of function In (ADLs) through the review date.Date Initiated: 04/29/2026Revision on: 05/14/2026Target Date: 08/07/2026 Intervention/Tasks:EATING: The resident requires set up/clean up assist x1 staff to eat.Date Initiated: 04/29/2026Revision on: 05/14/2026 Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function.Date Initiated: 04/29/2026Record review of Resident #3's Face Sheet, dated 06/12/2026, reflected a [AGE] year-old female admitted [DATE] and readmitted on [DATE] with diagnoses including systolic (congestive) heart failure, dementia (a decline in mental ability severe enough to interfere with daily life), Alzheimer's disease (a progressive, irreversible brain disorder that slowly destroys memory, thinking skills, and the ability to carry out simple tasks), stage 3 kidney disease (kidneys have moderate damage and are functioning at 30% to 59% of their normal capacity), cerebral infarction (stroke) and oropharyngeal dysphagia (difficulty transferring food or liquid from the mouth into the throat and esophagus). Record review of Resident #3's Quarterly MDS assessment, dated 05/19/2026, reflected a BIMS score of 3, indicating severe cognitive impairment, which suggested Resident #3 may need extra assistance with daily activities and/or specific tasks and may be in cognitive decline. The MDS Assessment reflected [Resident #3] was independent and did not require assistance eating. Record review of Resident #3's Care Plan, printed 06/12/26, reflected: Focus: [Resident #3] had the potential nutritional problem r/t protein calorie malnutrition and dysphagia. Goals:The resident will comply with recommended diet for weight reduction daily through review date. The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern,altered cardiac output, diabetes, impaired mobility through review date. Interventions/Tasks: Explain and reinforce to the resident the importance of maintaining the diet ordered. Encourage the resident to comply. Explain consequences of refusal, obesity/malnutrition risk factors. Monitor/document/report PRN any s/sx of dysphagia: pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Focus: [Resident #3] was dependent on staff etc. for meeting emotional, intellectual, physical, and social needs r/t Cognitive deficits. Goals: [Resident #3] will maintain involvement in cognitive stimulation, social activities as desired through review date. Interventions/Tasks: EATING: The resident is able to feed self. Focus:[Resident #3] had a Cerebrovascular Accident (CVA) - commonly known as stroke, which occurred when blood flow to a part of the brain was interrupted or reduced, depriving brain tissue of oxygen and nutrients. Goals: The resident will show improvement to maximum potential to perform ADL's by review date. The resident will show improvement to maximum potential with mobility and cognition by review date. Interventions/Tasks: Monitor intake to assure an adequate fluid intake to prevent dehydration. If resident is able to eat, make sure diet is the correct consistency to facilitate safe swallowing. If resident is unable to swallow, give enteral feeding as ordered by the physician. Monitor/document ability to chew and swallow. If resident is presenting with problems, obtain order for Speech therapy to evaluate and treat. During an interview on 06/12/26 at 11:25 A.M., Resident #2 said she did not know how long the food (chicken strips and green peas) observed in her room on 06/12/26 was on the floor in her room. Resident #2 was unable to provide any further information during her interview due to her medical diagnoses. During an interview on 06/12/26 at 11:29 A.M., Resident #2 said she did not know how long the food (chicken strips and green peas) observed in her room on 06/12/26 was on the floor in her room. Resident #3 was unable to provide any further information during her interview due to her medical diagnoses. During an interview on 06/12/26 at 3:07 PM, the Administrator said he had been employed at the facility for 6 years. The Administrator stated he was unaware there was food from the dinner meal on 06/11/26 observed on the floor in Resident #2's and Resident #3's room on 06/12/26. The Administrator stated there was 1 Housekeeper assigned daily to clean the facility's Memory Care Unit. He stated [Housekeeper C] was assigned to the facility's Memory Care Unit. The Administrator stated he was not sure of [Housekeeper C's] work schedule. The Administrator stated the Maintenance Director was the current Interim Housekeeping Supervisor. He stated staff assigned to the 2nd shift (2 PM - 10 PM), 3rd shift (10 PM - 6 AM) in the facility's Memory Care Unit on 06/11/26 should have done rounds every 2 hours, or as needed, and noticed the food on the floor in Resident #2's and Resident #3's room. He stated staff on the 1st shift (6 A.M. - 2 PM) in the facility's Memory Care Unit on 06/11/26 should have done rounds every 2 hours, or as needed, and noticed the food on the floor in Resident #2's and Resident #3's room. He stated a staff member from the 3 shifts should have noticed and cleaned up the food from the floor in Resident #2's and Resident #3' room during their rounds. He stated he would meet with the DON to reeducate staff via In-Service Training on Housekeeping and ensuring the residents' rooms were clean. The Administrator stated he did not feel there was any potential of risk and harm to anyone including Resident #2 and Resident #3 due to there being food on the floor in the residents room. The Administrator stated the facility did not have any policies on Housekeeping and resident rooms. During an attempted telephone interview on 06/12/26 at 3:30 p.m., Housekeeper C did not answer. During an interview on 06/12/26 at 3:31 PM, the Maintenance Director stated he had been employed at the facility for 6 months. He stated he was the Interim Housekeeping Supervisor since the beginning of May 2026. The Maintenance Director stated he had 5 staff members in the Housekeeping Department. He stated there was 1 Housekeeper assigned to the Memory Care Unit where Resident #2 and Resident #3 resided. He stated Houskeeper C was assigned full time to the Memory Care Unit. He stated staff in the facility's Memory Care Unit were responsible for cleaning the debris and trash on the floor in the residents rooms after Housekeeper C completed her shifts. He stated he was unaware that food (chicken strips and green peas) from the dinner meal served on 06/11/26 was observed on the floor on 06/12/26 in Resident #2's and Resident #3's room. The Maintenance Director stated if the food was missed by staff in the facility's Memory Care Unit resided, Housekeeper C would have cleaned the food from the floor during her shift on 06/12/26. He stated the risk of food on the floor in the residents' rooms included a tripping hazard, falls, cross contamination, if someone picked up the food from the floor and ate it, and a choking hazard. He stated harm could be caused if someone picked up the food and ingested it and they had food allergies to the food they ingested. During an interview on 06/12/26 at 3:45 PM, CNA A stated she had been employed at the facility for 1 year. CNA A stated on 06/12/26 she was assigned to the facility's Memory Care Unit where Resident #2 and Resident #3 resided. CNA A stated she was unaware there was food (chicken strips and green peas) from the dinner meal on 06/11/26 observed on the floor in Resident #2's and Resident #3's room on 06/12/26. CNA A stated if she observed food on the floor in a resident's room, she would have immediately picked up the food from the floor by sweeping the floor. She stated she would then mop the floor to ensure the floor was clean. CNA A stated the risk to a resident due food on the floor was infection, due to someone ingested the food which was unhealthy, unclean and unsanitary. CNA A stated harm could be caused to anyone who ingested food from the floor by aspiration (choking). During an interview on 06/12/26 at 3:55 PM, CNA B stated he had been employed at the facility for 1 week. CNA B stated on 06/12/26 he was assigned to the facility's Memory Care Unit. CNA B stated he was unaware there was food (chicken strips and green peas) from the dinner meal on 06/11/26. observed on the floor in Resident #2s and Resident #3's room on 06/12/26. CNA B stated he did a walkthrough of all the rooms in the Memory Care Unit at the beginning of his shift. CNA B stated if he observed food on the floor in a residents room, he would have immediately removed the food and cleaned the floor. CNA B stated after he removed the food from the floor, he would immediately notify the Housekeeping Department and notify them the resident's floor needed a deep clean since there had been food on the floor. CNA B stated if the situation occurred after the Housekeeping Department's working hours, he would mop the floor himself. CNA B stated the Housekeeping Department cleaned the rooms in the facility's Memory Care Unit at least once a day. CNA B stated food on a resident's floor was a potential risk for anyone to pick up the food and ingest it. CNA B stated someone who was on a specialized diet, such as mechanical or pureed, could pick up the food from the floor and ingest the food and experience aspiration (choking). CNA B stated there was a potential for infection due to the ingestion of food on the floor being unhealthy and unsanitary. CNA B stated harm could be caused to anyone who ingested food from the floor. CNA B stated the harm caused would be bacterial and stomach issues. During an interview on 06/12/26 at 4:41 PM, the Dietary Manager stated the dinner meal served to residents on 06/11/26 was chicken strips w/ cream gravy, oven browned potatoes, smothered green peas, Texas toast, margarine, ice cream, milk, and beverage (water, tea). Record review of the posted Mealtimes in the facility's Dining Room revealed, Breakfast - 7:30 AM, Lunch - 11:30 AM, Dinner - 4:30 PM. Record review on 06/12/26 at 4:47 PM, revealed a posted sign on the wall in the facility's Dining Room with the Food Menus, which included the Dinner Meal on 06/11/2026. The Dinner Meal on 06/11/26 served from the facility's kitchen to residents included: chicken strips w/ cream gravy, Oven browned potatoes, Smothered [NAME] Peas, Texas Toast, Margarine, Ice Cream, Milk, Beverage (water, tea). Record review of the facility's policy, Resident Rights, dated 2001 and revised February 2021, reflected: Policy Statement:Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation:1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect.g. exercise his or her rights as a resident of the facility and as a resident or citizen of the United States;h. be supported by the facility in exercising his or her rights;.x. communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter;.jj. equal access to quality care.4. Orientation and in-service training programs are conducted quarterly to assist our employees in understanding our residents' rights.

Based on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #85 and Resident#9) reviewed for catheter care. The facility failed to ensure Resident #85 and Resident #9's catheters were not secured with a Stat Lock (used to secure catheters to patients inner thigh) or leg strap. This failure could place residents at risk of urethral tears or dislodging the catheter.Record review of Resident #85's quarterly MDS assessment, dated 01/30/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-entry of 01/24/2026. Her BIMs score was 12, which indicated moderate cognitive impairment. Her diagnosis included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it). Section H-Bowel and Bladder reflected the resident was coded to have indwelling catheter. Record review of Resident #85 's care plans, dated 06/30/25, reflected: The resident requires a suprapubic catheter (a thin, indwelling tube inserted through the lower abdomen into the bladder to drain urine), R/T neuromuscular dysfunction (disorders affecting the nerves controlling voluntary muscles and the muscles themselves, causing breakdown in communication) of bladder associated with Multiple Sclerosis (.a chronic autoimmune disease of the central nervous system where the immune system attacks the protective myelin sheath surrounding nerves, causing communication issues between the brain and body). She is at risk for complications such as catheter related trauma and infections. Facility interventions included: Do not allow tubing or any part of the drainage system to touch the floor. Record review of Resident #85 's active orders, dated 03/04/26, reflected: Suprapubic catheter care Q shift and PRN every 8 hours as needed Every shift as needed. Order start dated 02/23/2026. Suprapubic catheter care Q shift and PRN every shift order start date 02/23/2026. Suprapubic catheter Dx: Neuromuscular Dysfunction of Bladder, Unspecified order started date 02/23/2026. During an observation on 03/04/26 at 1:30 PM revealed Resident #85's indwelling catheter was not secured with a stat lock or leg strap. 2. Record review of Resident #9's quarterly MDS assessment, dated 02/09/26, reflected a [AGE] year-old female originally admitted to the facility on [DATE]. Her BIMs score was 08, which indicated his cognitive status was moderately impaired. Her diagnoses included hypertension (high blood pressure). Section H-Bowel and Bladder H0100 resident was not coded to have indwelling catheter. Section M -M0300 skin Conditions reflected Resident #9 was not coded to have current pressure ulcer. Record review of Resident #9's active care plan reflected no care plan problem goals, or intervention related to the resident's Indwelling catheter. Record review of Resident #9's active physician orders, dated 03/04/26, reflected: Flush foley with 60cc NS as needed obstruction/occluded: start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/04/26, reflected Foley catheter 18french/10ml balloon dx: wound healing as needed for leakage, blockage, and sedimentation may change foley catheter start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/04/26, reflected Foley catheter 18french/10ml balloon dx: wound healing every shift for wound healing monitor leg strap placement start date 01/09/2026. During an observation on 03/04/26 at 1:40 PM revealed Resident #9's indwelling catheter was not secured with a stat lock or leg strap. During an interview on 03/04/26 at 1:43 PM with LVN A revealed she was Resident #85's and Resident #9's nurse. She stated she always checked to make sure the indwelling catheter was secured to the resident's inner thigh when doing her daily assessments. She stated the indwelling catheters should always be secured with a stat lock or leg strap to the resident's inner thigh. She stated the risk to the resident was pulling or dislodgement of the indwelling catheter. She stated she was in serviced on foley catheter care. During an interview on 03/04/25 at 1:57 PM with CNA J revealed if the resident's stat lock came off, she would notify the nurse. She stated the risk to the resident was the catheter would cause injury to the resident if it pulled and dislodged. She stated she was in serviced on catheter care. During an interview on 03/04/25 at 1:57 PM with CNA G revealed she was assigned to Resident#85. She stated she did not know the foley catheter was supposed to be secured with a device to prevent it from moving. She stated she made sure the catheter was positioned so it did not pull and dislodge. She stated she was in serviced on foley catheter care. During an interview on 03/04/25 at 2:47 PM with the ADON revealed the nurses were responsible for ensuring residents indwelling catheters were always secured with a stat lock or leg strap to the resident's inner thigh. She stated the risk to the resident was injury-like urethral tears and dislodgement of the indwelling catheter. She stated the nurses and CNAs were in-serviced on indwelling catheter. During an interview on 03/04/26 at 4:26 PM with the DON revealed her expectation was that nurses checked to ensure indwelling catheters were secure when providing catheter care every shift. She stated indwelling catheters should be secured with a stat lock or leg strap to the resident inner thigh. She stated the risk to the residents was dislodgment of the catheter. She stated the staff were in serviced on foley catheter care. Record review of the facility's policy, Catheter Care, Urinary, dated July 2024, reflected: Changing Catheters1. Changing indwelling catheters or drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as obstruction, or when the closed system is compromised.2. Ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh.)

Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry and freezer areas were removed. 4. The facility failed to ensure that dented cans were removed in the dry pantry area were separated from the other canned food. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other food-borne illnesses.Findings Included: Observation of the kitchen during the brief initial tour of the kitchen on 03/03/26 at 9:45 AM, revealed the following: Dry Pantry area:* 1 package of 6.6 oz. presweetened lemonade flavored soft drink mix with an expiration date of 07/10/25.* 5 packages of 6.6 oz. presweetened orange flavored soft drink mix with an expiration date of 09/05/25.* 9 boxes of 16 oz. baking soda with an expiration date of 02/22/26.* 1 package of 106 oz. pasta noodles were unsealed and exposed to air.* 2 boxes of 36 oz. grain and wild rice were unsealed and exposed to air.* 1 opened bag of 25 lb. bag of seasoned fish fry was unsealed in an unsealed brown box and exposed to air.* 1 white plastic container of 5 lb. creamy peanut butter was unsealed and exposed to air.* 1 blue plastic bag of infused dried cranberries was unsealed in an unsealed box and exposed to air.* 1 box of lasagna was unsealed and exposed to air.* 2-gallon bag of graham cracker crumbs was unsealed and exposed to air.* 1 plastic container of labeled sugar was unsealed and exposed to air.* 1 dented can of 106 oz. spaghetti sauce.* 1 dented can of 105 oz. sliced pears.* 1 dented can of 106 oz. Manwich sloppy joe.* 1 dented can of 106 oz. black beans. Refrigerator area:* 1 plastic Ziploc bag labeled, bread was unsealed and exposed to air. Freezer area:* 1 blue plastic bag of pureed bread and dessert mix was unsealed in an unsealed box and exposed to air.* 1 blue plastic bag of chocolate chip cookies was unsealed in an unsealed box and exposed to air.* 1 container of vanilla ice cream was unsealed and exposed to air.* 1 box of shredded hash browns with an expiration date of 09/03/25. In an interview with the Interim Dietary Manager on 03/03/26 at 10:15 AM, she stated that she had been employed at the facility for 1 1/2 years. The Dietary Manager was informed about the state surveyors findings during the initial brief tour of the kitchen, which included dented cans, labeling, expired and unsealed items in the dry storage, refrigerator, and freezer areas. She stated that she performed daily checks in the dry storage, refrigerator and freezer areas in the facility's kitchen. She stated that the items that were found by the state surveyor were overlooked by mistake. She stated that the staff in the kitchen are all responsible for ensuring that the items in the dry storage, refrigerator, and freezer areas in the kitchen are labeled, including the name of the item, the date the item was stored and the use by date. She stated that all items in the dry storage, refrigerator, and freezer areas in the kitchen should be sealed and closed and expired items, if found should be immediately thrown away. She stated that all items that were unsealed in the kitchens dry pantry, refrigerator and freezer areas during the brief tour of the kitchen would immediately be discarded and thrown in the trash. She stated that if staff found dented cans, the dented cans were to be immediately removed from the shelf and placed in the designated area that is marked as Dented Cans. The Dietary Manager stated all kitchen staff have been reeducated and retrained on Food Storage, Food Safety and Food Preparation via in-service training. She stated that the staff also have been reeducated on using the First In, First Out (an asset management and valuation method where the oldest inventory, stock, or data items are processed, sold, or used first) procedures to ensure there were not any expired food items throughout the dry pantry, refrigerator, and freezer areas facility's kitchen. The Dietary Manager stated that she would inform all kitchen staff of the findings of the state surveyor's initial brief tour of the kitchen and provide an In-Service Trainings. She stated if staff were to find any food items such as expired items, her expectation was they immediately throw away the item (s) and inform her about the item (s) that were thrown away. She stated if any item (s) were not labeled and/or dated, her expectation was for her staff to inform him of their findings, therefore she would reeducate and retrain all kitchen staff through in-service training. She stated all kitchen staff were to ensure items in the kitchen's dry pantry, refrigerator, and freezer areas were not expired, unsealed, labeled and dated. She stated the kitchen staff were reeducated and retrained through in-service training regularly, at least monthly. She stated that she could not recall when the kitchen staff received their previous in-service training on Food Storage was taken. She stated if anyone ate food from the kitchen that was expired, dented cans and unsealed containers or bags, there was risk of becoming very ill, which could cause them to have stomach aches, vomiting and diarrhea. In an interview with [NAME] L on 03/04/26 at 11:35 AM, she stated he had been employed at the facility for 1 1/2 years. She stated that she was unaware there were expired and unsealed items in the dry storage, and refrigerator areas. [NAME] L stated that the Dietary Manager informed the kitchen staff about the state surveyors findings during the initial brief tour of the kitchen on 03/03/26. She stated all the staff were responsible for labeling and storing the items on the shelf and checking the expiration dates on everything in the dry storage, refrigerator, and freezer areas in the facility's kitchen. [NAME] L stated dented cans were to be immediately removed from the shelf with the other dented cans and placed in the designated area marked Dented Cans. [NAME] L stated that all kitchen staff received previous education and training on food storage utilizing the FIFO method. [NAME] L stated if she observed food that was expired and/or unsealed, and not labeled in the dry pantry, refrigerator, and/or freezer areas, she would immediately trash the item(s), then immediately notify the Dietary Manager of her findings. [NAME] L stated that prior to 03/03/26, the Dietary Manager provided several In-Service training courses for all kitchen staff on food storage, handling and preparation. [NAME] L stated if someone ingested food from the facility's kitchen dry pantry, refrigerator and freezer areas that were unsealed or expired, they were at risk for food-borne illness from cross-contamination and could become sick. She stated that any ingestion of food that had been unsealed or expired, can cause a person to have stomach issues including stomach aches, diarrhea and vomiting. Record review of the facility's policy, Food Receiving and Storage, dated 2001 and November 2022 revealed, Policy Statement:Foods shall be received and stored in a manner that complies with safe food handling practices.Dry Food Storage:. 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging untilthey are ready to use.4. Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date).Such foods are rotated using a first in - first out system.Refrigerated/Frozen Storage:1. All foods stored in the refrigerator or freezer are covered, labeled and dated ( use by date).3. Refrigerated foods are stored in such a way that promotes adequate air circulation around food storagecontainers.7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded.8.Wrappers of frozen foods must stay intact until thawing. Record review of the U.S. Food and Drug Administration (FDA) Code (2022) revealed, PACKAGED FOOD shall be labeled as specified in LAW, including 21 CFR 101 FOOD Labeling, 9 CFR 317 Labeling, Marking Devices, and Containers, and 9 CFR 381 Subpart N Labeling and Containers, and as specified under S 3-202.18. FOOD shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3-306. Tag: F689/N4027S/S= DSurveyor Name: [NAME] BrimidgeImmediate Supervisor: [NAME] DoyleBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (200 Hallway) out of 2 hallways reviewed for accidents and hazards. 1.The facility failed to ensure that the mechanical lift on the 200 Hallway was locked and secured when not in use. 2.The facility failed to ensure that the mechanical lift on the 200 Hallway in the entry of the Dining/Activity Room area was locked and secured when not in use. These failures could place residents at risk of falls and/or injury. Findings Include:Observation of the facility's 200 Hallway on 03/04/26 at 10:15 AM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. Observation of the facility's 200 Hallway on 03/04/26 at 12:01 PM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. Observation on 3/04/2025 at 12:11 PM revealed an unlocked Mechanical Lift on the 200 Hallway near the 2nd floor elevator in front of the entry to the dining room. Residents and staff were observed going around the Mechanical Lift as they entered and exited the Dining/Activity Room. In an interview on 3/04/2025 at 12:21 PM with CNA I, she stated that she should not have left the Mechanical Lift by the elevator on the 200 Hallway in front of the entry to the Dining/Activity Room. She stated she used the Mechanical Lift for a resident and had to take a resident downstairs due to being in a rush and did not store the Mechanical Lift in the Supply Room where the Mechanical Lifts are stored. CNA I stated that when she placed the Mechanical lift where it was observed by the Surveyor, she did not lock the Mechanical Lift. CNA I stated that she had taken previous In-Service Trainings on accidents, hazards and Mechanical Lift Storage. CNA I stated that leaving an unattended and unlocked Mechanical Lift in the Hallways, there was a risk for residents to be injured, which there is a potential for harm. CNA I stated that all Mechanical Lifts were to be stored in the designated area on the 200 hallway. CNA I stated that there was a risk that a resident could fall and trip on an unlocked and unsecured Mechanical Lift in the Hallways. CNA I stated that a resident can fall and hit their head or have bruises if they were trying to lift themselves using an unlocked and unsecured Mechanical Lift for assistance with standing. In an interview on 3/04/2026 at 12:30 PM with CNA A revealed that she observed residents going around the unlocked and unsecured Mechanical Lift that was near the elevator in the walkway of the dining/activity room. CNA A confirmed that she observed the residents as they exited the dining/activity room and observed the residents that were from the elevator. CNA A stated the reason she did not move the unlocked and unsecured Mechanical Lift from the area was because she had a food tray in her hands. CNA A stated that all Mechanical Lifts are to be stored at all times in the facility's Utility Room on the 200 Hallway. CNA A stated that she had previously taken In-Service training on accidents, hazards and Mechanical Lifts and Mechanical Lift Storage. CNA A stated that residents could be at risk for injuries when an unlocked Mechanical Lift is left on the hallway and not stored in the designated area. CNA A stated that improper storing equipment, such as Mechanical Lift could result in a resident(s) injuring or cutting themselves. In an interview with LVN E on 03/05/26 at 3:46 PM, she stated that she had been employed at the facility for 5 months. She stated that she was unaware that there were 2 Mechanical Lifts unlocked and unsecured in different areas on the 200 Hallway on 03/04/26. LVN E stated that Mechanical Lifts should not be stored on the hallways and should be stored in the Utility Closet on each floor. LVN E stated that all staff have been trained via In-Service training on accidents, hazards and Mechanical Lifts and Mechanical Lift Storage. LVN E stated that all staff would be reeducated and retrained on Mechanical Lifts and Mechanical Lift Storage including safety, accidents, and hazards. LVN E stated that the Mechanical Lift being stored in the hallway was a fire hazard. LVN E revealed that every staff member was responsible for ensuring equipment was locked and safely stored. LVN E stated that there is a risk of someone hitting their head or tripping on an unlocked and unsecured Mechanical Lifts that are stored in the hallway. LVN E stated that if someone tripped on a Mechanical Lift that was stored in the hallway, they could have a fall and break their hips, break their legs, have superficial injuries, which may require sutures. In an interview with the DON on 03/05/26 at 5:20 PM, she stated that she had been employed at the facility for 2 years. The DON stated that she was unaware that there were 2 Mechanical Lifts unlocked and unsecured in different areas on the 200 Hallway on 03/04/26. The DON stated that all mechanical lifts were to be stored safely in the Utility Room near the Nurses Station on the 200 Hallway when they were not in use. The DON stated that Mechanical Lifts should never be stored on the hallways and should not block the entry or exit areas. The DON stated that she had provided ongoing In-Service training with all staff regarding safety, accidents, hazards and Mechanical Lifts including Mechanical Lift Storage. She stated that she will reeducate staff with In-Service training on Mechanical Lifts and Mechanical Lift Storage. She stated that there was a risk to anyone to incur injuries when there was an unlocked and unsecured Mechanical Lift stored on the Hallways. The DON stated that there was a potential of harm to anyone if an unlocked and unsecured Mechanical Lift stored on the hallways. The DON stated that residents can slip and/or fall if there was an unlocked and unsecured Mechanical Lift stored on the hallways. Record review of the facility's policy, Safety and Supervision of Residents, dated 2001 and November July 2017 revealed, Policy Statement:Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.3. When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.Individualized, Resident-Centered Approach to Safety1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff;b. Assigning responsibility for carrying out interventions;c. Providing training, as necessary;d. Ensuring that interventions are implemented; ande. Documenting interventions.5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; andd. Evaluating the effectiveness of new or revised interventions.Systems Approach to Safety:1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:.b. Safe lifting and movement of residents;c. Falls;.e. Unsafe wandering;g. Electrical safety.2. Other topics related to resident risk and environmental hazards may be addressed within related policies and procedures (for example, adequate lighting is addressed under the topic of falls). Record review of the facility's policy, Lifting Machine, Using a Mechanical, dated 2001 revealed, Purpose:The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions.General Guidelines:.2. Mechanical lifts may be used for tasks that require:a. Lifting a resident from the floor;b. Transferring a resident from bed to chair;c. Lateral transfers;d. Lifting limbs;e. Toileting or bathing; [NAME]. Repositioning.3. Types of lifts that may be available in the facility are:a. Floor-based full body sling lifts;b. Overhead full body sling lifts; andc. Sit-to-stand lifts.3. Types of lifts that may be available in the facility are:a. Floor-based full body sling lifts;b. Overhead full body sling lifts; andc. Sit-to-stand lifts.Steps in the Procedure:. 7. Make sure the lift is stable and locked.

Based on observation, and interview, the facility failed to provide foods which were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal observed for food preparation. (lunch 03/04/26). 1.The facility failed to serve food at an appetizing temperature for the lunch meal on 03/04/26 for the regular, mechanical soft and pureed meals. This failure could place residents who consumed food prepared in the kitchen at risk for reduced meal satisfaction, diminished nutritional intake, weight loss and a decreased quality of life.Findings included: In confidential resident interviews on at an undisclosed date and time, the residents stated that their food for all 3 of their daily meals was often cold. In an observation on 03/04/26 at 12:30 PM, the State Survey Team participated in the sampling of the Lunch Meal which included 3 Test Trays (regular, mechanical, and puree). The 3 lunch trays were served with covered tops. The 3 Test Trays consisted of roasted pork loin, baked sweet potato, seasoned cauliflower, and dinner roll. The food on all 3 Test Trays were cold. In an Interview with [NAME] L on 03/04/2026 at 2:54 PM, she stated he had been employed at the facility for 1 1/2 years. She stated that she was unaware that all the meals on the State Surveyors Test Tray were cold. She stated that temperatures of each meal are taken daily. [NAME] L stated that she did not receive any returned food trays to the kitchen after the Lunch Meal on 03/04/26. She stated that if a resident received cold food, she advised the staff to return the food to the kitchen and the resident will be served another food tray, which food temperatures would be taken to ensure that the replacement food tray is warm and not cold. [NAME] L stated that the food trays [NAME] L stated that if anyone ingested cold food from the facility's kitchen, there was a risk of sickness such as diarrhea and vomiting, which can cause some harm to the body. In an interview with Dietary Manager on 03/04/26 at 3:13 PM she stated he had been employed at the facility for 1 1/2 years. The Dietary Manager stated that her expectation is that all meals to be served from the facility's kitchen are warm and flavorful. The Dietary Manager tasted the pureed mashed potatoes and confirmed the mashed potatoes lacked flavor. The Dietary Manager revealed it was the responsibility of the kitchen staff to taste the food for palatability, flavor and temperatures before the food was served to the residents. The Dietary Manager stated that she did not try the food served from the facility's kitchen for the lunch meal served on 03/04/26. The Dietary Manager stated that the food temperatures are taken every day and the problem is that the food trays are taken from the kitchen to the floor and the staff are not giving the food to the residents in a timely manner, therefore the food trays may be cold when they are given to the residents. The Dietary Manager stated that there was a risk of anyone to become sick and ill if they eat food from the facility's kitchen that is cool. She stated that different foods are supposed to be eaten at a certain temperatures and harm can be caused to a person's stomach if they ingest cold food. In a confidential group interview on an undisclosed date and time, residents said their food was seldom hot when it arrived to their rooms. In an interview with the Administrator on 03/05/26 at 4:00 pm, he stated that his expectation that the food was served to the residents warm and not cold. The Administrator stated that if residents were to receive cold food, they can notify the staff and a new tray would be provided to them. He stated that he had eaten the food from the facility's kitchen before and he did not have any concerns. The Administrator revealed that he did not try the food served from the facility's kitchen for lunch served on 03/04/26. Record review of the facility's policy, Food and Nutrition Services, dated 2001 and revised October 2017 revealed, Policy Statement:Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional andspecial dietary needs, taking into consideration the preferences of each resident.Policy Interpretation and Implementation:1. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess eachresident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, andpsychosocial factors that affect eating and nutritional intake and utilization.7. Food and nutrition services staff will inspect food trays to ensure that.the food appears palatable and attractive, and it is served at a safe and appetizing temperature.a. a meal does not appear palatable, nursing staff will report it to the food service manager so that a new food tray can be issued. Record review of the facility's policy, Food Preparation and Service, dated 2001 and revised November 2022 revealed, Policy Statement:Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe foodhandling practices.Policy Interpretation and Implementation1. Danger Zone means temperatures above 41 degrees Fahrenheit (F) and below 135 degrees F that allowthe rapid growth of pathogenic microorganisms that can cause foodborne illness. Potentially HazardousFoods (PHF) or Time/Temperature Control for Safety (TCS) Foods held in the danger zone for more than4 hours (if being prepared from ingredients at ambient temperature) or 6 hours (if cooked and cooled) maycause a foodborne illness outbreak if consumed. 2. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food meansfood that requires time/temperature control for safety to limit the growth of pathogens (i.e., bacterial orviral organisms capable of causing a disease or toxin formation). Examples of PHF/TCS foods includeground beef, poultry, chicken, seafood (fish or shellfish), cut melon, unpasteurized eggs, milk, yogurt andcottage cheese. General Guidelines:1. Identification of potential hazards in the food preparation process and adhering to critical control points canreduce the risk of food contamination and thereby minimize the risk of foodborne illness. Food Preparation, Cooking and Holding Time/Temperatures1. The danger zone for food temperatures is above 41 F and below 135 F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness.2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese.3. The longer foods remain in the danger zone the greater the risk for growth of harmful pathogens. Therefore, PHF must be maintained at or below 41 F or at or above 135 F.7. Fresh, frozen or canned fruits and vegetables are cooked to a holding temperature of 135 F.Food Distribution and Service:1. Proper hot and cold temperatures are maintained during food distribution and service.

Based on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for 5 residents (Resident# 71, Resident# 13, Resident#34's, Resident# 75, Resident# 42 ) on 2 of 3 medication carts reviewed for medication storage (200 hall and 100 (secure unit) hall Medication cart) The facility failed to ensure Resident# 71's expired Nitroglycerin (a fast-acting medication used to treat or prevent angina (chest pain) by relaxing blood vessels, which increases oxygen-rich blood flow to the heart) was removed from the 100 Hall nurses' medication cart and disposed of. The facility failed to ensure Resident#34's expired morphine (a potent, fast-acting opioid used for severe acute or chronic pain management and sometimes for severe shortness of breath) was removed from the 200 hall nurses' medication cart and disposed of. The facility failed to ensure Resident# 13's Nystatin (a prescription antifungal agent used to treat skin infections) was stored in the medication cart and not in the resident's room. The facility failed to ensure Resident# 75's Nystatin (a prescription antifungal agent used to treat skin infections) was stored in the medication cart and not in the resident's room. The facility failed to ensure Resident#42's discontinued triamcinolone 0.1% cream (a prescription-strength corticosteroid used to treat skin conditions reducing itching, redness, and inflammation) was removed from the 100 hall nurses' medication cart and disposed of. The facility failed to ensure an opened bottle of Keppra 100 mg/ml was labeled with the resident's name before storing it in the 200 hall nurses' medication cart. The facility failed to ensure an expired bottle of Colace 100 mg was removed from the 100 hall nurses' medication cart and disposed of. The facility failed to ensure an expired opened bottle of oyster shell calcium 500mg was removed from the 100 hall nurses' medication cart and disposed. These failures could place residents at risk for compromised medication efficacy, unsafe administration, and increased harm to residents. Record review of Resident #71's Quarterly MDS assessment, dated 02/23, 2026, reflected he was a [AGE] year-old male re-admitted to the facility on [DATE]. His BIMs score was 04, indicating his cognitive status was severely impaired. His diagnoses included hypertension. Record review of Resident #71's active care plan, as of 01/23/2026, revealed no care plan problem goals, or intervention related to the resident's prescribed medication. Record review of Resident #71's active Physician Order, dated 3/3/26, reflected: NITROGLYCERIN 0.4 MG TABLET SL Give 1 tablet sublingually every 5 minutes as needed for Chest pain Q5mins PRN for chest pain x3 days. If there is no relief call MD. Order start date 09/09/2025. Record review of Resident #34's Quarterly MDS assessment, dated 02/23/2026, reflected she was [AGE] year-old female originally admitted [DATE], re admitted to the facility on [DATE]. Her BIMs score was 08, indicating her cognitive status was moderately impaired. Her diagnoses included Medically Complex Conditions (with severe, chronic, and multi-system conditions requiring intensive, ongoing, and specialized care). Record review of Resident #34's active care plan revealed Date Initiated: 01/15/2026 Acute Pain / Chronic Pain. Facility interventions: Administer prescribed medication before activity and therapy. Record review of Resident #34's active care plan Date Initiated: 01/15/2026, revealed: Risk for Impaired Circulatory. Facility interventions: Administer pain medications per order if non-medication interventions are Ineffective. Record review of Resident #34's active Physician Order, dated 3/3/26, reflected: Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 1 hour as needed for Pain - Mild; Shortness of Breath. Order start dated 09/23/2025.Record review of Resident #34's active Physician Order, dated 3/3/26, reflected: Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.5 ml by mouth every 1 hours as needed for Pain - Moderate; Shortness of Breath. Order start dated 09/23/2025.Record review of Resident #34's active Physician Order, dated 3/3/26, reflected: Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 0.75 ml by mouth every 1 hours as needed for Pain - Moderate ;Shortness of Breath Order start dated 09/23/2025 Record review of Resident #34's active Physician Order, dated 3/3/26, reflected: Morphine Sulfate (Concentrate) Oral Solution 20MG/ML (Morphine Sulfate) Give 1 ml by mouth every 1 hours as needed for Pain - Severe; Shortness of Breath. Order start dated 09/23/2025. Record review of Resident #13's Quarterly MDS assessment, dated 01/28, 2026, reflected he was a [AGE] year-old male re-admitted to the facility on [DATE]. His BIMs score was 04, indicating his cognitive status was severely impaired. His diagnoses included hypertension. Record review of Resident #13's active care plan, as of 10/13/25, revealed: Resident is at risk for pressure ulcers R/T limited mobility and incontinent: Interventions include: Keep clean and dry as possible. Minimize skin exposure to moisture. Record review of Resident #13's active Physician Order, dated 3/3/26, reflected: Nystatin External Powder 100000 UNIT/GM (Nystatin Topical) Apply to Groin topically two times a day Order start date:02/05/2026. Record review of Resident #75's Quarterly MDS assessment, dated 02/25, 2026, reflected she was a [AGE] year-old female admitted [DATE] re-admitted to the facility on [DATE]. Her BIMs score was 10, indicating her cognitive status was moderately impaired. Her diagnoses included hypertension and cancer. Record review of Resident #75's active care plan, as of 01/23/2026, revealed no care plan problem goals, or intervention related to the resident's prescribed medication. Record review of Resident #75's active Physician Order, dated 3/3/26, reflected: Nystatin External Powder 100000 UNIT/GM Nystatin (Topical) Apply to Skin folds topically every day and evening shift for Redness. Order start date 01/02/2026. Record review of Resident #42's Quarterly MDS assessment, dated 02/11/ 2026, reflected he was a [AGE] year-old female admitted [DATE] re-admitted to the facility on [DATE]. No BIMs score was recorded. Her diagnoses included hypertension and pneumonia. Record review of Resident #42's active care plan. Dated 06/27/2025 reflected Resident is at risk for pressure ulcers due to impaired sensory perception. Interventions included skin assessment and inspection weekly. Record review of Resident #42's active Physician Order, dated 3/3/26, reflected: No active orders for triamcinolone 0.1% cream apply 1 application to affected area externally for 30 days. During an observation on 3/3/26 at 9:41 am with LVN C on the 100 East nurses' med cart revealed Resident# 71's expired Nitroglycerin, Resident#42's discontinued triamcinolone 0.1% cream, expired bottle of Colace 100 mg and an expired opened bottle of oyster shell calcium 500mg. During an interview on 3/3/26 at 9:47 AM with the LVN C she said it was the nurse's responsibility to ensure all medication in the cart was properly labeled and within date. She stated Resident#42's triamcinolone 0.1% cream was discontinued. She stated all expired and discontinued medication should be removed immediately from the medication cart and disposed of or given to the DON for destruction. She stated the risk to the resident was administering expired medication that would be ineffective and could have adverse reaction to the resident and leading to hospitalization. She stated the risk of discontinued medication was medication error due to administering medication with no active physician orders. She stated she had been in-serviced on medication storage and labeling. During an observation on 3/4/26 at 9:55am in Resident# 13's room revealed white powder in a medication cup with the resident's name and room number on Residents #13's nightstand. Resident#13 was not interview able and could not explain what was in the medication cup. During an interview on 3/4/26 at 9:57am with the ADON revealed she was the nurse assigned to Resident #13. She stated that the white powder was nystatin powder. She stated she was not sure who put the medication in the resident's room. She stated that medication should not be left in the resident's room. She stated the risk of leaving medication in a resident's room was that another resident would have access to the medication or a resident could overdose without the staff knowing. During an observation on 3/4/26 at 10:55am in Resident# 75's room revealed a bottle of Nystatin External Powder 100000 UNIT/GM on the resident's TV stand. Resident #75 requested that surveyor get her another bottle of nystatin powder so she can have two bottles because the one in the room was halfway through and she did not want to run out. She stated she applied the powder to areas with skin folds and kept the medication in her room all the time. During an interview on 3/4/26 at 10:57am with the LVN B revealed Resident#75 should not have medication in her room and that all her medication was to be administered by the nurses only. She stated the risk to the resident was another resident having access to the medication or the resident could overdose on medication. She stated that she had been in-serviced on medication storage and labeling. During an observation on 3/4/26 at 2:21 PM with RN F on the 200 nurses' medication cart revealed Resident #34's expired morphine, Keppra 100 mg/ml with no patient label. During an interview on 3/4/26 at 2:32 PM with RN F revealed it was the nurses' responsibility to ensure all medication had the patients label, and all medications were within date. She stated if the label came off the nurse was to contact pharmacy or send the medication back for proper labeling or follow any instructions given by pharmacy to include discarding the medication. She stated the risk to the residents was medication error and medication not being effective due to expiration. She stated that she had been in-serviced on medication storage and labeling. During an interview on 3/04/2026 at 3:32PM with LVN E revealed nurses were responsible for ensuring the medication carts were clean, all medications were within date, and all medications had proper patient labels. She stated if medication did not have the proper label, it would not be possible to complete medication rights before administering medication to a resident. She stated risk to the resident when there was expired medication in the cart was medication would lose its potency and not be effective to treat the resident leading to health complications including hospitalization. During an interview on 3/04/2026 at 3:45 PM with ADON revealed the nurses were responsible for ensuring the medication cart was clean, and all medications were within date, and properly labeled. She stated the pharmacy consultant audits the medication rooms and the medication carts monthly. She stated the risk to the resident when expired medication is in the medication cart was accidentally administering expired medication which could be ineffective or could cause adverse reaction to the residents stated if medication does not have the proper label to include a resident's name it could lead to medication error. She stated the nurses had been in-serviced on medication storage. During an interview on 03/4/26 at 4:04 PM, the DON stated her expectation was the nurses would ensure there was no expired medication in the medication cart and all medications had the proper label with the right resident's name. She stated the nurses were responsible for ensuring the medication cart was clean, and all medications were within date, and properly labeled. She stated the pharmacy consultant audits the medication rooms and the medication carts monthly. She stated the risk to the resident when expired medication is in the medication cart was accidentally administering expired medication which could be ineffective or could cause adverse reaction to the residents stated if medication does not have the proper label to include a resident's name it could lead to medication error. She stated the nurses had been in-serviced on medication storage. Review of the facility's policy Medication Storage and Labeling in the Facility Revised February 2023 reflected the following:1. Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers.3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.6. Medication requiring refrigeration is stored in a refrigerator located in the medication room at the nurse's station or other secured location. Medications are stored separately from food and are labeled accordingly.Medication labeling1. Labeling of medication and biologicals dispensed by the pharmacy is consistent with applicable federal and state requirements and currently accepted pharmaceuticals practices.2. The medication label includes, at a minimum:a. Medication name (generic and /or brand).b. Prescribed dose.c. Strength d. Expiration date, when applicable.e. Residents' name.f. Route of administration; andg. Appropriate instructions and precautions.8. If medication containers are missing, incomplete, improper, or incorrect labels, contact the dispensing pharmacy for instructions regarding returning or destroying these items.

Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 3 (Resident #5, Resident #21 and Resident #35) out of 6 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure that Resident #5's Comprehensive Care Plan included his physician's order for G-Tube, Advanced Directives, and active diagnoses.2. The facility failed to ensure that Resident #21's Comprehensive Care Plan included her active diagnoses of dementia, diabetes, schizoaffective disorder, bipolar, anxiety and she was a Smoker.3. The facility failed to ensure that Resident #35's Comprehensive Care Plan included her active diagnoses of dementia, diabetes, end-stage renal disease, and dialysis services. These failures could place residents at risk of having received inadequate interventions not individualized to their care needs and diagnoses. Findings Included:Record review of Resident #5's admission face sheet dated 03/05/26 reflected he was a [AGE] year-old male admitted to the facility on [DATE] with active diagnoses that included: hemiplegia and hemiparesis following cerebral infarction (one-sided motor deficits occurring after a cerebral infarction (stroke) affecting left non-dominant side, candidal sepsis (a severe, life-threatening systemic infection where Candida yeast enters the bloodstream and spreads throughout the body, often causing organ failure and septic shock), cirrhosis of the liver (late-stage, chronic scarring (fibrosis) of the liver caused by long-term damage from diseases like hepatitis or alcohol abuse), dysphagia (difficulty, pain, or discomfort when swallowing food, liquids, or saliva), cognitive communication deficit, contracture of the left hip, dementia without behavioral disturbance, acquired absence of the left and right legs above knee, generalized muscle weakness, seizures, cerebral infarction (stroke), and Type 2 diabetes. Resident #5's Advance Directive was Full Code. Record review of Resident #5's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 00 indicating severe cognitive impairment. Resident #5's MDS Assessment reflected he required a Feeding Tube and required total assistance with ADL Care. Resident #5's MDS Assessment reflected diagnoses of Non-Alzheimer's Dementia, aphasia, cerebrovascular accident, transient ischemic attack, or stroke, and hemiplegia or hemiparesis, and seizure disorder or epilepsy. Record review of Resident #5's Care Plan dated 01/26/2025 reflected,Focus: [Resident #5] is dependent on staff etc.for meeting emotional, intellectual, physical, and social needs r/t Cognitivedeficits, Physical LimitationsDate Initiated: 01/26/2026Revision on: 01/26/2026 Goals: [Resident #5] will maintain involvement in cognitive stimulation, social activities as desired/tolerated through reviewdate.Date Initiated: 01/26/2026Revision on: 01/26/2026Target Date: 03/07/2026 Interventions: [Resident #5] needs 1:1 (1 staff member care for only 1 patient at a time) at bedside/in-room visits and activities if unable to attend out of room events. EX: sports talk, musical ent, social visits/ current eventsDate Initiated: 01/26/2026Revision on: 01/26/2026 [Resident #5] prefers activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as musical ent, socials, current events,Date Initiated: 01/26/2026Revision on: 01/26/2026 When [Resident #5] choose not to participate in organized activities, the resident prefers to listen to music for social and sensory stimulation.Date Initiated: 01/26/2026Revision on: 01/26/2026 Record review of Resident #5's Care Plan reflected no information regarding Advanced Directives, G-Tube (a medical device inserted through the abdomen directly into the stomach to provide nutrition, fluids, and medication to individuals who cannot consume enough by mouth), and dementia. Record review of [Resident #5's] Living Will signed by [Resident #5] on 03/30/2021 revealed:I request that I be kept alive in this terminal condition using available life sustaining treatment. I request to be kept alive in this irreversible condition using available life-sustaining treatment. Record review of Resident #5 's active physician orders, dated 08/23/2025, reflected:**Code Status: FULL CODE. Record review of Resident #5 's active physician orders, dated 02/05/2025, reflected: Other one time a day Liquid Protein 30 mL q day via G tube r/t low albumin and creatinine. Record review of Resident #35's admission face sheet dated 03/05/26 reflected she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included: Type 2 diabetes, hyperlipidemia (high cholesterol), dementia without behavioral disturbance, muscle weakness, neuralgia (intense, sharp, burning, or shock-like pain caused by damaged or irritated nerves, often occurring suddenly along specific nerve pathways) and neuritis (the inflammation of a nerve or a group of nerves, often resulting in pain, sensory disturbances (tingling, numbness), weakness, or loss of reflexes in the affected body part) end stage renal disease (he final, irreversible stage of kidney failure where kidney function drops below 15% of normal), presence of cardiac pacemaker, cardiac arrythmia (abnormal heart rhythm where the heart beats too fast), and dependence on renal dialysis (a life-saving, artificial process that filters waste, toxins, and excess fluid from the blood when kidneys have failed). Resident #35's Advance Directive was Full Code. Record review of Resident #35's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Resident #35's MDS Assessment reflected she required dialysis due to renal insufficiency, renal failure, or end-stage renal disease. Resident #35's MDS Assessment reflected a diagnosis of Non-Alzheimer's Dementia, diabetes mellitus, and hyperlipidemia. Record review of Resident #35's Care Plan reflected no information regarding Advanced Directives, and active diagnoses of dementia, end-stage renal disease, and dialysis treatments. Record review of Resident #21's admission face sheet dated 03/05/26 reflected she was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with active diagnoses that included:, dementia without behavioral disturbance, COPD (a group of lung diseases that cause ongoing airflow obstruction and breathing difficulties), schizoaffective disorder a chronic mental health condition combining symptoms of schizophrenia (hallucinations, delusions, disorganized thinking) with a major mood disorder, such as bipolar disorder (mania) , bipolar (a chronic mental health condition causing extreme, often disabling, shifts in mood, energy, and activity levels), anxiety, hypertension (high blood pressure), shortness of breath, and diabetes mellitus with diabetic neuropathy (a type of nerve damage that can happen with diabetes). Resident #21's Advance Directive was Full Code. Record review of Resident 21's Quarterly MDS assessment dated [DATE], reflected a BIMS score of 12 indicating moderate cognitive impairment. Resident #21's MDS Assessment reflected that she required dialysis due to renal insufficiency, renal failure, or end-stage renal disease. Resident #21's MDS Assessment reflected a diagnosis of Non-Alzheimer's Dementia, diabetes mellitus, and hyperlipidemia. Record review of Resident #21's Care Plan dated 12/09/2025 reflected, no information regarding Advanced Directives, and active diagnoses of dementia, COPD, diabetes mellitus, schizoaffective disorder, bipolar, anxiety, hypertension, and Resident #21 being a smoker. In an observation and interview with Resident #21 on 03/03/26 at 1:45 PM, she stated that she had been at the facility for about 5 years. Resident #21 stated that she had COPD and had smoked cigarettes almost her entire life and had medical issues such as shortness of breath because of her smoking cigarettes. Resident #21 stated that several times a day, she will use her walker to go across the street to smoke her cigarettes and buy items such as snacks and drinks from the gas station located across the street from the facility. Resident #21 appeared to be well groomed during her interview and observation. In an interview with the MDS Nurse on 03/05/26 at 12:45 PM revealed, she had been employed at the facility for 10 months. The MDS Nurse stated that at the beginning of her employment at the facility, she was given directives by Corporate Office to begin working on updating the Comprehensive Care Plans for all residents in the facility. She stated that when she began employment at the facility, the software program being utilized was Matrix (a cloud-based EHR and practice management software designed for out-of-hospital care, including skilled nursing, home health, hospice, and senior living). She stated that last year, the facility switched software programs from Matrix to PCC (Point Click Care is cloud-based healthcare technology platform for the senior care market in North America). She stated that Corporate Office's expectation of her was to take a residents Comprehensive Care Plan and place everything from their Comprehensive Care Plans from Matrix and transfer everything into PCC. The MDS Nurse confirmed that many of the Comprehensive Care Plans for residents have not been updated and transferred from Matrix into PCC. She stated that she had started transferring the data from Matrix into PCC, but the task is a huge task for 1 person to complete by herself and the expectation was unrealistic. The MDS Nurse stated that she informed Corporate Office that the Comprehensive Care Plans were not completed and was given a directive from Corporate Office to have a RN open the Comprehensive Care Plans for each resident in PCC. The MDS Nurse stated that transferring and entering data from Matrix to PCC should be a collective collaboration with all departments, but the tasks have not been completed by everyone. The MDS Nurse stated that a resident's Care Plan should be updated and completed because they are the voice for the residents because sometimes, they do not have a voice. The MDS Nurse confirmed that the Care Plans for the 3 residents (Resident #5, Resident #21, and Resident #35) were not updated and completed and the Comprehensive Care Plan situation at the facility is terrible. The MDS Nurse stated that Corporate Office is aware of the Care Plan issue, which was a mess. The MDS Nurse stated that there are several risks associated with a resident's Comprehensive Care Plan not being updated such as their Advanced Directives not being on their Comprehensive Care Plan. She stated that if a resident's choice was DNR and there were not any information on the Comprehensive Care Plan, someone may perform a Full Code and provide CPR to the resident, which is against the resident's choice and that could lead to legal issues and psychological harm to the resident. In an interview with the DON on 03/05/26 at 5:20 PM, she stated that she had been employed at the facility for 2 years. The DON stated that she was unaware that the Care Plans for 3 residents (Resident #5, Resident #21, and Resident #35) were not updated and completed with their medical diagnoses, advanced directives and Resident #21 was a Smoker. The DON stated that the MDS Nurse/Coordinator was responsible for having the resident's data for their Comprehensive Care Plans transferred from Matrix to PCC. The DON stated that each department is responsible for inputting data on a resident's Comprehensive Care Plan, such as Physical Therapy, Dietary, Nursing and Activities. The DON stated that there are risks to a resident if their Comprehensive Care Plan is not updated. The DON stated that if the Comprehensive Care Plan is not up to date, the resident's care needs may not be met because all staff that review resident's Care Plan need to have the most updated information available to care for the residents. The DON stated that there is potential for harm if a resident's Comprehensive Care Plan is not updated. The DON stated that there had not been any harm caused to any resident's due to their Comprehensive Care Plan not being updated. Record review of the facility's policy, Care Plans, Comprehensive Person-Centered, dated 2001 revealed, Policy Statement:A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation1. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legalrepresentative, develops and implements a comprehensive, person-centered care plan for each resident.2. The comprehensive, person-centered care plan is developed within seven (7) days of the completion ofthe required MDS assessment (Admission, Annual or Significant Change in Status), and no more than 21days after admission.3. The care plan interventions are derived from a thorough analysis of the information gathered as part ofthe comprehensive assessment.4. Each resident's comprehensive person-centered care plan is consistent with the resident's rights toparticipate in the development and implementation of his or her plan of care, including the right to:a. participate in the planning process;b. identify individuals or roles to be included;c. request meetings;d. request revisions to the plan of care;e. participate in establishing the expected goals and outcomes of care;f. participate in determining the type, amount, frequency and duration of care;g. receive the services and/or items included in the plan of care; andh. see the care plan and sign it after significant changes are made.5. The resident is informed of his or her right to participate in his or her treatment, and provided advancenotice of care planning conferences.6. If the participation of the resident and his/her resident representative in developing the resident's careplan is determined to not be practicable, an explanation is documented in the resident's medical record.The explanation should include what steps were taken to include the resident or representative in theprocess.7. The comprehensive, person-centered care plan:a. includes measurable objectives and timeframes;b. describes the services that are to be furnished to attain or maintain the resident's highest practicablephysical, mental, and psychosocial well-being, including:(1) services that would otherwise be provided for the above, but are not provided due to theresident exercising his or her rights, including the right to refuse treatment;(2) any specialized services to be provided as a result of PASARR recommendations; and(3) which professional services are responsible for each element of care;c. includes the resident's stated goals upon admission and desired outcomes;d. builds on the resident's strengths; ande. reflects currently recognized standards of practice for problem areas and conditions.8. Services provided for or arranged by the facility and outlined in the comprehensive care plan are:a. provided by qualified persons;b. culturally competent; andc. trauma-informed.9. Care plan interventions are chosen only after data gathering, proper sequencing of events, carefulconsideration of the relationship between the resident's problem areas and their causes, and relevantclinical decision making.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptomsor triggers.11. Assessments of residents are ongoing and care plans are revised as information about the residents andthe residents' conditions change.12. The interdisciplinary team reviews and updates the care plan:a. when there has been a significant change in the resident's condition;b. when the desired outcome is not met;c. when the resident has been readmitted to the facility from a hospital stay; andd. at least quarterly, in conjunction with the required quarterly MDS assessment.13. The resident has the right to refuse to participate in the development of his/her care plan and medicaland nursing treatments. Such refusals are documented in the resident's clinical record in accordance withestablished policies.

Based on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident#13) reviewed for respiratory care. The facility failed to ensure Resident #13's nebulizer mask was changed weekly, which was consistent with facility's policy. This failure could place residents at increased risk of infections. Record review of Resident #13's Quarterly MDS Assessment, dated 01/28/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. She had a BIMs score of 04, which indicated severe cognitive impairment. The resident had diagnoses which included respiratory failure (when the respiratory system cannot adequately provide oxygen to the body), heart failure (a chronic, progressive condition where the heart muscle is too weak or stiff to pump enough blood to meet the body's needs for oxygen) and hypertension (a chronic condition defined as consistently high blood pressure). Record review of Resident #13's Comprehensive Care Plan revealed a care plan, Date Initiated: 10/10/2026, Resident is at risk for impaired gas exchange R/T COPD and he is a smoker. Facility intervention includes Monitor oxygen saturation via pulse oximetry Q shift and PRN. Assess and record signs of impaired gas exchange (confusion, restlessness, irritability, inability to move secretions.) Record review of Resident #13's active physician orders, dated 02/01/2026, reflected Iprat-Albut 0.5-3(2.5) MG/3 ML 1 vial inhale orally every 6 hours as needed for SOB related to Start date 09/08/2025. During an observation on 3/3/2026 at 1:05 p.m. revealed Resident #13's nebulizer mask was in a plastic bag. The nebulizer mask was dated 2/16/2026.The resident was not showing any signs of respiratory distress or infection. Resident# 13 was uninterviewable. During an interview on 3/3/2026 at 1:34 p.m. with LVN D, she stated the Nebulizer mask should be changed every Sunday night and as needed. She stated the risk to the resident was respiratory infections due to bacteria growing in the mask. She stated she had been in serviced on infection control and respiratory treatments. During an interview on 3/3/2026 at 1:44 p.m. with LVN B revealed she was Resident #13's nurse. She stated she was not aware Resident #13 nebulizer mask and tubing had not been changed and was dated 2/16/2026. She stated he had not had breathing treatment on her shift. She stated the nebulizer mask and tubing was supposed to be changed weekly and as needed. She stated she usually checked the nebulizer mask and tubing to make sure they were dated. She stated the importance of changing the nebulizer mask and tubing was to track its age so it could be replaced according to the recommended schedule. She stated she had been in-serviced on infection control and respiratory equipment care. During an interview on 3/4/2026 at 1:52 p.m. with the ADON revealed her expectation was the assigned nurse should check and make sure, the nebulizer mask and tubing's were within date and stored in plastic bags. She stated the facility policy was to change the nebulizer mask and tubing every week on Sunday night shift and PRN. She stated the risk to the resident if tubing was not changed as scheduled was growth of bacteria leading to infection to the resident. She stated the nurses were in serviced on infection control and respiratory. During an interview on 3/4/2026 at 2:02 p.m. with the DON revealed her expectation was the assigned nurse should check the nebulizer mask and tubing as part of the overall assessment to make sure, the tubing's were within date and stored in plastic bags. She stated the facility policy was to change the nebulizer mask and tubing every week on Sunday night shift and PRN. She stated the risk to the resident if tubing was not changed as scheduled was growth of bacteria leading to infection to the resident. She stated the nurses were in serviced on infection control and respiratory equipment's care. She stated when the nebulizer mask and tubing was changed the nurse should document the treatment administration record. Record review of the facility's policy titled Oxygen Administration, Revised 10/ 2020, reflected:Weekly Documentation Oxygen/nebulizer tubing/masks to be changed by nursing department, weekly, and documented in the electronic health record.

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 1 of 5 Residents (Resident#85) reviewed for infection control. The facility failed to ensure Resident #85's foley catheter was not on the floor. This failure could place residents at risk of urethral tears or dislodging catheter and urinary tract infections.Record review of Resident #85's quarterly MDS assessment, dated 01/30/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-entry of 01/24/2026. Her BIMs score was 12, which indicated moderate cognitive impairment. Her diagnosis included neurogenic bladder (a condition that affects the bladder's ability to function properly due to damage or dysfunction in the nerves that control it). Section H-Bowel and Bladder reflected the resident was coded to have an indwelling catheter. Record review of Resident #85 's care plans, dated 06/30/25, reflected: The resident requires a suprapubic catheter R/T neuromuscular dysfunction of bladder associated with MS. She is at risk for complications such as catheter related trauma and infections. Facility interventions included: Do not allow tubing or any part of the drainage system to touch the floor. Record review of Resident #85's active orders, dated 03/04/26, reflected: Suprapubic catheter care Q shift and PRN every 8 hours as needed Every shift as needed. Order start dated 02/23/2026. Suprapubic catheter care Q shift and PRN every shift order start date 02/23/2026. Suprapubic catheter Dx: Neuromuscular Dysfunction of Bladder, Unspecified order started date 02/23/2026. During an observation on 03/04/26 at 1:40 PM revealed Resident #85's catheter drainage bag was on the floor. The catheter was not anchored to a non-moveable part of the bed. During an interview on 03/04/26 at 1:40 PM with the Resident#85 revealed the CNA had emptied her drainage bag at the end of her shift. During an interview on 03/04/26 at 1:43 PM with LVN A revealed she was Resident #85's nurse. She stated the Foley drainage bag should always be anchored on a non-moveable part of the resident's bed and not on the floor. She stated the risk to the patient when the Foley drainage bag was placed on the floor was contamination leading to urinary tract infections and the bag could get punctured. She stated she was in serviced on foley catheter care and infection control. During an interview on 03/04/25 at 1:57 PM with CNA G revealed she was assigned to Resident #85. She stated she emptied the foley at the end of her shift but did not recall placing the drainage bag on the floor. She stated the foley catheter drainage bag should always be positioned below the bladder, anchored on the side of the bed and not on the floor. She stated the risk to the resident was risk for infection. She stated she was in serviced on foley catheter care and infection control. During an interview on 03/04/25 at 2:47 PM with the ADON revealed all foley drainage bags should never be placed on the floor. She stated the CNA and the nurse were responsible for ensuring the foley drainage bag was properly anchored on a non-moveable part of the resident's bed. She stated the risk to the resident was the foley could be caught on something and dislodge and/or put the resident at risk for infection. She stated the nurses and CNAs were in-serviced on indwelling catheter care and infection control. During an interview on 03/04/25 at 3:37 PM with LVN B revealed the Foley catheter drainage bag needed to be positioned below the bladder, anchored on the side of the bed and not on the floor. LVN B stated the risk to the residents was risk for infection. She stated she was in service on foley catheter care and infection Control. During an interview on 03/04/26 at 4:26 PM with the DON revealed her expectation was that nurses and the CNA's provided catheter care every shift. She stated Foley catheter drainage bags should never be on the floor and they should be anchored to the bed frame. The DON stated placing the drainage bag on the floor could put the residents at risk of urinary tract infection, and dislodgment of the catheter. She stated the staff were in serviced on foley catheter care and infection Control. Record review of the facility's policy, Catheter Care, Urinary, dated July 2024, reflected: PurposeThe purpose of this procedure is to prevent catheter-associated urinary tract infections.Infection Control1. Use standard precautions when handling or manipulating the drainage system.2. Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag.a. Do not clean the periurethral area with antiseptics to prevent catheter-associated UTIs while the catheter is in place. Routine hygiene (e.g., cleansing of the meatal surface during daily bathing or showering) is appropriate.b. Be sure the catheter tubing and drainage bag are kept off the floor.c. Empty the drainage bag regularly using a separate, clean collection container for each resident. Avoid splashing and prevent contact of the drainage spigot with the nonsterile container.d. Empty the collection bag at least every eight (8) hours.

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 2 medications on 1 of 3 medication carts, reviewed for pharmacy services. The facility failed to ensure proper disposal of Resident#38's Tramadol 50 mg (controlled medication) and Resident#35's Tramadol 50 mg (controlled medication) by taping narcotic medication. This failure could place residents at risk of drug diversion and risk of pills contamination due to broken seals. Record review of Resident #38's admission MDS Assessment, dated 01/22/26, reflected the Resident #38 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMs score of 08, which indicated moderate cognitive impairment. The resident had a diagnosis which included Pain Disorder with related psychological factors. Record review of Resident #38's Comprehensive Care Plan, dated 01/20/2026, reflected [Name] is on pain medication therapy Tramadol r/t generalized pain. Facility Interventions included: Ask physician to review medication if side effects persist Review quarterly for pain medication efficacy. assess whether pain intensity acceptable to resident, no treatment regimen or change in regimen required; Controlled adequately by therapeutic regimen no treatment regimen or change in regimen required but continue to monitor closely; Controlled when therapeutic regimen followed but not always followed as ordered; Therapeutic regimen followed, but pain control not adequate, changes required. Record review of Resident #38's active physician orders, dated 03/04/2026, reflected the resident had orders for tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 8 hours as needed for Pain order date: 01/14/2026. 2. Record review of Resident #35's Quarterly MDS Assessment, dated 02/10/26, reflected Resident #35 was a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. She had a BIMs score of 12, which indicated moderate cognitive impairment. Her diagnoses included Pain, unspecified. Record review of Resident #35's active physician orders, dated 03/04/2026, reflected the resident had orders for Tramadol HCl Oral Tablet 50 MG (Tramadol HCl) Give 1 tablet by mouth every 6 hours as needed for Pain Prescriber start date 01/28/2026. During an observation on 03/04/26 at 2:21 PM of the 200 [NAME] Hall Nurses Cart station, revealed Resident #38's tramadol 50mg had 2 blister seals broken and taped and Resident# 35's tramadol 50mg had 3 blister seals damaged. The damaged blisters had the pills still inside secured with tape at the time the state surveyor inspected the medication cart. During an interview on 03/04/26 at 2:32 PM, RN F stated she was unaware Resident#38's and Resident#35's Tramadol 50mg blister pack seal was broken and did not know how the blister packs were broken. She stated the risk of a damaged blister would be potential for drug diversion and contamination of the medication. She stated the nurses were responsible for checking the medication blister packs for broken seals during the count of narcotics during the change of shift. She stated she did not see the broken blister during the count. She stated she was in serviced on medication storage. During an interview on 3/04/26 at 3:12 PM with LVN B revealed when a narcotic bubble seal was broken the medication was to be disposed wasted and witnessed by two nurses. She stated the risk to the resident was potential medication error because there was no guarantee the pill in the broken seal was the prescribed medication. Narcotics should not be taped, and he would notify the charge nurse so the medication could be discarded. She stated she was in-serviced on medication storage. During an interview on 3/04/26 at 3:32 PM with LVN E revealed nurses were responsible for ensuring the medication cart was clean and narcotics were not supposed to be secured with tape. She stated that when a narcotic bubble seal was broken the medication was to be disposed wasted and witnessed by two nurses. She stated the risk to the residents was potential medication error and drug diversion. She stated she was in-serviced on medication storage. During an interview on 3/04/2026 at 3:45 PM with the ADON revealed the nurses were responsible for ensuring the medication cart was clean, and all medications were within date, and narcotics were secured. She stated the pharmacy consultant audited the medication rooms and the medication carts monthly. She stated the risk to the resident when narcotics were taped could be medication error because the pills could have been switched out and contamination of the pill due to a broken seal. She stated the policy was if the seal of a narcotic was broken the medication should be disposed of and wasted witnessed by two nurses. She stated the nurses were in serviced on medication storage and controlled medication storage. During an interview on 03/4/26 at 4:04 PM, the DON stated her expectation was that the nurses would not tape narcotics. She stated narcotics with broken seals should be wasted witnessed by two nurses. She stated the pharmacy consultant audited the medication rooms and the medication carts monthly. She stated the risk to the residents of taping narcotics was contamination and medication error. She stated the nurses were in serviced on medication storage. She stated the nurses were in serviced on medication storage. Record review of the facility's policy Medication Storage and Labeling in the Facility Revised February 2023, reflected the following:1. Medications and biologicals are stored in the packaging containers or other dispensing systems they are received in. Only the issuing pharmacy is authorized to transfer medications between containers.3. If the facility has discontinued, outdated, or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.7. Controlled substances (listed as Scheduled II-V of the comprehensive Drug Abuse Prevention Act of 1976) and other drugs subject to abuse are separately locked in permanently affixed except when using single unit package drug distribution sys in which the quantity store is minimal and a missing dose cane be readily detected.

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (Resident#9) reviewed for accuracy of assessments. The facility failed to ensure Resident #9's MDS accurately reflected the resident's clinical status for indwelling catheter and pressure ulcers. This failure could place residents at risk inaccurate resident assessments, inappropriate care planning, and misrepresentation of the residents' condition. Record review of Resident #9's Quarterly MDS assessment, dated 02/09/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her BIMs score was 08, which indicated his cognitive status was moderately impaired. Her diagnoses included hypertension (high blood pressure). Section H-Bowel and Bladder H0100 reflected the resident was not coded to have an indwelling catheter. Section M -M0300 skin Conditions Resident #9 was not coded to have current pressure ulcer. Record review of Resident #9 's care plans, dated 12/12/2025 and Revision on: 02/02/2026, reflected: I have actual impairment to skin integrity of the coccyx r/t rash (irritant contact dermatitis) stage 3 pressure ulcer. Facility interventions: Observe my skin. Keep my skin clean and dry. Hydrate my skin with lotion, as needed. I will specify any areas that should not have lotion applied coccyx. Report any skin alterations to nurses. Observe/document/report location, size, and treatment of skin injury and/or any new or worsened alterations in skin integrity. Weekly treatment documentation to include measurement of each area(s) of skin breakdown: width, length, depth; type of tissue and exudate; and any other notable changes or observations. Report improvements and declines to the MD. Record review of Resident #9 's active physician orders, dated 03/05/26, reflected: Flush foley with 60cc NS as needed obstruction/occluded: start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/05/26, reflected foley catheter 18french/10ml balloon dx: wound healing as needed for leakage, blockage, and sedimentation may change foley catheter start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/05/26, reflected foley catheter 18french/10ml balloon dx: wound healing as needed for soiled replace leg strap start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/05/26, reflected foley catheter 18french/10ml balloon dx: wound healing every shift foley catheter care with soap and water start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/05/26, reflected foley catheter 18french/10ml balloon dx: wound healing every shift for wound healing monitor leg strap placement start date 01/09/2026. Record review of Resident #9 's active orders, dated 03/05/26, reflected Foley catheter care Q shift and PRN every shift Phone. Record review of Resident #9 's active orders, dated 03/05/26, reflected wound care: cleanse coccyx with wound cleanser apply Manuka High Density superlite with superabsorbent. Daily and PRN one time a day for irritant contact dermatitis (common skin inflammation causing red, itchy, dry rashes, often triggered by immune system responses, genetics, or environmental irritants/allergens) one time a day for wound Record review of Resident #9 's active orders, dated 03/05/26, wound care: cleanse coccyx with wound cleanser apply medical honey fiber with superabsorbent. Daily and PRN May use Medi Honey paste and calcium alginate until Medi honey fiber come in. one time a day for irritant contact dermatitis order start date 02/18/2026. Record review of Resident #9's physician orders reflected the resident had an indwelling urinary catheter in place during the assessment period. During wound care observation on 3/5/2026 at 12:45 PM revealed Resident #9 had wound to the coccyx, and she had an indwelling urinary catheter draining yellow urine to gravity. During an interview on 3/5/2026 at 1:30 PM, the MDS Coordinator reviewed the record and acknowledged Resident #9 had an indwelling urinary catheter during the assessment reference period and should have been coded accordingly on the MDS assessment. She stated she was responsible for coding the residents urinary catheter in the MDS. She stated the risk to the resident was inaccurate care planning as the care plan relied on the MDS data to identify clinical conditions and develop appropriate interventions. During an interview on 3/5/2026 at 2:23 PM, the ADON stated the MDS Coordinator was responsible for MDS coding. She stated the care plans were pulled from the MDS. She stated the risk to the residents when the MDS was not coded correctly was there would be an inaccurate care plan which could put the residents at risk of not receiving the care they needed. She stated the nurses did assessments on admission and every shift and they were aware Resident #9 had a Foley catheter and received the care she needed. During an interview on 3/5/2026 at 3:23 PM with the DON revealed Resident #9 had an indwelling catheter during the assessment period. She stated each department inputted in different parts of the care plan, but the MDS coordinator was responsible for the overall MDS. She stated the risk to the resident, when the MDS was not coded correctly, was an inaccurate care plan which could put the resident at risk of not receiving the care they need.

Based on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (200 Hallway) out of 2 hallways reviewed for accidents and hazards. 1.The facility failed to ensure that the mechanical lift on the 200 Hallway was locked and secured when not in use. 2.The facility failed to ensure that the mechanical lift on the 200 Hallway in the entry of the Dining/Activity Room area was locked and secured when not in use. These failures could place residents at risk of falls and/or injury.Findings Include:Observation of the facility's 200 Hallway on 03/04/26 at 10:15 AM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room.Observation of the facility's 200 Hallway on 03/04/26 at 12:11 AM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room.Observation on 3/04/2025 at 12:11 PM revealed an unlocked Mechanical Lift on the 200 Hallway near the 2nd floor elevator in front of the entry to the dining room. Residents and staff were observed going around the Mechanical Lift as they entered and exited the Dining/Activity Room.In an interview on 3/04/2025 at 12:21 PM with CNA I, she stated that she should not have left the Mechanical Lift by the elevator on the 200 Hallway in front of the entry to the Dining/Activity Room. She stated she used the Mechanical Lift for a resident and had to take a resident downstairs due to being in a rush and did not store the Mechanical Lift in the Supply Room where the Mechanical Lifts are stored. CNA I stated that when she placed the Mechanical lift where it was observed by the Surveyor, she did not lock the Mechanical Lift. CNA I stated that she had taken previous In-Service Trainings on accidents, hazards and Mechanical lift and Mechanical Lift Storage. CNA I stated that leaving an unattended and unlocked Mechanical Lift in the Hallways, there was a risk for residents to be injured, which there is a potential for harm. CNA I stated that all Mechanical Lifts were to be stored in the designated area on the 200 hallway. CNA I stated that there was a risk that a resident could fall and trip on an unlocked and unsecured Mechanical Lift in the Hallways. CNA I stated that a resident can fall and hit their head or have bruises if they were trying to lift themselves using an unlocked and unsecured Mechanical Lift for assistance with standing.In an interview on 3/04/2026 at 12:30 PM with CNA A revealed that she observed residents going around the unlocked and unsecured Mechanical Lift that was near the elevator in the walkway of the dining/activity room. CNA A confirmed that she observed the residents as they exited the dining/activity room and observed the residents that were from the elevator. CNA A stated the reason she did not move the unlocked and unsecured Mechanical Lift from the area was because she had a food tray in her hands. CNA A stated that all Mechanical Lifts are to be stored at all times in the facility's Utility Room on the 200 Hallway. CNA A stated that she had previously taken In-Service training on accidents, hazards and Mechanical Lifts and Mechanical Lift Storage. CNA A stated that residents could be at risk for injuries when an unlocked Mechanical Lift is left on the hallway and not stored in the designated area. CNA A stated that improper storing equipment, such as Mechanical Lift could result in a resident(s) injuring or cutting themselves.In an interview with LVN E on 03/05/26 at 3:46 PM, she stated that she had been employed at the facility for 5 months. stated that she was unaware that there were 2 Mechanical Lifts unlocked and unsecured in different areas on the 200 Hallway on 03/04/26. LVN E stated that Mechanical Lifts should not be stored on the hallways and should be stored in the Utility Closet on each floor. LVN E stated that all staff have been trained via In-Service training on accidents, hazards and Mechanical Lifts and Mechanical Lift Storage. LVN E stated that all staff would be reeducated and retrained on Mechanical Lifts and Mechanical Lift Storage including safety, accidents, and hazards. LVN E stated that a Mechanical Lift being stored in the hallway was a fire hazard. LVN E revealed that every staff member was responsible for ensuring equipment was locked and safely stored. LVN E stated that there is a risk of someone hitting their head or tripping on an unlocked and unsecured Mechanical Lifts that are stored in the hallway. LVN E stated that if someone tripped on a Mechanical Lift that was stored in the hallway, they could have a fall and break their hips, break their legs, have superficial injuries, which may require sutures.In an interview with the DON on 03/05/26 at 5:20 PM, she stated that she had been employed at the facility for 2 years. The DON stated that she was unaware that there were 2 Mechanical Lifts unlocked and unsecured in different areas on the 200 Hallway on 03/04/26. The DON stated that all mechanical lifts including Mechanical Lifts were stored safely in the Utility Room near the Nurses Station on the 200 Hallway when they were not in use. The DON stated that Mechanical Lifts should never be stored on the hallways and should not block the entry or exit areas. The DON stated that she had provided ongoing In-Service training with all staff regarding safety, accidents, hazards and Mechanical Lifts including Mechanical Lift Storage. She stated that she will reeducate staff with In-Service training on Mechanical Lifts and Mechanical Lift Storage. She stated that there was a risk to anyone to incur injuries when there was an unlocked and unsecured Mechanical Lift stored on the Hallways. The DON stated that there was a potential of harm to anyone if an unlocked and unsecured Mechanical Lift stored on the hallways. The DON stated that residents can slip and/or fall if there was an unlocked and unsecured Mechanical Lift stored on the hallways.Record review of the facility's policy, Safety and Supervision of Residents, dated 2001 and November July 2017 revealed, Policy Statement:Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.Policy Interpretation and ImplementationFacility-Oriented Approach to Safety1. Our facility-oriented approach to safety addresses risks for groups of residents.2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.3. When accident hazards are identified, the QAPI/safety committee shall evaluate and analyze the cause(s) of the hazards and develop strategies to mitigate or remove the hazards to the extent possible.4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents.5. The QAPI committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary.Individualized, Resident-Centered Approach to Safety1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents.2. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for individual residents.3. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.4. Implementing interventions to reduce accident risks and hazards shall include the following:a. Communicating specific interventions to all relevant staff;b. Assigning responsibility for carrying out interventions;c. Providing training, as necessary;d. Ensuring that interventions are implemented; ande. Documenting interventions.5. Monitoring the effectiveness of interventions shall include the following:a. Ensuring that interventions are implemented correctly and consistently;b. Evaluating the effectiveness of interventions;c. Modifying or replacing interventions as needed; andd. Evaluating the effectiveness of new or revised interventions.Systems Approach to Safety:1. The facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.2. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment.3. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazards in the environment (such as construction) or if there is a change in the resident's condition.Resident Risks and Environmental Hazards1. Due to their complexity and scope, certain resident risk factors and environmental hazards are addressed in dedicated policies and procedures. These risk factors and environmental hazards include the following:.b. Safe lifting and movement of residents;c. Falls;.e. Unsafe wandering;g. Electrical safety.2. Other topics related to resident risk and environmental hazards may be addressed within related policies and procedures (for example, adequate lighting is addressed under the topic of falls). Record review of the facility's policy, Lifting Machine, Using a Mechanical, dated 2001 revealed, Purpose:The purpose of this procedure is to establish the general principles of safe lifting using a mechanical lifting device. It is not a substitute for manufacturer's training or instructions.General Guidelines:.2. Mechanical lifts may be used for tasks that require:a. Lifting a resident from the floor;b. Transferring a resident from bed to chair;c. Lateral transfers;d. Lifting limbs;e. Toileting or bathing; [NAME]. Repositioning.3. Types of lifts that may be available in the facility are:a. Floor-based full body sling lifts;b. Overhead full body sling lifts; andc. Sit-to-stand lifts.3. Types of lifts that may be available in the facility are:a. Floor-based full body sling lifts;b. Overhead full body sling lifts; andc. Sit-to-stand lifts.Steps in the Procedure:. 7. Make sure the lift is stable and locked.

Based on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner.The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner.These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance.Findings included:Observation on 03/04/26 at 2:45 PM the State Surveyor observed there were no grievance forms available in any common areas nor indications of places where grievance forms were normally kept. Interview on an undisclosed date and undisclosed date and time with six confidential residents revealed the residents were unaware where grievance forms were located. The residents stated that they did not know how to anonymously file a grievance. Residents expressed wanting to have the option to file an anonymous grievance. Interview on 3/4/26 at 2:45pm with CNA.A stated grievance forms are at the nurse's stations for the CNAs to give to residents if residents ask for them. After the resident fills out the grievance they give it to the nurse. If residents, ask for the nurse or CNA. to fill out the grievance for the residents they will do so. CNA.A stated the grievance forms are only kept at the nurse's station. The CNA. stated if a resident is not able to fill out grievance anonymously it violates their rights and could cause harm by causing trauma and retaliation. Interview on 3/5/26 at 1:50pm. The ADON revealed she was not sure where the blank grievance forms are kept. The ADON stated that when grievance forms are completed, they go to the social worker. The ADON stated she is not sure how a guest or resident would obtain a grievance form to fill out anonymously. The ADON stated if a resident, family member, visitor or anyone else wanted to fill out a grievance form anonymously and grievance form was not available it had the potential to cause harm due to prolonging an investigation. Interview on 3/5/26 at 3:03pm The LVN B stated she would notify The Administrator or The DON if someone wanted to do a grievance. If The Administrator or The DON are not around, she would notify her ADON. LVN B stated if someone wanted to complete an anonymous grievance they could go to Human Resources. LVN B said it is important for a resident to be able to file grievance because it is important for expressing themselves to get help with problems. Interview on 3/5/26 at 5:20pm with The DON. The DON stated residents can get grievance forms from The Social Worker or after hours at the reception desk. The DON stated residents can submit grievances anonymously to The Social Worker office by sliding the grievance under her door. The DON stated it is Important to be able to complete a grievance anonymously so there is no fear of retaliation. The DON stated the worse thing to happen would be not being able to file a grievance and would have unresolve grievances. Review of the facility's policy titled, Grievances/Complaints, Filing dated revised April 2017 revealed that the Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman).5. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously.13. If the grievance was filed anonymously, the grievance officer will inform the resident that a grievance has been anonymously filed on his or her behalf and the steps that will be taken to investigate the grievance(s) and report the findings. The grievance officer will reiterate to the residents that it is against facility policy and federal regulations to discriminate or sanction a resident who has filed or verbalized a complaint against the facility, and that his or her rights to be free of discrimination or reprisal will be protected. Review of the Resident's Rights subsection Grievances revealed.The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents; and other concerns regarding their LTC facility stay. The facility must make information on how to file a grievance or complaint available to the residents.

Based on observation, interview and record review the facility failed to provide a safe environment for the secure unit residents, staff and the public in two (rooms [ROOM NUMBERS]) of four resident rooms on the secure unit observed for safety. The facility failed to ensure no portable heaters or space heaters were used in residents' rooms on the secure unit. This failure could place residents at risk for injury or accidents and hazards. Findings included: Observation and interview on 01/29/26 at approximately 10:00 AM with CNA A revealed resident room [ROOM NUMBER] with a portable space heater plugged into the wall on Resident #1's nightstand. The portable space heater was in the on position with a digital temperature on the display of 85 degrees Fahrenheit. Resident #1, nor the roommate, were in the room. Observation of the resident room [ROOM NUMBER] revealed a portable space heater plugged into the wall on Resident #2's nightstand. The portable space heater was not on. Resident #2 was in bed. Resident #2 did not have a roommate. Interview with CNA A revealed she did not know how long each space heater had been in the resident rooms. Interview with CNA A revealed the heat was working on the secure unit and both rooms were warm. Interview on 01/29/26 at 12:02 PM with the DON revealed they should not be using space heaters in the residents' rooms. The DON stated she would remove the space heaters in rooms [ROOM NUMBERS] immediately. The DON stated she would check all rooms on the secure unit to ensure no space heaters were being used. The DON stated the facility did not have a policy on space heaters or portable heaters. The DON stated the facility should not use portable heaters or space heaters in resident rooms because they were a safety hazard. The DON stated the risk of using portable heaters or space heaters in a resident's room could result in injury. Interview on 01/29/26 at 12:27 PM with the Maintenance Director revealed the facility had placed space heaters on the secured unit on 01/27/26. The Maintenance Director stated that they missed picking the space heaters back up on the secured unit on 01/27/26. The Maintenance Director stated that all space heaters had been picked up from the secure unit as of today 01/29/26. The Maintenance Director stated the heat had been working and was still working on the secure unit since 01/27/26 after a valve was repaired. The Maintenance Director stated the valve repair took less than a couple of hours to repair on 01/27/26. The Maintenance Director stated the facility did not have a policy on portable heaters or space heaters. The Maintenance Director stated the risk of using space heaters in resident rooms could result in injury. Interview on 01/29/26 at 1:28 PM with the ADM revealed the facility did not have a policy on portable heaters or space heaters in residents' rooms. The ADM stated that the risk of using space heaters in a resident's room could result in injury. Review of the Facility's Provider Investigation Self Report Incident Template dated 01/27/26 revealed the following on 01/27/26 the facility received reports that heaters were not functioning properly. HVAC company was contacted and in the facility within two hours to assess issue with system.portable heaters were available.core repairs have been made. Review of the facility's Loss of Central Services Policy and Procedures, dated June 2025, revealed Heat Loss: 4) Staff will be responsible for assuring that residents are dressed appropriately for heat conservation. Several layers of loose clothing and two pairs of socks should be worn by the residents. Make sure to cover extremities. 5) Staff will provide hot beverages to the residents for consumption. 6) Extra blankets will be available and distributed to the residents. 7) Residents will be involved in as many activities as possible. 8) Close all windows and draw curtains.

Based on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for one (Resident #1) of four residents reviewed for abuse. The facility failed to report an allegation of abuse towards Resident #1 when reported by a staff member. This failure could place residents at risk for delayed investigation, intervention and abuse.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year-old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), diabetes (a chronic condition where the body can't effectively use or produce insulin, leading to high blood sugar), schizophrenia disorder (a chronic brain disorder causing symptoms like hallucinations, delusions, disorganized thinking and reduced emotional expression), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia hallucinations, delusions with a mood disorder), and insomnia (difficulty sleeping). Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, reflected a BIMS score of 06 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood problems identified and no verbal or physical behaviors directed towards others. Resident #1 had range of motion impairment on both sides of his lower extremities and used a walker as a mobility device. He required moderate/partial assistance for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 received high-risk medications which included antipsychotic, antidepressant, and hypoglycemic medication. Record review of Resident #1's current care plan, initiated 12/29/25, reflected no identified behaviors and no use of psychotropic medications. The current care plan did not discuss the acute behavioral incident on 12/24/25 and 12/31/25 and the new orders obtained for PRN medication. The previous care plan initiated in December 2024 (separate document) reflected Resident #1 took antipsychotic medication, had a diagnosis of vascular dementia and schizophrenia and required psychotropic medication for insomnia. The previous care plan did not indicate any identified behavioral issues or psychological concerns. Record review of Resident #1's psychiatric follow-up evaluation dated 12/17/25 by Psyche NP B, reflected Resident #1 was seen for medication monitoring and management of psychotropic medications following reports of irritability, restlessness and need for redirection and cues from staff. The evaluation reflected Resident #1 was observed eating lunch in the dining room, appeared calm, and was in no apparent physical or emotional distress at the time of the observation. Psyche NP B documented Resident #1 had dementia and insomnia with cognitive impairment. Chart review by NP B noted no supporting evidence to validate diagnosis of schizophrenia or schizoaffective disorder and Psyche NP B documented those diagnoses should be removed from Resident #1's medical record due to lack of evidence. Resident #1's current psychotropic medications were reflected as Seroquel (for agitation), Depakote sprinkles (for mood disorder), Trazadone (for agitation and dementia) and Remeron (for insomnia). Record review of nursing progress notes for Resident #1 reflected:-12/17/25 at 3:05 p.m.by LVN A, Resident noted with more jumpy behavior and combative during care and continues to have an outburst episodes, yelling mama, mama, and trying to kick staff, pt requires more cues to eat, redirected and educated multiple times but not effective, Pt vital signs WNL BP-106/66, P-63, R-18, T-97.7, Spo2- 97% RA, behavior reported to Psych NP. No new order.-12/24/25 at 9:05 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, pt redirected and educated several times but not effective, was reported to NP psych N/O received Xanax 0.5 mg PO every 6 hrs. PRN x 14 days r/t restlessness and agitation. Resident and family notified. MAR updated.-12/30/25 at 8:25 a.m.by LVN A, Late Entry: Note Text: Writer obtained order for prn Haldol IM inj, all orders carried. Will continue to update chart prn.-12/30/25 at 3:06 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, when brought to the dining area this AM resident started knocking down the chair and the tables, when redirecting, resident become more restless and agitated, hitting, scratching and kicking the staff members including this writer, he was quickly move out from the dining area and brought back to his room, this writer stayed with him notified DON, ADON and MD, N/O order obtained Haloperidol 5mg/ml Inject 1ml intramuscularly one time only as needed. MAR updated, resident and family informed.-12/30/25 at 3:09 p.m. by LVN A, Xanax 0.5 mg 1 tab PO was administered but not effective.-12/30/25 at 3:22 p.m. by LVN A, Late Entry: Also noted pt has a scratch to the right side of face.-12/30/25 at 3:29 p.m. by LVN A, The resident later calmed down and ate his breakfast 100% and lunch meal 100% with fluid as tolerated. Family members came visiting and later left. Plan of care continues.-12/31/25 at 9:25 a.m. by LVN A, Resident observed with disruptive behavior during care this Am. Haloperidol 5mg/ml 1ml intramuscular was administered per order. Pt. tolerated well with no adverse reaction noted. An observation and interview with Resident #1 was attempted on 01/07/26 at 1:46 p.m. and revealed he did not eat his lunch and his full plate of food was in front of him on the table. His eyes were closed and he was slightly slumped over in his wheelchair. A CNA tried to rouse him and he then jerked his body a few times in waking up and began slowly eating. Resident #1 was not responsive to questions and kept his eyes closed, including through eating his food. He was observed to be in a wheelchair, elderly and not able to particulate in an interview. He was not observed to have any visible injuries on his face, hands or arms at the time of the observation. An interview with CNA B on 01/06/25 at 1:22 p.m. revealed she worked in the secured unit on the morning shift, took care of Resident #1 for about a year and was very familiar with his behaviors and care needs. CNA B stated on the morning of 12/24/25, she was the CNA responsible for Resident #1. She said that morning, Resident #1 had stool in his brief and needed to be changed. She stated sometimes he did not want care, and when that happened, she went to the charge nurse for assistance. On that morning (12/24/25), CNA B said she notified LVN A that Resident #1 was resisting ADL care. LVN A came to assist with care and they placed Resident #1 in his wheelchair and took him to the dining room. She stated while in the dining room, Resident #1 began knocking on the table and making noise. She stated that behavior happened once in a while but not every day. CNA B stated because of the noise and the reactions of the other residents, she and LVN A decided to remove Resident #1 from the dining room to prevent further problems. She stated Resident #1 was taken back to his room and placed in bed so he would calm down and would not start pulling at other residents. She stated Resident #1 did not slap or hit any other residents during the dining room incident. CNA B stated if a resident hit staff, staff were not supposed to do anything back. She stated the usual response was to remove the resident from the situation and give them time to calm down. She stated that sometimes nursing staff administered medication to calm Resident #1 when he got agitated. CNA B stated that after time in his room, Resident #1 typically calmed down. CNA B stated after the incident on 12/24/25, she did not observe any bruises or injuries on Resident #1 when showering or providing care. An interview with CNA D on 01/06/25 at 1:30 p.m. revealed she reported a concern of abuse regarding Resident #1 and alleged there were failures by the facility leadership to appropriately report, investigate and protect staff from retaliation after her concerns were raised. CNA D stated that on or around 12/30/25 the previous week, concerns were reported regarding Resident #1 following a behavioral incident in the secured dining room. She reported a staff member (confidential) contacted her and expressed fear about reporting what occurred. CNA D stated the staff member believed staff on the secured unit was aggressive with Resident #1 during redirection and harmed the resident. CNA D stated she had photos of the resident's injuries and showed them to ADON G. CNA D stated when ADON G was informed of the incident, ADON G said she already knew about it and Resident #1 was not injured but struck LVN A's nose and caused injury. CNA D stated she asked ADON G if Resident #1 was assessed for injuries and ADON G instructed her to show the photos to LVN A and wanted the nurse to document any injuries. CNA D was concerned the person she was asked to show the photos to (LVN A), could possibly be involved, but she showed them to LVN A as directed. CNA D stated she was unaware of any meaningful follow-up or reporting to HHSC as a facility incident. She said she believed the facility failed to initiate a formal abuse or injury of unknown source investigation and failed to remove alleged involved staff from Resident #1's care. CNA D said she felt that instead of focusing on the resident's safety concern, leadership focused on the fact that photographs were taken of Resident #1. CNA D believed after that, she was targeted by leadership and corporate for 1) having unauthorized photos of Resident #1, 2) not identifying where the photos originated and who took them, and 3) not notifying corporate of her concerns prior to her reporting alleged abuse to State. CNA D expressed concern that facility leadership was not truthful about events and emphasized the situation involved peoples' loved ones. Regarding leadership involvement, CNA D stated she believed the administrator, who was the A/N coordinator, was on vacation during this incident and the DON served as the manager and abuse/neglect coordinator in his absence. Record review of photos provided via email (not time stamped or dated) provided by CNA D from a confidential source on 01/06/25 of Resident #1 reflected:1) long thin dark red scratch breaking the skin down the left side of Resident #1's face/cheek,2) right side of his face, small bloody scratch on upper cheek and left eye had slight discoloration,3) right mid-forearm had a reddened area that looked like a hand wrap or finger pressure, and4) left hand had a lighter reddened area on top of his hand. An interview with LVN A on 01/06/25 at 2:13 p.m. revealed she was the charge nurse on the secured unit. LVN A stated on 12/24/25, CNA B reported Resident #1 was being kind of resistant. He had a bowel movement and CNA B was trying to provide incontinent care. LVN A said she did not observe Resident #1 being resistant, but CNA B told her that he refused to let her turn him to provide incontinent care. LVN A stated, You know, she [CNA B] asked him to roll over, but he didn't want to, he wanted to stay on his back. LVN A said when she went to his room, she talked to him and said please and Resident #1 was compliant, so they got him dressed and took him to the dining room. Once in the dining room, Resident #1 was sat at a table where nobody else sat and started screaming mama mama! LVN A said Resident #1 knocked down a table and pushed a chair, so for the safety of the other residents, he was taken back to his room by herself and CNA B. LVN A stated she did not touch Resident #1 in the dining room and although he was trying to stand up, he sat back down on his own. She said Resident #1 hit her on the nose while trying to remove him from the dining room. When she got him back to his room, LVN A stated she asked Resident #1 if he was okay and he said no and kept repeating mama, mama, mama, mama. LVN A stated she then transferred him back to bed with CNA B, contacted the doctor, ADON G, and stayed with him until he calmed down. LVN A said Resident #1 calmed down through her talking to him. She said once he was calm, she administered him a PRN Xanax. LVN A stated, He was not really calmed down, but not like aggressive as before. So, I gave it to him to calm down. She said Resident #1 then ate his breakfast and went to eat lunch in the dining room later and was quiet in his demeanor. LVN A stated a couple of days later (date unknown-morning), Resident #1 was destructive and combative. She said CNA B went to get him up and he was tried to fight with her, so LVN A went to see what was going on. She stated Resident #1 was kicking at the air from his bed towards CNA B and herself. LVN A said he was combative and tried to kick her when she approached him. LVN A stated, So I said because I have an order for it (Haldol), well let me give it to him. She said he calmed down after the intramuscular medication administration. LVN A stated she did not have to restrain Resident #1 to administer the IM Haldol or hold his arm during administration because he was lying in bed. After the incident (date unknown), LVN A stated CNA D came to her with photos of Resident #1 on her phone and but LVN A did not know why and said CNA D was flipping through them so fast she could not see any specific details. She stated CNA D was concerned that Resident #1 had a scratch down the side of his right cheek, But it was self-inflicted. LVN A stated she witnessed Resident #1 scratch his own face. She stated he was wild, describing him as flailing his limbs and kicking. An interview with ADON G on 01/06/26 at 3:10 p.m. revealed she was present on 12/24/25 when Resident #1 had a behavioral escalation that involved throwing tables and chairs. ADON G said the incident occurred while an HHSC State investigator was present elsewhere in the building for a complaint investigation. She stated she received a text notification Resident #1 was throwing furniture and was returned to his room for safety. She stated she and the scheduler went to the secured unit shortly thereafter. ADON G stated Resident #1, at that time, was in his room with his breakfast tray present, standing near the bed. ADON G sated Resident #1 appeared agitated and fidgeted with paper. She stated she verbally redirected him, asking if he was hungry and encouraged him to sit and eat. She stated Resident #1 complied, sat down and began eating. She exited the room once he appeared calm. The next day, she stated CNA D approached her while she was working the floor and asked if she saw Resident #1 because he had scratches and bruising on his wrists. ADON G stated she told CNA D there was a known behavioral incident the prior day involving furniture throwing and staff injury. ADON G stated CNA D showed her photos depicting redness/scratches, which ADON G described as redness rather than broken skin. ADON G stated she did not believe the photos indicated abuse and felt any markings were a result of the known behavioral episode involving Resident #1 throwing furniture and redirected by staff. ADON G stated CNA D alleged abuse by staff, though not naming a specific staff member. ADON G stated she did not believe abuse occurred because staff actions were redirection and guidance rather than physical restraint or rough handling. ADON G stated she asked CNA D to show the photos to LVN A to ensure documentation and follow-up were completed. ADON G later spoke with LVN A in front of CNA D to confirm that documentation, body assessment and physician notification were completed. ADON G stated she advised CNA D the issue was addressed and that CNA D was not privy to internal investigative processes. ADON G stated she notified the DON of the allegation and concern that staff were stating they intended to contact the State. ADON G said the DON asked whether a body assessment was completed and ADON G reported that she personally did not observe injuries when she assessed Resident #1 after the incident. ADON G stated no internal abuse investigation was initiated at the facility level because leadership believed the source of any markings was known and related to resident behavior. She stated corporate later became involved after State surveyors arrived at the facility on 01/03/26. ADON G also stated that CNA D's dissatisfaction with facility leadership's response to the allegation of possible abuse led to her reporting the concern to the State. ADON G stated when staff raised allegation concerns, the facility leadership should evaluate the resident's safety, complete assessments, notify the physician and family as appropriate and separate residents in resident-to-resident situations. She stated staff were encouraged to report concerns to leadership, who then would determine the next steps. ADON G stated decisions regarding facility incident reporting requirement and investigations were primarily managed by the DON and Administrator. She stated she deferred detailed reporting process questions to those roles. Record review of Resident #1's skin checks on 12/31/25 and 01/02/26 reflected no bruising or scratches noted. An interview with the DON on 01/06/26 at 4:05 PM revealed she became aware of concerns involving Resident #1 on 01/03/26. Prior to that time, she had limited awareness of staff concerns and was informed by ADON G that a CNA heard Resident #1 sustained a facial injury and wrist bruising. The DON stated nursing staff completed a full skin assessment which revealed no injuries, no bruising, no scabbing and no evidence of healing wounds. She stated Resident #1 recently exhibited significant behavioral escalation, including throwing furniture and striking a nurse and that any redness or marks reported were believed to be related to Resident #1's own agitation and movement during redirection. The DON stated she did not personally view photographs of Resident #1 from CNA D and was not aware of their existence until 01/03/26. The DON stated staff statements were requested but not all were received and interviews had occurred and a review was ongoing. She said the facility did not identify the situation as meeting criteria for a mandatory report to HHSC as no injuries were identified and Resident #1's behaviors were documented and addressed. The DON said no staff were suspended or removed as alleged perpetrators. The DON stated that internal facility investigations were not a substitute for reporting to HHSC, but reporting was not warranted based on the findings. She stated that clearer communication with staff regarding reporting requirements and decision-making could have been beneficial. She stated facility protocols were followed appropriately and that no abuse, neglect or injury of unknown source was identified. An interview with C-RN F on 01/07/25 at 10:35 a.m. revealed she first became aware of any concerns about Resident #1 on Saturday 01/03/26 when HHSC did a complaint investigation related to Resident #1. She stated no staff had brought concerns to her prior to that time about abuse or injuries for Resident #1. C-RN F stated she did not personally view photographs of Resident #1 and did not initiate an internal investigation, deferring to the state investigation that was conducted on 01/03/26. She reported ADON G told her on that date she saw photos on a CNA's phone for Resident #1, but could not verify the origin, date or accuracy of the photos. C-RN F stated the CNA in question (CNA D) declined to provide further information regarding who took or sent the photos. C-RN F stated that when she assessed Resident #1 on 01/03/26, she did not observe visible injuries. She emphasized that without observable injury or verifiable photo evidence, she could not confirm abuse. She stated that witnesses were reportedly present during the incident and framed the situation as staff attempting to keep other residents safe during a behavioral incident. C-RN F stated allegations of abuse or injuries of unknown origin should be reported when identified by staff and there were internal discussions and application of an algorithm for abuse determinations, including injury of unknown origin. C-RN F stated if a CNA alleged abuse, management's responsibility was to notify leadership (ADON, DON, Administrator) and collectively determine next steps. She stated that in the case with Resident #1, she did not believe an allegation of abuse was made because CNA D reportedly did not use that term. C-RN F was asked whether the use of the word abuse was required to trigger reporting obligations to HHSC. She stated that proof and facts were critical, rather than belief. An interview with the ADM on 01/07/26 at 1:30 PM revealed he was the abuse/neglect coordinator and the week of 12/29/25 was not onsite at the facility. He stated he became aware of concerns involving Resident #1 on 01/03/26 when an HHSC surveyor arrived with allegations related to mistreatment of Resident #1. The ADM said corporate became involved because he was not present to assist with the situation. He said that in-services were initiated upon his return, including HIPAA and abuse/neglect education and those types of in-services were typically conducted when issues arose. The ADM stated his understanding of what occurred was photographs may have been taken or circulated in the facility, which prompted a HIPAA in-service. He stated assessments of Resident #1 conducted around that time reportedly showed no redness, bruising or visible injury. The ADM stated he was not informed of the situation while on vacation and learned of it upon returning to work. He stated that if he was unavailable, abuse and neglect concerns would typically start with the DON with corporate assisting if present. The ADM said an internal facility review was not a substitution and when staff raised abuse concerns, those concerns were investigated and documented as necessary. The ADM expressed concern regarding any unauthorized photographs of residents and stated that photographs should only be taken by appropriate personnel to include mainly a physician who was sent wound care photos by a nurse. The ADM stated he believed the photos of Resident #1 may have been used in a gotcha manner rather than through appropriate reporting protocols. An interview with CNA E on 01/07/26 at 1:55 PM revealed she was visibly emotional and tearful. She repeatedly expressed fear of retaliation and concern that speaking up could place her employment at risk. CNA E described Resident #1 as not normally aggressive and stated repeatedly, That man is not aggressive. She stated that she had worked with Resident #1 regularly since beginning her employment at the facility three weeks prior and had not observed him engaging in violent or combative behaviors. She stated that when she assisted Resident #1 with care, she was typically able to get him up, talked to him and redirected him without difficulty. On the morning of the incident (12/24/25), CNA E stated she first became concerned when she heard commotion and distress sounds coming from the dining room area. She stated she heard loud voices and raised tones and stated that the situation didn't feel right. She observed Resident #1 being brought into the dining room and he appeared upset, confused, was attempting to communicate but struggling to express himself clearly. She recalled him repeating fragments such as feel, feel, feel. CNA E stated she was able to calm Resident #1 by speaking softly and reassuring him, telling him, [NAME], it's me. She emphasized that this approach worked and helped him de-escalate. In contrast, she described the other staff, specifically CNA B and LVN A using loud, commanding voices and repeatedly telling Resident #1 to sit down, sit down! which she felt escalated the situation. She stated, Y'all didn't give him time, and explained that residents had the right to be mad and had the right to be left alone for a little while. She stated staff kept giving him commands rather than allowing him time to calm down. CNA E stated after the dining room incident, Resident #1 was taken back to his room. She stated she never saw Resident #1 flip tables or chairs and stated that while he may have pushed against furniture, he did not have the physical strength to seriously harm others. She stated she did not see him assault other residents and did not believe he posed the danger later described by staff. After Resident #1 was taken to his room, CNA E stated she observed physical injuries, including blood running down the side of his face, bruising, and swelling. She specifically noted swelling around the eye and bruising to the wrist and hand. CNA E expressed concern that following the incident, staff began characterizing Resident #1 as aggressive. She stated, That's not fair to him, and That's not fair to his family. CNA E stated she did not feel safe reporting concerns internally, explaining that trying to report through the Abuse/Neglect Coordinator's Phone number posted at the time was just the number to the facility, not the ADM. She reported hearing comments suggesting management would find out who called the state, which she perceived as threatening. She stated this reinforced her fear of retaliation and made her reluctant to report concerns. CNA E stated her main concern was that Resident #1 may have been harmed during a behavioral episode that she felt was escalated by staff actions. Record review of the facility's protocol for following reporting requirements reflected, Provider Letter PL 2024-14, Abuse, Neglect, Exploitation, Misappropriation of Resident Property and Other Incidents that a Nursing Facility Must Report to the Health and Human Services Commission, dated 08/29/24. In the PL 2024-14, it reflected, .A NF must report to CII the following types of incidents, in accordance with applicable state and federal requirements: Abuse, Neglect. Suspicious injuries of unknown source. A NF is not required to report to CII: serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to abuse; serious bodily injury or other injury that is NOT suspicious or of unknown source and that is NOT related to neglect, exploitation, or mistreatment; injury that is not suspicious or of unknown source;. State and federal law requires an owner or employee of a NF that has cause to believe that the physical or mental health or welfare of a resident has been or may be adversely affected by abuse, neglect, or exploitation (ANE) caused by another person to report the abuse, neglect, or exploitation. NFs must report all suspected or alleged incidents involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property. A NF must report these incidents to CII. HHSC rules define abuse as: 'The negligent or willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident'.CMS defines abuse as: 'The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of four residents reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to his care needs, which included psychotropic medications, dementia and related behaviors, and acute use of PRN antipsychotic medication after a behavioral incident. This failure could place residents at risk for inappropriate responses to behavioral symptoms and inappropriate use of psychotropic medications.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year-old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), diabetes (a chronic condition where the body can't effectively use or produce insulin, leading to high blood sugar), schizophrenia disorder (a chronic brain disorder causing symptoms like hallucinations, delusions, disorganized thinking and reduced emotional expression), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia hallucinations, delusions with a mood disorder), and insomnia (difficulty sleeping). Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, reflected a BIMS score of 06 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood problems identified, and no verbal or physical behaviors directed towards others. Resident #1 had range of motion impairment on both sides of his lower extremities and used a walker as a mobility device. He required moderate/partial assistance for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 received high-risk medications which included antipsychotic, antidepressant and hypoglycemic medication. Record review of Resident #1's current care plan, initiated 12/29/25, reflected no identified behaviors and no use of psychotropic medications. The current care plan did not discuss the acute behavioral incident on 12/24/25 and 12/31/25 and the new orders obtained for PRN medication. The previous care plan initiated in December 2024 (separate document) reflected Resident #1 took antipsychotic medication, had a diagnosis of vascular dementia and schizophrenia and required psychotropic medication for insomnia. The previous care plan did not indicate any identified behavioral issues or psychological concerns. Record review of Resident #1's physician order summary printed 01/06/25 reflected Resident #1 was prescribed the following medications: Haloperidol Lactate Injection Solution 5ml intramuscularly once time only related to restlessness and agitation for one date (Start Date: 12/30/25 4:15 PM), Xanax Oral Tablet 0.5mg give once every six hours as needed for restlessness and agitation for 14 days (Start Date 12/24/25 at 10:00 PM), Mirtazapine 7.5 mg once at bedtime for insomnia (antidepressant, start date 09/23/25), Seroquel Oral Tablet 200 mg two times a day for vascular dementia without behavioral disturbance (start date 12/03/25), Trazadone 50 mg give 0.5 tablet by mouth three times a day for depression (start date 10/01/25) and Depakote Sprinkles 125mg- give four capsules by mouth two times a day related to vascular dementia (Start date 10/23/25). Review of Resident #1's December 2025 MAR reflected he was administered prn Xanax on 12/28/25 at 8:03 a.m. The MAR also reflected he was administered prn IM Haldol on 12/31/25 at 7:20 a.m. An interview with LVN H on 01/07/26 1:17 p.m. revealed she was the MDS nurse and she was responsible for care planning residents prescribed psychotropic medications. LVN H stated around November 2025 the facility underwent a change of ownership. At that time, the existing care plans did not transfer to the new online system. As a result, all the residents' care plans had to be recreated. LVN H said rebuilding the care plans for a large number of residents while also managing MDS responsibilities was challenging as she was the only person doing it. She stated care plan conferences continued to occur with interdisciplinary participation, but individualized care plans required extensive reconstruction. LVN H stated Resident #1 was on her list, however, during this care plan transition time frame, she had not updated his yet. LVN H was uncertain if she was the only person who could update care plans for acute and new issues. She stated licensed nurses should be capable of initiating care plan updates as well as when clinically significant changes occurred. LVN H stated the importance of individualized behavior-based care planning for residents with dementia and psychotropic medication use and stated the care plans should include specific behaviors, triggers and interventions to guide nursing care. Review of the facility's policy titled, Comprehensive Person-Centered Care Plans, revised March 2022 reflected, .7. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.10. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers; 11. Assessments of residents are ongoing, and care plans are revised as information about the residents and the residents' conditions change.

Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #1) of four residents who were reviewed for psychotropic medications. The facility failed to ensure Resident #1, who had a diagnosis of dementia, was administered PRN Haldol (antipsychotic) with adequate indications for its use. The facility nurse administered PRN Haldol intramuscularly when Resident #1 refused ADL care and was combative. This failure could place residents at risk for being administered unnecessary antipsychotic medication to control behaviors and could have adverse side effects including over-sedation, confusion and decreased quality of life.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected he was an [AGE] year old male, admitted on [DATE]. Resident #1's diagnoses included metabolic encephalopathy (a brain dysfunction caused by systemic metabolic disturbances, leading to symptoms like confusion, memory loss and altered consciousness), vascular dementia (a type of dementia caused by reduced blood flow to the brain, leading to cognitive decline and memory issues), diabetes (a chronic condition where the body can't effectively use or produce insulin, leading to high blood sugar), schizophrenia disorder (a chronic brain disorder causing symptoms like hallucinations, delusions, disorganized thinking and reduced emotional expression), schizoaffective disorder (a serious mental illness blending symptoms of schizophrenia hallucinations, delusions with a mood disorder), and insomnia (difficulty sleeping). Record review of Resident #1's quarterly MDS assessment, dated 10/29/25, reflected a BIMS score of 06 which indicated severe cognitive impairment. Resident #1 had no signs or symptoms of delirium, no negative mood problems identified and no verbal or physical behaviors directed towards others. Resident #1 had range of motion impairment on both sides of his lower extremities and used a walker as a mobility device. He required moderate/partial assistance for all ADLs and was frequently incontinent of bowel and bladder. Resident #1 received high-risk medications which included antipsychotic, antidepressant, and hypoglycemic medication. Record review of Resident #1's current care plan, initiated 12/29/25, reflected no identified behaviors and no use of psychotropic medications. The current care plan did not discuss the acute behavioral incident on 12/24/25 and 12/31/25 and the new orders obtained for PRN medication. Record review of Resident #1's previous care plan initiated in December 2024 reflected Resident #1 took antipsychotic medication, had a diagnosis of vascular dementia and schizophrenia and required psychotropic medication for insomnia. The previous care plan did not indicate any identified behavioral issues or psychological concerns. Record review of Resident #1's psychiatric follow-up evaluation, dated 12/17/25, by Psyche NP B, reflected the resident was seen for medication monitoring and management of psychotropic medications following reports of irritability, restlessness and need for redirection and cues from staff. The evaluation reflected Resident #1 was observed eating lunch in the dining room, appeared calm, and was in no apparent physical or emotional distress at the time of the observation. Psyche NP B documented Resident #1 had dementia and insomnia with cognitive impairment. Chart review by Psyche NP B noted no supporting evidence to validate diagnosis of schizophrenia or schizoaffective disorder and Psyche NP B documented those diagnoses should be removed from Resident #1's medical record due to lack of evidence. Resident #1's current psychotropic medications were reflected as Seroquel (for agitation), Depakote sprinkles (for mood disorder), Trazadone (for agitation and dementia) and Remeron (for insomnia). Record review of Resident #1's physician order summary dated 01/06/25 reflected Resident #1 was prescribed the following medications: Haloperidol Lactate Injection Solution 5ml intramuscularly once time only related to restlessness and agitation for one date (Start Date: 12/30/25 4:15 PM), Xanax Oral Tablet 0.5mg give once every six hours as needed for restlessness and agitation for 14 days (Start Date 12/24/25 at 10:00 PM), Mirtazapine 7.5 mg once at bedtime for insomnia (antidepressant, start date 09/23/25), Seroquel Oral Tablet 200 mg two times a day for vascular dementia without behavioral disturbance (start date 12/03/25), Trazadone 50 mg give 0.5 tablet by mouth three times a day for depression (start date 10/01/25) and Depakote Sprinkles 125mg- give four capsules by mouth two times a day related to vascular dementia (Start date 10/23/25). Review of Resident #1's December 2025 MAR reflected he was administered prn Xanax on 12/28/25 at 8:03 a.m The MAR also reflected he was administered prn IM Haldol on 12/31/25 at 7:20 a.m. The MAR did not reflect any behaviors occurring at the time of prn administration under the behavior monitoring section. Record review of nursing progress notes for Resident #1 reflected:-12/17/25 at 3:05 p.m.by LVN A, Resident noted with more jumpy behavior and combative during care and continues to have an outburst episodes, yelling mama, mama, and trying to kick staff, pt requires more cues to eat, redirected and educated multiple times but not effective, Pt vital signs WNL BP-106/66, P-63, R-18, T-97.7, Spo2- 97% RA, behavior reported to Psych NP. No new order.-12/24/25 at 9:05 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, pt redirected and educated several times but not effective, was reported to NP psych N/O received Xanax 0.5 mg PO every 6 hrs. PRN x 14 days r/t restlessness and agitation. Resident and family notified. MAR updated.-12/30/25 at 8:25 a.m. by LVN A, Late Entry: Note Text: Writer obtained order for prn Haldol IM inj, all orders carried. Will continue to update chart prn.-12/30/25 at 3:06 p.m.by LVN A, Resident continues with outburst and aggressive behavior, yelling mama, mama, and trying to kick staff, when brought to the dining area this AM resident started knocking down the chair and the tables, when redirecting, resident become more restless and agitated, hitting, scratching and kicking the staff members including this writer, he was quickly move out from the dining area and brought back to his room, this writer stayed with him notified DON, ADON and MD, N/O order obtained Haloperidol 5mg/ml Inject1ml intramuscularly one time only as needed. MAR updated, resident and family informed.-12/30/25 at 3:09 p.m. by LVN A, Xanax 0.5 mg 1 tab PO was administered but not effective. An interview with CNA B on 01/06/25 at 1:22 p.m. revealed she worked in the secured unit on the morning shift, took care of Resident #1 for about a year and was very familiar with his behaviors and care needs. CNA B stated on the morning of 12/24/25, she was the CNA responsible for Resident #1. She said that morning, Resident #1 had stool in his brief and needed to be changed. She stated sometimes he did not want care, and when that happened, she went to the charge nurse for assistance. On that morning (12/24/25), CNA B said she notified LVN A of Resident #1's resistance to ADL care. LVN A came to assist with care and they placed Resident #1 in his wheelchair and took him to the dining room. She stated while in the dining room, Resident #1 began knocking on the table and making noise. She stated that behavior happened once in a while but not every day. CNA B stated because of the noise and the reactions of the other residents, she and LVN A decided to remove Resident #1 from the dining room to prevent further problems. She stated Resident #1 was taken back to his room and placed in bed so he would calm down and would not start pulling at other residents. She stated Resident #1 did not slap or hit any other residents during the dining room incident. CNA B stated if a resident hit staff, staff were not supposed to do anything back. She stated the usual response was to remove the resident from the situation and give them time to calm down. She stated that sometimes nursing staff administered medication to calm Resident #1 when he got agitated. CNA B stated that after time in his room, Resident #1 typically calmed down. CNA B stated after the incident on 12/24/25, she did not observe any bruises or injuries on Resident #1 when showering or providing care. An interview with LVN A on 01/06/25 at 2:13 p.m. revealed she was the charge nurse on the secured unit. LVN A stated on 12/24/25, CNA B reported Resident #1 was being kind of resistant. He had a bowel movement and CNA B was trying to provide incontinent care. LVN A said she did not observe Resident #1 being resistant, but CNA B told her that he refused to let her turn him to provide incontinent care. LVN A stated, You know, she [CNA B] asked him to roll over, but he didn't want to, he wanted to stay on his back. LVN A said when she went to his room, she talked to him and said please and Resident #1 was compliant, so they got him dressed and took him to the dining room. Once in the dining room, Resident #1 was sat at a table where nobody else sat and started screaming mama mama! LVN A said Resident #1 knocked down a table and pushed a chair, so for the safety of the other residents, he was taken back to his room by herself and CNA B. LVN A stated she did not touch Resident #1 in the dining room and although he was trying to stand up, he sat back down on his own. She said Resident #1 hit her on the nose while trying to remove him from the dining room. When she got him back to his room, LVN A stated she asked Resident #1 if he was okay and he said no and kept repeating mama, mama, mama, mama. LVN A stated she then transferred him back to bed with CNA B, contacted the doctor, ADON G, and stayed with him until he calmed down. LVN A said Resident #1 calmed down through her talking to him. She said once he was calm, she administered him a PRN Xanax. LVN A stated, He was not really calmed down, but not like aggressive as before. So, I gave it to him to calm down. She said Resident #1 then ate his breakfast and went to eat lunch in the dining room later and was quiet in his demeanor. LVN A stated a couple of days later (date unknown-morning), Resident #1 was destructive and combative. She said CNA B went to get him up and he was tried to fight with her, so LVN A went to see what was going on. She stated Resident #1 was kicking at the air from his bed towards CNA B and herself. LVN A said he was combative and tried to kick her when she approached him. LVN A stated, So I said because I have an order for it (Haldol), well let me give it to him. She said he calmed down after the intramuscular medication administration. LVN A stated Haldol was a one-time only medication and not ongoing. She said she already had the order for the Haldol from the day before. LVN A stated she did not give Resident #1 PRN Xanax during the behavioral incident in his room because he spit it out and that was why she administered PRN Haldol. LVN A stated she knew when it was time for a resident to be administered a PRN psychotropic medication, When the outburst becomes prolonged and you become combative. That's then it's time to administer. An interview with C-RN F on 01/07/26 at 10:30 a.m. revealed PRN IM Haldol would be appropriate for use when a resident had uncontrollable behaviors or behaviors that endangered other residents. She stated she did not know what behaviors occurred with Resident #1 that led to PRN Haldol administration. C-RN F stated there were some acknowledged errors in facility documentation, including no psychotropic medications listed on the care plan, no behaviors documented and behavior monitoring logs reflecting zeros despite medication administration for Resident #1. She stated IM antipsychotics should not be used to compel residents to get out of bed or comply with care. She stated monitoring following antipsychotic administration should occur for three days, including mood, appetite and behavior monitoring, with inclusion on the 24-hour report and emphasized that incomplete documentation undermined care delivery and regulatory compliance. She reported that an in-service on documentation was conducted with the nursing staff for those areas since the incident occurred. Interview with the ADM on 01/07/26 at 1:30 p.m. revealed IM antipsychotics such as Haldol should be used only when a resident posed a threat to themselves or others. He stated he would expect less restrictive interventions to be attempted first and then would review whether oral PRNs such as Xanax were effective. He stated that resisting care alone would not justify IM antipsychotic use and that staff should step away and return later. The ADM stated residents had the right to refuse care. For residents with dementia, he stated situations may be more complex but still emphasized encouragement, stepping away and physician involvement rather than immediate medication escalation. The ADM stated that oversight of PRN antipsychotic use would occur through review of orders and discussions during stand-up meetings with the management team. He stated the DON or the designee would typically review any decisions on psyche PRN use. An observation and interview with Resident #1 was attempted on 01/07/26 at 1:46 p.m. and revealed he did not eat his lunch and his full plate of food was in front of him on the table. His eyes were closed and he was slightly slumped over in his wheelchair. A CNA tried to rouse him and he then jerked his body a few times in waking up and began slowly eating. Resident #1 was not responsive to questions and kept his eyes closed, including through eating his food. He was observed to be in a wheelchair, elderly and not able to particulate in an interview. He was not observed to have any visible injuries on his face, hands or arms at the time of the observation. An interview with CNA E on 01/07/26 at 1:55 p.m. revealed Resident #1 was not normally aggressive and stated repeatedly, That man is not aggressive. She stated that she had worked with Resident #1 regularly since beginning her employment at the facility three weeks prior and had not observed him engaging in violent or combative behaviors. She stated that when she assisted Resident #1 with care, she was typically able to get him up, talked to him and redirected him without difficulty. On the morning of the incident (12/24/25), CNA E stated she first became concerned when she heard commotion and distress sounds coming from the dining room area. She described hearing loud voices and raised tones and stated the situation didn't feel right. She stated she observed Resident #1 being brought into the dining room and he appeared upset, confused, was attempting to communicate but struggling to express himself clearly. She recalled him repeating fragments such as feel, feel, feel. CNA E stated she was able to calm Resident #1 by speaking softly and reassuring him, telling him, [NAME], it's me. She emphasized that this approach worked and helped him de-escalate. In contrast, she described the other staff, specifically CNA B and LVN A using loud, commanding voices and repeatedly telling Resident #1 to sit down, sit down! which she felt escalated the situation. She stated, Y'all didn't give him time, and explained residents had the right to be mad and had the right to be left alone for a little while. She stated staff kept giving him commands rather than allowing him time to calm down. CNA E stated after the dining room incident, Resident #1 was taken back to his room. She stated she never saw Resident #1 flip tables or chairs and stated while he may have pushed against furniture, he did not have the physical strength to seriously harm others. She stated she did not see him assault other residents and did not believe he posed the danger later described by staff. Review of the facility's policy titled, Antipsychotic Medication Use, revised July 2022 reflected, Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed. Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time and are subject to gradual dose reduction and re-review. 9. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: a. The behavioral symptoms present a danger to the resident or others; AND: (1) the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or (2) behavioral interventions have been attempted and included in the plan of care, except in an emergency. 12. Antipsychotic medications will not be used if the only symptoms are one or more of the following: .c. Restlessness; . k. Uncooperativeness; 13. Residents will not receive PRN doses of psychotropic medications unless that medication is necessary to treat a specific condition that is documented in the clinical record.

Based on observation, interview and record review the facility failed to ensure residents were adequately equipped to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-four of six residents (Resident #2, #3, #4, and #5) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #2, #3, #4, and #5's rooms were in a position that was accessible to the residents on 12/30/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.Findings include: Record review of Resident #2's Face Sheet, dated 12/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included reduced mobility and lack of coordination. Record review of Resident #2's Quarterly MDS assessment, dated 12/09/25, reflected a severe cognitive impairment. For ADL care, it reflected the resident required total assistance and an active diagnosis of muscle wasting. Record review of Resident #2's Comprehensive Care Plan, dated 7/07/25, reflected the resident had limited physical mobility and an intervention included encouraging the resident to use the call light for assistance. In an observation on 12/30/25 at 8:38 AM, Resident #2 was observed lying in his bed and his call light was observed hanging from an assist handrail, touching the floor mat on the floor. He was asked if he knew where his call light was located and he stated no. In an interview and observation on 12/30/25 at 8:40 AM, Restorative Aid B showed Resident #2's call light location, and she stated she had just finished bathing the resident and had forgotten to place his call light within his reach. She stated he needed the call light to contact staff if he needed help. Record review of Resident #3's Face Sheet, dated 12/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnoses included muscle weakness and lack of coordination. Record review of Resident #3's Quarterly MDS assessment, dated 12/08/25, reflected severe cognitive impairment. For ADL care, it reflected the resident required extensive assistance. Active diagnosis included a stroke. Record review of Resident #3's Comprehensive Care Plan, dated 6/30/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident. In an observation on 12/30/25 at 8:43 AM, Resident #3 was observed lying in his bed and his call light was observed under his bed on the floor. He was asked if he knew where his call light was located and he stated he did and was pointing to his bed remote. In an interview and observation on 12/30/25 at 8:44 AM, CNA T showed Resident #3's call light location, and she stated someone had just finished bathing the resident and had forgotten to place his call light within his reach. She stated he needed the call light to contact staff if he needed help. Record review of Resident #4's Face Sheet, dated 12/30/25, reflected she was a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of mobility and unsteadiness on feet. Record review of Resident #4's Quarterly MDS assessment, dated 12/14/25, reflected severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Active diagnosis included fractures. Record review of Resident #4's Comprehensive Care Plan, dated 6/30/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident. In an observation on 12/30/25 at 8:46 AM, Resident #4 was observed lying in her bed. She was asked if she knew where her call light was located and she stated it was on her bed, but the call light was observed on the floor, on the far side of the nightstand. In an interview and observation on 12/30/25 at 8:47 AM, CNA T was shown Resident 4's call light location, and she stated she did not know why the resident's call light was not within her reach. She stated she was not the CNA for the resident. She stated the resident needed the call light within reach to contact staff if she needed help. Record review of Resident #5's Face Sheet, dated 12/30/25, reflected she was an [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included lack of mobility and unsteadiness on feet. Record review of Resident #5's Quarterly MDS assessment, dated 12/29/25, reflected severe cognitive impairment. For ADL care, it reflected the resident required substantial assistance. Active diagnosis included a lack of coordination. Record review of Resident #4's Comprehensive Care Plan, dated 6/27/25, reflected the resident was a fall risk and one of the interventions was to ensure call light was within reach of the resident. In an observation on 12/30/25 at 8:50 AM, Resident #5 was observed lying in her bed and her call light was observed on the floor, near the back wall. In an interview and observation on 12/30/25 at 8:52 AM, LVN N was shown Resident #5's call light location, and he stated he did not know why the call light was not within reach of the resident. He stated it was the nurses and CNAs responsibility to ensure the call lights were within the resident's reach so they could call for help if they needed it. In an interview on 12/30/25 at 11:24 AM, the DON was told about Resident #2, # 3, 4, and #5's call lights not being within reach of the residents and she stated all staff should be checking to ensure call lights were within reach of the residents so they could call for help if needed. Record review of the facility's policy on Call System, Residents, January 2025, revealed Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

Based on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's BPAP mask and nasal canula were properly stored in a bag when not in use on 12/30/25. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.Findings included: Record review of Resident #1's Face Sheet, dated 12/30/25, reflected he was a [AGE] year-old male admitted to the facility on [DATE]. Relevant diagnosis included COPD (shortness of breath). Record review of Resident #1's Quarterly MDS assessment, dated 12/16/25, reflected he had an intact cognitive response. The resident had an active diagnosis of COPD. Record Review of Resident #1's physician orders, dated 12/30/25, reflected BPAP to be worn at night on at HS and off in AM and Oxygen continuously via nasal canula In an observation and interview on 12/30/25 at 8:34 AM, Resident #1 was observed sitting in his wheelchair with his nasal canula from his oxygen concentrator attached to his nose and the nasal canula attached to the oxygen tank connected to the wheelchair was dragging on the floor. The resident's BPAP mask was observed sitting on top of his nightstand unbagged. Resident #1 stated he had not used the mask since 6:00 AM. In an interview and observation on 12/30/25 at 8:36 AM, RN J was shown Resident #1's nasal canula dragging on the floor and his BPAP mask unbagged. He stated he did not know why both items were not bagged. He stated both items should have been bagged to avoid the resident from getting an infection. In an interview on 12/30/25 at 11:24 AM, the DON was told about Resident #1 not having his nasal canula and his BPAP masked bagged. She stated the resident was very non-compliant. She stated it was the nurse's responsibility to ensure both items were bagged. She stated it should be bagged to prevent any cross contamination. In an interview on 12/30/25 at 1:00 PM, the ADON was advised of Resident #1's nasal canula and BPAP mask not being bagged and she stated they should be bagged when not in use to avoid contamination and the resident getting an infection. Review of the facility's policy Oxygen Administration, 10/2020, reflected The purpose of this procedure is to provide guidelines for safe oxygen administration. 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration.2. Review the resident's care plan to assess any special needs of the resident.3. Assemble the equipment and supplies as needed.

Based on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for 2 (Resident #1 and Resident #8) of 3 residents reviewed for accuracy of assessments. The MDS did not address Resident #1 and Resident #8's oxygen use. This failure could place residents at risk of missed services, treatments, and overall decline in health. Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). Record review of Resident #1's Comprehensive MDS Assessment, dated 10/29/2025, reflected the resident was cognitively intact with a BIMS score of 12, indicating the resident had moderately impaired cognition Section O Special treatments, procedures, and programs did not address resident oxygen treatment. Record review of Resident #1's Comprehensive Care Plan, dated 06/30/2025, reflected the resident The resident has Oxygen Therapy r/t COPD. She is at risk for shortness of breath. Resident's oxygen tubing often has discoloration r/t heavy smoking. Edited: 06/30/2025 interventions Monitor for s/sx of respiratory distress and report to MD PRN: Respirations, Pulse oximetry (a non-invasive medical procedure that measures the oxygen saturation of the blood), Increased heart rate (Tachycardia), Restlessness, Diaphoresis (excessive sweating), Headaches, Lethargy (lack of energy), Confusion, Atelectasis (partial or complete collapse of the lung), Hemoptysis (the coughing up of blood or bloody mucus from the lungs or airways.), Cough, Pleuritic pain (sharp stabbing pain). Accessory muscle usage, Skin color. OXYGEN SETTINGS: The resident has O2 via nasal prongs (two small tubes that are placed into a patient's nostrils to deliver supplemental oxygen.) @ 2LPM PRN. Resident is a smoker and is at risk for injury. Interventions monitor PRN when smoking to ensure residents safety perform smoking assessment according to facility policy. staff to supervise during smoke breaks. Resident #8Record review of Resident #8's face sheet dated 11/04/2025 reflected he was a [AGE] year-old male that was admitted on [DATE] with diagnosis of COPD Lung Record review of Resident #8's Comprehensive MDS Assessment, dated 10/16/2025, reflected the resident was cognitively intact with a BIMS score of 13, indicating the resident had moderately impaired cognition. Section O Special Treatments, Procedures, and programs did not address his oxygen treatments. The section was left blank. Record review of Resident #8's Comprehensive Care Plan, dated 09/07/2025 reflected [Resident #8] has Oxygen Therapy r/t SOB associated with COPD.interventions administer medications as ordered, Monitor for s/sx of respiratory distress and report to MD PRN. OXYGEN SETTINGS: The resident has, O2 via nasal @ 3 LPM. Position resident to facilitate ventilation/perfusion matching: Use upright, high-Fowlers position (a medical posture where the patient is sitting upright with the head of the bed elevated at a 60-90 degree angle. ) whenever possible to allow for optimal diaphragm , When on side, the good side should be down (damaged lung should be up). Record review of Resident #8's Physician's Order dated 08/26/2025 reflected Nurse to verify 02 humidification bottle/chamber has adequate amount of distilled water, at least every shift. every shift.Oxygen continuously via Nasal Cannula. May titrate between 2-5 LPM for shortness of breath or pulse oximetry < 90%. every shift for SOB and to maintain pulse ox > 90% . Nurse to verify 02 humidification bottle/chamber has adequate amount of distilled water, at least every shift.order dated 09/28/2025 reflected an order Check Oxygen Concentrator filter for placement and clean filter every week and PRN every night shift every Sun. Record review of Resident #8's October TAR reflected that the oxygen concentrator was checked, tubing and water was changed on 10/05/2025, 10/12/2025, 10/19/2025, and 10/26/2025. Record review of Resident #8's November TAR reflected that the Oxygen Concentrator filter was checked, tubing and water was changed on 11/02/2025 during the night shift. The water was checked for adequate distilled water on the Day, Evening, and night shift 11/01/2025, 11/02/2025, 11/03/2025, and 11/04/2025. Observation and interview on 11/04/25 at 10:50 AM revealed Resident #8 was awake, sitting in his wheelchair with nasal cannula on receiving oxygen via concentrator. During an interview on 11/04/2025 at 2:00 PM, the DON stated that she reviewed and signed the completed MDSs upon completion of all the sections as the RN. She stated that if the oxygen treatment was not coded, it meant the resident did not use it during the look back period. She would have to check the resident files. She did not address the negative outcome to the resident. During an interview on 11/04/2025 at 2:20 PM, the Administrator stated it was his expectation for the comprehensive MDS assessments to be completed accurately. During an interview on 11/06/2025 at 1:30 PM with MDS, revealed she completed sections B-health speech and vision, C-Cognitive, D-Mood, E-Behaviors, and Q-participation in Assessments and goal setting. She stated the importance of the resident's comprehensive MDS being accurate was to ensure the resident received the proper care they needed. Record review of facility policy dated 03/2022 and titled Resident assessments reflected The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.The RAI User's Manual (Chapter 2) provides detailed information on timing and submission of assessments. A comprehensive assessment includes completion of the Minimum Data Set (MDS); completion of the care area assessment (CAA) process; and development of the comprehensive care plan.

Based on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #1) reviewed for abuse. 1. Resident #1 was referred to as a pig and spoken to in a rude manner on a recorded video. 2. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity. The findings included: Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia (have trouble falling asleep or staying asleep), Essential Hypertension (high blood pressure), and Restlessness and Agitation. Record review of Resident #1's Admission MDS Assessment, dated 10/16/24, reflected Resident #1 had a BIMS score of 05, which indicated Resident #1 was severely impaired. Record review of video #1, posted online on 11/30/24, reflected the Activities Assistant as she spoke to Resident #1 reflected the Activities Assistant as she asked the Visitor Why does she (Resident #1) have so many (cupcakes), did you give her those. The visitor asked, She asked for two, can she not have two?. The Activities Assistant can then be heard telling the visitor, She (Resident #1) will make a pig out of herself so don't. The Visitor and Resident #1 sat at the table together at the time of the conversation. Record review of video #2, posted online on 11/30/24, reflected the Activities Assistant was at one table, and Resident #1 was at a table near the Activities Assistant. The residents were in the dining hall of memory care watching a movie. The Activities Assistant can be heard asking Resident #1, Why don't you go wash your hands?, Resident #1 replied, I am just teasing her (The Visitor), and the Activities Assistant replied to Resident #1, Go wash your hands. Look at the mess you made. An unknown person in the background stated, It's messy, and Activities Assistant can be heard saying, It is. Resident #1 can be seen rolling up the cupcake papers and napkins and stated to the Activities Assistant, I'll go. Resident #1 asked the Activities Assistant, Where can I wash at, and Activities Assistant replied, Try your room, as she starred at Resident #1. Resident #1 replied, Okay, no problem. I messed up. I have to clean up. Resident #1 was observed gathering the crumbs from the cupcake off the table. In an interview on 12/06/24 at 9:45 AM, Resident #1 stated she was having a good morning, as she sat and spoke with other residents in the dining hall of memory care. When Surveyor asked Resident #1 about Thanksgiving, Resident #1 just started Thanksgiving was good. Resident #1 stated the staff were good and she was treated well. Resident #1 did not remember anything specific about Thanksgiving when Surveyor asked. In an interview on 12/06/24 at 11:00 AM, Resident #1's Family Member stated she was very mad and upset when she saw the video on social media. The family member stated she and other family members were upset that someone filmed Resident #1, but they were also upset about how the Activities Assistant spoke to Resident #1. The Family Member stated Resident #1 did not really remember the incident, but she could only remember eating the cupcakes. The Family Member stated she was upset that the Activities Assistant referred to Resident #1 as a pig. The Family Member stated the family contacted the DON and asked for the DON to meet them at the facility. The Family Member stated they sent the videos to the DON, and the DON stated she would have been upset as well. The Family Member stated the DON and Administrator stated the Activities Assistant was going to be suspended. A telephone interview on 12/06/24 at 11:40 AM was attempted to the Activities Assistant, but there was no answer and no returned call. A telephone interview on 12/06/24 at 3:15 PM was attempted to the Visitor, but there was no answer and no returned call. In an interview on 12/06/4 at 3:22 PM, with the Administrator and the DON, the DON stated the facility did not have a policy regarding social media or recording other than for employees. The DON stated Resident #1 did not recall the incident, but Resident #1's family was not happy about how the Activities Assistant spoke to Resident #1. The DON stated they completed safe surveys with all residents. The DON stated they also completed in-services with the staff and the Activities Assistant was in-serviced and suspended at that time. The DON stated the Activities Assistant should not have spoken to Resident #1 in that manner. The DON stated the risk of staff speaking to the residents in that manner was the well-being and feelings of the resident. The Administrator stated he agreed with what the DON stated. Record review of the facility's policy titled, Abuse/Reportable Events, dated 12/01/18, reflected the following: Policy: All residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Residents should not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The facility will provide and ensure the promotion and protection of resident rights. It is everyone's responsibility to recognize, report, and promptly investigate actual or alleged abuse, neglect, exploitation, mistreatment of residents or misappropriation of resident property abuse and situations that may constitute abuse or neglect to any resident in the facility. Record review of the facility's policy, titled, Resident Rights, dated 12/01/18, reflected the following: Dignity and Respect You have the right to Be treated with dignity, courtesy, consideration, and respect

Based on interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy. 1. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy. The findings included: Record review of Resident #1's face sheet, dated 12/06/24, reflected a [AGE] year-old female, who admitted to the facility on [DATE]. Resident #1 had a diagnosis of Mood Disorder (mental illness that affects a person's emotional state), Insomnia (have trouble falling asleep or staying asleep), Essential Hypertension (high blood pressure), and Restlessness and Agitation. Record review of Resident #1's Admission MDS Assessment, dated 10/16/24, reflected Resident #1 had a BIMS score of 05, which indicated Resident #1 was severely impaired. Record review of video #1, posted online on 11/30/24, reflected the Activities Assistant as she spoke to Resident #1 reflected the Activities Assistant as she asked the Visitor Why does she (Resident #1) have so many (cupcakes), did you give her those. The visitor asked, She asked for two, can she not have two?. The Activities Assistant can then be heard telling the visitor, She (Resident #1) will make a pig out of herself so don't. The Visitor and Resident #1 sat at the table together at the time of the conversation. Record review of video #2, posted online on 11/30/24, reflected the Activities Assistant was at one table, and Resident #1 was at a table near the Activities Assistant. The residents were in the dining hall of memory care watching a movie. The Activities Assistant can be heard asking Resident #1, Why don't you go wash your hands?, Resident #1 replied, I am just teasing her (The Visitor), and the Activities Assistant replied to Resident #1, Go wash your hands. Look at the mess you made. An unknown person in the background stated, It's messy, and Activities Assistant can be heard saying, It is. Resident #1 can be seen rolling up the cupcake papers and napkins and stated to the Activities Assistant, I'll go. Resident #1 asked the Activities Assistant, Where can I wash at, and Activities Assistant replied, Try your room, as she starred at Resident #1. Resident #1 replied, Okay, no problem. I messed up. I have to clean up. Resident #1 was observed gathering the crumbs from the cupcake off the table. In an interview on 12/06/24 at 9:45 AM, Resident #1 stated she was having a good morning, as she sat and spoke with other residents in the dining hall of memory care. When Surveyor asked Resident #1 about Thanksgiving, Resident #1 just started Thanksgiving was good. Resident #1 stated the staff were good and she was treated well. Resident #1 did not remember anything specific about Thanksgiving when Surveyor asked. In a telephone interview on 12/06/24 at 11:00 AM, Resident #1's Family Member stated she was very mad and upset when she saw the video on social media. The family member stated she and other family members were upset that someone filmed Resident #1, and then it was uploaded to a public, social media application. The Family Member stated Resident #1 did not really remember the incident, but she could only remember eating the cupcakes. The Family Member stated she was upset Resident #1 was recorded in several videos. The Family Member stated the family contacted the DON and asked for the DON to meet them at the facility. The Family Member stated they sent the videos to the DON, and the DON stated she would have been upset as well. The Family Member stated she was not sure how the visitor got in the building, the staff told her they were still investigating to see who the visitor was and why she recorded the videos. The Family Member stated the DON stated the staff were not aware the visitor was recording the resident. In an interview on 12/06/24 at 12:40 PM, the DON stated the facility only had a policy regarding staff and electronic monitoring or rules for visitors, but she would research to confirm there was no other policy. In an interview on 12/06/24 at 3:22 PM, the DON stated no residents should be recorded without their permission, it goes against the resident's rights. The Administrator stated he agreed with the DON. Record review of the facility's policy, titled, Resident Rights, dated 12/01/18, reflected the following: Privacy and Confidentiality You have the right to Privacy, including privacy during visits, phone calls, and while attending to personal needs

Based on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for one (Resident #36) of 8 residents reviewed for pharmacy services . The facility failed to administer the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems. This failure could result in residents experiencing severe pain, not receiving medications prescribed by their physician and decreased quality of life. Findings included: Record review of Resident #36's Face Sheet dated 11/30/23 revealed she was readmitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm. Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications. Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician. Record review of Resident #36 Physician Encounter note dated 11/17/23 completed by NP J reflected the following: Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain. History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine. Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis] Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy . Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1 tab Q6 H PRN. Will closely monitor. Educated about SE [side effects] Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified. Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee. Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date: Open ended. Dx Other muscle spasm. Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00 Record review of Resident #36's Medication Administration Record (MAR) dated 11/1/23 through 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified. The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following: 11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F 11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I. 11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H. 11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G. 11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H. 11/30/23 7:00 AM: No entry. Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries: 11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E. 11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H. 11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry 11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H. 11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate. During an observation and interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day. On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again. During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available. Interview with the DON on 11/30/23 at 9:26 AM revealed she had been just made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out. The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same. The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately. The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative. Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days. During a follow-up interview on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.5-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again. In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill. A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications. During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available. During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable. An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning. LVN H stated medications should be ordered 3-5 days ahead of time to ensure availability. In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order. Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry: 11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D 11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn was being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D. 11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON. 11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E. Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0. Record review of the facility's Policy and Procedure titled Medication Administration dated 12/2018 revealed the following: POLICY It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. PROCEDURE 1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration .10. If a dose of regularly scheduled medication is withheld or refused, the space provided on the front of the MAR for that dosage administration is initialed and circled. The physician will be notified if medication is routinely refused. Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following: POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life. Procedure 1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is .10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures. Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following: Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident . Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy and Substandard Quality of Care had been identified in the area of Significant Medication Errors. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23. The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected: 11/30/2023 Plan of Removal - F-760 Medication Error- Immediate Action Taken Resident Specific The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale. Physician was notified/Medical director on 11/30/2023. Residents was immediately assessed for pain by the DON resident stated her pain was a 10/10 Alternative medication Norco 10/325mg one time dose Resident was reassessed in 1 hour by charge nurse after alternate medication was administered resident was asleep. Medication Error form completed. Pharmacy called by the DON awaiting medication to arrive. System Changes Residents will be monitored for pain daily all negative findings will be giving to the DON/ designee. 100% Audit will be completed of all resident's pain risk to ensure all at risk residents have been identified. Audit was initiated on 11/30/2023 and will be completed on 12/1/2023 by Nurse managers. DON/designee will monitor medication available report daily to ensure all medications are given as ordered to address any possible significant medication errors. System initiated on 11/30/2023. Education Regional Nurse Consultant, RNC educated DON/ADON/MDS if a resident is out of pain medication to notify the MD and DON immediately on 11/30/23. DON/Designee will educate Nurses CMA's if a resident is out of pain medication to notify the MD and DON immediately. Initiated on 11/30/2023 and will continue until all nurse / CMA's have been educated prior to working the floor. DON/Designee will educate staff on when to re-order medications. Initiated on 11/30/2023 and will continue until all nurse / CMA's have been educated prior to working the floor. DON/Designee will in-service on the availability of medication in the E-kit and calling the physician for any medications not available for an alternative dose or alternate medication that is available in the E-kit not following these instructions will result in disciplinary action. Initiated on 11/30/2023 and will continue until all nurse/CMA's have been educated prior to working the floor. Monitoring DON/Designee will randomly interview resident daily. Initiated on 12/1/2023 and 12/31/2023 end [sic] Residents will have a pain risk observation completed quarterly. Administrator and RNC will review each task overseen by DON / Designee weekly beginning 12/1/23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process. Monitoring of the facility's Plan of Removal included the following: Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review. Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose. In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D acknowledged the failure to administer scheduled medications was a medication error. She described the risks of medications errors as increased blood pressure for a resident who didn't receive their blood pressure medications and stated residents who did not receive their ordered pain medications as at risk suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors. In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She explained residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and monitor the resident. She stated she was responsible for investigating and documenting the errors. The DON stated all staff currently working had received their in-service training. All staff not yet trained will receive in-service prior to beginning their next shift. During an interview on 12/1/23 at 4:50 PM, the Regional Director of Operations stated he felt all the problems identified came down to communication. He stated medication issues should start with the nurse and move up the chain. He stated he had periodically attended the facility stand-up meeting and planned to attend more regularly and monitor the situation. The Regional Director of Operations stated he and his Regional Nurse Consultant would also increase their monitoring of the resident's clinical records for compliance. In an interview on 12/1/23 at 5:15 PM, the Administrator stated he expected medications to be ordered timely and he planned to oversee the process with the Regional Nu [TRUNCATED]

Based on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #36) of 8 residents reviewed for pharmacy services. 1. The facility failed to obtain the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication causing her to experience severe pain. The medications were received after surveyor inquiry. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems. This failure could place residents who require pain management at risk of suffering severe pain due to lack of medication availability. 2. The facility failed to prevent an employee with access to controlled medications from diverting an unknown number of Tylenol #3 tablets (a Schedule III narcotice used to treat pain) belonging to Resident #57 from a medication cart. This failure could place residents at risk for unrelieved pain due to his medication not being readily available. Findings included: 1. Record review of Resident #36's Face Sheet dated 11/30/23 revealed the resident was readmitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm. Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications. Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician. Record review of Resident #36 Physician Encounter note dated 11/17/23 completed by NP J reflected the following: Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain. History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine. Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis] Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy .Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1-tab Q6 H PRN. Will closely monitor. Educated about SE [side effects] Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified. Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee. Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date: Open ended. Dx Other muscle spasm. Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00 Record review of Resident #36's Medication Administration Record (MAR) dated 11/1/23 through 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified. The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following: 11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F 11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I. 11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H. 11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G. 11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H. 11/30/23 7:00 AM: No entry. Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries: 11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E. 11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H. 11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry 11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H. 11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate. During an interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E, and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day. On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again. During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available. Interview with the DON on 11/30/23 at 9:26 AM revealed she had been just made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out. The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same. The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately. The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative. Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days. During a follow-up interview on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.5-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again. In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill. A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications. During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available. During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable. An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning. LVN H stated medications should be ordered 3-5 days ahead of time to ensure availability. In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order. Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry: 11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D 11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn are being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D. 11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON. 11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E. Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0. Record review of the facility's Policy and Procedure titled Medication Administration dated 12/2018 revealed the following: POLICY It is the policy of this home that medications will be administered and documented as ordered by the physician and in accordance with state regulations. PROCEDURE 1. Medications are prepared, administered, and recorded only by licensed nursing, certified medication aides, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medications . 8. Medications are administered within 60 minutes of scheduled time, unless otherwise specified by the physician. The resident's MAR is initialed by the person administering a medication, in the space provided under the date, and on the line for that specific medication dose administration .10. If a dose of regularly scheduled medication is withheld or refused, the space provided on the front of the MAR for that dosage administration is initialed and circled. The physician will be notified if medication is routinely refused. Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following: POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life. Procedure 1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is .10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures. Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following: Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident . Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy had been identified in the area of pharmacy services. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23. The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected: 11/30/2023 Plan of Removal - F-755 Pharmacy Services Immediate Action Taken Resident Specific The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale. 100% orders and medications were immediately audited for medication availability by DON/ADON's no negative findings. System Changes DON/designee will audit medication carts and matching any new orders weekly for medication availability. Audit was initiated on 11/30/2023 and completed on 11/30/2023 by 5 p.m. Pharmacy reordering system will be followed during medication re-ordering and was initiated 11/30/23 and ongoing. E-Kit will be available for charge nurses to use if medication is not available from the pharmacy or if the physician will order alternative drug until the medication is available from the pharmacy. DON/designee will review all medication weekly for medication availability and for re-ordering this will be conducted simultaneously. Don/Designee conducted review for medication availability on 11/30/2023 and competed the process by 4 p.m. on 11/30/23. Education Regional Nurse Consultant, RNC educated DON/ADON on when to re-order medications. Education was conducted on 11/30/2023 and completed on 11/30/2023. DON/Designee will educate LVN/RN/CMA on when to re-order medications. Education was initiated on 11/30/2023 at 2p.m. and will continue until all LVN/RN/CMA are educated and prior to their next shift. Monitoring DON/Designee will randomly check all medication carts for matching medication and orders daily for medication availability. Monitoring began on 11/30/2023 and will end 12/14/2023. DON/designee will audit all medication carts monthly for medication availability matching orders with medication. Monitoring began 11/30/23. DON/Designee will pull medication availability report daily. Process was initiated on 11/30/2023 and will continue daily until 12/31/2023. Administrator and RNC will review each task overseen by DON/ Designee weekly beginning 12/1/ 23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process. Monitoring of the facility's Plan of Removal included the following: Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review. Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose. In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D stated the failure to administer scheduled medications was a medication error. She stated residents who did not receive their ordered pain medications are at risk of suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors. In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She stated residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and monitor the resident. She stated she was responsible for investigating and documenting the errors. The DON stated all staff currently working had received their in-service training. All staff not yet trained will receive in-service prior to beginning their next shift. During an interview on 12/1/23 at 4:50 PM, the Regional Director of Operations stated he felt all the problems identified came down to communication. He stated medication issues should start with the nurse and move up the chain. He stated he had periodically attended the facility stand-up meeting and planned to attend more regularly and monitor the situation. The Regional Director of Operations stated he and his Regional Nurse Consultant would also increase their monitoring of the resident's clinical records for compliance. In an interview on 12/1/23 at 5:15 PM, the Administrator stated he expected medications to be ordered timel[TRUNCATED]

Based on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #36) of 8 residents reviewed for pain management. The facility failed to ensure Resident #36 received her scheduled pain medication every six hours as ordered when her supply ran out. Resident #36 received no scheduled or PRN pain medication for more than two days until surveyor inquiry causing her to experience severe pain. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems. This failure placed residents who require pain management at risk of suffering severe pain. Findings included: Record review of Resident #36's Face Sheet dated 11/30/23 revealed she was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), congestive heart failure, muscle wasting and atrophy (loss of strength), anxiety disorder due to known physiological condition, pain in right knee, pain in right hip, difficulty walking and muscle spasm. Record review of Resident #36's most recent MDS assessment dated [DATE] revealed she had a BIMS score of 8 indicating she had moderately impaired cognition. She had occasional pain that occasionally affected her day-to-day activities and made it hard for her to sleep at night. The MDS Assessment also reflected she received routine and PRN pain medications. Record review of Resident #36's current Care Plan revealed the following entry dated 5/27/21, revised 6/22/23: Category: Medication. The resident is on Pain medication therapy r/t Diabetes Neuropathy. Goal: The resident will be free of any discomfort or adverse side effects from pain medication Approach: Administer medication as ordered: Gabapentin [nerve pain medication]; Norco [hydrocodone-pain medication]; Methocarbamol [muscle relaxer]; hot/cold menthol patch; Tramadol [pain medication] prn, as ordered. Discipline: Nursing, Physician. Record review of Resident #36's Physician Encounter note dated 11/17/23 completed by NP J reflected the following: Subjective: Chief Complaint: Reports low back pain, BL [bilateral] LE [lower extremity-legs] pain, Rt [right] knee pain, left knee pain. History of Present Illness: [AGE] year-old long term care resident with PMH significant for DM, cirrhosis, portal HTN [elevated pressure in vein leading to liver], CVA, seen for chronic [lasting a long time] pain management by the request of the primary care team and the nurse. Pt is requesting to take Norco [hydrocodone] routine. Pain HPI. LOCATION: right leg, left leg, right knee, left knee. QUALITY: aching, throbbing, dull SEVERITY: 9/10 without medication, 4/10 with medication DURATION: chronic in nature. TIMING: intermittent throughout the day. CONTEXT: DJD [degenerative joint disease-worn down tissue at the end of bones] OA [osteoarthritis] Physical Exam: .Musculoskeletal: general: Pain, weakness. Atrophy: Diffuse Muscular Atrophy . Plan: .Pain Medication Norco [hydrocodone] 7.5/325 1 tab by mouth Q6 H routine, and Robaxin [methocarbamol] 500 mg 1-tab Q6 H PRN. Will closely monitor. Educated about SE [side effects] Record review of Resident #36's Physician Order Report printed 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 8/14/23, End date: 11/28/23. Dx Pain, unspecified. Hydrocodone-acetaminophen tablet; 7.5-325 mg 1 tablet every 6 hours 07:00, 13:00, 19:00, 01:00 [administer at 7 AM, 1 PM, 7 PM and 1 AM] Hold when resident is sedative/sleepy. Start date: 11/28/23, End date: Open Ended. Dx Pain, unspecified. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 8/14/23, End date: 11/28/23. Dx Pain in right knee. Tylenol Extra Strength tablet 500 mg 1 tablet every 6-hour PRN Start date: 11/28/23, End date: Open Ended. Dx Pain in right knee. Methocarbamol (muscle relaxer) 500 mg 1 tablet every 8 hours PRN. Start date: 3/16/23-End date: Open ended. Dx Other muscle spasm. Pain Assessment Q Shift using the Numeric or PAINAD scale. Special Instructions: DOCUMENT RESULTS Every Shift; Day Shift 06:00 - 14:00, Evening Shift 14:00 - 22:00, Night Shift 22:00 - 06:00 Record review of Resident #36's Medication Administration Record dated 11/1/23 through 11/30/23 revealed the following entries: Hydrocodone-acetaminophen tablet; 7.5-325 mg Amount to Administer: 1 tablet every 6 hours. DX: Pain, unspecified. The last dose initialed as administered was 11/27/23 at 7:00 PM. The remaining doses reflected the following: 11/28/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: script needed. Signed by LVN F 11/28/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/28/23 7:00 PM: Not Administered: Drug/Item unavailable. Signed by LVN I. 11/29/23 1:00 AM: Not Administered: Drug/Item unavailable. Signed by LVN H. 11/29/23 7:00 AM and 1:00 PM: Not Administered: Drug/Item unavailable. Signed by ADON D. 11/29/23 7:00 PM: Not Administered: Other Comment: med not available, will f/u pharmacy. Signed by LVN G. 11/30/23 1:00 AM: Not Administered: Drug/Item unavailable Comment: awaiting pharmacy delivery. Signed by LVN H. 11/30/23 7:00 AM: No entry. Methocarbamol 500 mg every 8 Hours-PRN. Three doses were administered on 11/27/23 for pain and muscle spasms. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Tylenol Extra Strength 500 mg Every 6 Hours-PRN. No doses were signed as administered from 11/28/23 through 11/30/23 [reviewed 11/30/23 8:40 AM]. Pain Assessment Q Shift using the Numeric or PAINAD scale revealed the following entries: 11/28/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/28/23 Evening Shift 2:00 PM to 10:00 PM: Pain Level 0 signed by ADON E. 11/28/23 Night Shift 10 PM to 6:00 AM: Pain Level 0 signed by LVN H. 11/29/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. 11/29/23 Evening Shift 2:00 PM to 10:00 PM: No entry 11/29/23 Night Shift 10 PM to 6:00 AM: Pain Level 7/10 signed by LVN H. 11/30/23 Day Shift 6:00 AM to 2:00 PM: Pain level 0 signed by ADON D. During an observation and interview on 11/30/23 at 8:15 AM, Resident #36 was in her room, in her bed, she was frowning and asked if state surveyor could check on her medications for her. She stated she had not been getting her medicine for about four days, the staff kept telling her they were waiting for the pharmacy delivery. She stated the medication was hydrocodone for her pain. Resident #36 stated her legs, knees, and feet were very painful and they were not giving her anything for it. She shook her head, motioned toward her legs and rubbed her thighs. She stated she had been complaining of pain to the staff for days and they won't do anything! Resident #36 appeared upset and asked state surveyor to please let me know what is happening because no one will tell me anything! Resident #36's roommate, Resident #22, stated she had heard Resident #36 complaining of pain for the past couple of days and confirmed the staff had been telling her they were waiting for the pharmacy. She stated she did not have any medication issues herself but was worried about her roommate. During an observation and interview with ADON D and ADON E on 11/30/23 at 8:20 AM, ADON D confirmed she had cared for Resident #36 that week and stated the resident did not have any hydrocodone available on 11/29/23 and she had previously called NP J about it who told her she had sent the prescription to the pharmacy. She stated she called the pharmacy on 11/29/23 and was told it would be on the next delivery, but it was not. ADON D stated today is day two when asked how long she had been out of hydrocodone. ADON D stated Resident #36 was receiving scheduled doses of gabapentin and had muscle relaxers and Tylenol extra strength ordered as needed. When asked about an emergency medication kit (E-kit), ADON D stated they previously had a box and had recently been switched to a Pyxis (machine that distributes medication) and stated they were just filling it. ADON D checked a computer and stated Resident #36's last dose was 11/28/23. She stated she would call the pharmacy and check the E-kit, then walked away. ADON E was working with a medication cart and confirmed it was the cart that contained Resident #36's medications. She stated she was just coming on and did not know anything about her situation. The medication cart was checked with ADON E , and she confirmed there was no hydrocodone available for her. When asked how often medications were re-ordered for residents, ADON E stated she usually reordered when a resident was down to about 15 tablets or half a card just to be safe. She stated she may order them earlier if a resident takes multiple doses per day. On 11/30/23 at 8:28 AM, ADON D returned and stated she just checked the E-Kit and it only contained hydrocodone 5 mg and 10 mg tablets, and Resident #36 took 7.5 mg tablets. She stated she would contact the pharmacy again. During a follow-up interview and observation with Resident #36 on 11/30/23 at 8:30 AM, she stated she had not been given anything else for pain. ADON D entered the room during the interview and asked Resident #36 if she was in pain. Resident #36 stated she was hurting bad and rated her pain 10/10. When ADON D told the resident she had muscle relaxers and Tylenol available, Resident #36 replied, You know I don't want that Tylenol, it doesn't do anything! ADON D presented her cell phone and pointed out her text messages and stated she had texted NP J on Monday (11/27/23), told her about the scheduled hydrocodone and informed her there was only one tablet left. When asked if that meant she had not received any doses since Monday, ADON D did not answer, walked away toward her office, and took a phone call. Once off the phone, ADON D stated she had called NP J again on 11/29/23 (Wednesday)and told her the medication was not available. She stated she had checked the E-Kit on 11/29/23 as well but did not inform the pain doctor there were other dose strengths available. Interview with the DON on 11/30/23 at 9:26 AM revealed she had just been made aware of Resident #36's lack of available hydrocodone that morning. She stated she had just hung up with NP J and the Medical Director and they were getting a one-time order for hydrocodone 10 mg and pulling one from the E-kit while they get the issue resolved. She stated NP J told her she had sent the prescription to the pharmacy earlier in the week. The DON said she called the pharmacy, and they told her they had not received it. She stated the Medical Director was in the process of sending one at that time. The DON explained controlled medications, like hydrocodone, require special triplicate prescriptions. She stated they normally do not require them for refill order as the physicians will order a six-month supply. The facility has authorized agents, like herself, who can order refills. She explained, in this instance, Resident #36 did not have any more refills and required a new prescription. She stated normally either the pharmacy would have notified her, or the Charge Nurse would have notified the physician. The DON stated ADON D told her she had notified NP J prior to the medication running out. The DON stated she knew Resident #36 had Tylenol available as well as muscle relaxers but did not know if any had been administered. She stated she would not consider Tylenol Extra Strength to be a suitable replacement for hydrocodone but Resident #36 had muscle relaxers ordered as well and she expected her pain to be managed in some form or fashion. The DON sated she did not know if Resident #36's pain had been monitored and said it should have been monitored and documented on the MAR. The DON stated she was aware the E-kit had been stocked but, unfortunately, did not have the hydrocodone 7.5 mg dose available that had been ordered for Resident #36. She stated she did not know if anyone had told NP J or the Medical Director there were alternate doses available in the E-kit. The DON stated, if a resident ran out of pain medication, she expected the nurses to check the E-kit, look for back-up medications or other PRN orders available for the resident. If the medications were not effective, she expected the nurses to notify the physician. When asked if she was aware this was a scheduled medication, she stated she was not, but her expectations would be the same. The DON explained medication reorders were discussed in their stand-up meetings. If a nurse ordered a medication, it was written on a board and followed for three days. She was not aware of Resident #36's medication. She stated they had missed their stand-up meeting on 11/28/23 as the survey began that day so that possibly contributed. She stated there was no facility policy for medication reorders, but she expected her nurses to use their judgement and order medications three to five days ahead of time. The DON stated pain monitoring and medication administration were important because she wanted everyone to be comfortable and pain free for quality of life. She stated, My expectation is for my staff to take care of the patients and manage their pain appropriately. The DON stated medications could be ordered any time of day. When asked about other nurses caring for Resident #36 during the last three days, the DON identified LVN G and LVN I as agency nurses and LVN H as working night shift and PRN. She stated she had the same expectations for Agency nurses as she had for facility staff. She stated, I would think they would know as nurses not to let residents go without pain medications. It is very easy to reorder medications in [the computer software]. She stated the failure was of the nurse who first ordered it to notify her and that did not happen. The DON stated they try to keep their E-kit stocked with whatever medications residents have ordered. When it was noted hydrocodone 7.5 mg was not available, they should have tried to contact the physician for an alternative. Observation and interview with Resident #36 on 11/30/23 at 11:10 AM revealed she was resting in bed with her eyes closed and responded to voice. She stated she had received some medication and was feeling better. She stated she was grateful because I have been asking for days. During a follow-up interview and observation on 11/30/23 at 11:16 AM, ADON D showed her cell phone with text messages. She identified the texts as being between herself and NP J. The text was dated Monday, 11/27/23 at 1:49 PM and reflected, Hey, [Resident #36] has 2 hydrocodone 7.6-325 can you please reorder? The text response reflected, Ok. ADON D stated she called NP J again today and was told she was sending the triplicate again. In an interview on 11/30/23 at 11:30 AM, the Administrator and Regional Operations Manager stated there was no policy regarding reordering medications. The Administrator said the medications should have been ordered and they knew the resident had missed 9 doses of regularly scheduled hydrocodone 7.5.mg. They said the nurse should have informed the ADON or DON and the emergency meds should have contained the correct dose for the resident. The Administrator said they failed to have the appropriate medications on hand, in the emergency dispenser, and the staff did not tell anyone they needed to be ordered - they said this was a concern and placed the resident in harm due to missing their pain medication. The Administrator and Regional Operations Manager stated the Regional Nurse Consultant was at home and ill, but they planned to call her. A telephone interview with the Medical Director on 11/30/23 at 12:08 PM revealed he was Resident #36's attending physician. He stated he had been made aware of an issue with Resident #36's prescription and had just stopped by the facility and provided an order for a one-time dose of pain medication for her while the prescription was sorted out with pharmacy. He stated he was aware she had chronic pain issues which was why he had previously consulted pain management physician. He stated he had not been notified before today there was any issues with her medication availability. He stated Resident #36 had bad arthritis. He stated he had not had any issues or concerns regarding residents receiving their medications. During an interview on 11/30/23 at 12:12 PM, the DON provided a list of all facility residents receiving pain medications. She stated she had conducted an audit of all medication carts and ensured all residents receiving pain medications had medications available. During an interview on 11/30/23 at 12:16 PM with ADON D stated she should check pain scales when residents receive pain medications and every shift. She stated she recalled checking Resident #36 on Tuesday, 11/28/23 and she was sleeping so she coded a 0/10. She could not recall what time she checked her or if she checked her again during her shift. She did not respond when asked about coding Resident #36's pain level as a 0 on 11/29/23 and again that morning, even though we had both seen she was in pain. She stated Resident #36 received her last dose of hydrocodone on Tuesday, 11/28/23. ADON D was shown Resident #36's MAR and asked to clarify because the last dose was signed out on Monday, 11/27/23 at 7:00 PM. ADON D stated she would check her computer. She stated she contacted the pharmacy on Wednesday, 11/29/23 and was told the medication had been ordered and was enroute. She stated when it hadn't arrived at the end of her shift, she let LVN F know the medication was not there. She confirmed she did not notify the physician the medications were unavailable. An interview on 11/30/23 at 2:09 PM with LVN H revealed he worked the 10:00 PM to 6:00 AM shift and had cared for Resident #36. He stated the day shift had reported her hydrocodone was not available. He stated he discussed the situation with Resident #36 and let her know she had PRN medications available. LVN H stated Resident #36 would sometimes sleep through her dose hydrocodone on his shift and he did not recall her complaining of pain during his shift. He stated lately she had been sleeping better since getting scheduled medications. LVN H stated, if scheduled medications were not available for administration, he would report the information on the 24-hour report, but Resident #36's information had already been documented. He stated if she had been acting like she was in pain or throwing a fit he would have called the physician. When asked about his rating of her pain as 7/10 on her MAR for his shift, LVN H stated, What they say, may or may not be what's happening. He stated he provided other means for relief such as repositioning. In a telephone interview on 11/30/23 at 5:00 PM, NP J confirmed she worked under a pain management specialist. She stated she had received a request to refill Resident #36's hydrocodone on 11/27/23 and sent the prescription to the pharmacy the same day. She stated, for some reason, the prescription did not go through. NP J stated she knew Resident #36 well and she needed her pain medication. She stated the nurses usually sent the request further ahead of time, two to three days before because the pharmacy takes a few days to fill it. She stated the nurses knew they should order it at least two to three days ahead. NP J stated she did not know when Resident #36 received her last dose but when she was told it was still unavailable, she called the pharmacy right away. She stated she did not know the script never went through. NP J stated Resident #36 had orders for [muscle relaxer] and Tylenol as well and the nurses could have administered those. She stated, if the resident was in severe pain, the nurses could have called her for an E-kit order. Record review of Resident #36's progress notes revealed the most recent nurse's entry was dated 11/13/2023. The following entries were made after surveyor inquiry: 11/29/2023 9:14 AM: [Recorded as Late Entry on 11/30/2023 08:35] This writer spoke with pain management about the resident medication is unavailable, resident rated pain 10/10, contacted pharmacy and was told that medication has been ordered, will continue to monitor for any changes in condition. Signed by ADON D 11/30/2023 8:35 AM: This writer assessed resident this morning, pain medication has not been delivered, resident rated pain 10/10, prn are being given, called the physician and received an onetime dose for Hydrocodone 10-325, also reached out to [NP J] (pain management) but no answer yet, left message, will continue to monitor for any changes of condition. Signed by ADON D. 11/30/23 10:49 AM: Interviewed resident about pain. Resident stated that she is improved somewhat from the administration of muscle relaxer but states her pain is still a 10 in the bilateral [both sides] legs. Informed resident that we had a onetime dose of 10-325 hydrocodone for her. Administered the 10/325 hydrocodone and will re-assess pain. Signed by DON. 11/30/23 11:50 AM: Resident notes with eyes closed, easily aroused, resident denies any pain at this time level 0/10. Signed by ADON E. Record review of resident #36's Controlled Drug Record for her hydrocodone 7.5-325 mg revealed the final entry was dated 11/27/23 and reflected the last dose was signed out on Monday, 11/27/23 at 8:00 PM. Amount Remaining reflected 0. Record review of the facility's Policy and Procedure titled Pain Management dated 12/2018 revealed the following: POLICY It is the policy of this home that residents experiencing pain will be assessed and pain management provided to the degree possible to provide comfort and enhance the resident's quality of life. Procedure 1. Each resident's pain will be assessed using the [Pain Assessment] in the clinical software, upon admission, re-admission, the onset or an increase in pain, quarterly and whenever there is a significant change in condition that may cause an increase in pain. 2. The home promotes residents self-reporting as the most reliable indicator of pain. 3. The home recognizes that a resident's response to pain is subjective and individual .5. The home will treat the resident under the premise that pain is present whenever the resident says that it is. 6. Nursing staff will identify situations or interventions where an increase in the resident's pain may be anticipated (i.e., wound care, ambulation, repositioning). Pain medication will be offered appropriately preceding these identified activities. 7. The resident's pain will be evaluated routinely each shift. 8. Residents will be re-assessed 30 - 60 minutes after pain management interventions to determine the effectiveness of the intervention. 9. Nursing staff will evaluate how pain is affecting mood, activities of daily living, sleep and the resident's quality of life including complications (i.e., falls, gait disturbance, social isolation). 10. The physician will order appropriate pain medication intervention both routine and PRN to address the individual's pain. 11. Residents with unrelieved pain will be evaluated by the nurse and the physician notified. Pain interventions will be adjusted accordingly and may include non-pharmacological measures. Record review of the facility's Policy and Procedure titled Medication-Unusual Occurrences dated 12/2017 revealed the following: Policy: It is the policy of this home to administer medications within the Standards of Practice and in compliance with Regulatory Guidelines. Definitions: Medication Error: A medication error occurs when a medication is administered in any manner that is inconsistent with the physician's order for that medication. Medication errors include, but are not limited to, administering the wrong medication, administering at the wrong time, administering the wrong dosage strength, administering by the wrong route of administration, and/or administering to the wrong resident . Procedure: 1. Unusual occurrences may be medication errors and/or adverse drug reactions. Medication errors and adverse drug reactions shall be immediately reported to the resident's physician and the Director of Nursing .4. Licensed nurses who observe such unusual occurrences are to: a. Take whatever immediate action is necessary to protect the resident's safety and welfare. b. Report the incident immediately to the Director of Nursing. C. Make the appropriate records and notifications required above The Administrator and Regional Operations Manager were notified on 11/30/23 at 12:51 PM that Immediate Jeopardy and Substandard Quality of Care had been identified in the area of pain management. The IJ Template was provided to the Administrator and DON on 11/30/23 06/08/2023 at 1:12 PM and they were informed the POR was due to HHSC by 2:30 PM on 11/30/23. The following Plan of Removal submitted by the facility was accepted on 12/1/23 at 2:48 PM and reflected: 11/30/2023 Plan of Removal - F-697 Pain Management Immediate Action Taken Resident Specific The facility failed to ensure Resident #36 received her physician-ordered pain medication, Hydrocodone 7.5 milligrams (mg), every 6 hours due to the facility failing to re-order the medication after the last dose was administered on Monday, 11/27 /23, at 7:00 PM. As of 11/30/23, the resident has missed a total of 9 doses. The resident reports having pain at a level of 10 out of 10 on the pain scale. Residents was immediate assessed for pain on 11/30/2023 by nursing staff. Physician was notified on 11/30/2023 by DON. Alternate pain medication order was obtained, and medication was given on 11/30/2023 by nursing staff. System Changes Residents will be monitored for pain daily all negative findings will be giving to the DON/designee, Initiated on 11/30/2023 by nursing staff. 100% Audit will be completed of all resident's pain risk to ensure all at risk residents have been identified. Audit initiated on 11/30 by DON/designee and will be completed on 12/1/2023 and report any negative findings. Every shift pain assessment will be completed by nursing and monitored by DON/designee daily Initiated on 11/30/2023. Education Regional Nurse Consultant, RNC provided education to DON/ADON related to re-ordering medication/pain assessment monitoring on 11/30/2023. DON/Designee will educate nursing staff if a resident is out of pain medication to notify the MD and DON immediately/assess resident/ask for alternate medication/call pharmacy related to when the medication will arrive/ask pharmacy to send out stat if possible. Initiated on 11/30/2023 and each nurse/medication aide will be educated prior to working the floor. DON/Designee will educate staff on when to re-order medications in a timely manner following the pharmacy medication card system. Initiated on 11/30/2023 and each nurse/medication aide will be educated prior to working the floor. Monitoring DON/Designee will randomly interview residents with routine pain medication orders daily x4 weeks on pain level/if pain medication was given. Initiated on 11/30/23 and will end on 12/15/2023. Residents will have a pain risk observation completed quarterly by the charge nurse with the MDS or significant change of condition. The facility will ensure residents do not run out of pain medications by the DON/designee conducting a weekly audit for all pain medications to ensure they are ordered timely if needing a [NAME]. The MD will be notified weekly if a [NAME] is needed. The DON/designee will call the pharmacy to ensure the [NAME] was received. DON/designee will check daily to ensure the medication has arrived See Pain Management/Medication Administration policy. The process was initiated on 11/30/2023 and will continue through 12/15/2023. DON/designee will notify the MD if the provider fails to response within 4 hours of requesting the [NAME]. The process will begin 11/30 and continue through 12/15/2023. DON/designee will conduct an in-service related to medications available in the e-kit if not available the physician an alternate medication disciplinary action if instruction not followed. Training initiated on 11/30/2023 and each nurse will be educated before working the and will continue until all nurses have been educated. Administrator and RNC will review each task overseen by DON/Designee weekly beginning 12/1/23 and will end 12/31/2023 to ensure tasks are completed. At that time further review will be conducted through the QAPI process. Monitoring of the facility's Plan of Removal included the following: Interview with the DON on 12/1/23 at 3:00 PM revealed in-service training was initiated on 11/30/23 and was still in progress. The training topics included identification of signs and symptoms of pain, how and when to re-order medications, and proper documentation of pain medication administration. In-service content and sign-in sheets were requested for review. Interviews were conducted on 12/1/23 from 3:40 PM to 4:05 PM with direct care nurses including ADON E, 1 GVN, 1 RN and 2 LVNs. The staff indicated they had been in-serviced on pain management including assessments, medication administration and documentation. The staff stated they would contact the attending physician and DON immediately if any medications were unavailable and check the E-kit for availability. The staff stated medications should be re-ordered one week in advance of the last dose. In an interview on 12/1/23 at 4:20 PM, ADON D stated she had received in-service training from the Regional Nurse Consultant. She stated medications should be re-ordered a week ahead of the last dose available. ADON D acknowledged the failure to administer scheduled medications was a medication error. She described the risks of medications errors as increased blood pressure for a resident who didn't receive their blood pressure medications and stated residents who did not receive their ordered pain medications as at risk suffering more from pain. She stated the resident's physician and DON should be notified of any medication errors. In an interview on 12/1/23 at 4:18 PM, the DON revealed she had been in-serviced by the Regional Nurse Consultant and was still in progress in-servicing all staff. She stated medications should be ordered approximately a week in advance. The DON stated all nurses should be assessing residents for pain every shift and as needed. She explained residents should also be assessed around the administration of pain medications and treatments. She stated she was also in-servicing CNAs regarding pain assessments as well. She had instructed them to report any signs of pain to the charge nurse and to come to her if they felt the resident's pain was not managed. She stated she had begun auditing pain assessments and will continue to monitor to ensure completion. The DON stated, if medications were not available, the nurses should check the E-kit for availability. She stated she printed the inventory and placed it with the E-kit machine so that nurses could more quickly check availability. If the medication was not available, the nurse should contact the physician and the DON to obtain an order. The DON stated any medication errors were to be reported immediately to the physician and herself and monitor the resident. She stated she was responsible for investigating and documenting the errors. The DON stated all staff currently working had received their in-service training. All staff not yet trained will receive in-service prior to beginning their next shift. During an interview on 12 [TRUNCATED]

Based on interview and record review the facility failed to ensure residents received adequate supervision and assistance devices for one (Resident #65) of six residents reviewed for accidents and incidents. The facility failed to implement monitoring, supervision, and interventions for Resident #65, who had a known history of illegal substance abuse and was HIV positive. An Immediate Jeapordy (IJ) situation was identified on 07/01/21 at 4:10 PM. While the IJ was removed on 07/02/21, the facility remained out of compliance at a scope of a pattern with potential for more than minimal harm due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for injury and/or death from drug-related harm, including overdose. Findings include: Record review of Resident #65's quarterly MDS assessment, dated 06/09/21, revealed a [AGE] year old female, admitted to the facility on [DATE]. Her diagnoses included: [CONDITION(S)], [CONDITION(S)], Anxiety Disorder, respiratory failure. Record review of Resident #65's Psychiatric Subsequent Assessment, dated 05/27/21, revealed Resident #65 had a psychiatric history of anxiety, dementia, depression, [CONDITION(S)], HIV, [CONDITION(S)] C, repeated falls, [CONDITION(S)], GERD, hepatic impairment, seizures, and a history of cocaine and heroin abuse. Record review of Resident #65's discharge medical documents from the hospital, dated 02/03/20, revealed Resident #65 was admitted on [DATE] due to Opioid use disorder, severe dependence; polysubstance abuse; altered mental status, unspecified; substance induced mood disorder, drug withdrawal, cocaine use disorder: moderate dependence, tobacco use disorder; moderate dependence, HIV, and blood clot in vein. Resident #65 was discharged from the hospital on 02/03/20 to the nursing facility. Observation of Resident #65 on 07/01/21 at 11:10AM reflected she was lying in bed. She had multiple small, circular bruises along the tops and bottoms of both arms. The bruises were light brown in color and around the size of a fingertip. Interview with Resident #65 on 07/01/21 at 11:10AM revealed she had a long-time history of drug use, which included heroin. She stated when she was admitted to the facility, she stopped using drugs; however, she did have a relapse in January 2021 and overdosed. She said she obtained heroin from someone who did not reside at the facility but did not specify exactly how she obtained it. She stated when she used the heroin she had obtained, she used the amount she used prior to being admitted to the facility and because she had not used in a while, the amount she used caused her to overdose. She stated she had not used again since that time [when she overdosed in January 2021]. She stated the needle which was found in her room [in June 2021] was from when she used in January 2021. Interview with Administrator on 07/01/21 at 10:15 AM revealed Resident #65 went to the hospital because she was unconscious on 01/05/21. He stated he received a report from the hospital, which stated the resident had overdosed. He stated it was the result of illegal drug use and not medications provided by the facility. The resident had a history of drug use. He stated the day the resident was found unconscious, was the same day she left the faciity on pass to meet with a friend. He stated the resident returned to the facility and was later found unresponsive in her bed. He stated a report was not filed with the State because the resident had a history of drug use and it was her right. He stated when the resident was found unresponsive, he did not see it as abuse and neglect. He stated, The things which should be reported to the State were: resident to resident abuse, staff to resident abuse, verbal abuse, physical abuse and injury of an unknown origin. Interview with LVN F on 07/01/21 at 11:01 AM revealed she worked with Resident #65 for the past 2 to 3 weeks. She stated the resident smoked cigarettes, but she did not know if the resident participated in drugs or had a history of illegal drug use. She stated the resident was happy but would become upset if she did not receive her [MEDICATION(S)] or Tylenol 3 when it was requested. She stated both medications were as needed or at least every 6 hours. Interview with the DON on 07/01/21 at 11:43AM revealed he worked with Resident #65 a couple of times when he was the Weekend RN Supervisor (dating back to January 2021). He said he knew from speaking with Resident #65 that she had a history of drug use, but he did not know what type of drugs she used. He said he was not sure if the staff who worked with Resident #65 knew about her history of drug use. This was not something the facility would typically notify/in-service staff about and/or ask them to monitor, as Resident #65 did not have friends or family whom she visited. The DON stated he was not aware of Resident #65's drug overdose. He said when he started working at the facility, he was not told about the resident's drug use or overdose. He said he had no idea drugs were an issue for Resident #65 until she told him about her history of drug use; however, he did not know she had any current substance abuse problems. The DON stated he would have wanted to know about Resident #65's drug use and overdose upon hire so he could monitor her more closely. He said she obviously found a way to acquire the drugs while she was a resident at the facility. The DON further stated he was not aware a syringe was found in Resident #65's room in June 2021. He stated he believed he was still in the role of ADON at that point (he was the ADON prior to accepting the position of DON); the previous DON nor the Administrator notified him of the incident. He said he should have been made aware of this incident, so he could have monitored Resident #65 more closely. He explained his office was on the same floor as Resident #65, and he tended to keep a closer eye on the residents on his floor simply because of his close proximity. He said he was not aware of any in-services which had been completed with staff regarding the facility's protocols if drugs and/or drug paraphernalia was found, resident drug use, signs/symptoms of overdose, etc. He said the nurses and aides who worked with Resident #65 should have been made aware of the incidences from January 2021 and June 2021. He said the risk of staff not knowing about the need to monitor Resident #65 included them not being aware of what signs/symptoms to monitor which could put the resident at risk for another overdose. The DON said if he truly would have known about the syringe found in Resident #65's room, he would have completed an in-service with all staff to ensure everyone was aware and there wasn't a breakdown in communication. He said Resident #65 was not on any medications which would require a syringe, and he had to assume if one of his nurses dropped a syringe on the floor during a medication pass, they would have properly disposed of it. He said he was not sure if there was a failure on the facility's part. He explained he was not aware of the incidents (the drug overdose and the syringe found in her room); therefore, he did not know if any interventions were in place. The DON said now he was aware of the incidents involving Resident #65, he would put all his effort into making sure the incidents didn't happen again. He said due to Resident #65's history of drug use, she would probably be willing to do just about anything to obtain drugs. Because of this, she would need to be closely monitored and supervised. He said Resident #65 would go out on the patio to smoke cigarettes. He confirmed Resident #65's roommate had dementia and was ambulatory. Telephone interview with the Previous DON on 07/01/21 at 12:11PM revealed she was notified by the Administrator and the current DON that Resident #65 had to take a drug test because something (unknown what) was found by facility staff, but she thought whatever item was found was discovered the weekend prior to her hire (05/29/21 or 05/30/21). She said she was not aware of any concerning items found while she was employed by the facility, nor was she ever advised of Resident #65's history of substance abuse. She also stated she was never notified of the results of the drug test; every time she asked about the drug test she was advised by the Administrator and the current DON that they did not know the results. She said Resident #65 was never brought up during any meetings. She said she was not aware of any in-services which were completed during her time at the facility regarding the facility's protocols if drugs and/or drug paraphernalia was found, resident drug use, signs/symptoms of overdose, etc. The Previous DON stated it would be important for these in-serviced to be completed because drug use could cause an overdose which could result in a residents death, and another resident could find the illegal substances and/or items used (for example, a syringe) and could harm themselves. She stated she was not aware Resident #65 overdosed on drugs. Interview with LVN M on 07/02/21 at 3:14 PM revealed he was familiar with Resident #65 but was not aware the resident overdosed. He stated he was aware a syringe was found in the resident's room because he was the one who found it. He stated the syringe was found on the floor, near the resident's bed, while Resident #65 was sitting in her wheelchair. LVN M stated once found the syringe, he reported it to the administrator, and contacted the nurse practitioner and was given an order for CBC, PMP and drug test. He stated once he reported it to administration, he threw the syringe in the sharps container. He stated he observed the resident and she was alert. He stated he asked Resident #65 if the needle was hers and she initially stated it was not, but later said, Don't tell anybody. In an interview with Corporate RN on 07/02/21 at 6:00 PM revealed, Tthe facility did not have a policy in place for illicit drug use and/or substance abuse prior to Immediate Jeopardy (IJ) being identified on 07/01/21 at 4:10 PM. An Immediate Jeopardy (IJ) was identified on 07/01/21 4:10 PM. The Administrator and Corporate RN were notified of the IJ in the area of accidents/supervision and the IJ template was provided to the Administrator via email on 07/01/21 at 4:15 PM. The plan of removal was accepted on 07/02/21 at 11:00 AM and included: Plan of Removal: 07/01/2021 Completion date: 07/02/2021 Interventions: 1. An order was placed on [Resident #65's]chart in MatrixCare to Monitor resident for signs and symptoms of illicit drug use, drug overdose, and possession of drug paraphernalia. Notify DON, Admin, MD if any signs or symptoms are observed. every shift on 7/1/2021. [Resident #65] was assessed by DON [NAME] [NAME], RN, Interim DON for signs and symptoms of drug overdose on 7/1/2021 at 17:15 PM and no signs or symptoms were observed. 2. MD (Resident Physician) was notified (Phone) by the Administrator LNFA on 7/1/2021 at 5:55 PM. MD (facility medical director) was notified (Phone) by Dale [NAME], Administrator LNFA on 7/1/2021 at 5:30 PM. The LTC ombudsman was notified (Email) by the Administrator on 7/1/2021 at 8:46 PM. The resident is her own responsible party. 3. Due to the risk, her behaviors pose to others, [Resident #65] was moved to a private room (Room 234) on 7/1/2021 at 8:37 PM. 4. Resident 65's consented to weekly serum drug screens on 7/1/2021 when a contract was presented to her. The contract contained two statements that read as follows: 1) On 1-5-2021 and 6-2-2021 it was discovered that [Resident #65] was engaging in activities that put herself at risk. These activities also violated The Facility's policy. We have re-educated [Resident #65] on the facilities policies and have reiterated that illicit drug use is strictly prohibited while residing at The Facility. [Resident #65] was also re-educated on items that are prohibited within skilled nursing facility setting. [Resident #65] will also consent to random drug screens. This form was then signed by the Social Worker, LBSW who presented this form to [Resident #65]. 2) I, [Resident #65], agreed to abide by the facility's policy as well as refrain from illicit drug use. I understand that the failure to comply with this agreement will result in my immediate discharge from the facility. This form was then signed by [Resident #65] in the presence of the Social Worker, LBSW on 7/1/2021. 5. On 7/2/2021, [Resident #65] was presented a written contract by the Social Worker, LBSW and agreed to have her possessions searched for illicit drugs and drug paraphernalia when returning to the facility from leave and when there is reasonable suspicion that she may be in possession of illicit substances or drug paraphernalia. [Resident #65] agrees that if she refuses consent to search she will be given an immediate discharge from the facility due to the risk my behavior and actions pose to the health and safety of others. [Resident #65] also agree that if illicit substances or drug paraphernalia are found in my possession, I will also be given an immediate discharge from the facility. 6. [Resident #65] will be referred to substance abuse treatment program for evaluation. Referral will be completed by 1PM on 7/2/2021. 7. [Resident #65's] plan of care was updated with new interventions on 7/1/2021 at 9:04 PM by regional MDS consultant, LVN Y. The new intervention on the plan of care read as follows: Problem: [Resident #65] has a history of illicit substance abuse prior to admission to facility and since admission as evidenced by drug overdose, positive serum drug screen, finding drug paraphernalia in [Resident #65's] room. Goal: [Resident #65] will be free from negative outcomes related to illicit substance use. 1) Approach: Educate resident on facilities policy on illicit drug use and prohibited items in the skilled nursing facility. 2) Approach: Educate staff on signs/symptoms of drug overdose, drug paraphernalia. 3) Approach: Monitor resident for signs and symptoms of illicit drug use, drug overdose, and possession of drug paraphernalia every shift. Notify DON/ADMIN/MD if any signs or symptoms are observed. 4) Approach: [Resident #65] will have a private room. 5) Approach: Weekly serum drug testing. 6) Approach: Resident agrees to search of her person and belongings when returning to the facility from leave and when there is reasonable suspicion that she may be in the possession of illicit substances and drug paraphernalia. 8. MD (Medical Director) provided in servicing to RN (Interim DON), [NAME] [NAME], LVN X, CRT (MDS Nurse), Administrator, LNFA (Administrator) and Corporate RN, RN, EMT-LP (Regional Clinical Consultant) on the signs and symptoms of drug use and drug overdose on 7/1/2021 at 8:49 PM. 9. DON and LVN X [NAME] [NAME], LVN, CRT assessed all residents for signs and symptoms of drug use/drug overdose on 7/1/2021 and was completed by 11:59 PM. No residents were identified with any signs and/or symptoms of drug use and/or drug overdose. 10. [NAME] [NAME], AD and Social Worker [NAME] Martin, LBSW interviewed all interview able residents regarding if they have used illicit drugs in the last two years on 7/1/2021 at 06:30 PM. 11. All available Referral medical records of current residents were reviewed by LVN Y [NAME] [NAME], LVN (Regional MDS Nurse) and LVN X [NAME] [NAME], LVN, CRT (MDS Nurse) for history of drug use and/or drug overdose to identify residents with a history of drug use and the potential for overdose. This was completed on 7/1/2021 at 06:30 PM. All residents identified had their plan of care updated on 7/1/2021. 12. The facility Administrator, LNFA implemented the policy titled, Weapons, Alcohol, and Illegal Drug Use on 7/1/2021. On 7/2/2021 Social Worker, LBSW and , AD began education and provided a copy to all residents able to understand on the facilities policy titled, Weapons, Alcohol, and Illegal Drug Use. At time of education, residents were provided information on who to contact if they are interested in learning more about help with substance abuse. Education on the facilities policy and information distribution will be completed by 7/2/21 at 12:00 PM. 13. Resident identified with a history of drug use and the potential for drug overdose will be asked to consent to random drug screening. Residents who agree will be asked to sign an agreement with the facility. This will be completed by, AD and Social Worker, LBSW by 12:00 PM on 7/2/2021. 14. The Point of Care section of MatrixCare will be updated to identify to clinical staff those residents with the potential for drug overdose and clinical staff educated on how to find this information by DON/designee. This will be completed by 7/2/2021 at 1:00 PM 15. All resident identified as at risk for drug use will have an order placed in MatrixCare to Monitor resident for signs and symptoms of illicit drug use, drug overdose, and possession of drug paraphernalia. Notify DON, Admin, MD if any signs or symptoms are observed. every shift. This was completed on 7/1/2021 by LVN Y, LVN (Regional MDS Nurse) at 9:00 PM. 16. All resident identified as at risk for drug overdose will have their plan of care updated with interventions. This was completed on 7/1/2021 by LVN Y (Regional MDS Nurse) at 9:00 PM. 17. Administrator, Social Worker, and DON were reeducated on the facility's policy on Abuse and Neglect, the investigation of such issues, and the timely reporting to State agencies on 7/1/2021 by Corporate , RN, EMT-LP (Regional Clinical Consultant). 18. Education and training will be provided to all staff on 7/2/2021 by DON, Administrator , LNFA (Administrator), Corporate RN , RN (Regional Clinical Consultant), and LVN Y, (Regional MDS Nurse). Competency shall be established by posttest to be completed by 1pm. Signs and Symptoms of Drug Overdose-All Staff Signs and Symptoms of Drug Abuse-All Staff Identifying Drug Paraphernalia-All Staff Biohazardous Waste Handling-All Staff What to do if a resident asks for illicit drugs. - All Staff 19. Admin/ designee will ensure all staff receive all above training prior to working the next shift or will not be allowed to work. Monitoring DON /ADMIN or designee will review all residents identified to be at risk for drug overdose to ensure all measures. Beginning 7/1/21 DON/ designee will review all referrals upon receipt for the history of drug use and the potential for drug overdose. Beginning 7/1/21 DON/ designee will educate all new staff upon hire on: o Signs and Symptoms of Drug Overdose o Signs and Symptoms of Drug Use o Identifying Drug Paraphernalia o Biohazardous Waste Handling o What to do if a resident asks for illicit drugs Education will continue until IJ is removed. DON/ADMIN or designee shall monitor all interventions listed above until IJ is removed. Record review of the Letter of attestation for the facility, signed, dated 07/02/21, by MD revealed, I attest I provided education to the Meadows leadership team on substance abuse, signs and symptoms of illicit substance use, identifying drug use and drug overdose. Training was conducted at 8:49 AM on 07/01/21. Those in attendance included: Corporate RN, DON, MDS Coordnator, Administrator,LVN Y, and Social worker. Record review of the Plan of Removal on 07/01/21. Staff were in-serviced on illicit drugs signs and symptoms. Staff received a competency test, once in-serviced on illicit drugs on 07/01/21 and continued through 07/02/21. Record review of the in-servicing documents of Overdose symptoms, sign-in sheet and Inservice Attendance Record, dated for 07/02/21. Record review of Resident's 65's Monitoring Administration History, dated 07/01/21-07/02/21, as well as signed document, which revealed, I, [Resident 65] agree to abide by the facility's policy as well as refrain from illicit drug use. I understand that the failure to comply with this agreement will result in my immediate discharge from the facility. The document was not dated. Record review of a signed agreement, dated 07/02/21, revealed, I, [Resident #65] agree to have my possessions searched for illicit drugs and drug paraphernalia when retuning to the facility from leave and when there is reasonable suspicion that I may be in possession of illicit substances or drug paraphernalia. I, [Resident #65] agree if I refuse consent to search I will be given an immediate discharge from the facility due to the risk my behavior and actions pose to the health and safety of others. I, [Resident #65] also agree that if illicit substances or drug paraphernalia are found in my possession, I will also be give an immediate discharge from the facility. Record review of Resident #65 updated care plan, dated for 07/01/21, revealed the identified problem of past and present illicit substance abuse, the long-term goal for the identified problem of illicit substance abuse and the interventions, which would be taken. The long-term goal was dated, 10/01/21. Record review of residents screened for illicit drug use, not dated. Record review of the signed facility policy, Weapon, Alcohol, and Illegal Drug Use, not dated, by all residents and/or responsible party. This policy revealed .Residents are prohibited from using of illegal drugs while a resident of the Facility. Participation in illegal behavior, such as use, posession or distruibution of illegal drugs will result in the notification of local authorities. Violation of this policy may compromise your health and safety of other residents, and the safety of staff due to the increased potential for unsafe behavior and interactions with the prescribed drug regimen. If a resident is actively observed using alcohol, illegal drugs, or in posession of a weapon, appropriate action will taken immediately. If Facility staff suspect a resident of using of illegal drugs and/or alcohol, appropriate testing will be performed under the direction of the resident's attending physician. Refusal of drug testing will be considered an admission of guilt. Visitors in violation of this policy will be asked to leave, and may be subject to restricted visiting access in the future . Interviews were started on 07/02/21 at 9:00 AM and continued through 07/02/21 at 5:00 PM with 19 staff across all three shifts, including weekdays and weekends, as well as all departments. The staff were interviewed about signs and symptoms of drug overdose, signs and symptoms of drug use, identifying drug paraphernalia, biohazardous waste handling, and what steps to take if a resident asked for illicit drugs. Staff members verbally demonstrated knowledge on these topics and verbalized an understanding of what to do in these types of situations. Additionally, the Corporate RN provided an in-service to the Administrator and DON regarding Abuse and Neglect. The following staff were interviewed during the monitoring time frame and were able to articulate what they had been taught and new protocols put in place by the facility regarding substance abuse: RN B, CNA C, CNA D, CNA E, LVN F, CNA G, CNA H, CNA I, LVN J, CNA K, CMA L, CNA N, CMA O, Dietary Aide P, Dietary Aide Q, Housekeeper R, Housekeeper S, the Kitchen Manager, and the Social Worker. On 07/02/21 at 11:00 AM pm the Immediate Jeopardy was lowered on 07/02//21, and the facility remained out of compliance at a severity of solated with a scope of no actual harm with the potential for more than minimal harm.

Based on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #59, #85, and #497) of five residents reviewed for quality of care. The facility failed to ensure Residents #59, #85, and #497 received treatment and care for their Central Venous Catheters, including routinely monitoring and assessing the site for infections or complications, changing the dressing and access port routinely and as needed, maintenance and monitoring of the port's patency, and physician's orders to establish management of the catheter. Resident #59 went without treatment for [REDACTED].#85 for over 20 days, and Resident #497 for over 10 days. An Immediate Jeopardy (IJ) was identified on 10/16/19 at 2:55 PM. While the IJ was removed on 10/18/19 at 3:12 P.M., the facility remained out of compliance at the severity level of potential harm that is not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal. The IJ template was given to the facility on [DATE] at 2:55 PM. These failures could place the resident at risk for developing systemic infection, complications with blockage or restrictive access, dislodgement, collapsed lung, and [MEDICAL CONDITION]. Findings: 1.Review of Resident #59's Face Sheet dated 08/28/19 reflected he was admitted to the facility on [DATE] then re-admitted on [DATE] . Review of Resident #59's Admission Minimum Data Set (MDS) assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. The BIMS score revealed no cognition issues. His [DIAGNOSES REDACTED]. The assessment revealed he was receiving intravenous (IV) medications within 14 days while not a resident in the facility and while a resident of the facility. Review of Resident #59's Comprehensive History, completed by Physician Y and dated 08/30/19, revealed Resident #59 had a tunneled Central Venous Catheter (CVC). The comprehensive history revealed the CVC was for administering antibiotics and the line should be removed when the antibiotics were completed on 09/22/19. According to the Center for Disease Control (CDC) a central venous catheter is a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly. These long, flexible catheters empty out in or near the heart, allowing the catheter to give the needed treatment within seconds. (accessed from https://www.cdc.gov/hai/bsi/catheter_faqs.html on 10/25/19) According to the American Nurse Today (journal of the American Nurses Association) article entitled, Providing optimal care for patients with central catheters, dated 05/11/14, care and maintenance of central venous catheters requires vigilance and attention to detail to prevent complications and maintain patency. The article revealed more than 80% of bloodstream infections are linked to vascular access devices and 50% of these infections are preventable. The article indicated dressings at the insertion site help protect the catheter and transparent dressings should be changed every 7 days and gauze dressings every 48 hours. The article also revealed the catheter must be flushed to maintain patency, and failure to maintain patency could lead to occlusion, malfunction, and infection. The article indicated all central catheters should be flushed with normal saline solution before and after medication administration and additional flushing should be based on the facility's guidelines. According to the article competent, confident central-catheter care and maintenance can help prevent dangerous complications that imperil a patient's life. (accessed from https://www.americannursetoday.com/providing-optimal-care-for-patients-with-central-catheters/ on 10/25/19) According to the Center for Disease Control and Prevention's Guidelines for the Prevention of Intravascular Catheter-Related Infections, updated 02/2017, catheter sites should be monitored visually when the dressing is changed and by palpation through an intact dressing on a regular basis, depending on the clinical situation of the individual patient. The guidelines also revealed intravascular catheters that are no longer essential should be promptly removed to help prevent infection. The guidelines indicated needleless components should be changed based on the facility's determination or according to the manufactures' recommendations. (accessed from https://www.cdc.gov/infectioncontrol/guidelines/bsi/recommendations.html on 10/25/19) Observation of Resident # 59 's central venous catheter site on 10/15/19 at 10:25 AM revealed the transparent dressing over the right chest was dated 08/26/19. The dressing was intact with loosened edges. Review of Resident #59's care plan dated 06/04/19 , revealed the care plan did not address the CVC to his right chest area. There were no goals or interventions identified for the CVC. Review of Resident#59's Admission /Readmission assessment dated [DATE] revealed Resident #59's CVC was not identified or addressed in the assessment. Review of Resident #59's consolidated physician orders from 08/28/19 until 10/15/19 revealed the following order with a start date of 08/28/19:[MEDICATION NAME] HCI Solution (antibiotic) Reconstituted 1 grams intravenously every 12 hours for infection until 09/22/19. No physician orders were noted for treatment of [REDACTED]. Review of Resident #59's Treatment Administration Records from 08/28/19 until 10/15/19, revealed there was no documentation of a treatment order or treatment related to the CVC being flushed, the dressing being changed, or the site being assessed. Review of Resident #59's nurses note from 08/28/19 until 10/15/19 revealed no documentation of the following: assessments of Resident #59's CVC site, dressing changes, needleless component changes, and flushes . Review of Resident #59's weekly skin assessments dated 09/11/19, 09/20/19, 09/27/19, 10/09/19 and 10/14/19 revealed no documentation related to Resident #59's CVC. Review of Resident #59's physician's progress note, completed by Physician X and dated 09/30/19, revealed Resident #59 completed intravenous antibiotics on 9/22/19 and his CVC should be discontinued. There were no additional orders related to the care and treatment of [REDACTED]. Review of Resident #59's Nurse Practitioner's progress note dated 10/07/19 revealed Resident #59 had a CVC to his upper right chest and arrangement needed to be made for the catheter to be discontinued at the hospital. Observation on 10/15/19 at 10:30 AM revealed the DON checked the date on Resident #59's CVC dressing . She stated the dressing was dated 08/26/19. She stated that the dressing should have been changed every seven days. An interview on 10/15/19 at 10:30 AM with Resident #59 revealed the CVC was inserted in the hospital prior to his admission to the facility. Resident # 59 stated his CVC site had not been flushed and the dressing had not been changed since he returned from the hospital . He stated the CVC was put in while he was in the hospital. He stated he had asked his physician and Nurse Practitioner if he could have it removed, since he no longer needed it, but nothing had ever been done . 2. Review of Resident #85's Face Sheet dated 09/21/19 reflected he was admitted to the facility on [DATE] . Review of Resident #85's Admission MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. The BIMS score reflected no cognition issues. His [DIAGNOSES REDACTED]. The assessment revealed Resident #85 was receiving IV medications while a resident of the facility. Review of Resident #85's Admission History and Physical, completed by Physician Z and dated 9/20/19, revealed a Resident #85 had a CVC placed on 09/09/19. Observation on 10/15/19 at 10:34 AM of Resident #85's CVC site revealed an undated, transparent dressing over the right chest wall. The dressing was intact, but with rolled, loosened edges. Resident #85 stated the dressing of his CVC site was last changed when he returned from an overnight pass . (A nurse's note dated 09/24/19 indicated Resident #85 returned from an overnight pass) Review of Resident #85's care plan dated 10/03/19 revealed the care plan did not address his CVC, including dressing changes, flushes, or monitoring for signs and symptoms of infections. Review of Resident #85's consolidated physician orders for (MONTH) 2019 and (MONTH) 2019 revealed there were no orders related to the care and treatment of [REDACTED]. There were orders dated 09/25/19 and 10/08/19 for the CVC to be discontinued. Review of Resident #85's Treatment Administration Record from 09/21/19 through 10/15/19 reflected there were no documentation related to the care and treatment of [REDACTED]. Review of Resident #85's Medication Administration Record [REDACTED]. Review of Resident# 85's weekly skin assessment dated [DATE] revealed there was no documentation related to Resident #85's CVC. Review of Resident #85's Nurse Practitioner Progress Note dated 10/07/19 revealed a tunneled central line (CVC) was placed on 09/09/2019. There was no documentation or new orders related to the care and treatment of [REDACTED]. Review of Resident #85's clinical record revealed a progress note from the Vascular Access Service Provider, dated 10/08/19, that indicated they attempted to remove Resident #85's CVC, but he was not at the facility. The note indicated the nurse was to notify the service provider when the resident returned to the facility . Review of Resident #85's nurses note from 09/21/19 through 10/15/19 revealed no documentation of Resident #85's CVC site being assessed or monitored, the CVC line being flushed, or the dressing covering the CVC being changed . In an interview on 10/15/19 at 2:30 PM ADON M revealed it was the ADON's responsibility to follow up with the Vascular Access Service Provider once Resident #85 returned to the facility. She stated she did not know why removal of Resident #85's CVC was not rescheduled. 3. Review of Resident #497's Face Sheet dated 10/02/19 reflected he was admitted to the facility on [DATE] Review of Resident #497's Admission MDS assessment dated [DATE] revealed he was a [AGE] year-old male admitted to the facility on [DATE]. The BIMS score revealed no cognition issues. His [DIAGNOSES REDACTED]. The MDS assessment also revealed Resident #497 was receiving IV medications while a resident of the facility. Observation on 10/15/19 at 10:40 AM revealed Resident #497's had a CVC on his right upper arm. The transparent dressing covering the CVC site was dated 10/02/19. The dressing was intact, but with loosened edges. In an interview on 10/16/19 at 10:45 AM Resident #497 revealed his CVC dressing has not been changed since his admission to the facility . Review of Resident #497's physician's orders for 10/02/19 through 10/15/19 revealed there were no orders related to the care and treatment of [REDACTED]. Review of Resident #497's Treatment Administration Record from 10/02/19 through 10/15/19 reflected there were no documentation there were no documentation related to the care and treatment of [REDACTED]. Review of Resident #497's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of Resident# 497's weekly skin assessment dated [DATE] revealed there was no documentation related to Resident #497's CVC. Review of Resident #85's nurses note from 10/10/19 through 10/15/19 revealed no documentation of Resident #85's CVC site being assessed or monitored, the CVC line being flushed, or the dressing covering the CVC being changed. In an interview on 10/15/19 at 9:38 AM LVN A revealed she was the charge nurse for Residents #59, #85 and #497. She stated she was not aware Resident #59 or Resident #85 had a CVC. LVN A stated she was not IV certified, and LVN F would be taking care of Resident# 497's CVC and medication administration. In an interview on 10/15/19 at 9:42 AM with LVN F revealed she was IV certificated. She stated she would be caring for Resident #497's CVC and medication administration . LVN F stated she was not aware Resident #59 and # 85 had a CVC . In an interview on 10/15/19 at 10:30 AM the DON stated she had only been the DON for two days and she was not aware of any residents with CVC. The DON observed the dressing on Resident #59's CVC site that was dated 08/26/19, and the observed Resident #89 (dated 09/24/19 and Resident #497's (dated 10/02/19) CVC sites. The DON stated the dressings were not changed every seven days. She stated she was not aware Residents #59, #85, and #497 did not have orders related to their CVC line being flushed or the dressing being changed. In an interview on 10/15/19 at 2:36 PM the NP revealed she was not aware Resident #59, #85, and #497 did not have physician orders for the care and treatment of [REDACTED]. She stated the CVC line needed to be flushed before and after medication administration or every shift if the resident was not receiving medication through the line. The NP stated the dressing should be changed according to the facilities protocol or policy. She stated there were no standing orders for the facility for care and treatment of [REDACTED]. In an interview on 10/16/19 at 8:05 AM Regional RN O revealed the facility did have standing or protocols orders . She expected the nursing staff LVNs and RNs to follow facility policy for dressing changes and assessments related to CVC. The Regional RN O stated staff should follow the facility policy related to documentation. The Regional RN O stated not changing the dressing over a CVC site could lead to infection and not flushing the lines could result in the lines occluding. In an interview on 10/16/19 at 12:00 PM ADON M revealed the admitting charge nurse was responsible for making sure the orders for the care and treatment of [REDACTED]. ADON M stated once the orders are received from the physician they are reviewed by the ADON for accuracy, and then reviewed by the DON in the morning meeting. ADON M stated she would get clarification because nurses can't flush a CVC without a physician's order In an interview on 10/16/19 at 3:30 PM LVN H revealed he was not aware Resident #59 had a CVC but was aware that Resident #85 and Resident #497 had CVC. He stated he had changed Resident #85's CVC dressing a couple of weeks ago. He stated he was not aware Residents #59, #85, and #497 did not have orders for their CVC lines to be flushed. He stated he just assumed there were orders. LVN H stated he gets busy and forgets to document that he changed the dressing and assessed the site area . He stated he was Intravenous Certified. In an interview on 10/17/19 at 2:30 PM ADON L revealed the admitting charge nurse was responsible for ensuring there were orders for care and treatment of [REDACTED]. ADON L stated there should be orders for the dressing to be changed every seven days. ADON L stated all new orders are reviewed by the DON in the morning meeting. In an interview on 10/17/19 at 2:45 PM LVN [NAME] revealed she was not aware Residents #59 and #85 had Central Venous Catheters . She stated she was aware that Resident #497 had a CVC because she had seen the resident's intravenous medication in the medication room. She said the staff documented the assessment of the CVC under Batch Orders in the resident's medical records. LVN [NAME] searched in an electronic medical record under the Batch Orders section, but she was unable to find an area to document on CVC. LVN [NAME] stated she was not aware that there were no physician's orders for the CVC to be flushed . In an interview on 10/18/19 at 3:20 PM LVN K revealed he was not aware Resident #59 had CVC. He stated he had done the weekly assessments on Resident #59, but he did not remember that Resident #59 had CVC. LVN K stated he was aware Residents #85 and #497 had CVC. He stated he put his daily assessments of Resident# 85 under the Batch Orders in the resident's electronic health reach. LVN K searched in an electronic health record under the Batch Orders section, but there was no area in this section to document on CVC care. He stated he must have forgot to make an entry in the nurse's progress notes . Review of the facility's policy for Central Venous Catheter Dressing Changes, dated 2006, revealed, the Central venous catheter dressing will be changed at a specific interval, or when needed, to prevent catheter-related infection that are associated with contaminated, loosened, soiled, or wet .Change transparent semi-permeable membrane dressing at least every 7 days and PRN, when wet, soiled, or not intact. Change needless connection device, extension tubing, and stabilization device at the time of the routine dressing change .Needleless connection device .should be changed after dressing is changed. Review of the facility's policy Flushing Midline and Central Line IV Catheters, dated 2006, revealed Midline and central line IV catheter type will be flushed to maintain patency of the vascular access devices to prevent mixing of incompatible medications and solutions: and ensure dose of solution or medication is administered into the venous system .flush catheters at regular intervals to maintain patency, and before and after administration of intermittent solutions, medications, blood and blood products, obtaining blood samples, converting from continuous to intermittent therapies. Each lumen of the catheter is a separate catheter. Each lumen must be flushed at least every twenty-four hours to prevent occlusion .some may need to be flushed more often. The Administrator and DON were notified on 10/16/19 at 2:55 PM. that an Immediate Jeopardy situation was identified, and a Plan of Removal was requested at that time . The facility's Plan of Removal was accepted on 010/14/19 at 6:34 PM and included: 1. All IV sites were assessed through clear/ transparent dressing by an RN on 10/16/19 at 5:00 PM and this was documented in the progress notes. All dressings were noted to have a last change date of 10/15/10. All dressings were intact and sites free from signs and symptoms of infection. 2. The physician /RP for the residents #59, #497, #85, #316 and #248 were notified of the current assessment of the IV sites on 10/16/19 at 5:00 PM and this was documented in the process notes. 3. All care plans for resident's with IV's were reviewed and updated on 10/16/19 at 5:30 AM. 4. Orders were clarified /obtained to include assessments of site every shift, dressing changes every week and PRN, flushes before and after medication or every shift if not currently receiving medication on 10/16/19 at 4:30 PM.IV dressing changes will be scheduled for Tuesday on the day shift and PRN. 5. Administrator, DON and ADONs were re-educated on Abuse/neglect by corporate RN on 10/16/2019 at 3:30 PM. Completion date 10/17/19. 6. All staff re-educated regarding abuse/neglect began on 10/16/19 at 5:00 P.M. Completion will be 10/17/19 by 11:00 PM. Any staff that is unable to be trained during this period will not be allowed to work until they have received training. 7. Don and ADON will ensure all staff have received abuse and neglect training prior to working. 8. All nursing staff re-educated regarding sign and symptoms of infection began on 10/16/19 at 5:00 P.M. Completion will be 10/17/2019 by 11:00 P.M. Any staff that is unable to be trained during this period will not be allowed to work until they have received training. 9. DON or ADON will ensure all staff have received re-education on sign and symptoms of infection prior to working. 10. All nurse's re-education regarding facility's IV Policy and procedure began on 10/16/19 at 5:00 PM. Completion will be 10/17/19 at 11:00 PM. Any staff that is unable to be trained during this period will not be allowed to work until they have received training. 11. DON and ADON will ensure all nurses have received training on IV policy and procedure prior to working. 12. All nurse re-education began to contact the DON and ADON with any questions related to IV's on 10/16/19 at 5:00 PM. Completion will be 10/17/19 at 11: P.M. Any staff that is unable to be trained during this time period will not be allowed to work until they have received training. 13. DON or ADON will ensure all nurses have received training on who to contact in case of IV questions prior to working. 14. IV certification class to include education and competency held by Venous Access Service Provider for nurses. IV certification class held at 10:00 am has been completed with 12 nurses. An additional class will be held 10/18/19 at 10:00 [NAME]M. completion dated 10/18/19. Any nurses that have not completed the IV certification course will not be permitted to provide IV care, administer IV medication, or perform IV dressing changes. The nurse must complete IV certification course prior to performing any of the previously tasks. 15. The schedule was reviewed to ensure there is an RN or IV certified LVN in the facility at all times on 10/16/2019 at 4:45 P.M. Completion 10/16/2019. 16. Ombudsman was notified of immediate jeopardy situation on 10/16/2019 at 4:45 P.M. 17. Medical Director was notified immediate jeopardy situation on 10/16/2019 at 4:45 P.M. 18. Completed education and training: Staff trained on Abuse and Neglect reporting events including definition of abuse and neglect. IV care to include: flushing, assessment medication administration, documentation, dressing changes, orders, contacting the RN with Questions. Signs and symptoms of infection. Monitoring: Interviews with facility staff representing multiple shifts (LVN A, LVN E,LVN H, LVN K, LVN J and ADON L and ADON M) on 10/18/19 between 6:30 a.m. and 2:00 p.m. revealed they had received in- service training for Central Venous Catheters, including documentation, flushing the CVC lines, dressing changes according to the physician orders, and assessment of the insertion site for infection. The interviewed staff revealed they were in-serviced on obtaining physician orders on admission and documentation of medication administration . Interviews with facility staff representing multiple shifts (LVN A, LVN E, LVN H, LVN K, LVN J,ADON L, ADON M, CNA B, CNA C, and CNA D) on 10/18/19 between 6:30 a.m. and 1:30 p.m. revealed they had received in-service training regarding identifying signs of neglect and reporting immediately to their supervisor and the abuse coordinator. Review of the IV Certification Class for the LVN's revealed the following nurses completed the class on 10/17/19:LVN A, LVN E, LVN H, LVN L, ADON M, LVN P, LVN Q, LVN R, LVN S, LVN T, LVN U, LVN V and LVN W. Review of the facility's Nursing Schedule from 10/17/19 through 10/23/19 revealed there was an IV certified LVN or RN scheduled for each shift providing twenty-four hour coverage. Review of Residents #16, #59, #85, #248 and #497 with Central Venous Catheters for current dressing changes as of 10/15/19 for documentation and assessment for CVC Care in the medical record for each resident were charted. Review of Residents #16, #59, #85, #248 and #497's care plan revealed the care plans were updated and addressed the CVC Care. An Immediate Jeopardy (IJ) was identified on 10/16/19 at 2:55 PM. While the IJ was removed on 10/18/19 at 3:12 P.M., the facility remained out of compliance at the severity level of potential harm that was not immediate jeopardy and at a scope of pattern because the facility was still monitoring the Plan of Removal.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision for one (Residents #1) of six residents reviewed for incidents. The facility failed to provide adequate supervision to prevent Resident #1 from wandering from the facility. The facility was not aware the resident was missing until they were notified by police. An Immediate Jeopardy (IJ) was identified on [DATE] at 12:45 PM. While the IJ was removed on [DATE] at 6:12 PM, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm and a scope of pattern due to the facility was still monitoring the effectiveness of the Plan Removal. This failure could place residents at risk of elopement, with resulting physical harm, pain, and mental anguish or emotional distress. Findings included: 1. Review of Resident #1's quarterly MDS assessment, dated [DATE], revealed he was a [AGE] year-old male who admitted to the facility on [DATE]. His Brief Interview for Mental Status (BIMS) score of 04 revealed his cognition as severely impaired. His Acute onset mental status for residents disorganized and inattention was coded as 1 (behavior continuously present, does not fluctuate). Review of resident's admissions record dated [DATE] revealed residents' responsible parties as his son and daughter. Attempted to call during and after survey with no success. Review of Resident #1's order summary report [DATE] revealed [DIAGNOSES REDACTED]. The following orders were listed: Device: alarm check via electronic machine everyday - Order date: [DATE] Device: alarm visually checked every shift - Order date: [DATE] Monitor wander guard on patient closely - Order date: [DATE] - D/C'd [DATE] May go out on pass with medications - Order date: [DATE] Review of Resident #1's care plan dated [DATE] revealed the following: Resident is impaired cognitive function/dementia or impaired thought process r/t dementia. Initiated [DATE] Resident has [MEDICAL CONDITION] or an acute confusional episode r/t acute disease process (Specific), alcohol use/abuse, electrolyte imbalance. Initiated [DATE] Resident is an elopement risk/wanderer r/t impaired safety awareness, resident wanders aimlessly. Initiated [DATE] and resolved [DATE] Review of residents Elopement risk dated [DATE] revealed resident was at risk for elopement. Review of Residents Elopement risk assessment dated [DATE] revealed no risk identified for elopement. Review of resident elopement risk assessment dated [DATE] revealed no risk identified for elopement. Review of resident elopement risk assessment dated [DATE] revealed no risk identified for elopement. Review of resident's elopement risk assessment dated [DATE], signed completed [DATE] revealed no risk identified for elopement. Review of progress note dated [DATE] revealed, Resident continues to require constant redirection and supervision related to safety awareness. Attending physician was notified and an order obtained for wander guard as precautionary measure. RP was also notified, will continue to monitor. Review of Progress note dated [DATE] revealed patient continued to be confused and disoriented and attempting to go out but was stopped and reoriented and he went to his room and got back to bed. Review of resident's electronic health record revealed three notes documented for the months (MONTH) - (MONTH) (YEAR) and none related to resident's cognition or wandering state. Review of resident's [DATE] revealed resident noted with slow mentation and altered mental status related to end stage hepatic failure, medication was administered per order and tolerated. Resident requires close supervision and care was provided per care plan. Review of progress note dated [DATE] revealed, Resident noted with slow mentation and altered mental status this AM, required continued close supervision and total assist with ADL'S, medication was given per order and tolerated. Will continue to monitor. Progress note dated [DATE] revealed, Resident noted with increased confusion and altered mental status, requires close supervision and assist with ADL'S, care was provided per care plan. Will continue to monitor. Review of police incident date sheet report, dated [DATE], revealed on [DATE] at about 6:07 pm police responded to a call regarding Resident #1 walking in the lanes of a busy street. When police arrived Resident #1 was walking in the lanes of traffic and being walked to the grass by individuals who stopped to assist. Resident #1 did not have any identification and was notably confused and was only able to provide his first name. Resident was dressed in sleepwear and house shoes. Resident was transported to the hospital. Police went to the facility to see if they were missing a resident and was told they were not missing anyone, and every resident was accounted for. At the hospital officers checked Resident #1's shirt tag and identified Resident #1's last name and room number written on it. Officers contacted the facility again and spoke with LVN L. Officers gave Resident #1's name and LVN L confirmed Resident #1 was a resident of the facility and said they would look into it and hung up before getting any further information. Address provided in the report was approximately 0.6 miles walking distance from the facility. Interview with Officer on [DATE] at 4:35pm revealed was called out on the call and when he and his partner arrived there were bystanders redirecting Resident #1 out of the street. He stated the resident was very disoriented and confused. He stated an ambulance was called out and determined residents blood sugar levels were very high and transported him to the hospital. He stated his partner went to the facility to ask if the facility was missing a resident and was told no without the person even going to look. He stated after going to the hospital with the resident he checked the resident's shirt which had the resident last name and room number. He stated he then contacted the facility and spoke with a male nurse (names LVN L) and asked were they missing Resident #1. He stated LVN L stated yes and he told them the resident was located at the hospital. He stated LVN L did not ask any questions about residents' condition or incident. Interview with Officer on [DATE] at 8:30 am revealed the location he found the resident did not have any side walks and was located in the intersection of a four way stop that consisted of three lane traffic. Review of Resident #1's incident report dated [DATE] and completed by LVN N revealed, Resident was found on the street by the police wandering and he was taken to the emergency room for evaluation even though he was able to give his address and name. Location of the incident revealed on the street. Cognitive state prior to incident/accident answer revealed slightly confused. Interview with the DON and Administrator on [DATE] at 12:55 PM revealed at the time the ADM. could not recall if he had called in Resident #1's incident of elopement. The DON stated the police contacted the facility and stated Resident #1 was able to give his name, address and room number to them. He stated he was not sure if the resident signed out of the facility the day of the incident. The DON stated the sign-in and out process was not implemented very well throughout the facility. The DON stated the resident would regularly leave the facility to go get beer from the convenience store across the street. The DON stated the resident had [MEDICAL CONDITION] of the liver and would get confused after drinking, which could have been what took place the day of the incident. Interview with LVN L on [DATE] at 3:30 PM revealed he was contacted by police regarding a missing resident, however he could not remember the date of the call or the resident's name. He stated when he answered the phone the police asked if the facility was missing a resident. He stated he told the officer he was not missing anyone on his unit and transferred the officer to the charge nurse upstairs. He stated the officer called back again after approximately 45 minutes with the resident's name. He stated he then transferred the call to LVN N. He stated he did not document the incident because it was not on his hall. He stated he was not asked to write any statements regarding what happened after the incident. Interview with LVN N on [DATE] at 2:15 PM revealed there was an incident that took place with Resident #1 leaving the facility, but she could not recall the month or date of when the incident took place. She stated she last saw the resident around 4:00 PM on the date of the incident after administering his medication. She stated when it was time for dinner a staff member notified her that the resident was not in his room and she began looking for him around 5pm. She stated she went across the street to the convenience store because that was the only place the resident went to buy cigarettes. She stated when she got to the store, the convenience store employees told her they saw the police pick the resident up and go towards the local hospital. She stated after getting back to the facility she was notified by LVN L the police had called and had a resident with them. She then told LVN L that was who she was looking for. She stated the police called back again and told her the resident was able to give his own name and address and they transported him to the hospital. She could not remember an exact time of the phone call. She stated she did call a code purple and notified the DON of the event. She reported the resident was kept at the hospital for monitoring and could not remember when he returned. She stated she did not consider the incident an elopement because Resident #1 did not show any form of confusion on the unit and was okay on that day. She stated she guessed the resident got confused at the convenience store. She confirmed Resident #1 did have some confusion on some days and some days he did not. She stated the resident did have a Wander guard in place for being confused. She continued to go back and forth on her decision as to if the resident was confused or not. She stated resident was confused and required redirection before going to the hospital, but she was unable to give a date or approximate time resident went to the hospital. She stated she did notify the Administrator, family and doctor of the incident. Interview with CNA Z on [DATE] at 12:20 pm revealed Resident #1 was a little confused and when she was working she would keep an eye on him. She stated she was not sure if Resident #1 ever had a wander guard. Interview with CNA X on [DATE] at 12:43 pm revealed Resident #1 would have to go out with staff to smoke. She stated she has observed Resident #1 go outside to smoke and get turned around. She stated Resident #1 did have a wander guard. She stated she did not know Resident #1 left the facility and was sent to the hospital following the incident. She stated it was her first time hearing of the incident. She stated she did work with Resident #1 and did not know resident's wander guard was ever removed. Interview with LVN M on [DATE] at 12:55 pm revealed Resident #1 was the last incident of elopement that happened at the facility. She stated Resident #1 went across the street to get cigarettes and got confused. She stated resident never left the building before and it didn't happen on her shift. Interview on [DATE] at 9:33 AM with Resident #1's daughter revealed Resident #1 was able to sign himself in and out of the facility sometimes. She stated he had a disease that would make him confused and it was hard to tell when he would be confused or not. She stated the facility was well aware Resident #1 confusion. She stated the facility allows all of their residents to go and come when they want. She stated for a while her father was bed ridden and was unable to walk She stated that last time he went to the hospital in (MONTH) (YEAR) she was contacted by the hospital. She stated the hospital staff wanted to get a report on Resident #1 and his history. She stated the hospital staff told her that Resident #1 was admitted by the police who found him wandering in the streets. She stated she contacted her brother and mother after talking with the hospital. She stated the facility never informed her or her brother of the incident or her father returning to the facility from the hospital. She denied her father ever having a wander guard while he was a resident at the facility. Review of Out of Facility Release of Responsibility, revealed all dates other than [DATE] were recognizable and revealed Resident #1 had not signed himself out of the facility. Interview on [DATE] at 4:45 PM with the DON and Administrator revealed the ADM did not call in the report of the elopement to the state because it was not uncommon for Resident #1 to leave the facility. The ADM stated Resident #1 had an order giving him access to go out on pass. The ADM stated the resident had signed out of the facility multiple times before with no issues. The ADM stated he could not remember when he was contacted regarding the event, but he was not contacted on the evening it happened. The ADM stated if there were residents who were unsafe and left the facility, the staff would notify him when the incident happened; or if the resident was gone for an extended period, they would look into it. The ADM stated in Resident #1's situation, he was his own responsible party and was not incapacitated by a judge or had any letters stating he was incapacitated by a doctor. The ADM stated there was no urgent need for the staff to contact him in Resident #1's situation. DON stated Resident #1 had a elopement risk done on [DATE] and [DATE] and passed them. DON unable to explained why the elopement risk for resident #1 where done. DON reported he could not remember why wander guard was taken off the resident. DON reported nursing staff are responsible for completing elopement assessments upon admissions, quarterly and if residents have a change in condition. DON stated they are supposed to look back at the resident's health record when doing assessment to compare information. He stated if the assessments are done wrong he cannot keep up with that. The following actions were immediately put in place upon being notified of the immediate jeopardy: Actions for affected Residents #1 and Resident # 3 The affected resident no longer resides at this facility. On (MONTH) 9, (YEAR), Resident #1 expired in the facility peacefully from end stage [MEDICAL CONDITION] while being seen by hospice. Resident #3 left out on pass on (MONTH) 26, (YEAR) and decided not to return. Patient reported he was going to see his wife. Resident #3 decided not to return to the facility. Last known place of shelter is (Local Shelter). Resident #3 is indigent and elects to live a homeless life style. DON or designee will complete 100% audit on elopement risk assessments. This will be initiated on [DATE] and will be completed by [DATE] at 3pm. One resident (Resident #54), has been identified as an elopement risk. Our facility Elopement Risk Assessment is the tool used to determine the level of risk for elopement. The elopement risk assessments that were audited have been updated within the quarter and 100% of residents had a completed elopement assessment. No other residents were identified as elopement risk. The audit was completed by MDS Coordinator Z. Following the audit, 1 resident continues to identify as an elopement risk. This resident care plan will be updated with new information. 0 new residents were identified as an elopement risk. Residents at risk for elopement and exit seeking will be assessed for wander guard. If the wander guard is not a safe option, then alternative placement will be initiated for resident safety. Care plans will be updated by MD, ADON, DON or designee as need for update is identified. Administrator and/or DON will monitor compliance of care plan updates daily for 4 weeks, then weekly for 4 weeks. This POR will be executed and reviewed for compliance by the administrator for the duration of the POR. This issue will be reviewed for compliance by the Administrator for the duration of the POR. This issue will be reviewed in QAPI by the IDT monthly for no less that 90 days. The Administrator will determine when substantial compliance has been achieved/maintained. A binder will be located at each nurse station and front desk with picture and demographics of residents identified as an elopement risk according to the facility elopement risk assessment. When a new resident is identified as an elopement risk, ADON or designee will notify staff of the update. The elopement book will be reviewed weekly and updated as the change of residents occur. New orders, new admissions, re-admissions, 24-hour report and Incident/Accident reports to include elopements will be reviewed daily by the DON or designee for completion and compliance. The on-call nurse will cover the weekends and report these incidents to the Administrator or DON. Any identified issue(s) will be addressed immediately by the DON or designee. Any potential reportable incidents incident(s) will be investigated and reported to appropriate state agencies by the Administrator or designee. MDS, ADON will review the elopement binder and update as a change is identified. Elopement management program including missing person procedure is attached. DON or designee will re-educate all staff, including PRN and part-time staff, regarding Policy and Procedure on monitoring and reporting of residents that exhibit exit seeking behavior, following the policy and procedure for elopement management, and abuse neglect and misappropriation and how to supervise at risk residents. Regional Nurse Consultant, re-educated DON, Administrator and department heads on failure to safely supervise residents who are and elopement risk and exit seeking, failure to initiate and investigate missing resident and follow policy and procedures for elopement and missing residents and failure to report elopement/missing residents at 7 PM on [DATE]. This re-education will be initiated on [DATE] and will be completed on [DATE] by 4pm. Any staff member who has not completed this re-education will not be allowed to work until re-education has been completed. Pre and Posttest are required and included education on how to supervise residents at risk for elopement, redirecting and distracting at risk residents with other activities, reporting abuse and neglect, and identifying abuse and neglect, and elopement management. Blank copies are attached. Department heads were given and in-serviced on the scope of the provider letter No. ,[DATE] which includes the following: Missing resident: A NF must report a missing resident to DADS if the resident is not located during a search of the NF, NF ground, and immediate vicinity and circumstances place the resident's health, safety, or welfare at risk. The NF must make report to DADS as soon as the NF becomes aware that the resident is missing and cannot be located. Regardless of the circumstances, a NF must report any resident missing for eight hours. In addition, the NF must contact the DADS CRS section every day until the resident is found. The (Medical Director) was notified about the Immediate Jeopardy on [DATE] at 1:45 pm. Medical Director is an active member of the Quality Assurance Performance Improvement Committee which will monitor completion and compliance of the plan monthly during QAPI for no less than 90 days until substantial compliance has been achieved/maintained. Medical Director will attend Quality Assurance Performance Improvement monthly meeting. Other attendees may include but not limited to: Administrator, DON, ADON, RPM and LCSW. AD Hoc Quality Assurance Performance Improvement meeting was held on [DATE] to review and discuss Immediate Jeopardy. Administrator will report progress of this plan to the Quality Assurance Performance Improvement Committee monthly meeting. The facility Administrator will monitor plan and make changes as needed. Interviews were conducted on [DATE] starting at 4:00 PM with 35 staff across various disciplines and all three shifts were interviewed to ensure they had been properly in-serviced. Staff indicated comprehension of the training and comprehension of elopement, missing residents, abuse and neglect and reporting abuse and neglect. Competency was established and there were no concerns noted with the trainings. On [DATE] at 6:12 PM, the ADM was notified the IJ was removed. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of potential harm that is not an Immediate Jeopardy and a scope of ISOLATED because the facility was still in-servicing staff and the facility was monitoring the implementation of the Plan of Removal.

Based on observations, interview, and record review, the facility failed to provide treatment and care in accordance with the comprehensive person-centered care plan and in accordance with professional standards of practice for 1 (Resident #60) of 2 residents reviewed for quality of care 1. The facility failed to provide the dietitian recommended [DEVICE] feeding to Resident #60, who had experienced significant weight loss. 2. The facility and dietician failed to recognize and adequately address Resident #60's significant weight loss as it increased from an 8.9% loss in three months, to a 20.96% loss in 5 months. These failures could affect 11 residents receiving tube feedings by placing them at risk for weight loss and not having their needs identified met resulting in a decline in heath and illness caused by malnutrition. Findings included: Review of Resident #60's clinical record revealed a [AGE] year-old female admitted on [DATE] to the facility with the [DIAGNOSES REDACTED]. Review of Resident #60's most recent quarterly MDS assessment, dated 08/21/18, reflected documented a BIMS score of 14, indicating intact cognition. Resident #60 required total assistance with all ADLs including eating. Furthermore , documentation in the MDS revealed the facility answered no or unknown when it was asked if Resident #60 gained 5% or more in the last month or gain of 10% or more in the last 6 months. Review of weight log dated 05/14/18 through 10/30/18 reflected, the resident admission weight was 130.7 pounds on 05/14/18. The last documented weight was 103.3 pounds on 10/03/18 However, Resident #60 weight loss on 07/05/18 was 128.2 pounds and on 08/21/18 weight of 119.1 pounds for a 7% weight loss. Review of Resident #60 electronic chart listed the following significant weight and dates: -05/14/18: 130.7 Lbs.-Admission weight -07/05/18: 128.2 Lbs. -08/21/18: 119.1 Lbs. -10/09/18: 108.0 Lbs. -10/30/18: 103.3 Lbs. Review of Resident #60's initial nutritional assessment by the physician dated 05/16/18 revealed she had an admission weight of 130.7 and was on [DEVICE] feeding of [MEDICATION NAME] 1.2 at 55cc x 22 hours with free water 20ml/hour X22 hours. Review of a document titled, SPL(Speech Language Pathologist) Evaluation & Plan of Treatment, dated 05/15/18 for Resident #60, revealed: Clinical impression: Patient presents with mild dysphagia(difficulty Swallowing) impairment as well as moderate expressive language impairment. Patient has hx (history) of poor intake PO(by mouth) and exhibit slow oral manipulation of bolus and mild delay onset of pharyngeal swallow. She also presents with expressive language deficit as evidenced by inability to effectively communicate wants and needs. Review of Resident #60's comprehensive care plan dated 10/02/18 revealed: -Resident requires tube feeding related to swallowing problem -Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight stable, signs and symptoms of malnutrition or dehydration through review date -Registered Dietitian to evaluate quarterly and PRN. Observe caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed -The resident is dependent with feed tube feeding and water flushes. There were no interventions/approaches that identified or addressed weight loss or swallowing problems in Resident #60 care plan Review of Nutrition RD assessment dated [DATE] revealed an order for [REDACTED].>Review of Registered Dietitian progress note dated 06/08/18 revealed an order to start [MEDICATION NAME] 1.2 at 55cc/hour x22 hours Review of Registered Dietitian progress note dated 07/26/18 revealed order to start [MEDICATION NAME] 1.2 at 55cc/hour x22 hours n Review of Registered Dietitian progress note dated 10/02/18 revealed the following orders: 1) Discontinue [MEDICATION NAME] 1.2 at 80cc/hour 6p-6a. 2) Discontinue free water 20ml every 2 hours 3) Start [MEDICATION NAME] 1.2 @ 65cc/hour X22hours 4) Free water 20ml/hour X22 hours Review of physician order [REDACTED].@ 65ml/hour X22 hours with free water20ml/hour for 22 hours. Feeding will only be down 2 hours. Observation of Resident #60's [DEVICE] feeding on 11/01/18 at 11:02 a.m. revealed the pump was turned off. Observation of Resident #60 on 11/01/18 at 1:23 p.m. revealed it the feeding pump was turned off. Observation of Resident #60 on 11/01/18 at 2:15 p.m. revealed it the feeding pump was turned off. Resident was aphasic and could not respond to command. During interview with LVN O on 11/01/18 at 2:20 p.m., he said he was the charge nurse responsible for Resident #60 on the 2:00 p.m. to 10:00 p.m. shift. He explained that the Resident #60 was not receiving the tube feeding because the order was for 80cc/hour 6p-6a, noting he thought the order was changed from [MEDICATION NAME] 1.2 at 65cc/hour 6p-6a. When asked, he stated he did not know if Resident #60 has lost weight. He said he did not know the present order for Resident #60 was for [MEDICATION NAME] 1.2 at 65cc/hour x22 hours. Interview with the ADON on 11/01/18 at 2:25 p.m. revealed she was new to the facility and was not familiar with the care of Resident #60. She stated she would find out what the resident was receiving. The ADON returned and noted Resident #60 was supposed to receive [MEDICATION NAME] 1.2 at 65cc/hour x22 hours. She said she did not know Resident #60 was not getting the [DEVICE] feeding as ordered. In an interview with LVN P on 11/01/18 at 2:32 p.m., he stated he took care of Resident #60 on the 6:00 a.m. to 2:00 p.m. shift. He explained the resident did not receive her [DEVICE] feeding because the order was for [MEDICATION NAME] 80cc/hour at 6:00p.m to 6:00a.m. He said he did not know the present order was for Resident #60 was for [MEDICATION NAME] at 65cc/hour x22 hours. Interview with the Physician K on 11/03/18 at 3:43 p.m. revealed he was the doctor in care of Resident #60. He said he was not aware that the facility was not following the order by the dietitian. He explained he gave the responsibility to the dietitian, and she would let him know if there was a problem or issues. He stated the resident has [DIAGNOSES REDACTED]. Interview with Resident #60 mother on 11/03/18 at 12:40p.m revealed she was not informed by the facility that the resident was losing weight. She explained the resident let her know almost on every visits that she was losing weight. She said the resident has [MEDICAL CONDITION] and may be contributing to the weight loss. She stated she did not know the facility was not following the physician's orders [REDACTED]. Interview with Dietitian on 11/05/18 at 12:41 p.m. revealed she was the dietitian for Resident #60. She said she had been the dietitian in the facility since (MONTH) (YEAR). She explained when she writes an order, the physician had to sign off on it before the staff carried it out. She said the Resident #60 was supposed to receive [MEDICATION NAME] 1.2 @ 65cc/hour x22 hours. She said she adjusted Resident #60 for long period because of her weight loss. The facility weight management policy and procedure states, Residents nutritional status will be monitored on a regular basis to aide in the maintenance of acceptable parameter, such as body weight and protein levels, unless the residents clinical condition demonstrates that this is not possible. Accurate weights are obtained by having staff follow a consistent approach to weighing and by using appropriately serviced and functional scale. Resident are offered therapeutic diets when there is a nutritional concern and when the health care provider orders a therapeutic diet Weight can be a useful indicator of nutritional status, when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight(loss or gain) or insidious weight loss may indicate a nutritional problem. Review of the policy did not reveal what the facility will do if a resident had significant weight loss. 1. The facility failed to provide the dietitian recommended [DEVICE] feeding to Resident #60, who had experienced significant weight loss. 2. The facility and dietician failed to recognize and adequately address Resident #60's significant weight loss as it increased from an 8.9% loss in three months, to a 20.96% loss in 5 months. These failures could affect 11 residents receiving tube feedings by placing them at risk for weight loss and not having their needs identified met resulting in a decline in heath and illness caused by malnutrition. Findings included: Review of Resident #60's clinical record revealed a [AGE] year-old female admitted on [DATE] to the facility with the [DIAGNOSES REDACTED]. Review of Resident #60's most recent quarterly MDS assessment, dated 08/21/18, reflected documented a BIMS score of 14, indicating intact cognition. Resident #60 required total assistance with all ADLs including eating. Furthermore , documentation in the MDS revealed the facility answered no or unknown when it was asked if Resident #60 gained 5% or more in the last month or gain of 10% or more in the last 6 months. Review of weight log dated 05/14/18 through 10/30/18 reflected, the resident admission weight was 130.7 pounds on 05/14/18. The last documented weight was 103.3 pounds on 10/03/18 However, Resident #60 weight loss on 07/05/18 was 128.2 pounds and on 08/21/18 weight of 119.1 pounds for a 7% weight loss. Review of Resident #60 electronic chart listed the following significant weight and dates: -05/14/18: 130.7 Lbs.-Admission weight -07/05/18: 128.2 Lbs. -08/21/18: 119.1 Lbs. -10/09/18: 108.0 Lbs. -10/30/18: 103.3 Lbs. Review of Resident #60's initial nutritional assessment by the physician dated 05/16/18 revealed she had an admission weight of 130.7 and was on [DEVICE] feeding of [MEDICATION NAME] 1.2 at 55cc x 22 hours with free water 20ml/hour X22 hours. Review of a document titled, SPL(Speech Language Pathologist) Evaluation & Plan of Treatment, dated 05/15/18 for Resident #60, revealed: Clinical impression: Patient presents with mild dysphagia(difficulty Swallowing) impairment as well as moderate expressive language impairment. Patient has hx (history) of poor intake PO(by mouth) and exhibit slow oral manipulation of bolus and mild delay onset of pharyngeal swallow. She also presents with expressive language deficit as evidenced by inability to effectively communicate wants and needs. Review of Resident #60's comprehensive care plan dated 10/02/18 revealed: -Resident requires tube feeding related to swallowing problem -Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight stable, signs and symptoms of malnutrition or dehydration through review date -Registered Dietitian to evaluate quarterly and PRN. Observe caloric intake, estimate needs. Make recommendations for changes to tube feeding as needed -The resident is dependent with feed tube feeding and water flushes. There were no interventions/approaches that identified or addressed weight loss or swallowing problems in Resident #60 care plan Review of Nutrition RD assessment dated [DATE] revealed an order for [REDACTED].>Review of Registered Dietitian progress note dated 06/08/18 revealed an order to start [MEDICATION NAME] 1.2 at 55cc/hour x22 hours Review of Registered Dietitian progress note dated 07/26/18 revealed order to start [MEDICATION NAME] 1.2 at 55cc/hour x22 hours Review of Registered Dietitian progress note dated 10/02/18 revealed the following orders: 1) Discontinue [MEDICATION NAME] 1.2 at 80cc/hour 6p-6a. 2) Discontinue free water 20ml every 2 hours 3) Start [MEDICATION NAME] 1.2 @ 65cc/hour X22hours 4) Free water 20ml/hour X22 hours Review of physician order [REDACTED].@ 65ml/hour X22 hours with free water20ml/hour for 22 hours. Feeding will only be down 2 hours. Observation of Resident #60's [DEVICE] feeding on 11/01/18 at 11:02 a.m. revealed the pump was turned off. Observation of Resident #60 on 11/01/18 at 1:23 p.m. revealed it the feeding pump was turned off. Observation of Resident #60 on 11/01/18 at 2:15 p.m. revealed it the feeding pump was turned off. Resident was aphasic and could not respond to command. During interview with LVN O on 11/01/18 at 2:20 p.m., he said he was the charge nurse responsible for Resident #60 on the 2:00 p.m. to 10:00 p.m. shift. He explained that the Resident #60 was not receiving the tube feeding because the order was for 80cc/hour 6p-6a, noting he thought the order was changed from [MEDICATION NAME] 1.2 at 65cc/hour 6p-6a. When asked, he stated he did not know if Resident #60 has lost weight. He said he did not know the present order for Resident #60 was for [MEDICATION NAME] 1.2 at 65cc/hour x22 hours. Interview with the ADON on 11/01/18 at 2:25 p.m. revealed she was new to the facility and was not familiar with the care of Resident #60. She stated she would find out what the resident was receiving. The ADON returned and noted Resident #60 was supposed to receive [MEDICATION NAME] 1.2 at 65cc/hour x22 hours. She said she did not know Resident #60 was not getting the [DEVICE] feeding as ordered. In an interview with LVN P on 11/01/18 at 2:32 p.m., he stated he took care of Resident #60 on the 6:00 a.m. to 2:00 p.m. shift. He explained the resident did not receive her [DEVICE] feeding because the order was for [MEDICATION NAME] 80cc/hour at 6:00p.m to 6:00a.m. He said he did not know the present order was for Resident #60 was for [MEDICATION NAME] at 65cc/hour x22 hours. Interview with the Physician K on 11/03/18 at 3:43 p.m. revealed he was the doctor in care of Resident #60. He said he was not aware that the facility was not following the order by the dietitian. He explained he gave the responsibility to the dietitian, and she would let him know if there was a problem or issues. He stated the resident has [DIAGNOSES REDACTED]. Interview with Resident #60 mother on 11/03/18 at 12:40p.m revealed she was not informed by the facilty that the reesident was losing weight. She explained the resident let her know almost on every visits that she was losing weight. She said the resident has [MEDICAL CONDITION] and may be contributing to the weight loss. She stated she did not know the faciity was not following the physician's orders [REDACTED]. Interview with Dietitian on 11/05/18 at 12:41 p.m. revealed she was the dietitian for Resident #60. She said she had been the dietitian in the facility since (MONTH) (YEAR). She explained when she writes an order, the physician had to sign off on it before the staff carried it out. She said the Resident #60 was supposed to receive [MEDICATION NAME] 1.2 @ 65cc/hour x22 hours. She said she adjusted Resident #60 for long period because of her weight loss. The facility weight management policy and procedure states, Residents nutritional status will be monitored on a regular basis to aide in the maintenance of acceptable parameter, such as body weight and protein levels, unless the residents clinical condition demonstrates that this is not possible. Accurate weights are obtained by having staff follow a consistent approach to weighing and by using appropriately serviced and functional scale. Resident are offered therapeutic diets when there is a nutritional concern and when the health care provider orders a therapeutic diet Weight can be a useful indicator of nutritional status, when evaluated within the context of the individual's personal history and overall condition. Significant unintended changes in weight(loss or gain) or insidious weight loss may indicate a nutritional problem. Review of the policy did not reveal what the facility will do if a resident had significant weight loss.

Based on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent avoidable accidents for one (Resident #1) of three residents reviewed for supervision. On [DATE], CNA E failed to notify Resident #1's charge nurse, the DON and Administrator when she returned the resident to her room after finding her outside without staff supervision. On [DATE], CNA F failed to notify Resident #1's charge nurse, the DON and Administrator when she returned the resident to her second floor room after finding her outside on a patio without staff supervision. On [DATE] at 1:10 PM, Resident #1 was found outside on the pavement face down with no pulse. CPR was initiated and continued when EMS arrived. Her death was pronounced at 1:30 PM. These failures resulted in a past noncompliance Immediate Jeopardy that occurred on [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could affect three residents, who were identified by the facility as wanderers and/or an elopement risk by placing them at risk injury, harm or death. Findings included: Resident #1 ' s Closed Record reflected on the Admission Record that she admitted to the facility on [DATE] at the age of 59. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was diagnosed with [REDACTED]. Resident #1 was diagnosed as an elopement risk/wanderer with impaired cognition on [DATE]. Interventions included check placement and function of safety monitoring device every shift, identify pattern of wandering, and intervene as appropriate. Care Plan revealed Resident #1 used a wheelchair for mobility. Resident #1 ' s Elopement Risk Assessment conducted on [DATE] revealed a score of 16. A score of 16 reflects that Residents #1 was mobile with a device, resistant to long term care placement, was cognitively impaired shown by decreased safety awareness, disturbances in judgment, and had shown a history of elopement within the past six months. A score of 12 or higher was considered at risk for elopement. Review of the facility's Progress Note, dated [DATE] and completed by LVN A, revealed, Resident was observed by this nurse at around 0620 laying down in her bed during the initial morning rounds at the beginning of the shift. Around 0720 this nurse met the resident on the hallway by her room and I redirected her back into the room where I checked her blood sugar and administered her morning medications as scheduled and per MAR. The resident then left for the dining room to get her breakfast. Resident was again seen by this nurse around 0945 back in her room. This was the last time the resident was seen by this nurse. Around 1258 resident was noted missing from her room, this nurse and the CNA working on the floor tried to locate the resident within the unit and nearby lounge but resident could not be seen. Elopement code was activated and active search began all staff was initiated both within and outside the building. This nurse found the resident laying down on her back and facing up with all extremities extended on the pavement just outside the building at around 1315. I tried to elicit response from the patient both verbally and touch by shaking her but there was no response, no pulse upon assessment. I alerted one of the staff to call 911and get the crash cart while I started CPR. This nurse and one of nurses alternated performing CPR until the paramedics arrived to the scene about seven minutes later. Resident was pronounced dead on the site by the paramedics. This nurse called the family and responsible party to notify them of the incident. Np on-call for the primary physician was also notified about the incident. Review of the facility ' s Incident/Accident Report, dated [DATE], revealed Resident was found outside the building unresponsive, attempted to resuscitate .pronounced dead by the paramedics upon arrival. Incident/Accident Report revealed no physical injuries were noted to resident. Family and physician were notified. Review of the facility's Investigation Follow-Up, dated [DATE] and completed by the DON, revealed, At 1310 (1:10 PM) found resident lying on a pavement with her wheelchair besides her not responding to call. Lie (sic) face up. Assessed pulse not felt. CPR initiated. EMS called. Skin assessed with [REDACTED]. CPR continued until EMS arrived. Resident had a wander guard (sic) as a preventative measure from eloping. She had been re-directed several times when she attempted to elope in the past. In an interview with the DON on [DATE] at 11:45 AM, the DON revealed Resident #1 was identified as a wanderer and was on two hour routine checks. The DON revealed that when Resident #1 admitted to the facility she resided on the first floor and transitioned to long term care on the second floor. Resident #1 did have cognition deficits and would wander throughout the building. The facility would monitor her wandering and re-direct her back up upstairs to her room. Resident #1 did not have a history of elopement prior to the incident. Resident #1 did not attempt to exit the building in the past. Resident #1 did wear a Wanderguard bracelet. On [DATE], Resident #1 was found lying on her back by the DON, with her wheelchair beside her, on the sidewalk beside the facility. Resident #1 did not have any vital signs and the staff called 911 and initiated CPR. The paramedics arrived, continued CPR, and then pronounced Resident #1 expired at 1:30 PM. The family and medical examiner were notified. The facility did not know if an autopsy was performed or the cause of death. There were no signs of injuries, bruises, or scrapes when Resident #1 was found. The DON stated further the facility began an investigation on [DATE] which revealed Resident #1 was last seen around 10:00 AM on [DATE], by nursing staff on the second floor near her room. Around 12:30 PM, the staff were passing lunch trays and noted Resident #1 was not in her room. The staff initiated the missing resident protocol and found Resident #1 outside on the sidewalk around 1:00 PM. During the investigation, she became aware of additional incidents of elopement by Resident #1 that had occurred in the days just prior to the incident on [DATE]. Two facility staff revealed that they witnessed Resident #1 outside of the facility after hearing the Wanderguard alarm sound on two separate occasions. Both facility staff re-directed the resident back inside to her room on the second floor. Both staff members denied reporting either incident to their immediate supervisor, Director of Nursing, or Administrator. The first incident occurred on [DATE] and the following incident occurred in the morning on [DATE] prior to Resident #1 being reported missing later the same day on a separate occurrence. In an interview on [DATE] at 9:30 AM, the ADON A stated the Wanderguard alarm was working correctly on [DATE]. During the facility investigation residents revealed that they did hear the alarm go off, but could not provide specific details of regarding the time. All staff present during the incident involving Resident #1 missing on [DATE], denied entering the code in order to turn the Wanderguard alarm off. Residents that were present at the door that Resident #1 exited the building denied entering the code in order to turn the alarm off when Resident #1 exited the building. Follow up interviews were conducted with residents that stated they heard the alarms go off were not consistent with previous interviews. The facility would then have to change all the codes. The facility was in-serviced on being secure with the codes to exit the building. Review of CNA E's Witness Statement, dated [DATE] revealed, On [DATE] I saw (Resident #1) downstairs between the hours of 7 to 7:30PM when the alarms went off I quickly ran and check (sic) I saw her and I re-directed her and she followed me back upstairs. Interview by telephone with CNA E on [DATE] at 1:40 PM revealed she found Resident #1 outside of the facility on [DATE] around 7:00 PM due to the Wanderguard alarm going off. CNA E revealed she was downstairs on her lunch break when she heard the Wanderguard alarm from an exit door on the first floor. CNA E stated she immediately brought Resident #1 inside the building and re-directed her back to the second floor. Resident #1 was in her wheelchair and did not provide any resistance being re-directed back into the building. CNA E stated she did not notify her immediate supervisor, THE DON, or Administrator about finding Resident #1 outside of the facility. CNA E reported she did not inform any facility staff regarding the incident. CNA E stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of CNA F's Witness Statement, dated [DATE] revealed, On [DATE]th 2016 when I clocked in at ,[DATE] AM notice (sic) that wander guard (sic) system was going off on back patio went to see if any PT (Physical Therapist) was outside noticed (Resident #1) was sitting out on the back patio with another Pt. (patient) re-directed .back upstairs to .unit on 2-central. Interview with CNA F on [DATE] at 1:52 PM revealed on [DATE], she heard the Wanderguard system going off around 7:00 AM when she was about to clock in. She immediately went to check the door and found Resident #1 outside on the back patio with another resident. CNA F disabled the door alarm and re-directed Resident #1 inside the facility and back upstairs to her room. CNA F revealed Resident #1 was in her wheelchair and did not appear to be in any distress, only confused. CNA F stated she did not report finding Resident #1 outside of the facility to her immediate supervisor, the DON, or Administrator. CNA F stated she announced to the second floor that she brought Resident #1 from downstairs back to her room. CNA F did not directly inform any facility staff. CNA F stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of the facility's Resident Elopement Policy, revised [DATE] revealed, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence. Review of the facility's Resident Elopement Policy regarding missing residents, revised [DATE] revealed, Upon return of the resident to the facility, the Director of Nursing and the Administrator should: Examine the resident for injuries (Director of Nursing); Contact the attending physician, report findings and conditions of the resident, and follow the physician's order [REDACTED]. records (Director of Nursing); Investigate how the resident eloped and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement (QAPI) Committee and or the Safety Team Committee (as necessary); and Update the resident ' s care plan with interventions for elopement prevention. Review of the facility ' s Testing the Wanderguard System, revised February 2010 revealed, regular testing of Wanderguard door monitors and signaling devices in the alarm system will be conducted to verify the integrity of the system. The internal batteries will be replaced at least once a year or when the red light does not come on when pressed. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester. Nursing staff will check the wristbands for tears or other damage and replace bands immediately if damaged and record the test was conducted in the resident ' s record. Maintenance will inspect and test each door monitor and test the range of the door monitors weekly. Review of all staff in-service training revealed in-services regarding keeping doors and door codes secure, missing residents, and elopement risks were conducted on [DATE] by ADON A. A total of 98 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. Review of the Facility Elopement Drill revealed drills were conducted by the Maintenance Supervisor on [DATE] on the first, second, and third shifts. A total of 59 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Observations throughout the investigation on [DATE] revealed Wanderguard alarms were functioning properly. In an interview with CNA C on [DATE] at 9:50 AM, CNA C revealed residents that are identified as a wanderer/elopement risk wear a wander guard around their wrist. CNA C revealed Resident #1 was a wanderer and needed constant re-directing. Residents that are identified as wanderers or an elopement risk are supposed to be checked on at least every two hours. CNA C revealed that if a resident is found outside that is identified as an elopement risk/wanderer the staff must report to their supervisor immediately. Individual Interviews were conducted with facility staff from various shifts (Maintenance Supervisor, Central Supply Coordinator, CNA A, CNA B, CNA C, CNA D, MA A, and ADON B) throughout the investigation on [DATE] during the first shift, revealed they had received elopement and missing resident training during orientation and routine in-services. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. CNA A, CNA B, CNA C, CNA D, MA A, and ADON B were able to identify the correct residents that were wanderers/elopement risks as identified by the facility. Direct care staff interviewed were able to identify behaviors to identify wanderers or exit-seeking behavior. On [DATE], the DON was notified of an Immediate Jeopardy at Past Noncompliance had been identified. The IJ occurred [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. On [DATE] the DON provided the resident roster with three residents identified as wanderers/elopement risks.

Based on observation, interview and record review, the facility failed to implement their policies and procedures that prohibit neglect for one (Resident #1) of one residents reviewed for neglect to provide adequate supervision. On [DATE], CNA E failed to notify Resident #1 ' s charge nurse, the DON and Administrator when she returned the resident to her room after finding her outside without staff supervision. On [DATE], CNA F failed to notify Resident #1 ' s charge nurse, the DON and Administrator when she returned the resident to her second floor room after finding her outside on a patio without staff supervision. On [DATE] at 1:10 PM, Resident #1 was found outside on the pavement face down with no pulse. CPR was initiated and continued when EMS arrived. Her death was pronounced at 1:30 PM. These failures resulted in a past noncompliance Immediate Jeopardy that occurred on [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could affect three residents, who were identified by the facility as wanderers and/or an elopement risk by placing them at risk injury, harm or death. Findings included: The Resident Elopement Policy, revised [DATE] reflected, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence. Review of the facility's Resident Elopement Policy regarding missing residents, revised [DATE] revealed, Upon return of the resident to the facility, the Director of Nursing and the Administrator should: Examine the resident for injuries (Director of Nursing); Contact the attending physician, report findings and conditions of the resident, and follow the physician's order [REDACTED]. records (Director of Nursing); Investigate how the resident eloped and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement (QAPI) Committee and or the Safety Team Committee (as necessary); and Update the resident ' s care plan with interventions for elopement prevention. Review of the facility ' s Testing the Wanderguard System, revised February 2010 revealed, regular testing of Wanderguard door monitors and signaling devices in the alarm system will be conducted to verify the integrity of the system. The internal batteries will be replaced at least once a year or when the red light does not come on when pressed. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester. Nursing staff will check the wristbands for tears or other damage and replace bands immediately if damaged and record the test was conducted in the resident ' s record. Maintenance will inspect and test each door monitor and test the range of the door monitors weekly. Review of the facility ' s Abuse and Neglect Prohibition Policy, revised [DATE], revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Resident #1 ' s Closed Record reflected on the Admission Record that she admitted to the facility on [DATE] at the age of 59. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was diagnosed with [REDACTED]. Resident #1 was diagnosed as an elopement risk/wanderer with impaired cognition on [DATE]. Interventions included check placement and function of safety monitoring device every shift, identify pattern of wandering, and intervene as appropriate. Care Plan revealed Resident #1 used a wheelchair for mobility. Resident #1 ' s Elopement Risk Assessment conducted on [DATE] revealed a score of 16. A score of 16 reflects that Residents #1 was mobile with a device, resistant to long term care placement, was cognitively impaired shown by decreased safety awareness, disturbances in judgment, and had shown a history of elopement within the past six months. A score of 12 or higher was considered at risk for elopement. Review of the facility ' s Progress Note, dated [DATE] and completed by LVN A, revealed, Resident was observed by this nurse at around 0620 laying down in her bed during the initial morning rounds at the beginning of the shift. Around 0720 this nurse met the resident on the hallway by her room and I redirected her back into the room where I checked her blood sugar and administered her morning medications as scheduled and per MAR. The resident then left for the dining room to get her breakfast. Resident was again seen by this nurse around 0945 back in her room. This was the last time the resident was seen by this nurse. Around 1258 resident was noted missing from her room, this nurse and the CNA working on the floor tried to locate the resident within the unit and nearby lounge but resident could not be seen. Elopement code was activated and active search began all staff was initiated both within and outside the building. This nurse found the resident laying down on her back and facing up with all extremities extended on the pavement just outside the building at around 1315. I tried to elicit response from the patient both verbally and touch by shaking her but there was no response, no pulse upon assessment. I alerted one of the staff to call 911and get the crash cart while I started CPR. This nurse and one of nurses alternated performing CPR until the paramedics arrived to the scene about seven minutes later. Resident was pronounced dead on the site by the paramedics. This nurse called the family and responsible party to notify them of the incident. Np on-call for the primary physician was also notified about the incident. Review of the facility ' s Incident/Accident Report, dated [DATE], revealed Resident was found outside the building unresponsive, attempted to resuscitate .pronounced dead by the paramedics upon arrival. Incident/Accident Report revealed no physical injuries were noted to resident. Family and physician were notified. Review of the facility's Investigation Follow-Up, dated [DATE] and completed by the DON, revealed, At 1310 (1:10 PM) found resident lying on a pavement with her wheelchair besides her not responding to call. Lie (sic) face up. Assessed pulse not felt. CPR initiated. EMS called. Skin assessed with [REDACTED]. CPR continued until EMS arrived. Resident had a wander guard (sic) as a preventative measure from eloping. She had been re-directed several times when she attempted to elope in the past. In an interview with the DON on [DATE] at 11:45 AM, the DON revealed Resident #1 was identified as a wanderer and was on two hour routine checks. The DON revealed that when Resident #1 admitted to the facility she resided on the first floor and transitioned to long term care on the second floor. Resident #1 did have cognition deficits and would wander throughout the building. The facility would monitor her wandering and re-direct her back up upstairs to her room. Resident #1 did not have a history of elopement prior to the incident. Resident #1 did not attempt to exit the building in the past. Resident #1 did wear a Wanderguard bracelet. On [DATE], Resident #1 was found lying on her back, with her wheelchair beside her, on the sidewalk beside the facility. Resident #1 did not have any vital signs and the staff called 911 and initiated CPR. The paramedics arrived, continued CPR, and then pronounced Resident #1 expired at 1:30 PM. The family and medical examiner were notified. The facility did not know if an autopsy was performed or the cause of death. There were no signs of injuries, bruises, or scrapes when Resident #1 was found. The DON stated further the facility began an investigation on [DATE] which revealed Resident #1 was last seen around 10:00 AM on [DATE], by nursing staff on the second floor near her room. Around 12:30 PM, the staff were passing lunch trays and noted Resident #1 was not in her room. The staff initiated the missing resident protocol and found Resident #1 outside on the sidewalk around 1:00 PM. During the investigation, she became aware of additional incidents of elopement by Resident #1 that had occurred in the days just prior to the incident on [DATE]. Two facility staff revealed that they witnessed Resident #1 outside of the facility after hearing the Wanderguard alarm sound on two separate occasions. Both facility staff re-directed the resident back inside to her room on the second floor. Both staff members denied reporting either incident to their immediate supervisor, Director of Nursing, or Administrator. The first incident occurred on [DATE] and the following incident occurred in the morning on [DATE] prior to Resident #1 being reported missing later the same day on a separate occurrence. There was no documentation regarding the first two instances of Resident #1 setting off the Wanderguard alarm due to the two facility employees not reporting finding Resident #1 outside of the facility. The DON revealed the facility has two additional residents that have been identified as a wanderer/elopement risk. In an interview on [DATE] at 9:30 AM, the ADON A stated the Wanderguard alarm was working correctly on [DATE]. During the facility investigation residents revealed that they did hear the alarm go off, but could not provide specific details of regarding the time. All staff present during the incident involving Resident #1 missing on [DATE], denied entering the code in order to turn the Wanderguard alarm off. Residents that were present at the door that Resident #1 exited the building denied entering the code in order to turn the alarm off when Resident #1 exited the building. Follow up interviews were conducted with residents that stated they heard the alarms go off were not consistent with previous interviews. The facility would then have to change all the codes. The facility was in-serviced on being secure with the codes to exit the building. Review of CNA E's Witness Statement, dated [DATE] revealed, On [DATE] I saw (Resident #1) downstairs between the hours of 7 to 7:30PM when the alarms went off I quickly ran and check (sic) I saw her and I re-directed her and she followed me back upstairs. Interview by telephone with CNA E on [DATE] at 1:40 PM revealed she found Resident #1 outside of the facility on [DATE] around 7:00 PM due to the Wanderguard alarm going off. CNA E revealed she was downstairs on her lunch break when she heard the Wanderguard alarm from an exit door on the first floor. CNA E stated she immediately brought Resident #1 inside the building and re-directed her back to the second floor. Resident #1 was in her wheelchair and did not provide any resistance being re-directed back into the building. CNA E stated she did not notify her immediate supervisor, THE DON, or Administrator about finding Resident #1 outside of the facility. CNA E reported she did not inform any facility staff regarding the incident. CNA E stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of CNA F's Witness Statement, dated [DATE] revealed, On [DATE]th 2016 when I clocked in at ,[DATE] AM notice (sic) that wander guard (sic) system was going off on back patio went to see if any PT (Physical Therapist) was outside noticed (Resident #1) was sitting out on the back patio with another Pt. (patient) re-directed .back upstairs to .unit on 2-central. Interview with CNA F on [DATE] at 1:52 PM revealed on [DATE], she heard the Wanderguard system going off around 7:00 AM when she was about to clock in. She immediately went to check the door and found Resident #1 outside on the back patio with another resident. CNA F disabled the door alarm and re-directed Resident #1 inside the facility and back upstairs to her room. CNA F revealed Resident #1 was in her wheelchair and did not appear to be in any distress, only confused. CNA F stated she did not report finding Resident #1 outside of the facility to her immediate supervisor, the DON, or Administrator. CNA F stated she announced to the second floor that she brought Resident #1 from downstairs back to her room. CNA F did not directly inform any facility staff. CNA F stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of all staff in-service training revealed in-services regarding keeping doors and door codes secure, missing residents, and elopement risks were conducted on [DATE] by ADON A. A total of 98 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. Review of the Facility Elopement Drill revealed drills were conducted by the Maintenance Supervisor on [DATE] on the first, second, and third shifts. A total of 59 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Observations throughout the investigation on [DATE] revealed Wanderguard alarms were functioning properly. In an interview with CNA C on [DATE] at 9:50 AM, CNA C revealed residents that are identified as a wanderer/elopement risk wear a wander guard around their wrist. CNA C revealed Resident #1 was a wanderer and needed constant re-directing. Residents that are identified as wanderers or an elopement risk are supposed to be checked on at least every two hours. CNA C revealed that if a resident is found outside that is identified as an elopement risk/wanderer the staff must report to their supervisor immediately. Individual Interviews were conducted with facility staff from various shifts (Maintenance Supervisor, Central Supply Coordinator, CNA A, CNA B, CNA C, CNA D, MA A, and ADON B) throughout the investigation on [DATE] during the first shift, revealed they had received elopement and missing resident training during orientation and routine in-services. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. CNA A, CNA B, CNA C, CNA D, MA A, and ADON B were able to identify the correct residents that were wanderers/elopement risks as identified by the facility. Direct care staff interviewed were able to identify behaviors to identify wanderers or exit-seeking behavior. On [DATE], the DON was notified of an Immediate Jeopardy at Past Noncompliance had been identified. The IJ occurred [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. On [DATE] the DON provided the resident roster with three residents identified as wanderers/elopement risks.

Based on observation, interview and record review, the facility failed to implement their written policies and procedures that prohibit neglect for one (Resident #1) of one residents reviewed for neglect to provide adequate supervision. On [DATE], CNA E failed to notify Resident #1 ' s charge nurse, the DON and Administrator when she returned the resident to her room after finding her outside without staff supervision. On [DATE], CNA F failed to notify Resident #1 ' s charge nurse, the DON and Administrator when she returned the resident to her second floor room after finding her outside on a patio without staff supervision. On [DATE] at 1:10 PM, Resident #1 was found outside on the pavement face down with no pulse. CPR was initiated and continued when EMS arrived. Her death was pronounced at 1:30 PM. These failures resulted in a past noncompliance Immediate Jeopardy that occurred on [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. This failure could affect three residents, who were identified by the facility as wanderers and/or an elopement risk by placing them at risk injury, harm or death. Findings included: Review of the facility ' s Abuse and Neglect Prohibition Policy, revised [DATE], revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. The Resident Elopement Policy, revised [DATE] reflected, It is the responsibility of all personnel to report any resident attempting to leave the premises, or suspected of being missing, to the Director of Nursing and the Administrator and to document the occurrence. Review of the facility's Resident Elopement Policy regarding missing residents, revised [DATE] revealed, Upon return of the resident to the facility, the Director of Nursing and the Administrator should: Examine the resident for injuries (Director of Nursing); Contact the attending physician, report findings and conditions of the resident, and follow the physician's order [REDACTED]. records (Director of Nursing); Investigate how the resident eloped and make recommendations regarding safety measures to the Quality Assurance and Performance Improvement (QAPI) Committee and or the Safety Team Committee (as necessary); and Update the resident ' s care plan with interventions for elopement prevention. Review of the facility ' s Testing the Wanderguard System, revised February 2010 revealed, regular testing of Wanderguard door monitors and signaling devices in the alarm system will be conducted to verify the integrity of the system. The internal batteries will be replaced at least once a year or when the red light does not come on when pressed. Nursing staff will perform daily checks to verify the operation of the signaling device using a signaling device tester. Nursing staff will check the wristbands for tears or other damage and replace bands immediately if damaged and record the test was conducted in the resident ' s record. Maintenance will inspect and test each door monitor and test the range of the door monitors weekly. Review of the facility ' s Abuse and Neglect Prohibition Policy, revised [DATE], revealed, Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, injuries of unknown origin, and misappropriation of property. Resident #1 ' s Closed Record reflected on the Admission Record that she admitted to the facility on [DATE] at the age of 59. Review of Resident #1's Care Plan, dated [DATE], revealed Resident #1 was diagnosed with [REDACTED]. Resident #1 was diagnosed as an elopement risk/wanderer with impaired cognition on [DATE]. Interventions included check placement and function of safety monitoring device every shift, identify pattern of wandering, and intervene as appropriate. Care Plan revealed Resident #1 used a wheelchair for mobility. Resident #1 ' S Elopement Risk Assessment conducted on [DATE] revealed a score of 16. A score of 16 reflects that Residents #1 was mobile with a device, resistant to long term care placement, was cognitively impaired shown by decreased safety awareness, disturbances in judgment, and had shown a history of elopement within the past six months. A score of 12 or higher was considered at risk for elopement. Review of the facility ' s Progress Note, dated [DATE] and completed by LVN A, revealed, Resident was observed by this nurse at around 0620 laying down in her bed during the initial morning rounds at the beginning of the shift. Around 0720 this nurse met the resident on the hallway by her room and I redirected her back into the room where I checked her blood sugar and administered her morning medications as scheduled and per MAR. The resident then left for the dining room to get her breakfast. Resident was again seen by this nurse around 0945 back in her room. This was the last time the resident was seen by this nurse. Around 1258 resident was noted missing from her room, this nurse and the CNA working on the floor tried to locate the resident within the unit and nearby lounge but resident could not be seen. Elopement code was activated and active search began all staff was initiated both within and outside the building. This nurse found the resident laying down on her back and facing up with all extremities extended on the pavement just outside the building at around 1315. I tried to elicit response from the patient both verbally and touch by shaking her but there was no response, no pulse upon assessment. I alerted one of the staff to call 911and get the crash cart while I started CPR. This nurse and one of nurses alternated performing CPR until the paramedics arrived to the scene about seven minutes later. Resident was pronounced dead on the site by the paramedics. This nurse called the family and responsible party to notify them of the incident. Np on-call for the primary physician was also notified about the incident. Review of the facility ' s Incident/Accident Report, dated [DATE], revealed Resident was found outside the building unresponsive, attempted to resuscitate .pronounced dead by the paramedics upon arrival. Incident/Accident Report revealed no physical injuries were noted to resident. Family and physician were notified. Review of the facility's Investigation Follow-Up, dated [DATE] and completed by the DON, revealed, At 1310 (1:10 PM) found resident lying on a pavement with her wheelchair besides her not responding to call. Lie (sic) face up. Assessed pulse not felt. CPR initiated. EMS called. Skin assessed with [REDACTED]. CPR continued until EMS arrived. Resident had a wander guard (sic) as a preventative measure from eloping. She had been re-directed several times when she attempted to elope in the past. In an interview with the DON on [DATE] at 11:45 AM, the DON revealed Resident #1 was identified as a wanderer and was on two hour routine checks. The DON revealed that when Resident #1 admitted to the facility she resided on the first floor and transitioned to long term care on the second floor. Resident #1 did have cognition deficits and would wander throughout the building. The facility would monitor her wandering and re-direct her back up upstairs to her room. Resident #1 did not have a history of elopement prior to the incident. Resident #1 did not attempt to exit the building in the past. Resident #1 did wear a Wanderguard bracelet. On [DATE], Resident #1 was found lying on her back, with her wheelchair beside her, on the sidewalk beside the facility. Resident #1 did not have any vital signs and the staff called 911 and initiated CPR. The paramedics arrived, continued CPR, and then pronounced Resident #1 expired at 1:30 PM. The family and medical examiner were notified. The facility did not know if an autopsy was performed or the cause of death. There were no signs of injuries, bruises, or scrapes when Resident #1 was found. The DON stated further the facility began an investigation on [DATE] which revealed Resident #1 was last seen around 10:00 AM on [DATE], by nursing staff on the second floor near her room. Around 12:30 PM, the staff were passing lunch trays and noted Resident #1 was not in her room. The staff initiated the missing resident protocol and found Resident #1 outside on the sidewalk around 1:00 PM. During the investigation, she became aware of additional incidents of elopement by Resident #1 that had occurred in the days just prior to the incident on [DATE]. Two facility staff revealed that they witnessed Resident #1 outside of the facility after hearing the Wanderguard alarm sound on two separate occasions. Both facility staff re-directed the resident back inside to her room on the second floor. Both staff members denied reporting either incident to their immediate supervisor, Director of Nursing, or Administrator. The first incident occurred on [DATE] and the following incident occurred in the morning on [DATE] prior to Resident #1 being reported missing later the same day on a separate occurrence. There was no documentation regarding the first two instances of Resident #1 setting off the Wanderguard alarm due to the two facility employees not reporting finding Resident #1 outside of the facility. The DON revealed the facility has two additional residents that have been identified as a wanderer/elopement risk. In an interview on [DATE] at 9:30 AM, the ADON A stated the Wanderguard alarm was working correctly on [DATE]. During the facility investigation residents revealed that they did hear the alarm go off, but could not provide specific details of regarding the time. All staff present during the incident involving Resident #1 missing on [DATE], denied entering the code in order to turn the Wanderguard alarm off. Residents that were present at the door that Resident #1 exited the building denied entering the code in order to turn the alarm off when Resident #1 exited the building. Follow up interviews were conducted with residents that stated they heard the alarms go off were not consistent with previous interviews. The facility would then have to change all the codes. The facility was in-serviced on being secure with the codes to exit the building. Review of CNA E's Witness Statement, dated [DATE] revealed, On [DATE] I saw (Resident #1) downstairs between the hours of 7 to 7:30PM when the alarms went off I quickly ran and check (sic) I saw her and I re-directed her and she followed me back upstairs. Interview by telephone with CNA E on [DATE] at 1:40 PM revealed she found Resident #1 outside of the facility on [DATE] around 7:00 PM due to the Wanderguard alarm going off. CNA E revealed she was downstairs on her lunch break when she heard the Wanderguard alarm from an exit door on the first floor. CNA E stated she immediately brought Resident #1 inside the building and re-directed her back to the second floor. Resident #1 was in her wheelchair and did not provide any resistance being re-directed back into the building. CNA E stated she did not notify her immediate supervisor, THE DON, or Administrator about finding Resident #1 outside of the facility. CNA E reported she did not inform any facility staff regarding the incident. CNA E stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of CNA F's Witness Statement, dated [DATE] revealed, On [DATE]th 2016 when I clocked in at ,[DATE] AM notice (sic) that wander guard (sic) system was going off on back patio went to see if any PT (Physical Therapist) was outside noticed (Resident #1) was sitting out on the back patio with another Pt. (patient) re-directed .back upstairs to .unit on 2-central. Interview with CNA F on [DATE] at 1:52 PM revealed on [DATE], she heard the Wanderguard system going off around 7:00 AM when she was about to clock in. She immediately went to check the door and found Resident #1 outside on the back patio with another resident. CNA F disabled the door alarm and re-directed Resident #1 inside the facility and back upstairs to her room. CNA F revealed Resident #1 was in her wheelchair and did not appear to be in any distress, only confused. CNA F stated she did not report finding Resident #1 outside of the facility to her immediate supervisor, the DON, or Administrator. CNA F stated she announced to the second floor that she brought Resident #1 from downstairs back to her room. CNA F did not directly inform any facility staff. CNA F stated she was verbally counseled about the facility policy to report to her immediate supervisor, DON, or Administrator immediately after finding a resident leaving the facility or attempting to leave the facility. Review of all staff in-service training revealed in-services regarding keeping doors and door codes secure, missing residents, and elopement risks were conducted on [DATE] by ADON A. A total of 98 facility staff participated in the in-service training, including staff that directly work with residents that are identified as a wanderer/elopement risk. Facility staff from all shifts were present and received the training. Review of the Facility Elopement Drill revealed drills were conducted by the Maintenance Supervisor on [DATE] on the first, second, and third shifts. A total of 59 facility staff participated in the drills. Staff that are assigned to residents with wandering/elopement risk were included in the drill. Observations throughout the investigation on [DATE] revealed Wanderguard alarms were functioning properly. In an interview with CNA C on [DATE] at 9:50 AM, CNA C revealed residents that are identified as a wanderer/elopement risk wear a wander guard around their wrist. CNA C revealed Resident #1 was a wanderer and needed constant re-directing. Residents that are identified as wanderers or an elopement risk are supposed to be checked on at least every two hours. CNA C revealed that if a resident is found outside that is identified as an elopement risk/wanderer the staff must report to their supervisor immediately. Individual Interviews were conducted with facility staff from various shifts (Maintenance Supervisor, Central Supply Coordinator, CNA A, CNA B, CNA C, CNA D, MA A, and ADON B) throughout the investigation on [DATE] during the first shift, revealed they had received elopement and missing resident training during orientation and routine in-services. Interviewed staff revealed they had participated in elopement drills. Interviewed staff were able to provide sufficient knowledge of the facility's elopement and missing resident policies. CNA A, CNA B, CNA C, CNA D, MA A, and ADON B were able to identify the correct residents that were wanderers/elopement risks as identified by the facility. Direct care staff interviewed were able to identify behaviors to identify wanderers or exit-seeking behavior. On [DATE], the DON was notified of an Immediate Jeopardy at Past Noncompliance had been identified. The IJ occurred [DATE] through [DATE] at a scope of pattern with actual harm. The facility had implemented actions that corrected the non-compliance prior to the beginning of the investigation. On [DATE] the DON provided the resident roster with three residents identified as wanderers/elopement risks.

Based on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment of the resident, one (Resident #2) of six residents reviewed for pressure ulcers, sores received the necessary treatment and services to prevent a new pressure ulcer from developing. Resident #2, who was at risk for developing pressure ulcers and had two current pressure ulcers, was found with an unidentified pressure ulcer on his left heel by the surveyor. Resident #2's heels were not off-loaded and anti-pressure boots had not been applied to his feet. These failures to implement physician-ordered and care planned interventions to prevent the development of pressure ulcers, resulted in Resident #2 developing a pressure ulcer on his right heel and placed the 16 other residents identified with pressure ulcers at risk for developing more pressure ulcers. the development of new pressure ulcers result in the need for continuing treatments, discomfort and/or pain for the residents, the need for increased medication, the development of an infection, resulting in a loss of health and well-being, and the development of depression, having a negative impact on their quality of life. Findings included: Review of the face sheet dated 01/25/12, revealed Resident #2 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #2's MDS assessment dated [DATE] revealed he had the following Diagnoses: [REDACTED]. The MDS assessment reflected the resident was at risk for developing pressure ulcers and the resident had one Stage Three pressure ulcer. During initial rounds with LVN O on 11/19/13 at 9:00 AM, she stated Resident #2 was totally dependent on staff for all ADLs, and he had a Stage Four pressure ulcer on his coccyx. Observation on 11/19/13 at 9:30 AM and 11:30 AM, revealed Resident #2 was laying on his back. The resident's heels rested directly on the mattress and were not off-loaded. The resident was not wearing any pressure-relieving device on his feet. The resident's feet were contracted, a dressing was noted on the right lateral foot. Observation on 11/20/13 at 8:00 AM revealed Resident #2 was in bed on his back; his heels were not off-loaded and rested directly on the mattress. The resident was not wearing any pressure-relieving device on his feet. Resident #2's consolidated Physician order [REDACTED]. Resident #2's current care plan, updated 11/14/13, reflected the resident had a pressure ulcer on the "right proximal foot" and the resident was to wear an "EZ boot" (PODUS BOOT) when in bed. On 11/19/13 at 11:30 AM, CNA G and CNA Q were observed transferring the resident from the bed into the wheelchair. A nickel-sized, dark purple/black circular area was observed on the resident's right heel. LVN P, the Wound Care Nurse, was observed providing treatment to Resident #2's pressure ulcers on the left buttock and the outer aspect of the right on 11/20/13 at 12:50 PM. Resident #2 was observed with a Stage Three pressure ulcer on the left buttock and a Stage Two pressure ulcer on the lateral outer portion on the right foot. When the surveyor inquired about the pressure ulcer on the resident's right heel, LVN P stated it was not being treated, and she was not aware of it. She then measured the right heel pressure ulcer, and it was 1.7 cm x 1.7 cm. During an interview on 11/20/13 at 6:00 PM, the responsible party for Resident #2 stated the resident was supposed to be wearing PODUS boots to protect his feet. She stated when she visited Resident #2, the PODUS BOOTS were often not on the resident's feet. She stated she had asked staff in the past why they were not being used. She stated staff would tell her they were in the laundry. On 11/21/13 at 9:15 AM, when interviewed, CNA G stated Resident #2 shad not worn the EZ boot because they were in the laundry. On 11/20/13, facility staff updated the current treatment record for Resident #2. They classified the area on the resident's heel as deep tissue injury and obtained treatment orders. Following surveyor inquiry on 11/20/13, the area was on Resident #2's right foot was further assessed as a deep tissue injury by the wound care nurse, LVN P, and treatment orders were obtained from the physician. Resident #2's physician order [REDACTED]. An article by the National Pressure Ulcer Advisory Panel (NPUAP) entitled "Updated Pressure Ulcer Staging System" dated December 2007 reflected a deep tissue injury was the newest pressure ulcer in the updated staging system. This type of pressure ulcer presents as a dark purple or maroon localized area due to damage of underlying tissue from pressure or friction. The CMS 672, Resident Census and Conditions of Residents, dated 11/19/13, and signed by the DON reflected the facility had 17 residents with pressure ulcers.

Based on observation, interview and record review, the facility failed to allow one (Resident #1) of four residents reviewed the right to be from interference, coercion, discrimination, and reprisal from the facility in exercising her rights. Resident #1 was subjected to a drug screen without prior permission. The physician and facility misinterpreted the results of the test and openly accused the resident of use of illegal drugs. The physician and facility staff chastised and defamed the resident in front of other staff and family members. The resident was unjustly refused the right to visit her ex-family member without supervision. These failures resulted in Resident #1 experiencing psychological harm and withdrawal. These failures could affect the 129 residents in the facility. Findings included: 1) Resident #1's Face Sheet dated 09/17/10 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#1 had no Legal Guardian. Review of an undated Nursing Admission Assessment revealed Resident #1 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED].#1 was alert and oriented to person, place and time. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. According to the MAR, the resident received the medication as ordered. 2) On 10/01/10 at 11:45 a.m., SW D revealed a meeting was scheduled because of the results of Resident #1's drug screen. SW D stated she attended the meeting. At the meeting, she thought ADON C told Resident #1 she (the resident) tested positive for cocaine. The SW stated, "She (Resident #1) was very upset. Family believed it to be true." The SW revealed during the meeting, Resident #1 stated, "If it was in my system, you guys gave it to me." The SW stated, "She (Resident #1) was yelling at _____ (Physician F). She was very irate; very upset." The SW D revealed that during the meeting, ADON C stated, "Latest labs said you had cocaine and [MEDICATION NAME] in your system. How did you get it?" Resident #1's Social Progress Notes dated 08/31/10 reflected a care plan meeting was held for the resident. The notes reflected the resident, two family members, the DON, ADON C, two Social Workers and the resident's physician attended. Resident #1 had recently been lethargic and falling. ADON C and PHYSICIAN F ordered a urine analysis for a drug screening to be done. SW D documented the drug screen was positive for [MEDICATION NAME] and cocaine. The resident was confronted with the information at the care plan meeting. Resident #1 denied having taken [MEDICATION NAME] and cocaine and said the lab results were wrong. At the meeting, the DON informed Resident #1 she would have to have supervised visits when her ex-family member in the common area of the facility when he came to visit. The resident agreed to the supervised visits. Physician F stated he would review Resident #1's list of medications and re-evaluate the dosage. The notes reflected at that point, Resident #1 began yelling at Physician F, calling him a liar and stating she needed all of her medications. The resident became hositle. Resident #1 was very upset as SW D wheeled the resident back to her room. While doing so, SW D told the staff on Resident #1's hall of the visitation boundaries with Resident #1's ex-family member. 3) Review of the urine drug screen lab report with a draw date of 08/26/10 and was delivered 08/28/10 revealed Resident #1 tested positive for [MEDICATION NAME], benzodiazepines, opiates, and tricyclics. The report reflected the sample had been tested for other substances, including cocaine and [MEDICATION NAME], but did not reflect the sample tested positive for those two substances. A signature (illegible) was noted on the report. The signature was dated 08/30/10. On 10/01/10 at 10:42 a.m. a representative (Lab A) of the facility-contracted lab company was interviewed. Lab A stated if the sample had tested positive for cocaine and [MEDICATION NAME], the lab report would have reflected so. Lab A stated the lab specimen for drug screen was not tested through their lab; it was sent to another lab. On 10/01/10 at 11:05 a.m. the surveyor interviewed a representative (Lab B) from the second lab. Lab B was not forthcoming with information about Resident #1's lab report due to privacy concerns. Lab B did report a a specific test was used to screen for [MEDICATION NAME]. On 10/01/10 at 12:03 p.m. another representative (Lab E) from the facility contracted lab revealed they had no lab report reflecting Resident #1 tested positive for cocaine or [MEDICATION NAME]. 4) On 10/01/10 at 10:10 a.m. an ex-family member of Resident #1 revealed he was concerned about the resident. He stated he walked in on a meeting and Resident #1 was crying when he came to visit the resident visited Resident #1 on 08/31/10. "She was down the hallway crying - bawling." He stated Resident #1's physician informed the resident he believed her recent falls were a result of her taking [MEDICATION NAME] and cocaine. The ex-family member stated, "That's an insult. She wasn't on those." 5) On 10/01/10 at 11:13 a.m., ADON C revealed Resident #1 had recently had a few episodes of being lethargic and had been having falls. She stated Physician F ordered a drug screen test. ADON C stated, "___ (DON) told me she (Resident #1) tested positive for cocaine." ADON C stated, "We had a case conference with her." The interview revealed the meeting was attended by the Resident #1, two social workers, and two of the resident's family members. ADON C stated the results of the lab test, and the visitation parameters of the resident's ex-family member were discussed. 6) On 10/01/10 at 11:27 a.m., the DON revealed a concern Resident #1's ex-family member was providing unperscribed/illegal substances to the resident. The DON stated, "We did a drug screen. It came back with cocaine. We had a meeting with the responsible parties." The DON stated in the meeting, Resident #1 screamed at Physician F. When queried, the DON revealed the lab report dated 08/26/10 was the only documentation from the lab regarding the drug screen. Upon review of Resident #1's drug screen dated 08/26/10 with the DON, the DON revealed the report of "opioids" found in the specimen was an indication of cocaine use. The surveyor asked the DON if the [MEDICATION NAME] the facility was administering four times daily could cause a positive result for "opioids." The DON stated, "Oh, I see where there's a problem." 7) On 10/01/10 at 12:30 p.m. Resident #1 was interviewed. The resident appeared to be alert and oriented. She stated Physician F told her, "Well, I know what's wrong with you. You're on cocaine and [MEDICATION NAME]." Resident #1 stated she told the physician she had never taken either. Resident #1 revealed that during a meeting, "They started saying I was on that, drugs. I told them I never did. _____ (Physician F) threw down the paper and said. 'We have it documented.' I was never so hurt in all my life. They brought my ____ (friend) into it. 'Maybe he's bringing you dope.' I said I wanted to change doctors. I have been upset ever since that." Resident #1 stated she did not give consent for the drug test. She added, "I was never so upset in all my life. I don't hardly go outside in the hall anymore. I make my own healthcare decisions. My ____ (family member) is power of attorney but he doesn't make decisions for me right now. I'm not in very good health, but I can make my own decisions. I would like to know how the lab read how I was on cocaine and [MEDICATION NAME]. I didn't see the paper. He (Physician F) throwed it down. He lied." 8) The facility census dated 09/30/10 reflected there were 129 residents.

Based on observation, interview, and record review, it was determined the facility failed to ensure that one (Resident #1) of four residents reviewed was fully informed in advance in a manner she could understand of her total health status and was fully informed in advance about the treatment, which could affect the resident's well-being. A lab test for a drug screen was ordered by Physician F, because Resident #1 had been having episodes of lethargy and falling. The resident was not fully informed about the lab test, which had been ordered and therefore, was not given the option to decline. The lab test, a urine drug screen, was then misinterpreted, and the resident was accused of ingesting illegal drugs at the facility. These failures resulted in Resident #1 experiencing psychological harm and withdrawal. These failures could affect the 129 residents in the facility. Findings included: 1) Resident #1's Face Sheet dated 09/17/10 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#1 had no Legal Guardian. Review of an undated Nursing Admission Assessment revealed Resident #1 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED].#1 was alert and oriented to person, place and time. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. According to the MAR, the resident received the medication as ordered. 2) On 10/01/10 at 11:45 a.m., SW D revealed a meeting was scheduled because of the results of Resident #1's drug screen. SW D stated she attended the meeting. At the meeting, she thought ADON C told Resident #1 she (the resident) tested positive for cocaine. The SW stated, "She (Resident #1) was very upset. Family believed it to be true." The SW revealed during the meeting, Resident #1 stated, "If it was in my system, you guys gave it to me." The SW stated, "She (Resident #1) was yelling at _____ (Physician F). She was very irate; very upset." The SW D revealed that during the meeting, ADON C stated, "Latest labs said you had cocaine and [MEDICATION NAME] in your system. How did you get it?" Resident #1's Social Progress Notes dated 08/31/10 reflected a care plan meeting was held for the resident. The notes reflected the resident, two family members, the DON, ADON C, two Social Workers and the resident's physician attended. Resident #1 had recently been lethargic and falling. ADON C and PHYSICIAN F ordered a urine analysis for a drug screening to be done. SW D documented the drug screen was positive for [MEDICATION NAME] and cocaine. The resident was confronted with the information at the care plan meeting. Resident #1 denied having taken [MEDICATION NAME] and cocaine and said the lab results were wrong. At the meeting, the DON informed Resident #1 she would have to have supervised visits when her ex-family member in the common area of the facility when he came to visit. The resident agreed to the supervised visits. Physician F stated he would review Resident #1's list of medications and re-evaluate the dosage. The notes reflected at that point, Resident #1 began yelling at Physician F, calling him a liar and stating she needed all of her medications. The resident became hositle. Resident #1 was very upset as SW D wheeled the resident back to her room. While doing so, SW D told the staff on Resident #1's hall of the visitation boundaries with Resident #1's ex-family member. 3) Review of the urine drug screen lab report with a draw date of 08/26/10 and was delivered 08/28/10 revealed Resident #1 tested positive for [MEDICATION NAME], benzodiazepines, opiates, and tricyclics. The report reflected the sample had been tested for other substances, including cocaine and [MEDICATION NAME], but did not reflect the sample tested positive for those two substances. A signature (illegible) was noted on the report. The signature was dated 08/30/10. On 10/01/10 at 10:42 a.m. a representative (Lab A) of the facility-contracted lab company was interviewed. Lab A stated if the sample had tested positive for cocaine and [MEDICATION NAME], the lab report would have reflected so. Lab A stated the lab specimen for drug screen was not tested through their lab; it was sent to another lab. On 10/01/10 at 11:05 a.m. the surveyor interviewed a representative (Lab B) from the second lab. Lab B was not forthcoming with information about Resident #1's lab report due to privacy concerns. Lab B did report a a specific test was used to screen for [MEDICATION NAME]. On 10/01/10 at 12:03 p.m. another representative (Lab E) from the facility contracted lab revealed they had no lab report reflecting Resident #1 tested positive for cocaine or [MEDICATION NAME]. 4) On 10/01/10 at 10:10 a.m. an ex-family member of Resident #1 revealed he was concerned about the resident. He stated he walked in on a meeting and Resident #1 was crying when he came to visit the resident visited Resident #1 on 08/31/10. "She was down the hallway crying - bawling." He stated Resident #1's physician informed the resident he believed her recent falls were a result of her taking [MEDICATION NAME] and cocaine. The ex-family member stated, "That's an insult. She wasn't on those." 5) On 10/01/10 at 11:13 a.m., ADON C revealed Resident #1 had recently had a few episodes of being lethargic and had been having falls. She stated Physician F ordered a drug screen test. ADON C stated, "___ (DON) told me she (Resident #1) tested positive for cocaine." ADON C stated, "We had a case conference with her." The interview revealed the meeting was attended by the Resident #1, two social workers, and two of the resident's family members. ADON C stated the results of the lab test, and the visitation parameters of the resident's ex-family member were discussed. 6) On 10/01/10 at 11:27 a.m., the DON revealed a concern Resident #1's ex-family member was providing unperscribed/illegal substances to the resident. The DON stated, "We did a drug screen. It came back with cocaine. We had a meeting with the responsible parties." The DON stated in the meeting, Resident #1 screamed at Physician F. When queried, the DON revealed the lab report dated 08/26/10 was the only documentation from the lab regarding the drug screen. Upon review of Resident #1's drug screen dated 08/26/10 with the DON, the DON revealed the report of "opioids" found in the specimen was an indication of cocaine use. The surveyor asked the DON if the [MEDICATION NAME] the facility was administering four times daily could cause a positive result for "opioids." The DON stated, "Oh, I see where there's a problem." 7) On 10/01/10 at 12:30 p.m. Resident #1 was interviewed. The resident appeared to be alert and oriented. She stated Physician F told her, "Well, I know what's wrong with you. You're on cocaine and [MEDICATION NAME]." Resident #1 stated she told the physician she had never taken either. Resident #1 revealed that during a meeting, "They started saying I was on that, drugs. I told them I never did. _____ (Physician F) threw down the paper and said. 'We have it documented.' I was never so hurt in all my life. They brought my ____ (friend) into it. 'Maybe he's bringing you dope.' I said I wanted to change doctors. I have been upset ever since that." Resident #1 stated she did not give consent for the drug test. She added, "I was never so upset in all my life. I don't hardly go outside in the hall anymore. I make my own healthcare decisions. My ____ (family member) is power of attorney but he doesn't make decisions for me right now. I'm not in very good health, but I can make my own decisions. I would like to know how the lab read how I was on cocaine and [MEDICATION NAME]. I didn't see the paper. He (Physician F) throwed it down. He lied." 8) The facility census dated 09/30/10 reflected there were 129 residents.

Based on observation, interview, and record review, it was determined the facility failed to promote care for one (Resident #1) of four residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect in full recognition of his or her individuality. Resident #1 was subjected to a drug screen without prior permission. The physician and facility misinterpreted the results of the test and openly accused the resident of use of illegal drugs. The physician and facility staff chastised and defamed the resident in front of other staff and family members. The resident was unjustly refused the right to visit friends and family members without supervision. These failures resulted in Resident #1 experiencing psychological harm and withdrawal from social interaction. These failures could affect the 129 residents in the facility and placed them at risk for not being respected or provided with dignity. This could result in residents experiencing psychological harm and withdrawl from social interaction. Findings included: 1) Resident #1's Face Sheet dated 09/17/10 reflected the resident, a [AGE] year-old female, was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED].#1 had no Legal Guardian. Review of an undated Nursing Admission Assessment revealed Resident #1 was admitted on [DATE] to the facility with [DIAGNOSES REDACTED].#1 was alert and oriented to person, place and time. Resident #1's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The MAR indicated [REDACTED]. According to the MAR, the resident received the medication as ordered. 2) On 10/01/10 at 11:45 a.m., SW D revealed a meeting was scheduled because of the results of Resident #1's drug screen. SW D stated she attended the meeting. At the meeting, she thought ADON C told Resident #1 she (the resident) tested positive for cocaine. The SW stated, "She (Resident #1) was very upset. Family believed it to be true." The SW revealed during the meeting, Resident #1 stated, "If it was in my system, you guys gave it to me." The SW stated, "She (Resident #1) was yelling at _____ (Physician F). She was very irate; very upset." The SW D revealed that during the meeting, ADON C stated, "Latest labs said you had cocaine and [MEDICATION NAME] in your system. How did you get it?" Resident #1's Social Progress Notes dated 08/31/10 reflected a care plan meeting was held for the resident. The notes reflected the resident, two family members, the DON, ADON C, two Social Workers and the resident's physician attended. Resident #1 had recently been lethargic and falling. ADON C and PHYSICIAN F ordered a urine analysis for a drug screening to be done. SW D documented the drug screen was positive for [MEDICATION NAME] and cocaine. The resident was confronted with the information at the care plan meeting. Resident #1 denied having taken [MEDICATION NAME] and cocaine and said the lab results were wrong. At the meeting, the DON informed Resident #1 she would have to have supervised visits when her ex-family member in the common area of the facility when he came to visit. The resident agreed to the supervised visits. Physician F stated he would review Resident #1's list of medications and re-evaluate the dosage. The notes reflected at that point, Resident #1 began yelling at Physician F, calling him a liar and stating she needed all of her medications. The resident became hositle. Resident #1 was very upset as SW D wheeled the resident back to her room. While doing so, SW D told the staff on Resident #1's hall of the visitation boundaries with Resident #1's ex-family member. 3) Review of the urine drug screen lab report with a draw date of 08/26/10 and was delivered 08/28/10 revealed Resident #1 tested positive for [MEDICATION NAME], benzodiazepines, opiates, and tricyclics. The report reflected the sample had been tested for other substances, including cocaine and [MEDICATION NAME], but did not reflect the sample tested positive for those two substances. A signature (illegible) was noted on the report. The signature was dated 08/30/10. On 10/01/10 at 10:42 a.m. a representative (Lab A) of the facility-contracted lab company was interviewed. Lab A stated if the sample had tested positive for cocaine and [MEDICATION NAME], the lab report would have reflected so. Lab A stated the lab specimen for drug screen was not tested through their lab; it was sent to another lab. On 10/01/10 at 11:05 a.m. the surveyor interviewed a representative (Lab B) from the second lab. Lab B was not forthcoming with information about Resident #1's lab report due to privacy concerns. Lab B did report a a specific test was used to screen for [MEDICATION NAME]. On 10/01/10 at 12:03 p.m. another representative (Lab E) from the facility contracted lab revealed they had no lab report reflecting Resident #1 tested positive for cocaine or [MEDICATION NAME]. 4) On 10/01/10 at 10:10 a.m. an ex-family member of Resident #1 revealed he was concerned about the resident. He stated he walked in on a meeting and Resident #1 was crying when he came to visit the resident visited Resident #1 on 08/31/10. "She was down the hallway crying - bawling." He stated Resident #1's physician informed the resident he believed her recent falls were a result of her taking [MEDICATION NAME] and cocaine. The ex-family member stated, "That's an insult. She wasn't on those." 5) On 10/01/10 at 11:13 a.m., ADON C revealed Resident #1 had recently had a few episodes of being lethargic and had been having falls. She stated Physician F ordered a drug screen test. ADON C stated, "___ (DON) told me she (Resident #1) tested positive for cocaine." ADON C stated, "We had a case conference with her." The interview revealed the meeting was attended by the Resident #1, two social workers, and two of the resident's family members. ADON C stated the results of the lab test, and the visitation parameters of the resident's ex-family member were discussed. 6) On 10/01/10 at 11:27 a.m., the DON revealed a concern Resident #1's ex-family member was providing unperscribed/illegal substances to the resident. The DON stated, "We did a drug screen. It came back with cocaine. We had a meeting with the responsible parties." The DON stated in the meeting, Resident #1 screamed at Physician F. When queried, the DON revealed the lab report dated 08/26/10 was the only documentation from the lab regarding the drug screen. Upon review of Resident #1's drug screen dated 08/26/10 with the DON, the DON revealed the report of "opioids" found in the specimen was an indication of cocaine use. The surveyor asked the DON if the [MEDICATION NAME] the facility was administering four times daily could cause a positive result for "opioids." The DON stated, "Oh, I see where there's a problem." 7) On 10/01/10 at 12:30 p.m. Resident #1 was interviewed. The resident appeared to be alert and oriented. She stated Physician F told her, "Well, I know what's wrong with you. You're on cocaine and [MEDICATION NAME]." Resident #1 stated she told the physician she had never taken either. Resident #1 revealed that during a meeting, "They started saying I was on that, drugs. I told them I never did. _____ (Physician F) threw down the paper and said. 'We have it documented.' I was never so hurt in all my life. They brought my ____ (friend) into it. 'Maybe he's bringing you dope.' I said I wanted to change doctors. I have been upset ever since that." Resident #1 stated she did not give consent for the drug test. She added, "I was never so upset in all my life. I don't hardly go outside in the hall anymore. I make my own healthcare decisions. My ____ (family member) is power of attorney but he doesn't make decisions for me right now. I'm not in very good health, but I can make my own decisions. I would like to know how the lab read how I was on cocaine and [MEDICATION NAME]. I didn't see the paper. He (Physician F) throwed it down. He lied." 8) The facility census dated 09/30/10 reflected there were 129 residents.