Every finding on record at Bethany Woods Nursing and Rehabilitation Center

Based on record reviews, and interviews with the police detective, pharmacy consultant, physician and staff, the facility failed to protect the residents' right to be free from misappropriation of multiple non-narcotic medications when Nurse #1 was found with a bag of prescribed medications during a traffic stop. This deficient practice affected 16 of 16 residents reviewed for misappropriation (Residents #2, #10, #31, #37, #60, #68, #78, #86, #88, #121, #122, #123, #124, #125, #126, and #127).The findings included: A review of the facility's policy entitled Abuse, Neglect, Misappropriation and Exploitation dated August 2019 read in part . The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.Misappropriation of resident property is defined as the deliberate misplacement, exploitation or wrongful, temporary, or permanent use of a resident's belongings or money without consent. A review of sheriff's office incident sheet dated 9/4/25 read that on 9/4/25 at 3:08 PM, a traffic stop was conducted with Nurse #1 due to a vehicle registration infraction. Nurse #1's vehicle was searched due to the smell of marijuana and multiple prescription medications were found inside a bag and under the passenger seat. Nurse #1 stated that she got them from the facility she had worked at, put them in her pocket and forgot to return them. The report indicated that the facility was made aware of the findings and confirmed that Nurse #1 was a former employee that had been terminated. The prescription medications were placed into evidence pending further investigation and Nurse #1 was taken into custody. A phone interview occurred on 3/31/26 at 1:09 PM with the Police Detective. He stated that he oversaw the narcotics division and special operations and was present at the traffic stop of Nurse #1 on 9/4/25. He recalled during the search of her vehicle finding multiple packs of single medications as well as medication cards in multiple areas of her vehicle. He stated that Nurse #1 expressed to them that she was a nurse and had forgotten the medications were in her pocket, inadvertently taking them home at the end of her shift. The Police Detective confirmed there were no narcotic medications found in Nurse #1's possession. The facility was notified of the findings. He stated that the Administrator came to the police station the following day to take an inventory of what had been found in Nurse #1's possession. The interview further revealed the medications were kept as evidence and not released back to the facility. An initial allegation report was submitted to the State by the prior Administrator on 9/5/25. The report read that the facility initially became aware of the incident on 9/4/25 at 4:00 PM, alleging that Nurse #1 was detained during a traffic stop and was found with various medications belonging to facility residents. The facility investigation was initiated. Review of the facility investigation completed by the prior Administrator on 9/12/25 revealed that on 9/4/25, she was informed by the local law enforcement that Nurse #1 was stopped for a traffic violation and was observed with a zip lock bag of medications belonging to the facility. Nurse #1 was taken into custody and claimed the medications had been inadvertently taken home after being placed in her pocket. An inventory was taken of the medications in Nurse #1's possession on 9/5/25 with a total of 16 residents identified. Assessments associated with the medications in the nurse's possession were completed for all identified in-house residents with no adverse outcomes. The in-house identified residents' medication orders, Medication Administration Records (MARs) and progress notes were reviewed with no negative findings. Interviews were conducted with nursing staff and alert and oriented residents with no concerns expressed regarding the nurses' practice of medication administration. Nurse #1 had worked at the facility from 9/17/24 to 1/25/25 and again from 7/15/25 to 8/25/25. Both times she had been terminated for poor attendance. Nurse #1's personnel file was reviewed, including pre-hire background screening and licensure verification with no significant findings. She had received training on the policy of misappropriation upon her employment on 9/17/24 and 7/15/25. The facility investigation determined that, while the nurse was found in possession of resident medications as documented by law enforcement, there was no evidence to indicate that residents missed any prescribed doses or that their care was compromised. MARs indicated that medications were administered in accordance with physician orders. However, the way the medications were removed from the facility and when could not be determined. The facility substantiated the police report findings but had no prior knowledge of any unauthorized removal of medications by the nurse before being notified by law enforcement. The facility notified all alert and oriented residents, Responsible Parties (RPs), Adult Protective Services and the Board of Nursing. The residents involved were reimbursed for the medications identified by law enforcement. The facility report detailed the medications in Nurse #1's possession as follows:Belonging to Resident #2: A multidose medication card with six Gabapentin (a medication used to treat nerve pain and seizures) 300 milligrams (mg) tablets. Belonging to Resident #10: A multidose medication card with three Gabapentin 400 mg tablets. Belonging to Resident #31: A single dose smart pack of one Carvedilol (a medication used to treat high blood pressure)12.5 mg tablet and a single dose smart pack of two and half Paroxetine (an antidepressant medication) 20 mg tablets.Belonging to Resident #37: A single dose smart pack of two Gabapentin 100mg tablets, a single dose smart pack of one Carbamazepine (a medication used to treat pain and seizures) 200 mg tablet, a single dose smart pack of one Meloxicam (a medication used to treat joint pain) 15 mg tablet and a single dose smart pack of one Xifaxin (an antibiotic) 550 mg tablet.Belonging to Resident #60: A multidose medication card with 14 Zofran (an antinausea medication) 4 mg tablets.Belonging to Resident #68: A multidose medication card with 10 Trazodone (an antidepressant) 50 mg tablets and a multidose medication card with one Trazodone 50 mg tablet. Belonging to Resident #78: A multidose medication card with 13 Simethicone (a medication used to treat gas) 125 mg tablets.Belonging to Resident #86: A single dose smart pack with one Gabapentin 300 mg tablet, a single dose smart pack with one Lisinopril (a medication used to treat high blood pressure) 20 mg tablet, a single dose smart pack with three Divalproex (a medication used to treat seizures and mood) 125 mg tablets, a single dose smart pack of one Vitamin B12 1000 micrograms (mcg) tablet, and a single dose smart pack of one Paliperidone (an antipsychotic medication) 6 mg tablet. Belonging to Resident #88: A multidose medication card with one Levaquin (an antibiotic) 500 mg, a multidose medication card with seven Prednisone 10 mg tablets, a multidose medication card with two Vitamin B12 1000 mcg tablets, and a multidose medication card with eight Gabapentin 300 mg tablets. Belonging to Resident #121: A multidose medication card with 16 Guaifenisin (a medication used to treat cough) 400 mg tablets. Belonging to Resident #122: A single dose smart pack of one Sertraline (an antidepressant) 0.25 mg tablet and one single dose smart pack of a Xarelto (a blood thinner) 10 mg tablet.Belonging to Resident #123: One multidose Albuterol inhaler (a medication used to treat wheezing) 108 mcg. Belonging to Resident #124: A multidose medication card with six Prilosec 20 mg tablets and one tube of Voltaren Gel. Belonging to Resident #125: A multidose medication card with two Gabapentin 300 mg tablets. Belonging to Resident #126: A multidose medication card with 16 Phenergan (an antinausea medication)12.5 mg tablets. Belonging to Resident #127: A multidose medication card with 16 Benzonate (a medication used to treat cough and congestion) 200 mg. Belonging to an unknown resident: One Albuterol inhaler 108 mcg. Belonging to an unknown resident: One Levalbuterol inhaler.Belonging to an unknown resident: A multidose medication card of seven oval shaped white tablets with the marking F on one side the 91 on the other. Per pharmacy verification the tablet was identified as Zofran. Multiple attempts to contact Nurse #1 from 3/31/26 to 4/2/26, were unsuccessful. A phone interview was conducted on 3/31/26 at 2:00 PM with the prior Administrator. She recalled being notified by the local law enforcement that Nurse #1 had been stopped for a traffic violation and was found to have multiple residents' medications that belonged to the facility. She stated that both she and the Director of Nursing (DON) went to the police station the following morning to take an inventory of what was found in Nurse #1's possession. There was a total of 16 residents that were identified and 3 medications that were unidentified. The Administrator stated that once the resident medications were identified, the physician, pharmacy, alert and oriented residents and responsible parties were notified. She stated that both she and the DON investigated how or when Nurse #1 misappropriated the medications but was difficult to determine as she worked at the facility two separate times and some of the residents she was not assigned to care for. It was thought that the discontinued medications may have still been on the medication cart or in the medication room waiting for pharmacy return. The prior Administrator stated that Nurse #1 had been terminated from the facility for poor attendance prior to the traffic stop. The interview further revealed all identified residents were reimbursed for the medications that had been misappropriated. The DON was interviewed on 4/1/26 at 10:44 AM and stated that she had been employed at the facility for approximately 3 weeks with the misappropriation incident occurred involving Nurse #1. She recalled it was difficult to determine when the medications had been removed from the facility as Nurse #1 had been employed twice at the facility. She stated that she and the prior Administrator went to the police station the day after being notified to take an inventory of the medications in Nurse #1's possession. The pharmacy was notified and assisted with when the medications had been dispensed and the reimbursement rate. An interview occurred with the Medical Director on 4/1/26 at 12:09 PM and stated that he had been notified of the incident in September 2025 and was aware of each resident that could have potentially been affected. He stated that he and his Nurse Practitioner (NP) assessed the residents' that were affected and found no negative effects. A phone interview was completed with the Pharmacy Consultant on 4/1/26 at 1:12 PM and verified she had been made aware of the misappropriation incident in September 2025. She stated the pharmacy assisted the Administrator to identify when the medications had been dispensed and the reimbursement rates for refund. The Pharmacy Consultant stated that she was at the facility monthly and completed a medication pass with a nurse as well as reviewed medication carts for expired medications. She stated that she would not have been able to determine from the medication cart audits if a medication had been discontinued or if a resident who no longer resided in the facility had medications on the medication carts. The Administrator was interviewed on 4/2/26 at 11:22 AM and stated that efforts were still ongoing to prevent misappropriation of resident medications. The facility provided a plan of correction that was not acceptable to the State Agency as the facility did not include a systemic approach to prevent future incidents of misappropriation of resident property.

Based on observations and staff interviews, the facility failed to secure medications left on top of and in an unattended unlocked medication cart (400 hall medication cart) and failed to remove one (1) bottle of expired eye drops, label an Ozempic insulin pen with the name of the specific resident for whom it was prescribed and the date it was opened, and stored an unopened insulin pen in the medication cart (800 hall medication cart). This was for 2 of 3 medication carts observed for medication storage (400 hall and 800 hall medication cart). The findings included: 1. A continuous observation of an unattended medication cart on the 400 hall was made on 4/2/26 from 12:35 PM until 12:38 PM. The medication cart was observed to be unlocked (a red dot is visible on the lock mechanism when in the unlocked position), the narcotic medication drawer was pulled out and open, allowing the medications in the narcotic drawer to be exposed. In addition, a cup of crushed white pills and a small white bottle of medication containing a red liquid were observed on top of the medication cart. The medication cart was parked in the hallway between rooms [ROOM NUMBERS]. There were no observed residents, staff or visitors around the location of the medication cart. Nurse #2 walked up to the medication cart and stated she didn't mean to leave the narcotic drawer open, the medication cart unlocked or the medications on top of the cart. During an interview on 4/2/26 at 12:38 PM, Nurse #2 indicated she was assigned to the 400-hall medication cart and stated she had stepped into a resident's room and forgot to close the narcotic drawer, secure the medications on top of the medication cart as well as secure the medication cart. She verified that the medication left on top of the medication cart was a bottle of liquid Morphine (an opioid) and the crushed medications in the medication cup were Fluoxetine (an antidepressant) and Gabapentin (a non-narcotic medication used for pain). She added that medications should never be left unattended and the medication carts were to be locked when unattended. In an interview on 4/2/26 at 1:11 PM, the Director of Nursing (DON) stated that medications should not be left unattended on top of the medication carts and medication carts should be secured. She indicated that a resident could have come up and removed the medication from the cart and swallowed it. 2. On 4/1/26 at 10:16 AM an observation was conducted of the 800-hall medication cart in the presence of Medication Aide (MA) #2. The following medications were noted stored in the medication cart: One (1) Ozempic pen open in use and not labeled. One (1) Lantus Solostar pen not in use and not refrigerated as the label directed. One (1) bottle of latanoprost eye drops opened and dated 2/4/26 with an expiration date of 6 weeks after opening as the label directed. One (1) bottle of geritussin opened and undated. One (1) bottle of guaifenesin liquid opened and undated. One (1) bottle of milk of magnesia opened and undated. On 4/1/26 at 10:20 AM, MA #2 was interviewed and stated she was unaware the Ozempic pen was unlabeled. MA #2 explained the Lantus insulin pen should have been refrigerated since it was not in use, and the latanoprost eye drops should have been discarded 6 weeks after opening. MA #2 stated the stock medications of geritussin, guaifenesin, and milk of magnesia should have been labeled with the date they were opened. She was not sure why the medications were not labeled with resident identifier or dated. MA #2 removed the medications from the medication cart to be disposed. Unit Manager #1 was interviewed on 4/1/26 at 2:45 PM and stated staff assigned to the medication cart should have checked the labels of all medications for resident identifiers as well as open and expiration dates. UM #1 indicated all insulin pens should have been labeled with the resident's identifiers, as well as the open date, and refrigerated if not in use, and all expired medications should have been discarded. On 4/2/26 at 2:01 PM the Director of Nursing (DON) was interviewed and stated the Unit Managers had been auditing the medication carts weekly to make sure the medications were labeled and dated correctly as well as all expired medications were disposed of. She indicated the Lantus Solostar pen on the 800-hall medication cart must have been delivered during the night shift on 3/31/26 and placed on the cart instead of stored in the refrigerator as the label instructed. She further explained that all medication bottles and insulin pens should be labeled with resident identifiers and dates when opened. The DON stated the eye drops should have been discarded as the label directed 6 weeks after opening.

Based on record review and resident and staff interviews, the facility failed to ensure that residents were treated in a dignified and respectful manner. This was evidenced by staff arguing with a resident and using profanity in the resident's presence for 1 of 4 residents reviewed for dignity (Resident #7).Findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses that included unspecified mood affective disorder and anxiety disorder.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed that Resident #7 was cognitively intact.Resident #7's active care plan, last reviewed on 3/2/26, indicated that he exhibits problematic behaviors related to ineffective coping, including verbal aggression and expressions of anger. These behaviors include use of profanity towards others, making threats toward staff, and making false accusations regarding his care. Interventions included avoid arguments with the resident.A review of the investigation report dated 3/23/26, completed by the Administrator, revealed that on 3/19/26, two nursing assistants (NA) #3 and NA #8, were having a discussion in the hallway. Resident #7 heard them from his bed and disagreed with the topic they were discussing. Resident #7 yelled out to NA #3 and NA #8 and shared his opinion. NA #8 responded, and a verbal exchange occurred between her and Resident #7 from the hallway. During this exchange, both Resident #7 and NA #8 used profanity. Unit Manager (UM) #2 removed NA #8 from the hallway and spoke with Resident #7 about the incident. Resident #7 stated that he and NA #8 had been arguing because she was talking about another staff member (NA #6), and he felt what she said was untrue.During an interview conducted with Resident #7 on 3/30/26 at 12:44 PM, he reported that on 3/19/26 NA #8 and NA #3, were in the hallway talking about NA #6, who also worked in the facility. He said he told them to stop talking about NA #6 because he felt NA #6 did a good job. He explained that NA #8 was disrespectful and had no business arguing with him. He stated the exchange made him angry primarily because they were talking about NA #6. During an interview on 4/1/26 at 8:17 PM, NA #3 stated that she and NA #8 were in the hallway talking about another employee. She stated that Resident #7 heard them and began yelling and cursing, telling them to stop talking about the employee. NA #3 explained that at this point, NA #8 began arguing back with the resident. She stated that both Resident #7 and NA #8 used profanity during the verbal exchange.Attempts to speak with NA #8 by phone on 4/1/26 and 4/2/26 were unsuccessful.During an interview conducted with the Director of Nursing (DON) on 4/2/26 at 11:16 AM, she explained that the verbal exchange between Resident #7 and NA #8 should not have occurred. The DON confirmed that NA #8 admitted to her that she used profanity in the hallway during the verbal exchange with Resident #7. She stated that NA #8 should not have engaged or argued with Resident #7 and should not have used profanity in the hallway. The DON stated she felt NA #8 demonstrated poor customer service by arguing with Resident #7 and using profanity in the hallway.An interview with the Administrator on 4/2/26 at 11:33 AM revealed that NA #3 witnessed the verbal exchange between Resident #7 and NA #8. The Administrator stated that NA #3 confirmed NA #8 argued with Resident #7 and used profanity while discussing NA #6. The Administrator further stated that this interaction should not have occurred, as it was unprofessional and demonstrated poor customer service for a staff member to argue or use inappropriate language in front of residents. The Administrator confirmed that NA #8 was terminated based on her admission that she argued with the resident and used profanity in the hallway, along with NA #3's corroboration of the unprofessional communication.

Based on observations, record reviews, resident and staff interviews, the facility failed to ensure a resident's call light system was placed within reach and accessible for 1 of 8 residents reviewed for accommodation of needs (Resident #7).The findings included:Resident #7 was admitted to the facility on [DATE] with diagnoses including quadriplegia, diabetes mellitus, stage 3 chronic kidney disease.A quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #7 was cognitively intact, had impaired function in both upper and lower extremities, and was dependent on staff for all activities of daily living (ADL).Review of the active care plan, last reviewed 3/2/26, identified the resident required staff assistance for all ADL due to quadriplegia and utilized a mouth blowing call system device to summon assistance. The care plan also indicated the resident exhibited problematic manner behaviors, including calling 911 when not receiving timely attention. Interventions included responding promptly to requests.Review of Resident #7's care guide (Kardex), last reviewed 3/2/26, confirmed the resident used a mouth blowing call device.On 3/30/26 at 12:44 PM, an observation and interview conducted with Resident #7 revealed he was lying in bed. His call device was observed out of reach, positioned too far away from his mouth for activation. The resident stated he did not know how long it had been out of reach and that although the device was normally placed correctly, there were times he had to yell out to staff in the hallway to reposition it. He stated he yelled for help if he needed something because he was unable to move independently to reach the device.During an interview on 3/30/26 at 12:52 PM NA #2 stated she was assigned to Resident #7 on 3/30/26 from 7:00 AM to 3:00 PM. She indicated she was unaware the resident's call device was out of reach. She explained the device must be close enough to the resident's mouth for him to blow into it to activate the call system and reported it may have been moved during ADL care. NA #2 stated she had been in his room within the last hour but could not recall if she checked the placement of his call device. She stated that the resident could yell out if needed something. NA #2 immediately repositioned the call device within Resident #7's reach. On 4/1/26 at 2:20 PM, Unit Manager #3 reported Resident #7 was quadriplegic, dependent on staff for all care, and required the mouth blowing call device to request assistance. She stated she was unaware of any issues with the device being out of reach and confirmed that it needed to be close enough to the resident's mouth for use.On 4/2/26 at 10:08 AM, another observation found the resident lying in bed watching television with the call device positioned above his head and out of reach. Resident #7 confirmed he could not access the device. He stated he would yell out or use his voice activated phone to call the facility if he required assistance. He believed the device may have been pushed away earlier that morning during care.Attempts to reach NA #6, who provided early morning care on 4/2/26, were unsuccessful.During an interview on 4/2/26 at 10:15 AM NA #5 stated she was assigned to Resident #7 on 4/2/26 from 7:00AM to 3:00 PM. NA #5 indicated she was last in the residents' room sometime between 7:30 AM and 8:30 AM and had not observed the call device out of reach. She also stated she had not moved the call device that morning.At 10:19 AM on 4/2/26, Nurse #2 reported the resident had requested she move the call device closer during her earlier medication pass. She stated she repositioned it appropriately and that this was the first time she had observed it out of reach but noted he could yell out to staff if needed.During an interview with the Director of Nursing on 4/2/26 at 2:14 PM, she stated Resident #7 was able to make his needs known by yelling out or using his voice activated cell phone. She reported she was unaware of any issues with the call device but confirmed her expectation was for the device to always be within the resident's reach.

Based on observations, record review, and resident and staff interviews, the facility failed to provide personal privacy during incontinence care when Nurse Aide (NA) #1 captured a picture of Resident #42 with her cellphone while in the room during care. Resident #42 was partially clothed and uncovered in the photo. This deficient practice affected 1 of 1 resident reviewed for privacy (Resident # 42).The findings included:Resident #42 was admitted to the facility on [DATE] with diagnoses including diabetes type II, congestive heart failure, and peripheral vascular disease with a right below the knee amputation (BKA). The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #42 was cognitively intact, frequently incontinent, and dependent on assistance for activities of daily living (ADL).The Director of Nursing (DON) interview was conducted on 04/02/26 at 9:11 AM. The DON stated they received a call from an anonymous caller on 1/16/26 stating he had a screenshot of a resident from their facility that was taken by NA #1. The DON reported the photo was sent to her and at first, they could not identify the resident because you could not see the resident's face. The DON reported that you could see a person's backside, a leg amputation was noted, and part of a sweatshirt. The DON reported they narrowed it down by looking at only residents that had leg amputations, as well as the surroundings in the room. The DON reported they also spoke with NA #1 about their concerns. The DON reported NA #1 stated that she did recall a time when she was on her phone at the nurse's station and it was a Facetime call. The DON stated that NA#1 reported that she was putting the phone back in her pocket as she went into Resident #42's room and she assumes that the phone must have captured a view of Resident #42 before she got it put away. The DON reported that NA #1 reported not taking a picture of the resident but that her ex-boyfriend must have done a screenshot as she was putting the phone away. The DON reported that after she spoke with the anonymous caller about the concerns and received the picture from him, she requested that he delete the photo from his phone, and he agreed to do so. The DON reported that she asked NA #1 if she had the photo on her phone and she did not. The DON reported that it was the molding around the window that helped them to determine the time frame of the photo because the resident was in a different room during November and December 2025. The DON reported that NA #1 was terminated because she violated the cellphone policy. The DON reported that Resident #42 reported not recalling the incident happening. The DON felt NA #1 had taken the call on her cellphone but did not intend to invade Resident #42's privacy. The DON shared a photo of Resident #42 on 4/02/26 at 12:45 PM that was on her work cell phone. Resident #42 was lying on his right side facing the wall and window area receiving bowel incontinence care and had a right BKA. Resident #42's entire buttocks was uncovered and showing. Resident #42's genitals could not be seen in the photo. Resident #42 had feces behind his buttocks area on the bed. Resident #42 was wearing a striped, blue, yellow, and white long-sleeved shirt. Resident #42's face could not be seen in the photo, only the back of his head.An interview with NA #1 on 04/02/26 at 10:58 AM revealed that one evening she was working and continued to receive back-to-back calls on her cellphone from her ex-boyfriend. NA #1 reported that initially, she did not answer but while she was in Resident #42's room, the calls continued so she answered thinking it was an emergency call. NA #1 reported that she answered on Facetime with her earbuds in Resident #42's room. NA #1 reported that it was her boyfriend at the time, but it was not an emergency so she told him that she could not talk. NA #1 reported that later she found out that her phone had captured a picture of Resident #42's back side including his booty. NA #1 reported that she was not exactly sure how this happened, only that maybe it happened as she was locking her phone and putting it away in her pocket. NA #1 could not remember the name of the resident that was in the photo. NA #1 reported that the administrative staff spoke to her about it and initially suspended her during the investigation and then later terminated her employment because she had violated the cellphone policy. An interview with Resident #42 was conducted on 03/30/226 at 1:49 PM. Resident # 42 stated he does not remember an incident where his picture was taken during incontinence care or working with NA #1. An additional interview with Resident #42 was conducted on 04/02/26 at 12:31 PM. Resident # 42 verbalized that if a picture was taken of him during incontinence care and his buttocks was showing it would not bother him. He stated, People are going to do what they are going to do anyways. I don't care. An Administrator interview was conducted on 04/01/26 at 3:37 PM. The Administrator reported that the facility received a call on 1/16/26 from an anonymous caller stating that NA #1 had taken a photo of a resident while providing incontinence care. The Administrator reported that in the photo the resident was partially clothed and they were unable to identify him because you could not see his face. The Administrator reported that you could only see part of the back of his head, part of his backside, part of his sweatshirt, and part of his bed including some surroundings in the room including a windowpane. The Administrator reported that they were able to eventually identify who it was based on the windowpane area and his sweatshirt. The Administrator reported that they determined that the photo must have been taken between November and December 2025 when Resident #42 was in a previous room that matched the windowpane. The Administrator reported when they spoke to NA #1, she reported that her phone must have accidentally captured a picture of the resident when she was in his room providing care. The Administrator indicated that at the time, NA #1 stated that she was dating a guy that kept calling her that evening and she only answered her phone to say that she could not talk because she was at work. NA #1 explained she had earbuds in at the nurse's station and when she answered the call it was on FaceTime, which is when the picture must have been captured. The Administrator reported that even though they did believe the incident to be accidental, the employee was still terminated due to violation of the electronic device policy. The Administrator stated staff should maintain privacy during incontinence care and not use their cellphones when providing any type of care to the residents.

Based on observations, record reviews, and resident, staff, and Medical Director interviews, the facility failed to ensure oxygen was delivered at the prescribed rate. This deficient practice occurred for 1 of 4 residents reviewed for respiratory care (Resident #11).Findings included:Resident #11 was admitted to the facility on [DATE] with diagnoses which included chronic respiratory failure and COPD (chronic obstructive pulmonary disease).The care plan dated 12/31/25 revealed Resident #11 had an intervention for oxygen therapy as ordered related to COPD.A review of the electronic medical record for Resident #11 revealed a physician order dated 1/22/26 for oxygen therapy at 3 liters per minute (LPM) via nasal cannula continuously to keep oxygen saturation levels above 90%.The admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #11 was cognitively intact and was receiving oxygen therapy.An observation of Resident #11 was conducted on 3/30/26 at 2:20 PM. It was noted the oxygen concentrator was set at a flow rate of 2.5 LPM when viewed at eye level. Resident #11 was resting in bed and denied any shortness of breath, and she did not appear to be in respiratory distress.On 3/31/26 at 1:41 PM an observation was conducted of Resident #11's oxygen concentrator, and it was noted the oxygen concentrator was set at a flow rate of 2.5 LPM when viewed at eye level. Resident #11 was resting in bed and stated she was supposed to receive 3 LPM of oxygen therapy. She denied feeling short of breath, and she did not appear to be in respiratory distress.A review of the March 2026 medication administration record (MAR) revealed Medication Aide #1 had signed that Resident #11's oxygen concentrator was set at a flow rate of 3 LPM on 3/30/26 and 3/31/26.An observation and interview was conducted with Medication Aide (MA) #1 on 3/31/26 at 3:15 PM. MA #1 was accompanied to Resident #11's room to view the oxygen concentrator setting and immediately turned the oxygen concentrator flow rate to 0 LPM then adjusted the dial back and forth up the flow indicator field before stopping the dial stating that is how she would adjust the oxygen therapy flow level. MA #1 stood over the concentrator and stated, See, 3 liters. MA #1 was asked to view the oxygen therapy setting at eye level and agreed when viewed at eye level the flow level setting read 2.5 LPM. She then adjusted the oxygen therapy dial to 3 LPM when viewed at eye level. According to MA #1, she had assessed Resident #11's oxygen concentrator on both 3/30/26 and again on 3/31/26 while standing over the concentrator and documented the oxygen therapy flow rate was 3 LPM. MA #1 stated she evaluated Resident #11's oxygen concentrator flow rate as part of the medication pass, and if she had any problems with the oxygen therapy then she would notify the Unit Manager who was overseeing her work. On 3/31/26 at 3:31 PM Unit Manager (UM) #1 was interviewed. According to UM #1, she periodically checked the oxygen therapy concentrator flow rate settings when she entered a resident's room. However, she indicated she had not assessed Resident #11's oxygen therapy concentrator flow rate setting on 3/30/26 or 3/31/26.The Medical Director was interviewed on 4/1/26 at 12:16 PM and stated Resident #11 tended to get short of breath with activity, and it was his expectation that staff would follow orders as written for Resident #11 to receive oxygen therapy at 3 LPM.An interview was conducted with the Director of Nursing (DON) on 4/2/26 at 2:01 PM who stated Resident #11's oxygen therapy should have been delivered correctly at 3 LPM as ordered.

Based on observations, record reviews, and staff interviews, the facility failed to have a medication error rate of less than 5% as evidenced by 2 medication errors out of 27 opportunities, resulting in a medication error rate of 7.41% for 2 of 3 residents observed for medication administration (Resident #129 and Resident #110).The findings includeda. Resident #129 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation and cardiomyopathy.A review of Resident #129's active physician's orders included a current order for March 2026 of metoprolol succinate 25 milligrams (mg) by mouth once daily. Hold for systolic blood pressure less than 110 or heart rate less than 60.On 4/1/26 at 9:00 AM Nurse #3 was observed as she obtained Resident #129's blood pressure and heart rate. Resident #129's blood pressure was noted as 110/64 and heart rate was 79. Nurse #3 stated she was going to hold Resident #129's metoprolol succinate since her systolic (top number) blood pressure was so close to the hold parameter ordered by the physician. Nurse #3 did not call the physician to obtain and order to hold the medication, and she did not give Resident #129 her ordered dose of metoprolol succinate.b. Resident #10 was admitted to the facility on [DATE] with diagnoses of chronic obstructive pulmonary disease.A review of Resident #10's active physician's orders included a current order for March 2026 of fluticasone propionate 0.05 mg/actuation metered dose nasal spray, 2 sprays in both nostrils one time a day.On 4/1/26 at 9:12 AM Nurse #3 was observed as she handed Resident #10 the bottle of fluticasone nasal spray without any instructions on use. Resident #10 then rapidly administered 3 sprays of the medication back-to-back in the right nostril then repeated the 3 rapid sprays in the left nostril. Nurse #3 stood in front of Resident #10 and did not attempt to correct Resident #10's administration technique. The resident then handed the nasal spray back to Nurse #10 who exited the room. Nurse #3 was interviewed on 4/1/26 at 9:14 AM who stated Resident #10 preferred to administer her own nasal spray and liked to do it her own way. Nurse #3 stated she should have educated Resident #10 when she administered the medication incorrectly, but Resident #10 was in a hurry to go outside and did not like to wait around for education.Unit Manager (UM) #2 was interviewed on 4/1/26 at 2:55 PM and stated she expected Nurse #3 to administer the metoprolol succinate to Resident #129 according to the physician's order. She further stated Nurse #3 should have administered the fluticasone nasal spray herself instead of allowing Resident #10 perform the task. UM #2 stated Nurse #3 should have administered one spray per nostril and then repeated the same step for the second spray for correct administration of the ordered dosage.The Director of Nursing (DON) was interviewed on 4/2/26 at 2:01 PM and explained that Nurse #3 was using nursing discretion when she held the metoprolol succinate for Resident #129, and that Nurse #3 had contacted the physician to inform him she held it later that afternoon on 4/1/26. The DON further stated Nurse #3 should have administered the fluticasone nasal spray for Resident #10 according to the physician's order.

Based on observations and staff interviews, the facility failed to ensure resident rooms were maintained in good repair for 7 of 19 resident rooms reviewed for clean, comfortable and homelike environment (Residents #3, # 8, #31, #37, #63, #65, and #72). The facility also failed to ensure the Packaged Terminal Air Conditioner (PTAC) unit (Resident #3) was kept clean for 1 of 19 resident rooms observed. This deficient practice affected 3 of 8 facility hallways. The findings included: 1 a. On 3/30/26 at 10:31 AM, observation of Resident #63's room revealed scattered areas of damage to the wall behind the head of the bed, with sheetrock exposed. b. On 3/30/26 at 10:44 AM, observation of Resident #31's room showed scattered areas of wall damage behind the head of the bed that extended to the left side of the room on the same wall, with exposed sheetrock. c. On 3/30/26 at 10:56 AM, observation of Resident #37's room revealed multiple scattered areas of wall damage on the left side of the bed, with sheetrock exposed. In an interview with the Maintenance Director on 4/2/26 at 12:30 PM, he stated he was aware that walls in resident rooms throughout the facility needed repair. He reported he was behind on room repairs and believed the damage was caused by movement of the bed. He stated his plan was to begin wall repairs the following week. During an interview with the Administrator on 4/2/26 at 11:22 AM, he stated it was important for resident rooms to be maintained in good repair and kept homelike. 2a. On 3/30/26 at 12:38 PM, an observation of Resident #65's room showed scrape marks on the wall to the left side at the head of the bed. The scrapes exposed white material with a chalk like appearance. A subsequent observation completed on 4/1/26 at 12:42 PM revealed the wall in Resident #65's room continued to exhibit the same scrape marks as observed on 3/30/26. b. On 3/30/26 at 12:55 PM, observation of Resident #72's room revealed scrape marks on the wall at the head of the bed and along the full length of the wall along the left side of the bed. The scrapes exposed white wall material with a chalk like appearance. A subsequent observation completed on 4/1/26 at 12:45 PM revealed the walls in Resident #72's room continued to exhibit the same scrape marks as observed on 3/30/26. An observation and interview were conducted with the Maintenance Director on 4/1/26 at 4:01 PM. He reported he had been in the position for one month and was the only staff member in the department. After observing the resident room walls, the Maintenance Director stated he had repaired the damaged areas in Resident #65 and Resident #72's rooms approximately one week prior to survey. He noted the beds in both rooms continued to be pushed against the walls, and he believed the raising and lowering of the beds caused the recurring scrape marks. According to the Maintenance Director, he was seeking a more permanent solution to prevent continued wall damage. On 4/2/26 at 11:22 AM, the Administrator was interviewed and reported the Maintenance Director was behind on wall patching and repairs, noting scratches reappeared in rooms where repairs had been previously completed. The Administrator acknowledged resident rooms should be kept in good repair and home like and stated he would explore more permanent wall protection to prevent damage from beds and wheelchairs. 3a. On 3/30/26 at 10:30 AM, an observation of Resident #3's room revealed a large, scuffed area approximately 13 inches in size at the bottom corner of the wall between the closet and sink. The area had a thick application of patch but had not been sanded or painted. In addition, Resident #3's Packaged Terminal Air Conditioner (PTAC) unit revealed a large amount of grey dust particles to the left interior of the top vents. An observation and interview were conducted with the Maintenance Director on 4/1/26 at 10:15 AM. He observed the damaged wall at the bottom corner between the closet and sink of Resident #3's room and the large amount of grey dust particles to the left interior of the top vents of the PTAC unit. He indicated the wall was frequently damaged from the wheelchair and he had not finished repairing the area. He also indicated that he was responsible for cleaning the inside of the PTAC vents with the vacuum cleaner. The Maintenance Director stated that he tried to make a round in the facility every six months to clean the inside of the PTAC units but had gotten behind. He acknowledged Resident #3's wall and PTAC required attention and would be addressed. b. On 3/30/26 at 12:00 PM, an observation of Resident #8's room revealed multiple scattered areas of damage to the wall behind the head of the bed, exposing the sheetrock. In addition, the vinyl baseboard was coming away from the wall under the sink area, exposing the bare wall. An observation and interview were conducted with the Maintenance Director on 4/1/26 at 10:18 AM. He observed the area of exposed sheetrock behind the head of Resident #8's bed as well as the vinyl baseboard that was not attached to the wall under the sink. He indicated that he had gotten behind with room repairs and that movement of the bed had most likely caused damage to the wall. The Maintenance Director stated that he would like to find a more permanent fix to prevent damage to the walls where the head of the beds are located. He stated the areas required attention and would be addressed. The Administrator was interviewed on 4/2/26 at 11:22 AM and stated it was important for the residents' rooms to be in good repair and homelike.

Based on record review and staff interviews, the facility failed to post accurate daily staffing information as compared to the daily staffing schedules for licensed and unlicensed nursing staff for 19 out of 30 days (3/1/26, 3/2/26, 3/3/26, 3/4/26, 3/5/26, 3/6/26, 3/7/26, 3/8/26, 3/12/26, 3/13/26, 3/14/26, 3/17/26, 3/19/26, 3/20/26, 3/21/26, 3/24/26, 3/26/26, 3/27/26, and 3/28/26). The findings included: A review of the facility's daily posting for nursing staff for the past 30 days (3/1/26 to 3/30/26) as compared to the daily staffing schedule included an inaccurate total of nursing staff worked, which included the following: a. The nursing schedule for 3/1/26 indicated that 12 Nurse Aides (NAs) worked from 7:00 AM to 3:00 PM, 5 Licensed Practical Nurses (LPNs) worked 11:00 PM to 7:00 AM and one Medication Aide (MA) worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/1/26 documented that 14 NAs worked 7:00 AM to 3:00 PM, 6 LPNs worked 11:00 PM to 7:00 AM and no MA worked 11:00 PM to 7:00 AM. b. The nursing schedule for 3/2/26 indicated that 4 Registered Nurses (RNs) worked 7:00 AM to 3:00 PM and 8 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/2/26 documented that 3 RNs worked 7:00 AM to 3:00 PM and 9 NAs worked 11:00 PM to 7:00 AM. c. The nursing schedule for 3/3/26 indicated that 9 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 3/3/26 documented that 10 NAs worked from 7:00 AM to 3:00 PM. d. The nursing schedule for 3/4/26 indicated that 2 MAs worked 7:00 AM to 3:00 PM and 10 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/4/26 documented that 1 MA worked 7:00 AM to 3:00 PM and 8 NAs worked from 11:00 PM to 7:00 AM. e. The nursing schedule for 3/5/26 indicated that 8 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/5/26 documented that 10 NAs worked from 11:00 PM to 7:00 AM. f. The nursing schedule for 3/6/26 indicated that 10 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/6/26 documented that 11 NAs worked 11:00 PM to 7:00 AM. g. The nursing schedule for 3/7/26 indicated that 11 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/7/26 documented that 9 NAs worked from 11:00 PM to 7:00 AM. h. The nursing schedule for 3/8/26 indicated that 7 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/8/26 documented that 10 NAs worked 11:00 PM to 7:00 AM. i. The nursing schedule for 3/12/26 indicated that 2 MAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/12/26 documented that one MA worked from 11:00 PM to 7:00 AM. j. The nursing schedule for 3/13/26 indicated that 9 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/13/26 documented that 11 NAs worked 11:00 PM to 7:00 AM. k. The nursing schedule for 3/14/26 indicated that 5 LPNs worked from 7:00 AM to 3:00 PM and 8 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/14/26 documented that 6 LPNs worked 7:00 AM to 3:00 PM and 11 NAs worked 11:00 PM to 7:00 AM. l. The nursing schedule for 3/17/26 indicated that 6 LPNs worked 7:00 AM to 3:00 PM, 5 LPNs worked 11:00 PM to 7:00 AM and 7 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/17/26 documented that 5 LPNs worked 7:00 AM to 3:00 PM, 4 LPNs worked 11:00 PM to 7:00 AM and 9 NAs worked 11:00 PM to 7:00 AM. m. The nursing schedule for 3/19/26 indicated that 6 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/19/26 documented that 8 NAs worked from 11:00 PM to 7:00 AM. n. The nursing schedule for 3/20/26 indicated that 6 LPNs worked 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 3/20/26 documented that 5 LPNs worked 7:00 AM to 3:00 PM. o. The nursing schedule for 3/21/26 indicated that 9 NAs worked from 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 3/21/26 documented that 11.4 NAs worked 7:00 AM to 3:00 PM. p. The nursing schedule for 3/24/26 indicated that 7 LPNs worked 7:00 AM to 3:00 PM and 10 NAs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/24/26 documented that 6 LPNs worked from 7:00 AM to 3:00 PM and 8 NAs worked from 11:00 PM to 7:00 AM. q. The nursing schedule for 3/26/26 indicated that no RN worked and 6 LPNs worked 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/26/26 documented that one RN and 4 LPNs worked 11:00 PM to 7:00 AM. r. The nursing schedule for 3/27/26 indicated that one MA 7:00 AM to 3:00 PM. The daily posted nurse staffing sheet for 3/27/26 documented that no MA worked 11:00 PM to 7:00 AM. s. The nursing schedule for 3/28/26 indicated that 9 NAs worked from 11:00 PM to 7:00 AM. The daily posted nurse staffing sheet for 3/28/26 documented that 10 NAs worked from 11:00 PM to 7:00 AM. On 4/2/26 at 8:39 AM, an interview occurred with the Staffing Scheduler who stated that she managed the staffing schedule and daily postings. She reviewed the staffing schedules and daily postings and verified the number of staff working from 3/1/26 to 3/30/26 did not match. She stated that she failed to update the daily posted nurse staffing sheet when a staff member called out, was a no-show, or came in to cover a need. The Administrator was interviewed on 4/2/26 at 11:22 AM, and stated that the daily staff schedule posting, and the staffing schedule should match the number of staff worked on any given shift.

Based on record reviews, observations and interviews with residents and staff, the facility failed to provide routine hair trimming. This was for 4 of 6 residents reviewed for activities of daily living (ADL) (Residents #36, # 50, #53, and #77). The findings included: 1. Resident #36 was admitted to the facility on [DATE]. An annual Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #36 was cognitively intact. During an interview and observation with Resident #36 on 12/18/24 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it. He explained he had not been able to get his hair cut in four months since the facility no longer had anyone available to provide this service. Resident #36 was unable to recall the staff that he talked to about getting his hair cut. Resident #36's hair was long on the sides and was long around the ears. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #36 wanted his hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the Nursing Assistants (NAs) could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs could brush the residents' hair as part of routine activities of daily living (ADL) care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #36 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 2. Resident #50 was admitted to the facility on [DATE]. A quarterly Minimum Data Set assessment dated [DATE] indicated that Resident #50 was cognitively intact. During an interview and observation with Resident #50 on 12/18/14 at 10:00 AM, she expressed that she would like to have her hair cut as it was longer than she liked to wear it and stated she had to rely on family members to trim her hair since the facility did not have anyone able to perform this service for the last four months. She explained she had asked staff several times about getting her hair cut but was unable to recall which staff. Resident #50's hair touched her collar in the back and was long around the sides. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #50 wanted her hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs can brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #50 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 3. Resident #53 was admitted to the facility on [DATE]. An annual Minimum Data Set assessment dated [DATE] indicated that Resident #53 was cognitively intact. During an interview and observation with Resident #53 on 12/18/14 at 10:00 AM, she stated that she would like to have her hair cut as it was longer than she liked to wear it and stated the facility did not have anyone able to perform this service for the last four months. She explained she had asked staff several times about getting her hair cut but was unable to recall which staff. She stated that she had not been offered an appointment with anyone outside of the facility to get her hair cut. Resident #53's hair was past her shoulders and was sticking out around her head. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #53 wanted her hair cut. She added she was unsure whose role it was to cut residents' hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing on 12/18/24 at 11:04 AM. She stated that she has only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs could brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #53 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted. 4. Resident #77 was admitted to the facility on [DATE]. An annual Minimum Data Set assessment dated [DATE] indicated that Resident #77 was cognitively intact. During an interview and observation with Resident #77 on 12/18/14 at 10:00 AM, he expressed that he would like to have his hair cut as it was longer than he liked to wear it and stated he had to rely on family members to trim his hair since the facility did not have anyone able to perform this service for the last four months. He explained he had asked his son to let the staff know he wanted a haircut, but he was not sure which staff his son spoke with. Resident #77's hair was long on the sides. On 12/18/24 at 10:41 AM, the Social Services Director was interviewed and stated that she was not aware that Resident #77 wanted his hair cut. She added she was unsure whose role it was to cut resident's hair. The Activities Director was interviewed on 12/18/24 at 10:47 AM and stated that nursing staff did not trim residents' hair, but that some family members came in and cut their loved ones' hair. She stated she didn't know how other residents got their hair cut. She indicated that the NAs could not cut hair. The Activities Director further stated that the facility did not have transportation available to take residents out for hair trimming, but she clarified the facility does have transportation to take residents to medical appointments. An interview occurred with the Director of Nursing (DON) on 12/18/24 at 11:04 AM. She stated that she had only been in the DON position since October 2024. She stated she had not been informed that she was responsible for finding someone to cut the residents' hair. She stated that the NAs can brush the residents' hair as part of routine ADL care, but they were not allowed to trim it. She relayed there had been candidates interviewed for the position of hairstylist, but that no one had been hired to her knowledge. An interview was completed with the Administrator on 12/18/24 at 11:10 AM. She stated she was unaware Resident #77 wanted a haircut. She stated she had been recruiting for a hairstylist for the facility. The Administrator further stated that the facility had not been making appointments to take residents out for hair trimming due to being unaware this service was wanted.

Based on record reviews, and Nurse Practitioner, Medical Director, family member, and staff interviews, the facility failed to prevent significant medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included Eliquis (used to prevent blood from clotting), buspirone (used to treat anxiety disorders), gabapentin (used to treat epilepsy), isosorbide (used to treat high blood pressure), metoprolol (used to treat high blood pressure), spironolactone (used to treat high blood pressure), citalopram (used to treat depression). In addtion Resident #4 was administered medications prescribed to Resident #191 which included Aricept (used to treat dementia), Lexapro (used to treat depression) and Tramadol (used to treat pain). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #4). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #23 had orders for: - Ingrezza 40 milligrams (mg) by mouth one time a day for tardive dyskinesia. - Sertraline (an antidepressant medication) 50 mg, give1.5 tablets, by mouth one time a day related to generalized anxiety disorder and major depressive disorder. - alprazolam (a benzodiazepine-central nervous system depressant medication) 0.25 mg tablet by mouth two times a day for anxiety. - Benztropine Mesylate (an anticholinergic medication) 0.5 mg by mouth every 12 hours for EPS (extrapyramidal signs or muscle stiffness/rigidity). - Depakote Delayed Release Sprinkle (an anticonvulsant and mood stabilizer medication) 125 mg, give 2 capsules by mouth three times a day for schizophrenia. -Risperdal (an antipsychotic medication) 0.5 mg tablet, give 1.5 tablets, by mouth two times a day related to paranoid schizophrenia. The annual Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #23 had severely impaired cognition. Resident #240 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #240 had orders for: - Apixaban (an anticoagulant medication) 2.5 mg by mouth two times a day related to atrial fibrillation. -Buspirone (an anxiolytic medication) 10 mg HCl by mouth three times a day related to generalized anxiety disorder. -Gabapentin (an anticonvulsant medication) 300 mg by mouth two times a day related to polyneuropathy. Do not crush or chew. - Isosorbide Mononitrate Extended Release (a nitrate with vasodilating properties medication) 30 mg by mouth one time a day for hypertension. Do no crush or chew. - Metoprolol Tartrate (a beta blocker medication) 0.5 tablet to = 12.5 mg by mouth two times a day related to primary hypertension. -Spironolactone (used to treat hypertension) 25 mg by mouth one time a day for Hypertension. -Citalopram Hydrobromide (an antidepressant medication) 10 mg by mouth one time a day related to generalized anxiety disorder and major depressive disorder. A progress note written by Nurse #1 dated 07/30/24 , indicated that Resident #23 had received the wrong morning medications. Nurse Practitioner #1 was notified and stated to monitor Resident #23 for 48 hours. Resident #23 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. Nurse #1 stated she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #23 on 07/30/24. She indicated that she was a new nurse, did not have very much training and did not know the residents well. She stated that on the morning of 07/30/24 she was preparing medications for Resident #23 but inadvertently used Resident 240's medications. Nurse #1 explained when she administered the crushed medications to Resident #23 that the resident stated, [NAME]! and that's when she suspected she made the error. Nurse #1 indicated she did not know how it happened, but she realized it immediately and notified the unit manager and the Director of Nursing. Nurse #1 went on to say she notified the Nurse Practitioner of the error, and she received new orders to monitor Resident #23. She also explained Resident #23's family member was in the room at the time, but she did not inform her of the medication error. Nurse #1 stated she was new and was unsure what the steps were after notifying the NP on 7/30/24. She further explained that she did not have a preceptor with her on 07/30/24 and she was alone on the medication cart. Review of the Nurse Practitioner (NP) #1's acute visit note dated 07/31/24 revealed Resident #23 was seen due to reports of receiving the wrong medication on 07/30/24. Nurse #1 informed the NP that Resident #23 received the following significant medications in error: Eliquis 10mg, buspirone 10mg, gabapentin 300mg, isosorbide 30mg, metoprolol 25mg, spironolactone 25mg, and citalopram 10mg. The NP noted essentially, Resident #23 ended up receiving Resident #240's morning medications instead of her prescribed meds. During the phone call on 07/30/24 orders included for vital signs to be checked every six hours x 48 hours, hold Resident #23's morning and afternoon routine medications and resume her regular scheduled medications at bedtime. The nurse was also instructed to monitor for signs and symptoms of increased bleeding, bruising, hypo/hypertension, altered mental status and increased drowsiness x 48 hours. There were no reports of adverse effects from medications received on 07/30/24. Will continue to monitor of any adverse effects, today she was hemodynamically stable and in no acute distress. A phone interview occurred with the family member on 12/18/24 at 5:15 PM and she stated she was at the facility on 07/30/24 when the medication error had occurred, however no one told her it had occurred at that time. She explained that Nurse #1 administered Resident #23's morning medications in her presence. She further explained Nurse #1 came back to the room a few minutes later and got Resident #23's vital signs (VS) and the family member stated, oh you're getting her VS? The nurse only said yeah, they want me to get them, but never said why she was getting them. An interview occurred with the Medical Director on 12/18/24 at 1:10 PM and he stated he did not recall being notified of the medication error for Resident #23. He explained he felt the medication error was significant due to the medications that Resident #23 had received. He also stated he had not heard that the medications had caused any harm to Resident #23. A phone interview occurred with Nurse Practitioner (NP) #1 on 12/18/24 at 5:08 PM and she stated she would consider the medication error that occurred on 07/30/24 with Resident #23 a significant medication error. She explained she gave orders to monitor Resident #23's vital signs and monitor for signs and symptoms of bleeding. NP #1 further stated she evaluated Resident #23 the following day and she had no adverse outcomes from the medication error. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #23 was given the incorrect medications. Nurse #1 prepared the wrong medications and administered them to Resident #23. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator stated the staff did everything they should have done after the incident occurred. The Administrator stated that nursing staff should have provided the correct medication to the correct resident. 40197 2. Resident #4 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, congestive heart failure and diabetes type 2. Review of Resident #4's August 2024 physician orders included the following morning medications: - Clozaril (an antipsychotic medication) 50 milligrams (mg) give 1.5 tablet by mouth twice a day for paranoid schizophrenia. - Haldol (an antipsychotic medication) injection 5 mg per milliliters (ml). Inject 2 ml intramuscularly every shift for agitation. - Fentanyl patch (an opioid) 12 micrograms per hour. Apply one patch transdermally every 72 hours. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #4 had moderately impaired cognition. Resident #191 was admitted to the facility on [DATE]. A review of the August 2024 physician orders for Resident #191 included the following morning medications: - Aricept 5 mg one tablet by mouth every morning. - Lexapro (an antidepressant) 10 mg one tablet by mouth every morning. - Tramadol (used to treat pain) 25 mg one tablet by mouth twice a day. An incident report dated 8/24/24 written by Nurse #2 revealed Resident #4 had received the wrong morning medications by Nurse #1. The incident was reported to the Medical Director at 10:31 AM and the responsible party (RP) at 7:31 PM. A nursing progress note dated 8/24/24 indicated that Resident #4 had received the wrong morning medications. The physician was notified to and stated to monitor Resident #4 for 24 hours. Resident #4 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. Nuse #1 explained that she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #4 on 8/24/24. She stated that on the morning of 8/24/24 she was preparing medications for Resident #4 but inadvertently used Resident 191's medications. She stated that Nurse #2 was her preceptor as she was a new nurse and had asked her if Resident #4 had received her Haldol injection. That was when it was identified that Resident #4 had received Resident #191's medications in error. Nurse #1 went on to say that Nurse #2 notified the physician and RP of the error. On 12/18/24 at 10:31 AM, an interview occurred with Nurse #2. She explained that Nurse #1 was a new nurse and that she was precepting her on 8/24/24. She stated that she asked Nurse #1 if Resident #4 had received her Haldol injection that morning and Nurse #1 responded that Resident #4 wasn't ordered an injection. That prompted her to begin asking more questions and found out that Nurse #1 had given Resident #191's medications to Resident #4. She went to assess Resident #4 who was at her baseline and stable, then notified the physician and RP. Nurse #2 stated she should have been standing right next to Nurse #1 when she was preparing the medications. An interview occurred with the Medical Director on 12/18/24 at 1:00 PM and stated he was notified of the medication error, but didn't feel that any of the medications that were received by Resident #4 would have caused any harm. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #4 was given the incorrect medications. Nurse #1 was being precepted by Nurse #2 but was standing away from the medication cart when Nurse #1 prepared the medications for Resident #4. Nurse #1 prepared the wrong medications and administered them to Resident #4. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator further stated that Nurse #2 immediately notified the physician, assessed the resident and notified the RP following the incident. The Administrator stated the staff did everything they should have done after the incident occurred. She added that Nurse #2 should have been monitoring the medications that were being prepared by Nurse #1 closer. The Administrator stated that nursing staff should have provided the correct medication to the correct resident.

Based on record reviews, and Nurse Practitioner (NP), Medical Director, family member, and staff interviews, the facility failed to prevent medication errors when Nurse #1 administered medications to Resident #23 prescribed for Resident #240 which included fish oil (used to promote health by reducing triglycerides) and famotidine (decreases stomach acid and used to treat heart burn and gastroesophageal reflux disease). The facility also failed to prevent medication errors when medications were not administered as ordered by the physician (Resident #55). This deficient practice affected 2 of 8 residents whose medications were reviewed (Residents #23 and #55). The findings included: 1. Resident #23 was admitted to the facility on [DATE]. Resident #240 was admitted to the facility on [DATE]. A review of the physician orders dated July 2024, scheduled for 9:00 AM, revealed Resident #240 had orders for: - Famotidine 20 milligrams (mg) by mouth one time a day related to gastroesophageal reflux disease. -Fish Oil (reduces triglycerides) 1000 mg by mouth one time a day for nutritional support/supplementation for heart health. A progress note written by Nurse #1 dated 07/30/24 indicated that Resident #23 had received the wrong morning medications. Resident #23 had not shown any affects from the medications that were given. A phone interview occurred with Nurse #1 on 12/18/24 at 5:40 PM. She explained that she no longer was employed at the facility but recalled the details of the medication error that occurred with Resident #23 on 07/30/24. She stated that on the morning of 07/30/24 she was preparing medications for Resident #23 but inadvertently used Resident 240's medications. Nurse #1 explained when she administered the crushed medications to Resident #23 that the resident stated, [NAME]! and that's when she suspected she made the error. Nurse #1 indicated she did not know how it happened, but she realized it immediately and notified the unit manager and the Director of Nursing. Nurse #1 went on to say she also notified the NP of the error, and she received new orders to monitor Resident #23. Review of the Nurse Practitioner (NP) # 1's acute visit note dated 07/31/24 revealed Resident #23 was seen due to reports of receiving the wrong medication on 07/30/24. Nurse #1 informed the NP that Resident #23 received the following medications in error: fish oil and famotidine. Essentially, Resident #23 ended up receiving Resident #240's morning medications instead of her prescribed medications. There were no reports of adverse effects from medications received on 07/30/24. Will continue to monitor of any adverse effects, today she was hemodynamically stable and in no acute distress. A phone interview occurred with the NP #1 on 12/18/24 at 5:08 PM and she stated she was notified of the medication error that occurred on 07/30/24 with Resident #23. NP #1 further stated she evaluated Resident #23 the following day and Resident #23 had no adverse outcomes from the medication error. The Administrator was interviewed on 12/19/24 at 9:34 AM and explained that during a medication pass, Resident #23 was given the incorrect medications. Nurse #1 prepared the wrong medications and administered them to Resident #23. The Administrator stated that Nurse #1 no longer was employed at the facility. The Administrator also stated the staff did everything they should have done after the incident occurred. The Administrator further stated that nursing staff should have provided the correct medication to the correct resident. 2a. Resident #55 was admitted on [DATE] with a diagnosis of anxiety. The quarterly Minimum Data Set, dated dated dated [DATE] indicated she was cognitively intact, and she did not exhibit any behaviors. Resident #55 was coded for the use of antianxiety medication. Review of Resident #55's revised care plan dated 03/22/24 included a care area for problematic behaviors in which she exhibited ineffective coping related to anxiety in which she got upset easily yelling, cursing, and screaming at others. Review of a physician order dated 07/12/24 read Resident #55 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) three times a day for anxiety and anxiousness. Review of an incident report (medication error) dated 08/30/24 timed 3:12 PM read while giving Resident #55 her 8:00 AM medications, Nurse #2 popped her morning dose of Ativan out of the medication card, but she did not notice that the medication was still stuck in the backside of the card pack and did not fall into the medication cup. This was not noticed until the shift change during the medication count. The report was completed my Nurse #2. During an interview with Nurse #2 on 12/18/24 at 10:30 AM, she stated she was precepting Nurse #1 so she pulled the medications for Resident #55 for Nurse #1 to administer, she did not notice that when she popped the Ativan out of her narcotic medication card, that the Ativan had not fallen into the pill cup but was still stuck inside the plastic bubble on the back of the medication card and later during medication count, it was discovered. An interview was completed on 12/18/24 at 1:15 PM with NP #2. She confirmed she was working in the facility on 08/30/24 and was made aware of the omission of Resident #55's morning Ativan dose on 08/30/24. She stated there was no concern for harm to Resident #55. An interview was completed on 12/18/24 at 1:00 PM with the Medical Director. He stated there was no harm to Resident #55. An interview was completed with the Administrator on 12/19/24 at 9:34 AM. She stated she would expect nurses to provide all prescribed medications to Resident #55 and not omit any doses. 2b. Review of a physician order dated 07/12/24 read Resident #55 was prescribed Ativan (antianxiety medication) 0.5 milligrams (mg) three times a day for anxiety and anxiousness. Review of an incident report (medication error) dated 08/30/24 timed 2:47 PM for Resident #55 read she was given the wrong dose of Ativan at 2:00 PM. Instead of receiving 0.5 mgs, she received 1 mg. The report indicated NP #2 and Resident #55's RP. This report was completed by Nurse #1. A telephone interview was completed on 12/18/24 at 5:40 PM with Nurse #1. She recalled the medication error with Resident #55. She stated she did not pull the Ativan for Resident #55 but rather Nurse #2 did and handed it to her to administer to Resident #55. Nurse #1 stated Resident #55 did not have any 1 mg Ativan tablets in the narcotic box and that Nurse #2 must have pulled the 1 mg of Ativan from another resident's narcotic pill card. Nurse #1 stated she resigned that day. During an interview with Nurse #2 on 12/18/24 at 10:30 AM, she stated she was precepting Nurse #1 at the time of this medication error on Resident #55 at 2:00 PM on 8/30/24. Nurse #2 stated she was not standing over Nurse #1 at the time of this medication error, but she felt Nurse #1 was not checking the computer when she pulled the incorrect Ativan dose and administered it to Resident #55. When asked why she was not with Nurse #1 since she was precepting her, Nurse #2 stated she should have been right beside her, but she did not want to hover over her and make her more nervous. An interview was completed on 12/18/24 at 1:15 PM with NP #2. She confirmed she was working in the facility on 08/30/24 and was made aware of the double dose of Resident #55's Ativan on 08/30/24 was administered at 2:00 PM. She stated there was no concern for harm, but Nurse #1 and Nurse #2 were instructed to observed for increased sedation. An interview was completed on 12/18/24 at 1:00 PM with the Medical Director. He stated there was no harm to Resident #55. Another interview was completed with the Administrator on 12/19/24 at 9:34 AM. She stated she would expect nurses to provide the medications to the right person, the right route and right dose.

Based on observation and staff interview, the facility failed to maintain a clean floor and walls in the dry food storage room for 1 of 2 dry food storage rooms observed (the emergency dry food storage area). Findings included: On 08/28/23 at 9:34 am an initial observation of the kitchen, including the emergency dry food storage room was conducted. The dry food storage room floor and walls had black soiling all over them (entire floor and wall without shelves) as well as the front of the ice machine. The inside of the ice machine was clean and had ice. Concurrent interview with the Dietary Manager was conducted. He stated the floor had not been cleaned in a couple of days and the black was soil not aging of the floor tile and the front of the ice machine had splatter. The Dietary Manager stated that a couple of weeks ago the Maintenance staff had serviced the ice machine and caused the splatter which had not been cleaned. On 8/31/23 at 1:40 pm the Administrator was interviewed. The Administrator stated she was not aware the emergency dry food storage room floor and walls were dirty and would follow up with the Dietary Manager.

Based on record reviews and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the annual recertification and complaint survey conducted on 2/3/2022. This was for 5 deficiencies in the areas of resident rights, safe/clean/comfortable homelike environment, accuracy of assessments, care plans, and services to meet professional standards, previously cited on 2/3/2022 and recited on the current recertification and complaint survey of 8/31/23. The duplicate citations during two federal surveys of record show a pattern of the facility's inability to sustain an effective QAPI program. The findings included: This citation is cross referenced to: 1. F550- Based on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder. During the facility's recertification survey of 2/3/2022 the facility failed to promote a dignified dining experience by serving meals on disposable plates and utensils. The facility also failed to provide dignity by allowing a resident to eat in a room with a strong urine odor. 2. F584- Based on observations and staff interviews, the facility failed to have a Packaged Terminal Air Conditioner (PTAC) unit in good repair (room [ROOM NUMBER]). This was for 1 of 6 rooms reviewed for comfortable, clean, and homelike environment. During the facility's recertification survey of 2/3/2023 the facility failed to maintain a clean environment as evidenced by dirty toilets and strong urine smells in bathrooms and failed to provide clean bed linens for 2 of 2 residents. 3. F641-Based on record reviews and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessment accurately in the area of medications (Resident #13 and Resident #42) for 2 of 22 residents reviewed. During the facility's recertification survey of 2/3/2022 the facility failed to accurately code the MDS assessment in the areas of nutrition, falls, pressure ulcers, dental status, and urinary catheters. 4.F656-Based on record review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan. During the facility's recertification survey 2/3/2022 the facility failed to develop a comprehensive care plan for Activities of Daily Living (ADL) assistance, for the use of a prophylactic antibiotic, and for a right-hand contracture. 5. F658- Based on record reviews, observation, and staff interviews, the facility failed to clarify a consultation note and discontinue an order to flush an abscess drain (Resident #25). This was for 1 of 1 resident reviewed for well-being. During the facility's recertification survey of 2/3/2022 the facility failed to follow physician's order by not holding the Lantus and Lispro insulin (used to treat diabetes mellitus) for blood sugar of 150 or less.

Based on observations, record reviews, and staff interviews, the facility failed to avoid the use of the term feeder when referring to a resident who required assistance with meals for 1 of 1 dining observations (Resident # 87). The reasonable person concept was applied as individuals have the expectation of being treated with dignity and not be referred to as feeder. The findings included: Resident #87 was admitted [DATE]. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident was severely cognitively impaired and required supervision and set up only during the assessment period. Resident # 87's comprehensive care plan was last revised 8/3/2023 and included a focus for nutritional status due to inadequate intake. On 8/28/2023 at 12:37 PM Resident #87 was observed in the dining area. The Occupational Therapy Assistant (OTA) provided Resident #87 with assistance eating and drinking. On 8/29/2023 at 12:45 PM Resident #87 was observed in the dining area. OTA provided Resident #87 with assistance eating and drinking. On 8/30/2023 at 12:30 PM Resident #87 was observed sitting in the dining area with his lunch tray in front of him. He made several attempts to put a straw in the lid of a cup and was unsuccessful. He was observed making three attempts to grasp a piece of steamed broccoli and place it in his mouth with his fingers but dropped it in his lap before it reached his mouth. The resident was then observed attempting to place the straw into the lid of a cup again. After several attempts, Resident #87 lost his grip on the straw, and it fell to the floor. During the above observation, Nurse Assistant (NA) #3 was standing in the door of the dining room, directly behind Resident #87. NA #3 was not observed assisting Resident #87 with his meal. At 12:40 PM this writer asked NA#3 if Resident #87 needed assistance with meals. NA#3 stated, I don't know. I don't usually work back here, I am the scheduler. NA#3 then walked to another dining area, stood in the door of the dining room and asked NA #4 if Resident #87 was a feeder. NA#4 replied, yes. NA#3 then walked back to dining area #1, pulled up a chair and began to assist Resident #87 with his meal. On 8/31/2023 at 10:08AM and interview was conducted with NA#3. She stated she should not have referred to Resident #87 as a feeder. She should have asked NA#4 if Resident #87 required assistance with his meal. 08/31/2023 1:17 PM and interview with Unit Manager #1 was conducted. She stated staff have been provided education on not referring to residents as feeders.

Based on observation, record review, and staff and resident interviews, the facility failed to assess Residebt #22 for self administration of medication for 1 of 1 resident observed to self-administer medication. Findings included: Resident #22 was admitted to the facility on [DATE]. A review of Resident #22's current physician orders did not include an order for the resident to self-administer medications. The annual Minimum Data Set, dated dated dated [DATE] documented Resident #22 had a moderately impaired cognition. The resident's active diagnoses were hypertension, arthritis, and osteoporosis. Resident #22's care plan dated 7/1/23 revealed the resident was not care planned to self-administer medications. On 08/28/23 at 9:55 am entry to Resident #22's room (room [ROOM NUMBER]), it was observed that the resident was holding a medication cup with 3 pills. The resident was taking a pill independently during entry into the room. Nurse #1 was not present. The remaining pills were red and orange in color. The resident continued to take her medication one at a time with water. The resident was slow and careful. During concurrent interview with Resident #22, she stated that sometimes the Nurse had not waited until I take all my medication and left the room. I take long to swallow; it was difficult for me, and the staff left before I was finished. The resident stated she would prefer the staff stay in the room, I think that was what they were supposed to do. An interview was conducted on 8/28/23 at 10:15 am of Nurse #1. Nurse #1 stated that she provided Resident #22 with her morning medication, handed her the cup with medication, and left the room. Nurse #1 stated she knew she was not supposed to leave the room while a resident took their medication independently, and I should not have left the room before the resident had taken her medication. Nurse #1 further stated Resident #22 was not independent with taking her medication. Nurse #1 had no further comments. On 8/31/22 at 1:55 pm an interview was conducted with the Administrator. She stated that the Director of Nursing (DON) was aware Nurse #1 had administered medication to Resident #22 unsupervised and staff would receive education. Nurse #1 had informed the DON. All medication administration was required to be supervised unless there was an order for self-administration.

Based on record review and interviews with staff, the facility failed to request a level II Preadmission Screening and Resident Review (PASRR) for a resident (Resident #81) newly diagnosed mental illness for 1of 1 residents reviewed for PASRR. The findings included: Resident #81 was admitted from another facility on 6/7/22 with diagnoses of Diabetes, Congestive Heart Failure and Chronic Obstructive Pulmonary Disease. He was admitted with a level 1 PASRR as of 6/1/20 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Resident #81 was seen by Psychiatry on 12/14/22 due to anger, aggression and mood instability. Resident #81 was newly diagnosed with Borderline Personality Disorder, Bipolar Disorder and Narcissistic Personality Disorder. Resident #81's annual Minimum Data Set, dated dated dated [DATE] indicated he was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition. An interview was completed with Social Worker #1 on 8/29/23 at 1:50 PM. She stated she completed the requested for Resident #81 to be screened for a PASRR level 2 earlier on 8/29/23. Social Worker #1 stated she was not aware that a PASRR level 2 screen was required when a resident was newly diagnosed with a serious mental illness and/or intellectual disability or related condition. An interview was completed on 8/31/23 at 1:35 PM with the Administrator. She stated a PASRR level 2 screening request should have been sent at the time Resident #81 was newly diagnosed with Borderline Personality Disorder, Bipolar Disorder and Narcissistic Personality Disorder on 12/14/22.

Based on record review and staff and resident interviews, the facility failed to develop a comprehensive care plan in the areas of personal and incontinence care refusal (Resident #32) and nutrition and weight loss (Resident #50) for 2 of 22 residents reviewed for care plan. Findings included: 1. Resident #32 was admitted to the facility on [DATE] with the diagnosis of schizophrenia. A review of Resident #32's electronic medical records from 6/1/23 to 8/31/23 documented the resident refused care, including incontinence care when needed at least once a week. Resident #32's care plan dated 7/26/23 documented she was totally dependent of 2 staff for bathing and was incontinent of bowel and bladder. There was no mention of care refusal. Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had an intact cognition. The resident had feelings of being down and refused care 3 to 5 times a week. No other behaviors were coded. The resident was dependent for bathing and required assistance of 1 staff for dressing and incontinence care. On 8/30/21 at 2:40 pm an interview was conducted with Resident #32. The resident stated she did not like to get out of bed and staff provided care and she had no concerns (the resident had not recalled refusing care). On 8/31/23 at 11:50 am an interview was conducted with MDS Coordinator #1. She stated Resident #32 had a care plan for manipulative behaviors but not for refusal of care. A care plan for refusal of care would be added. On 8/31/23 at 2:40 pm an interview was conducted with the Administrator. The Administrator stated she was not aware Resident #32 had no care plan for refusal of care and she would follow up with the MDS Coordinator. 2. Resident #50 was admitted to the facility on [DATE] with dementia. Resident #50's quarterly Minimum Data Set (MDS) dated [DATE] documented the resident had cognition that was severely impaired. The diagnoses were dementia and gastric reflux disease. The resident had weight loss, an undetermined amount. A review of Resident #50's electronic medical record for the month of August 2023 documented she ate between 25 to 50% of her meals. The resident had weight loss of 11.2% in 3 months. The dietician notes documented she was following and requested weekly weights. The resident was receiving a protein supplement and multivitamin for weight gain. The Registered Dietician (RD) note dated 8/8/23 documented Resident #50 had continued weight loss for the past 30 days. The RD evaluated and prescribed nutritional supplement to prevent weight loss. The resident would be weighed weekly for 4 weeks or until weight was stable (no further weight loss). Resident #50 had a physician order dated 8/13/23 for Mirtazapine each day (appetite stimulant). On 8/31/23 at 11:50 am interview was conducted with MDS Coordinator #1. She stated Resident #50 had no care plan for nutrition and weight loss. A nutrition and weight loss care plan area would be added. On 8/31/23 at 2:40 pm an interview was conducted with the Administrator. The Administrator was not aware Resident #50 had no care plan for weight loss. The resident's weight loss was discussed in morning meetings and the Dietary Manager was addressing the issue.

Based on observations, resident and staff interviews and record review, the facility failed to provide assistance with eating to maintain a resident's ability to feed himself for 1 of 1 residents (Resident #87) reviewed for activities of daily living (ADL). The findings included: Resident #87 was admitted [DATE] with diagnoses that included dementia. The resident's quarterly Minimum Data Set (MDS) dated [DATE] indicated the resident required supervision and set up only during the assessment period. Resident # 87's care plan was last revised 8/3/2023 and included a focus for activities of daily living and personal care deficit. Interventions included provide supervision with minimal set up or assistance with cutting food, verbal cues and/or assist to complete meals as needed. Resident #87's medical record also contained an Occupational Therapy (OT) Plan of Care dated 8/4/2023. The OT care plan indicated the resident's current level of function required total assist for completion of meals. On 8/28/2023 at 12:37 PM Resident #87 was observed in the dining area. The Occupational Therapy Assistant (OTA) provided Resident #87 with assistance putting straw in cup lid and getting cup to his mouth. Additionally, the OTA was observed putting food on the utensils and assisting Resident #87 with getting the food up to his mouth. On 8/29/2023 at 12:45 PM Resident #87 was observed in the dining area. The OTA provided Resident #87 with assistance eating and drinking. On 8/30/2023 at 12:30 PM Resident #87 was observed sitting in the dining area with his lunch tray in front of him. The OTA was not present. Resident #87 made several attempts to put a straw in the lid of a cup and was unsuccessful. He was observed making three attempts to grasp a piece of steamed broccoli with his fingers and place it in his mouth but dropped it in his lap before it reached his mouth. The resident was then observed attempting to place the straw into the lid of a cup again. After several attempts, Resident #87 lost his grip on the straw, and it fell to the floor. During the above observation, Nurse Assistant (NA) #3 was standing in the door of the dining room, directly behind Resident #87. NA #3 was not observed assisting Resident #87 with his meal. When Resident #87 moved his wheelchair back to look for the straw he dropped, the wheelchair contacted NA#3. NA#3 picked up the straw, placed it in the trash, and placed a clean straw in the resident's cup. She then went back to standing in the door of the dining area. At 12:40 PM on 8/30/2023 this writer asked NA#3 if Resident #87 needed assistance with meals. NA#3 stated, I don't know. I don't usually work back here; I am the scheduler. NA#3 then walked to another dining area, stood in the door of the dining area and asked NA #4 (who was seated assisting another resident) if Resident #87 was a feeder. NA#4 replied, yes. NA#3 then walked back to dining area where Resident #87 was sitting, pulled up a chair, and assisted Resident #87 with his meal. On 8/31/2023 at 10:08AM and interview was conducted with NA#3. She stated she did not work in the unit very often. She was not aware Resident #87 received assistance with his meals. On 8/31/2023 at 10:18 AM an interview was conducted with the Occupational Therapist (OT). He stated Resident #87 was on OT case load and receiving therapy services. The OT stated Resident #87 had a global functional decline over the previous 4 weeks. He further stated the staff had noticed Resident #87 needed assistance with meals. The OT stated he communicated with the unit staff frequently since 8/4/2023 and the staff were aware of the resident's decline. He stated the resident may have fallen through the cracks on 8/30/2023 because the staff working in the unit that day were not familiar with the residents. 08/31/2023 1:17 PM and interview with Unit Manager #1 was conducted. She stated NA#3 did not work in the unit routinely and was not aware Resident #87 required assistance with his meal.

Based on observations and staff interviews, the facility failed to have a Packaged Terminal Air Conditioner (PTAC) unit in good repair (room [ROOM NUMBER]). This was for 1 of 6 rooms reviewed for comfortable, clean, and homelike environment. The findings included: On 8/28/23 at 12:30 PM, an observation of room [ROOM NUMBER] revealed the PTAC unit to have two broken vents and two missing sections of vent slats. Observations were conducted with the Maintenance Director on 8/31/23 at 8:50 AM. He observed the broken vent slats as well as the two sections of missing vents and indicated he was not aware of the damage to the PTAC unit. He acknowledged the area did require attention and would be repaired. The Administrator was interviewed on 8/31/23 at 1:45 PM and stated it was important for the environment to be well repaired and homelike.

Based on record review, staff interview, and observation, the facility failed to provide supervision to prevent 1 of 2 sampled cognitively impaired residents who displayed wandering behaviors from exiting the facility while unsupervised (Resident #163). Resident #163 was found unsupervised outside of the facility by facility staff and returned inside with no injuries. Immediate Jeopardy began on 7/22/18 when Resident #163 was found outside of the facility without supervision by Housekeeper #1 and Housekeeper #2. Resident #163 was seated on a picnic bench under a covered shelter adjacent to the rear parking of the facility at approximately 12:00 PM. Immediate Jeopardy was removed on 11/16/18 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility remains out of compliance at a lower scope and severity of D (no harm with the potential for more than minimal harm that is not immediate jeopardy) to ensure monitoring systems put in place are effective. The findings included: Resident #163 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record indicated Resident #163 was initially admitted to an unlocked unit of the facility (700 hall) on 6/12/18 but was relocated to the locked memory care unit on the 500 hall the same day (6/12/18). A Nursing Admission Evaluation dated 6/12/18 for Resident #163 indicated he was independent with no help required for bed mobility and transfers. He ambulated independently with supervision. Resident #163 was assessed with [REDACTED]. A nursing note dated 6/12/18 indicated Resident #163 was alert and oriented to situation with some confusion and was observed wandering about the facility. He was noted to have a history of sun-downing and increased wandering in the evenings. A Nurse Practitioner (NP) note dated 6/13/18 indicated Resident #163 had a significant history of [MEDICAL CONDITIONS], metabolic [MEDICAL CONDITION], and dementia. He was noted to be a poor historian. Resident #163 was admitted to the locked memory care unit of the facility and he continued on [MEDICATION NAME] (cognition enhancing medication) related to dementia which was felt to be alcohol induced. The NP indicated that Resident #163 was oriented to person and year, but he was not certain where he was. A wander risk evaluation dated 6/13/18 indicated Resident #163 was at risk for wandering. He was noted with cognitive loss, occasional problems remembering where he was at, and had some difficulty in new situations. The assessment indicated Resident #163 had made verbal statements of desire or intent to leave the facility. Follow up interventions were for Resident #163 to reside on the locked memory care unit and for a wanderguard (an electronic alert system that alarms and locks the facility exit doors when cognitively impaired residents with wandering behaviors attempt to exit the building) to be placed on his person. The Resident Care Guide indicated an alarm bracelet (wanderguard) was initiated for Resident #163 on 6/14/18. The Resident Care Guide had not indicated that Resident #163 had wandering behaviors. The plan of care for Resident #163 indicated the focus area of the potential for/actual ineffective breathing pattern related to [MEDICAL CONDITION] was initiated on 6/14/18. There was no initiated focus area related to Resident #163 ' s wandering behaviors or his wanderguard at that time. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #163 ' s cognition was moderately impaired. He was assessed with [REDACTED]. Resident #163 required the supervision of 1 for bed mobility, transfers, and locomotion on/off the unit. He required supervision with no set up help for walking in room and corridor. Resident #163 ' s balance was assessed as unsteady but able to stabilize without staff assistance. He had no functional limitations with range of motion and utilized no mobility devices. The Care Area Assessment (CAA) related to Cognitive Loss/Dementia was triggered for Resident #163 ' s 6/19/18 Admission MDS related to a [DIAGNOSES REDACTED]. He was noted with cognitive deficits requiring reorientation until he was familiar with his surroundings. Resident #163 had a history of [REDACTED]. He had [DIAGNOSES REDACTED]. Resident #163 required very minimal assistance, mainly supervision and cueing to complete tasks. He was noted as essentially homeless prior to admission with noted stays in hotels and sometimes sleeping in the woods of a local park. A Care Plan Return to Community note dated 6/19/18 completed by Social Worker (SW) #2 indicated Resident #163 wanted to return to the community but that he had been living in the woods up until his hospitalization that resulted in his admission to the facility. A Care Plan General Note dated 6/27/18 indicated an initial care plan meeting was conducted for Resident #163. Two of his family members were noted to be in attendance. Resident #163 had not attended the meeting. The family reported that Resident #163 had a history of [REDACTED]. A SW note dated 7/2/18 completed by SW #2 indicated a mini-mental status assessment was conducted for Resident #163 and expressed passive thoughts of death with no active thoughts or reported desire to harm himself. SW #2 indicated she asked Resident #163 what made him feel that way and he stated that wanted a beer and was unable to get it and also that he had not liked being on the locked memory care unit as he was, not like the other crazy people back there. The quarterly MDS assessment dated [DATE] indicated Resident #163 ' s cognition was severely impaired. Resident #163 was assessed with [REDACTED]. He required supervision with set up help only for bed mobility and locomotion off the unit. Resident #163 required supervision with no set up or physical help from staff for transfers, locomotion on the unit, and walking in room and corridor. Resident #163 was steady on his feet at all times. He had no functional limitations with range of motion and utilized no mobility devices. An Admissions Director note dated 7/10/18 indicated that she had spoken with Resident #163 ' s family member several times about whether to keep Resident #163 on the locked memory care unit or to move him to one of the unsecured units. This was noted to have been discussed with Resident #163 and he reported that he wanted to move off of the locked unit. Resident #163 moved out of the locked memory care unit and onto the 100 hall (unlocked) on this date (7/10/18). A behavior note dated 7/12/18 at 4:18 AM indicated Resident #163 was observed standing up in his bed feeling the walls. He was easily redirected but was seen shortly after ambulating out of another resident ' s room. A nursing note dated 7/12/18 at 11:30 AM completed by Nurse #2 indicated Resident #163 opened the fire exit door on the 100 hall (the hall he resided on). Staff were present at that time and Resident #163 had not exited the building. An NP note dated 7/12/18 indicated Resident #163 was evaluated and stated that he was somewhat upset because he believed people were touching his things and stealing his things but otherwise he had no complaints and was pleased to be moved off of the locked unit. The NP indicated Resident #163 needed close monitoring in case he was developing paranoia since leaving the locked unit. A behavior note dated 7/21/18 at 1:28 PM completed by Nurse #2 indicated Resident #163 was observed wandering in and out of other residents ' rooms all throughout the first shift (7:00 AM - 3:00 PM) An incident report dated 7/22/18 completed by Nurse #2 (the nurse assigned to Resident #163 during the first shift on 7/22/18) was informed by the 200 hall nurse (Nurse #3) that two housekeeping staff (Housekeeper #1 and Housekeeper #2) found Resident #163 sitting outside of the facility unsupervised around 12:00 PM at the picnic area adjacent to rear parking lot of the facility. He was brought back into the facility by Housekeeper #1 and Housekeeper #2. Resident #163 ' s wanderguard was noted to be intact to his right lower leg. (There was no mention as to whether or not the wanderguard was functioning.) Resident #163 was alert but was disoriented times three (person, place, and time). There were no injuries, pain, or shortness of breath noted. A predisposing factor to the incident was noted to be Resident #163 ' s recent move into the facility. A behavior note dated 7/22/18 completed by Nurse #2 indicated she was informed by Nurse #3 that Resident #163 was found sitting outside at the picnic area by Housekeeper #1 and Housekeeper #2. Nurse Supervisor #1 was notified, and she reported to the Director of Nursing (DON) via text message. Resident #163 was moved back to the 500 hall locked memory care unit. Resident #163 ' s family member was contacted as well as the NP. A review of the weather conditions per Weather Underground ' s website (www.wanderground.com) for Albemarle ' s weather history indicated the temperature on 7/22/18 at 11:55 AM was 78 degrees Fahrenheit, 76 percent humidity, and there was no precipitation. A Quality Assurance Wandering Review dated 7/26/18 completed by the Quality Improvement (QI) Nurse indicated Resident #163 had an unsupervised exit from the facility on 7/22/18 at 12:00 PM. Resident #163 was noted to be found by staff at the covered picnic area by the staff parking lot. Resident #163 was assisted back into the building. Resident #163 ' s wanderguard placement was noted to be confirmed when he was returned into the building. (The wanderguard ' s functioning was not noted to be confirmed.) Resident #163 was relocated to the 500 hall locked memory care unit. An observation was conducted on 11/15/18 at 12:45 PM of the area where Resident #163 was found outside of the building unsupervised on 7/22/18. This area had a concrete pad, picnic tables, and a covering that provided shade and was utilized as a smoking area for residents and staff. It was adjacent to the rear parking lot that was utilized primarily by staff. The area Resident #163 was located was approximately 167 feet away from the nearest facility exit. An observation was conducted, and an interview was attempted with Resident #163 on 11/16/18 at 7:45 AM. Resident #163 ambulated independently and was alert and oriented to self only. When asked about his unsupervised exit from the building on 7/22/18 he reported that he goes outside everyday. He was unable to provide any information related to the 7/22/18 incident. An undated handwritten statement completed by Housekeeper #1 indicated he had exited the facility around 12:00 PM to go to his car that was parked in the facility ' s rear parking lot to eat his lunch. He wrote that he saw Resident #163 get up from the picnic tables underneath the shelter and walk toward his car. Housekeeper #1 noted that he saw Housekeeper #2 coming outside and he asked her if Resident #163 was supposed to be outside unsupervised and she said he was not. Housekeeper #1 indicated he took Resident #163 back inside of the facility. A phone interview was conducted with Housekeeper #1 on 11/15/18 at 1:04 PM. Housekeeper #1 stated he had exited the building from the 700 hall door to eat his lunch in his car that was parked in the rear parking lot. He explained that this was the parking lot the staff used and that the 700 hall door required a numerical security code to unlock. Housekeeper #1 indicated he was moving his car from an unshaded spot in the lot to a shaded spot as it was hot outside. He stated that this was when he saw Resident #163 sitting at the picnic tables under the shelter. He revealed that Resident #163 was unsupervised. He stated that he thought Resident #163 looked tired and was breathing hard. Housekeeper #1 reported that at that time he saw Housekeeper #2 exiting the building through the 700 hall door. He stated that he asked her if Resident #163 was supposed to be outside by himself and she told him that he was not supposed to be outside unsupervised. Housekeeper #1 indicated he and Housekeeper #2 walked Resident #163 back to the 700 hall door, entered the security code, and brought him back into the building. He reported that as he was coming back in with Resident #163 when he saw Nurse #3 and she took the resident from there. This interview with Housekeeper #1 continued. He was asked how Resident #163 got out of the building. He stated that he did not know how Resident #163 had gotten out. He was asked if any changes had been made to the utilization of the exit doors that required a numerical security code. He indicated that the numerical code was changed regularly, but that the new code was given out department heads and then distributed to staff. He revealed staff still utilized these exit doors. An undated handwritten statement completed by Housekeeper #2 indicated she had exited the facility on 7/22/18 around 12:00 PM and was walking to her car. She noted that she saw Housekeeper #1 get out of his car and he asked her if Resident #163 was supposed to be outside of the building and she told him he was not. She indicated she and Housekeeper #1 took Resident #163 back inside the building. A phone interview was conducted with Housekeeper #2 on 11/15/18 at 1:20 PM. Housekeeper #2 stated that she had exited the building through the 700 hall door to get something from her car in the staff parking lot/rear parking lot. She reported that she entered the numerical security code to exit the door. She indicated that she couldn ' t recall much about the incident. She stated she saw Resident #163 outside at the picnic tables unsupervised and she knew he was not supposed to be outside without staff supervision. Housekeeper #2 reported she ran into Housekeeper #1 while she was outside. She stated that she went back into the building through 700 hall door by pressing the numerical security code and she reported to nursing staff that Resident #163 was outside unsupervised. She indicated that Housekeeper #1 walked the resident back inside through the 700 hall door. This interview with Housekeeper #2 continued. She was asked how Resident #163 got out of the building. She stated that she did not know how Resident #163 had gotten out. She was asked if any changes had been made to the utilization of the exit doors that required a numerical security code. She indicated that the numerical code was changed regularly, but that the new code was given out department heads and then distributed to staff. She revealed staff still utilized these exit doors. An interview was conducted with Nurse #2 on 11/15/18 at 12:39 PM. She confirmed she was assigned to Resident #163 on 7/22/18 at the time of his unsupervised exit. She additionally confirmed Resident #163 was wearing a wanderguard, had been an identified wanderer, and was cognitively impaired. She reported that she was unable to recall very many specifics about the incident. Nurse #2 stated that she was on her lunchbreak at the time Resident #163 was found outside unsupervised by two housekeepers (Housekeeper #1 and Housekeeper #2). She indicated that Nurse #3 was the person who informed her that Resident #163 had been found outside. She stated that she was unable to recall when she had last seen Resident #163 prior to the time he was found outside unsupervised. She indicated that once she was informed of the incident she checked Resident #163 ' s wanderguard for placement, but she could not recall if she had checked it for functioning. Nurse #2 stated she changed Resident #163 ' s wanderguard as a precaution. She reported she informed Nurse Supervisor #1 verbally and then she called the Director of Nursing (DON). She indicated that Resident #163 was moved to the locked memory care unit about 10 minutes after the incident. This interview with Nurse #2 continued. She was asked how Resident #163 got out of the building. She stated that it was never determined how Resident #163 exited the building. She was asked if any changes had been made to the utilization of the exit doors that required a numerical security code. She indicated that the numerical code was changed regularly, but that the new code was given out department heads, distributed to staff, and was sometimes given to visitors. Nurse #2 revealed staff and visitors still utilized these exit doors. An interview was conducted with Nurse Supervisor #1 on 11/15/18 3:23 PM. She confirmed she was working at the time of Resident #163 ' s unsupervised exit from the building on 7/22/18. She additionally confirmed that Resident #163 was an identified wanderer, he was wearing a wanderguard, and he was cognitively impaired. She stated that he wandered into other residents ' rooms and all throughout the facility during the time when he was on the unlocked unit. Nurse Supervisor #1 spoke about the incident on 7/22/18. She stated that Housekeeper #1 found Resident #163 outside of the building at the picnic tables adjacent to the rear parking lot. She reported that he was disoriented times 3 when he was brought inside the building. She indicated that a 100% head count was conducted to ensure all residents were in the building. Resident #163 ' s wanderguard was checked for placement. She stated she had not recalled if his wanderguard was checked for functioning. Nurse Supervisor #1 indicated that all of the exit doors were checked to ensure they were locked and they found no problems. She reported that Resident #163 was moved to the locked memory care unit that same afternoon. She stated she asked Nurse #2 when she had last seen Resident #163 and she thought it was about 10 minutes prior to her lunchbreak. She indicated it was estimated Resident #163 was outside unsupervised for about 15 minutes. This interview with Nurse Supervisor #1 continued. Nurse Supervisor #1 revealed it was never determined how Resident #163 had gotten out of the building. She stated that they didn ' t know if he slipped out behind a staff member or a visitor when they exited the building. She reported that Resident #163 ambulated independently, he walked fast, and he also looked like he could have been a visitor at the building rather than a resident. Nurse Supervisor #1 stated that another possibility was for Resident #163 to have exited the building behind a resident who was deemed as a safe smoker and had knowledge of the numerical security code to unlock the dining room exit door. She explained that safe smokers were given the security code so that they could enter and exit the building through the dining room exit door to access the smoking area independently. She reported that the numerical security code was changed regularly, but that the new code was given out to staff, visitors, and the safe smokers. Nurse Supervisor #1 revealed that there had been no changes with the security code being provided to staff, visitors, or the safe smoking residents since the incident. She stated that these exit doors continued to be utilized. An interview was conducted with Nurse #3 on 11/16/18 at 10:25 AM. She confirmed she was working at the time of Resident #163 ' s unsupervised exit from the building on 7/22/18. She additionally confirmed that Resident #163 was an identified wanderer, he was wearing a wanderguard, and he was cognitively impaired. She indicated that on 7/22/18 Housekeeper #2 came in and told her that Resident #163 was found outside unsupervised and that Housekeeper #1 was bringing him inside. She stated that she informed Nurse #2, Resident #163 ' s assigned nurse at that time, because she was on her lunchbreak. She then informed Nurse Supervisor #1 verbally. She reported that Resident #163 was moved to the locked memory care unit shortly after being brought back inside. This interview with Nurse #3 continued. She was asked how Resident #163 got out of the building. She stated that it was never determined how Resident #163 exited the building. She was asked if any changes had been made to the utilization of the exit doors that required a numerical security code. She indicated that the numerical code was changed regularly, but that the new code was given out department heads, distributed to staff, and was sometimes given to visitors. Nurse #3 revealed staff and visitors still utilized these exit doors. A phone interview was attempted with Nursing Assistant (NA) #3 on 11/15/18 at 1:57 PM and 11/16/18 at 8:56 AM. She was unable to be reached for interview. NA #3 was assigned to Resident #163 at the time of his unsupervised exit on 7/22/18. A phone interview was conducted with NA #4 on 11/15/18 at 2:30 PM. She confirmed she was working on Resident #163 ' s unit (100 hall) at the time of his unsupervised exit on 7/22/18. She was not able to recall any specific details of the incident. NA #4 stated that Resident #163 was a known wanderer and that the staff had to keep an eye on him at all times. She reported he wandered in and out of other residents ' rooms throughout the day as well as throughout the halls of the facility. An interview was conducted with the Maintenance Director on 11/15/18 at 4:10 PM. He stated that he was not working at the time of Resident #163 ' s unsupervised exit from the building on 7/22/18 and he had not been involved in the investigation of the incident. He revealed he had no knowledge that a resident had exited the building unsupervised. The Maintenance Director provided information on all of the buildings exits. He reported that there were 10 exits, all equipped for the wanderguard system, that Resident #163 could have potentially exited the building from. The distances from the 10 exits to the picnic shelter area where Resident #163 was found ranged from 167 feet to 954 feet. He stated that he changed the numerical security codes for the exit doors about once a week. He stated that the codes were provided to staff each time they were changed as the staff members exited the building through a variety of the exit doors. He indicated that there had been no changes made with the usage of any of these exit doors. The Maintenance Director was asked if any monitoring was conducted on the exit doors to ensure they were functioning properly. He reported he checked the functionality of the exit doors locking systems weekly using the computer system TELS (The Equipment Lifecycle System) to electronically log the monitoring. The Maintenance Director provided documentation from the TELS log to verify this weekly monitoring from (MONTH) (YEAR) through present (11/15/18). An interview was conducted with the Quality Improvement (QI) Nurse on 11/15/18 at 3:20 PM. She was responsible for oversight of the wanderguard function and placement monitoring. She stated that the third shift nursing staff was supposed to be checking wanderguards daily for function and placement. She revealed that about a week ago she identified that this task was not being done for any of the residents with wanderguards. The QI Nurse was unable to recall how she identified this lapse in monitoring, but she acknowledged that it was her responsibility for ensuring this task was completed and that as of this date (11/15/18) the wanderguard monitoring was re-initiated for all residents with wanderguards. An interview was conducted with the DON on 11/15/18 at 4:20 PM. She stated that she was aware the QI Nurse discovered that the third shift nursing staff were not checking wanderguards daily for function and placement. The DON was unable to offer an explanation as to how this system failure related to wanderguard monitoring had occurred. On 11/16/18 at 9:20 AM the Assistant Administrator provided a wanderguard monitoring log dated (MONTH) (YEAR) that indicated Resident #163 ' s wanderguard had been checked for function and placement on 11 of 29 days. There were 8 days in (MONTH) that had not indicated Resident #163 ' s wanderguard was checked for function and placement (6/17/18, 6/22/18 through 6/25/18, and 6/28/18 through 6/30/18). An interview was conducted with the Assistant Administrator on 11/16/18 at 9:21 AM. She was asked where the monitoring for Resident #163 ' s monitoring was for (MONTH) (YEAR) through 11/14/18. She stated that there was no evidence of function and placement monitoring for Resident #163 ' s wanderguard from (MONTH) (YEAR) through 11/14/18. She revealed the facility identified a system failure with wanderguard monitoring and had re-initiated the monitoring as of 11/15/18 by placing the wanderguard monitoring for function and placement on the Medication Administration Records (MARs). The Assistant Administrator explained that wanderguard monitoring had not been documented in the medical record prior to 11/15/18. She further explained that this monitoring had been documented on a separate form that was kept at the nursing stations and that each nursing station had a list of residents who resided on that unit with wanderguards in place. An interview was conducted with the Administrator on 11/15/18 at 12:20 PM. She confirmed Resident #163 had an unsupervised exit from the facility on 7/22/18 around 12:00 PM. She additionally confirmed Resident #163 had been identified as wanderer, he had exit seeking behavior, and he had a wanderguard in place prior to the unsupervised exit (7/22/18). She reported that Resident #163 was initially admitted to the locked memory care unit (500 hall) related to fluctuating confusion, dementia related to [MEDICAL CONDITION], and his family ' s request to place him on the locked unit as Resident #163 was alcohol seeking. She revealed he was moved off of the locked unit on 7/10/18. The Administrator was asked what precipitated Resident #163 ' s move to an unlocked unit. She stated that Resident #163 had reported he was not happy being on the locked unit and in an effort to promote his dignity he was moved to an unlocked unit. This interview with the Administrator continued. She stated that when Resident #163 was brought back in the building on 7/22/18 after his unsupervised exit, his wanderguard was checked for placement, the wanderguard was replaced as a precaution, and he was moved to the locked memory care unit. The Administrator was asked if Resident #163 ' s wanderguard had been checked on 7/22/18 after his unsupervised exit to ensure it was properly functioning at the time of his exit to rule out improper wanderguard functioning as a root cause of the unsupervised exit. She stated she had not known if the wanderguard Resident #163 was wearing at the time of his unsupervised exit had been checked for functioning. The Administrator stated that there were 9 exit doors, that all doors were equipped for the wanderguard system, and that each door had a numerical security code that was required to be entered to unlock the door. She revealed that it had never been determined which exit Resident #163 used to get out of the building. She additionally revealed there had been no changes made with the usage of any of the exit doors since Resident #163 ' s unsupervised exit from the facility on 7/22/18. She stated that staff, visitors, and safe smokers continued to utilize the numerical security code to exit through a variety of the doors. The Administrator was asked how a future incident was going to be prevented if they had not determined how Resident #163 got out of the building. She stated that she believed the problem had been addressed when Resident #163 was moved to the locked memory care unit. She was asked if there were other residents with wanderguards who resided on the unlocked units. She revealed that there were several residents with wanderguards on the unlocked units. The Administrator was unable to explain how these other residents with wanderguards who resided on the unlocked units had been addressed to ensure their wanderguards were functioning properly. The Administrator and DON were notified of the Immediate Jeopardy on 11/15/18 at 5:00 PM. On 11/16/18 at 5:37 PM the facility provided the following credible allegation of Immediate Jeopardy removal: CORRECTIVE ACTION FOR THE AFFECTED RESIDENT · On 7/22/18, Resident #163 was found, by two members of housekeeping staff, sitting outside in the picnic area adjacent to the rear parking lot. The resident was assisted back into the facility by the two members of housekeeping staff at 12:00. · On 7/22/18, the Hall Nurse confirmed Resident #163 ' s wander guard was in place. The wander guard bracelet was not changed. · On 7/22/18 at 12:05 pm, Resident #163 was assessed by the Hall nurse with no injury noted. · On 07/22/18 at 12:10 pm the RN supervisor notified the Director of Nursing (DON) of the Unsupervised exit of Res #163 and Resident was transferred to the SPARKS (Secured Dementia) unit. The resident is currently wearing a Wanderguard. The Wanderguard was checked for functionality 11/7/18 by the QI Nurse and re-checked by the DON for functionality on 11/15/18. · On 7 /22 /18 at 12:16pm, Resident #1 ' s physician was notified by the administrator of the resident ' s unsupervised exit. · On 7/22 /18, at 12:16pm Resident #163 ' s Resident Representative (RR) was notified by the staff nurse of the unsupervised exit. · On 7/24 /18, the Minimum Data Set (MDS) nurse confirmed Resident #163 was already assessed for At Risk of Wandering, wander guard was on and functional when checked by the admissions director 6/13/18. The resident was admitted to the facility on [DATE], the resident was assessed for risk for wandering on 6/13/18, the assessment revealed a score of 6 out of 21 total points. The Wandering Risk evaluation assessment was completed by the Registered Nurse QI Nurse. · On 7/24 /18, Resident #163 ' s wandering assessment was re-assessed on by the QI nurse and resulted in a score of 10 out of 21 total points. Resident #163 ' s care plan and care guide were reviewed and updated as appropriate on 7/23/18 by the MDS nurse. · On 7/22/18 at 12:10 pm the RN Staff Nurse documented the Wanderguard was intact to right lower leg. · On 7/22/18 at 12:05 pm The RN Supervisor on duty conducted 100% observation audit of all exit doors, the result of this audit showed no negative findings. The audit included checking all exit doors for functionality of alarms and / or locks. The RN Supervisor verbally reported the completion and results of the door audit to the Director of Nursing on 7/22/18. The RN Supervisor documented the audit in the written statement on 11/15/18. · The Maintenance Director checks weekly the functionality of the locking system on all exit doors. The Maintenance Director documents the results of all weekly checks in the TELS computer system. On 11/16/18 the Assistant Administrator printed from the TELS computer system of the Logbook Report of the Resident Monitoring Systems from 6/2/18 through 11/10/18. The Report reveals that weekly door checks have occurred since 6/2/18. · On 11/7/18 the QI nurse checked the functionality of Res # 163 ' s Wanderguard. On 11/15/18 at 8:55 pm the DON performed an observation audit on Res # 163 ' s Wanderguard for functionality and the Wanderguard was properly functioning with an expiration date of 10/2020. · During the investigation of the unsupervised exit that was initiated on 7/22/18, witness statements were obtained from two housekeepers that observed the resident in the outside picnic area and the RN Staff Nurse. Res # 163 was interviewed and was unable to verbalize the exit path that was taken. The RN supervisor interviewed other staff members and communicated to the DON the i (TRUNCATED)

Based on observations, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility neglected to assess, evaluate, monitor and treat a resident with continued complaints of left rib pain following a fall on 10/17/18. A diagnostic x-ray dated 10/30/18 revealed fractures to the 3rd through 7th ribs on the left side. This was for 1 (Resident #30) or 1 residents reviewed for neglect. The findings included: Resident #30 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #30's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with a Brief Mental Status (BIMS) score of 12. She was coded with no behaviors and limited assistance with ambulation. Resident #30 was coded with no impairments to her upper or lower extremities. She was coded for scheduled and as needed (PRN) pain medications. Resident #30 was coded as reporting no pain and as having no falls since previous MDS assessment. Review of the nursing 24 Hour Report dated 10/16/18 read Resident #30 slid to the floor on first shift with the Physician and Responsible Party (RP) notified. The 24-Hour Report indicated Resident #30 received Tylenol 2 tablets on second shift. Review of an incident report and nursing note dated 10/17/18 at 10:43 AM read Resident #30 had an unwitnessed fall in her room. She was ambulating on her own from her wheelchair to her closet when she fell . The report and nursing note read no injury, but Resident #30 complained of left rib pain. The nursing note read a correspondence was left for the NP and Medical Director. The intervention was a therapy screen. Review of a Physician Fax Communication sheet dated 10/17/18 read Resident #30 did not fall but sat on the floor and caught herself using her walker and recliner. Resident #30 complained of left rib pain. The Nurse Practitioner (NP) wrote the word monitor with her initials. The NP documentation was undated. Review of the nursing 24 Hour Report dated 10/17/18 read Resident #30 received Tylenol 2 tablets at 6:00 PM. Review of the (MONTH) (YEAR) Physician order [REDACTED]. There were also orders for [MEDICATION NAME] (opioid used to treat pain) 1 tablet as needed for pain. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Rehabilitation screen dated 10/18/18 read Resident #30 was not interested in participating in therapy. Review of the nursing 24 Hour Report dated 10/22/18 read Resident #30 complained of rib pain and received Tylenol on third shift. Review of a nursing 24 Hour Report dated 10/23/18 read Resident #30 went out of the facility with her RP on first shift. Review of a Physician Fax Communication dated 10/23/18 read Resident #30 continues to complain of left upper rib pain and stated she was going to have her RP drop her off at the hospital for evaluation if something was not done. The NP documented per Nurse #4, no complaints with the date 10/24/18 and her initials. Review of the electronic medical record revealed no nursing notes regarding Resident #30's continued complaints of left rib pain from 10/17/18 until 10/29/18. Review of a nursing note dated 10/29/18 at 4:56 PM read Resident #30 was complaining of soreness to her left side and left arm. Resident #30 requested an x-ray and the NP was notified. Review of an x-ray report dated 10/30/18 read as follows: Minimal displaced fractures of the third through seventh posterior lateral ribs left side suggested. The x-ray was undated but initialed by the NP. Review of Resident #30's MAR indicated [REDACTED]. Review of a NP note dated 10/30/18 at 2:11 PM, read in part as follows: Resident #30 had a fall approximately 2 weeks ago and continues to have left lower rib cage pain that worsens with coughing, deep breaths or with repositioning in bed. Resident #30 stated her pain medications do help alleviate the pain somewhat, but she is still very concerned since it is ongoing. Resident #30 stated otherwise, she is doing okay and has no complaints. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 11/13/18 at 4:49 PM, Resident #30 reported she fell in (MONTH) and immediately experienced left side pain. She stated she broke her ribs and she received no x-ray and saw no NP or MD until two weeks after the fall. She stated the pain was bad but has improved. She stated she continues to have pain with movement in bed and on transfers. She reached to guard her left side with facial grimacing. Resident #30's care plan last revised on 11/14/18 indicated she was at risk for pain related to complaints of soreness and discomfort to her left side and left arm on 10/29/18. The care plan revised 11/14/18 also read her x-ray dated 10/30/18 indicated fractures of her left 3rd through 7th ribs. Interventions included listening to her complaints of pain, medications as ordered, documenting verbal and non-verbal indicators of pain and notification of the physician if pain management was not effective. In an interview on 11/14/18 at 2:35 PM, Nurse #4 stated she was assigned Resident #30 most days and assigned to her the day she fell . She stated the NP was in the building that day and spoke to the NP about Resident #30's complaints of left side pain. Nurse #4 stated to her knowledge, the NP did not assess Resident #30 on 10/17/18. She stated the NP told her to monitor Resident #30 and administer the prn Tylenol if she needed it for pain. Nurse #4 stated about a week later, Resident #30 was still complaining of pain to her left side so Nurse Supervisor #3 requested an x-ray order from the NP. Nurse #4 stated to her knowledge, the NP did not assess Resident #30 because she had left the facility the with her RP on 10/23/18. Nurse #4 confirmed she neglected to report Resident #30's continued complaints of pain until another Physician Fax Communication form dated 10/23/18 was faxed to the NP. In an interview on 11/14/18 at 2:45 PM, Nursing Assistant (NA) #10 stated Resident #30 complained of left side pain after the fall and she reported it to Nurse #4. She confirmed Resident #30 continues to complain of occasional pain with transfers. In an interview on 11/14/18 at 3:05 PM, Nurse Supervisor #3 stated she was aware that Resident #30 had a fall and was experiencing left side pain. She stated the NP wanted nursing staff to monitor her for continued or worsening of the pain but confirmed there was little documentation to suggest the nurses were monitoring Resident #30's continued complaints of pain to her left side. She stated she contacted the NP on 10/29/18 and requested an x-ray because Resident #30 requested it. In an interview on 11/15/18 at 8:50 AM, NA #11 stated Resident #30 has complained of pain to her left side with care. NA #11 stated when Resident #30 complained of pain, she would report it to her assigned nurse. In an interview on 11/15/18 at 9:00 AM, the NP stated it was her expectation that when she directed the nursing staff to monitor Resident #30, they would have contacted her if she got worse, but she was likely going to be sore from the fall. The NP stated staff reported to her that Resident #30 was going out with her RP and she was able to function at her baseline, but the nurse neglected to report continued complaints of pain. The NP stated when the Nurse #4 faxed her on 10/23/18, she stopped in to see Resident #30, but she was out of the facility with her RP and she was not notified again until 10/29/18 by Nurse Supervisor #3. The NP stated that was when she ordered the x-ray. The NP confirmed the x-ray results of 5 fractured left side ribs. The NP confirmed she did not assess Resident #30 until 10/30/18. She stated there was no need for additional treatment and that Resident #30 was already taking [MEDICATION NAME] twice daily for pain and Tylenol as needed. The NP stated she did not routinely review the nursing notes but rather relied on the staff calling her for sending her a Physician Communication Fax form. The NP confirmed she was at the facility daily Monday through Friday and available by phone when she was not at the facility. In a second interview on 11/15/18 at 10:40 AM, Resident #30 was sitting up in her wheelchair with NA #11 present in the room. Resident #30 complained of left side pain where she broke her ribs. She was guarded of her left side with facial grimacing. NA #11 heard Resident #30's complaint of pain and stated she would notify her nurse. In an interview on 11/15/18 at 5:40 PM, Nurse #6 confirmed she was assigned Resident #30 and had cared for her since beginning her shift at 7:00 AM on 11/15/18. She stated NA #11 neglected to inform her that Resident #30 voiced left side pain earlier today after breakfast and that Resident #30 had not complained of pain to her, but she was due her scheduled [MEDICATION NAME] and would assess Resident #30. A telephone call was made to Resident #30's RP at both phone numbers listed with messages left to call surveyor. At time of exit, there had been no return call from RP. In an interview on 11/16/18 at 8:20 AM, Resident #30 stated she was feeling better today. She stated her RP told her to take it easy and rest. In a second interview on 11/16/18 at 10:20 AM, the NP stated it was her expectation that when NA #11 heard Resident #30 complain of left side pain on 11/15/18, she would have reported it to Resident #30's nurse. A telephone call was made to NA #11 on 11/16/18 at 11:18 AM with a message left to call the surveyor regarding not reporting Resident #30's complaints of pain on 11/15/18. At the time of exit, there had been no return phone call. In a telephone call on 11/16/18 at 11:35 AM, NA #12 confirmed she was assigned Resident #30 on 10/19/18 and 10/22/18 for second shift. She stated she recalled Resident #30 complaining of left rib pain especially when toileting and that she could not use her left arm to reach due to the pain. NA #12 stated she reported the pain the Resident #30's nurse on both days. In a telephone call on 11/16/18 a 11:42 AM, NA #13 confirmed she was assigned Resident #30 on 10/18/18 for third shift. She stated she recalled Resident #30 stated she was sore from the fall, but NA #13 could not recall if she reported anything to the nurse. In a second interview on 11/16/18 at 11:55 AM, NA #10 confirmed she was assigned Resident #30 first shift on 10/17/18, 10/18/18, 10/19/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/26/18 and 10/30/18. NA #10 stated Resident #30 did complain of left side pain on occasion, but she always reported the complaints to the nurse. In an interview on 11/16/18 at 12:30 PM, Nurse #7 confirmed he was assigned Resident #30 on 10/19/18, 10/26/18, 10/27/18 and 10/28. He stated he worked those days from 7:00 AM to 7:00 PM. Nurse #7 stated he received no notification that Resident #30 complained of pain and that she never complained of pain when he went in to give her medications. In a telephone interview on 11/16/18 at 5:00 PM, the MD stated it was his expectation that there would have been assessment completed by the NP at the time when Resident #30 first complained of pain on 10/17/18 and x-ray would have been ordered at that time to rule out injury. He further stated if Resident #30 reported continued pain and the NP did not assess her to rule out injury, it was expectation that the nursing staff would have contacted him for orders. Review of the medical record indicated new orders dated 11/16/18 for Resident #30 to have a pain assessment completed three times daily while awake for 2 weeks and to administer the prn [MEDICATION NAME] for pain as ordered.

Based on observations, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility failed to provide timely evaluation of a report of immediate pain following a fall on 10/17/18 and continued complaints of pain. The facility also failed to obtain a diagnostic x-ray until the resident requested one on 10/29/18. The x-ray results dated 10/30/18 revealed fractures to the 3rd through 7th ribs on the left side. This was for Resident #30. The facility also failed to promptly address a resident's expression of passive [MEDICAL CONDITION] and known depressive symptoms for 52 days after reported to the Social Worker (SW). This was for Resident #163. This deficient practice was for 2 of 2 residents reviewed for wellbeing. The findings included: 1. Resident #30 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #30's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with a Brief Mental Status (BIMS) score of 12. She was coded with no behaviors and limited assistance with ambulation. Resident #30 was coded with no impairments to her upper or lower extremities. She was coded for scheduled and as needed (PRN) pain medications. Resident #30 was coded as reporting no pain and as having no falls since previous MDS assessment. Review of the nursing 24 Hour Report dated 10/16/18 read Resident #30 slid to the floor on first shift with the Physician and Responsible Party (RP) notified. The 24-Hour Report indicated Resident #30 received Tylenol 2 tablets on second shift. Review of an incident report and nursing note dated 10/17/18 at 10:43 AM read Resident #30 had an unwitnessed fall in her room. She was ambulating on her own from her wheelchair to her closet when she fell . The report and nursing note read no injury, but Resident #30 complained of left rib pain. The nursing note read a correspondence was left for the NP and Medical Director. The intervention was a therapy screen. Review of a Physician Fax Communication sheet dated 10/17/18 read Resident #30 did not fall but sat on the floor and caught herself using her walker and recliner. Resident #30 complained of left rib pain. The Nurse Practitioner (NP) wrote the word monitor with her initials. The NP documentation was undated. Review of the nursing 24 Hour Report dated 10/17/18 read Resident #30 received Tylenol 2 tablets at 6:00 PM. Review of the (MONTH) (YEAR) Physician order [REDACTED]. There were also orders for [MEDICATION NAME] (opioid used to treat pain) 1 tablet as needed for pain. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Rehabilitation screen dated 10/18/18 read Resident #30 was not interested in participating in therapy. Review of the nursing 24 Hour Report dated 10/22/18 read Resident #30 complained of rib pain and received Tylenol on third shift. Review of a nursing 24 Hour Report dated 10/23/18 read Resident #30 went out of the facility with her RP on first shift. Review of a Physician Fax Communication dated 10/23/18 read Resident #30 continues to complain of left upper rib pain and stated she was going to have her RP drop her off at the hospital for evaluation if something was not done. The NP documented per Nurse #4, no complaints with the date 10/24/18 and her initials. Review of a nursing note dated 10/29/18 at 4:56 PM read Resident #30 was complaining of soreness to her left side and left arm. Resident #30 requested an x-ray and the NP was notified. Review of an x-ray report dated 10/30/18 read as follows: Minimal displaced fractures of the third through seventh posterior lateral ribs left side suggested. The x-ray was undated but initialed by the NP. Review of Resident #30's MAR indicated [REDACTED]. Review of a NP note dated 10/30/18 at 2:11 PM, read in part as follows: Resident #30 had a fall approximately 2 weeks ago and continues to have left lower rib cage pain that worsens with coughing, deep breaths or with repositioning in bed. Resident #30 stated her pain medications do help alleviate the pain somewhat, but she is still very concerned since it is ongoing. Resident #30 stated otherwise, she is doing okay and has no complaints. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 11/13/18 at 4:49 PM, Resident #30 reported she fell in (MONTH) and immediately experienced left side pain. She stated she broke her ribs and she received no x-ray and saw no NP or MD until two weeks after the fall. She stated the pain was bad but has improved. She stated she continues to have pain with movement in bed and on transfers. She reached to guard her left side with facial grimacing. Resident #30's care plan last revised on 11/14/18 indicated she was at risk for pain related to complaints of soreness and discomfort to her left side and left arm on 10/29/18. The care plan revised 11/14/18 also read her x-ray dated 10/30/18 indicated fractures of her left 3rd through 7th ribs. Interventions included listening to her complaints of pain, medications as ordered, documenting verbal and non-verbal indicators of pain and notification of the physician if pain management was not effective. In an interview on 11/14/18 at 2:35 PM, Nurse #4 stated she was assigned Resident #30 most days and assigned to her the day she fell . She stated the NP was in the building that day and spoke to the NP about Resident #30's complaints of left side pain. She stated she did not recall if the NP assess Resident #30 on 10/17/18 but the NP told her to monitor Resident #30 and administer the prn Tylenol if she needed it for pain. Nurse #4 stated about a week later, Resident #30 was still complaining of pain to her left side so Nurse Supervisor #3 requested an x-ray order from the NP. Nurse #4 confirmed she did not report Resident #30's continued complaints of pain until she sent the NP the Physician Fax Communication form dated 10/23/18. In an interview on 11/14/18 at 2:45 PM, Nursing Assistant (NA) #10 stated Resident #30 complained of left side pain after the fall and she reported it to Nurse #4. She confirmed Resident #30 continues to complain of occasional pain with transfers. In an interview on 11/14/18 at 3:05 PM, Nurse Supervisor #3 stated she was aware that Resident #30 had a fall and was experiencing left side pain. She stated the NP wanted nursing staff to monitor her for continued or worsening of the pain. She stated she contacted the NP on 10/29/19 and requested an x-ray because Resident #30 requested it. In an interview on 11/15/18 at 8:50 AM, NA #11 stated Resident #30 has complained of pain to her left side with care. NA #11 stated when Resident #30 complained of pain, she would report it to her assigned nurse. In an interview on 11/15/18 at 9:00 AM, the NP stated it was her expectation that when she directed the nursing staff to monitor Resident #30, they would have contacted her if she got worse, but she was likely going to be sore from the fall. The NP confirmed she did not assess Resident #30 until 10/30/18. The NP stated staff reported to her that Resident #30 was going out with her RP and she was able to function at her baseline. The NP stated when the Nurse #4 faxed her on 10/23/18, she stopped in to see Resident #30, but she was out of the facility with her RP and she was not notified again until 10/29/18 by Nurse Supervisor #3. The NP stated that was when she ordered the x-ray. The NP confirmed the x-ray results of 5 fractured left side ribs. The NP confirmed she did not assess Resident #30 until 10/30/18. She stated there was no need for additional treatment and that Resident #30 was already taking [MEDICATION NAME] twice daily for pain and Tylenol as needed. The NP stated she did not routinely review the nursing notes but rather relied on the staff calling her for sending her a Physician Communication Fax form. The NP confirmed she was at the facility daily Monday through Friday and available by phone when she was not at the facility. In a second interview on 11/15/18 at 10:40 AM, Resident #30 was sitting up in her wheelchair with NA #11 present in the room. Resident #30 complained of left side pain where she broke her ribs. She was guarded of her left side with facial grimacing. NA #11 heard Resident #30's complaint of pain and stated she would notify her nurse. In an interview on 11/15/18 at 5:40 PM, Nurse #6 confirmed she was assigned Resident #30 and had cared for her since beginning her shift at 7:00 AM on 11/15/18. She stated NA #11 did not inform her that Resident #30 voiced left side pain earlier today after breakfast and that Resident #30 had not complained of pain to her, but she was due her scheduled [MEDICATION NAME] and would assess Resident #30. A telephone call was made to Resident #30's RP at both phone numbers listed with messages left to call surveyor. At time of exit, there had been no return call from RP. In an interview on 11/16/18 at 8:20 AM, Resident #30 stated she was feeling better today. She stated her RP told her to take it easy and rest. In a second interview on 11/16/18 at 10:20 AM, the NP stated it was her expectation that when NA #11 heard Resident #30 complain of left side pain on 11/15/18, she would have reported it to Resident #30's nurse. A telephone call was made to NA #11 on 11/16/18 at 11:18 AM with a message left to call the surveyor regarding not reporting Resident #30's complaints of pain on 11/15/18. At the time of exit, there had been no return phone call. In a telephone call on 11/16/18 at 11:35 AM, NA #12 confirmed she was assigned Resident #30 on 10/19/18 and 10/22/18 for second shift. She stated she recalled Resident #30 complaining of left rib pain especially when toileting and that she could not use her left arm to reach due to the pain. NA #12 stated she reported the pain the Resident #30's nurse on both days. In a telephone call on 11/16/18 a 11:42 AM, NA #13 confirmed she was assigned Resident #30 on 10/18/18 for third shift. She stated she recalled Resident #30 stated she was sore from the fall, but NA #13 could not recall if she reported anything to the nurse. In a second interview on 11/16/18 at 11:55 AM, NA #10 confirmed she was assigned Resident #30 first shift on 10/17/18, 10/18/18, 10/19/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/26/18 and 10/30/18. NA #10 stated Resident #30 did complain of left side pain on occasion, but she always reported the complaints to the nurse. In an interview on 11/16/18 at 12:30 PM, Nurse #7 confirmed he was assigned Resident #30 on 10/19/18, 10/26/18, 10/27/18 and 10/28. He stated he worked those days from 7:00 AM to 7:00 PM. Nurse #7 stated he received no notification that Resident #30 complained of pain and that she never complained of pain when he went in to give her medications. In a telephone interview on 11/16/18 at 5:00 PM, the MD stated it was his expectation that there would have been assessment completed by the NP at the time when Resident #30 first complained of pain on 10/17/18 and x-ray would have been ordered at that time to rule out injury. He further stated if Resident #30 reported continued pain and the NP did not assess her to rule out injury, it was expectation that the nursing staff would have contacted him for orders. Review of the medical record indicated new orders dated 11/16/18 for Resident #30 to have a pain assessment completed three times daily while awake for 2 weeks and to administer the prn [MEDICATION NAME] for pain as ordered. 2. Resident #163 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record indicated Resident #163 was initially admitted to an unlocked unit of the facility (700 hall) on 6/12/18 but was relocated to the locked memory care unit on the 500 hall the same day (6/12/18). A Nurse Practitioner (NP) note dated 6/13/18 indicated Resident #163 had a significant history of [MEDICAL CONDITIONS], metabolic [MEDICAL CONDITION], and dementia. He was admitted to the locked memory care unit of the facility. The NP indicated that Resident #163 was oriented to person and year, but he was not certain where he was and stated that he was quite anxious about being at the here. The Admission Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #163 ' s cognition was moderately impaired. The resident ' s mood interview revealed he felt down/depressed/hopeless 12-14 days, had trouble falling asleep/staying asleep/or sleeping too much 12-14 days, feeling tired or having little energy 12-14 days, feeling bad about himself 7-11 days, and trouble concentrating on things 12-14 days. He was assessed with [REDACTED].#163 was administered antidepressant medication on 7 of 7 days. The plan of care for Resident #163 indicated the focus area of feelings of sadness, emptiness, anxiety, uneasiness, depression characterized by; ineffective coping, low self-esteem, tearfulness, motor agitation, withdrawal from care/activities related to: admission to facility, loss of independence/change in lifestyle. This focus area was initiated on 6/22/18. The interventions included: convey acceptance of resident and provide repeated honest appraisals of resident ' s strengths, discuss feelings about placement with resident, encourage loved ones to keep in contact/visit, medication as ordered, offer activities that resident has shown interest in, and provide emotional support to resident/family as needed regarding resident ' s alcoholism and lifestyle prior to admission. These interventions were all initiated on 6/22/18. A Social Work (SW) note dated 7/2/18 completed by SW #2 indicated a mini-mental status assessment was conducted for Resident #163 and he reported thoughts he ' d be better off dead but no thoughts of harming himself. SW #2 indicated she asked Resident #163 what made him feel that way and he stated that he wanted a beer and was unable to get it and also that he had not liked being on the locked memory care unit as he was, not like the other crazy people back there. The quarterly MDS assessment dated [DATE] indicated Resident #163 ' s cognition was severely impaired. The resident mood interview revealed he had felt down/depressed/hopeless 12-14 days, trouble falling asleep/staying asleep/or sleeping too much 12-14 days, feeling tired or having little energy 12-14 days, and had thoughts that he would have been better off dead or thoughts of hurting himself in some way on 2-6 days. He had no behaviors. Resident #163 was administered antidepressant medication on 7 of 7 days. The plan of care related to feelings of sadness (initiated 6/22/18) was updated in (MONTH) (YEAR) (no specific date noted) to indicate Resident #163 reported feeling down and depressed, trouble sleeping, feeling tired without energy, and having thoughts he ' d be better off dead with no thoughts of harming himself. The interventions initiated on 6/22/18 continued with no additions or revisions. An Admissions Director note dated 7/10/18 indicated that she had spoken with Resident #163 ' s family member several times about whether to keep Resident #163 on the locked memory care unit or to move him to one of the unsecured units. This was noted to have been discussed with Resident #163 and he reported that he wanted to move off of the locked unit. Resident #163 was noted to be moved out of the locked memory care unit and onto the 100 hall (unlocked) on this date (7/10/18). An NP note dated 7/12/18 indicated Resident #163 was evaluated and stated that he was somewhat upset because he believed people were touching his things and stealing his things but otherwise he had no complaints and was pleased to be moved off of the locked unit. The NP indicated Resident #163 needed close monitoring in case he was developing paranoia since leaving the locked unit. On 7/22/18 Resident #163 had an unsupervised exit from the facility. He was moved from the 100 hall unlocked unit to the 500 hall locked memory care unit on this same date (7/22/18). A behavior note dated 7/28/18 indicated Resident #163 was more anxious since returning to the 500 hall locked unit. He was unable to hold his body still for any period of time, and he had difficulty concentrating on one task. A physician's order [REDACTED].#163. This 8/1/18 order was 30 days after Resident #163 ' s report of passive thoughts of suicide on 7/2/18. A Psychiatric Nurse Practitioner (PNP) note dated 8/23/18 indicated Resident #163 was seen for his initial psychiatric evaluation and medication management. Staff reported Resident #163 had intermittent confusion, difficulty redirecting, increased anxiety, and some combativeness with care. He was noted with agitation, elevated/expansive/irritable mood, poor concentration, restlessness, physical aggression, combativeness, and resistance to care. No suicidality was noted on this PNPs assessment. This 8/23/18 PNP initial psychiatric evaluation was 52 days after Resident #163 ' s report of passive thoughts of suicide on 7/2/18. An observation was conducted, and an interview was attempted with Resident #163 on 11/16/18 at 7:45 AM. Resident #163 was alert and oriented to self only. He was not interviewable. An interview was conducted with SW #2 on 11/16/18 at 9:33 AM. The note dated 7/2/18 that indicated Resident #163 reported passive thoughts of suicide with no plan in place was reviewed with SW #2. She recalled Resident #163 reporting this information to her. She stated that Resident #163 was alcohol seeking and he wanted to leave the facility to drink. She indicated she had not completed any type of suicide assessment for Resident #163, but she had confirmed he had no active plan in place for harming himself. SW #2 was asked what she had done after Resident #163 reported this information to her. She stated she thought she informed one of the hall nurses and the Director of Nursing (DON) of this information verbally. She reported that this was the normal process for her when an issue came up that was related to mental health/psychiatric care. She indicated she was not supposed to independently contact the physician or the NP to request a psychiatric consultation. She stated that her responsibility was to pass the information off to nursing. SW #2 indicated that Resident #163 reported no suicidal thoughts to her since 7/2/18. An interview was conducted with the DON on 11/16/18 at 9:41 AM. The note dated 7/2/18 in which Resident #163 reported passive suicidal thoughts to SW #2 was reviewed with the DON. She stated she was unable to recall with any certainty if she had been told this information by SW #2. She reported that there was a lot going on with Resident #163 in (MONTH) (YEAR). She stated that on 7/10/18 Resident #163 was moved from the locked memory care unit to an unlocked unit, on 7/22/18 Resident #163 had an unsupervised exit from the facility, and on that same date he was moved back to the locked unit. The DON confirmed SW #2 ' s statement that she was not supposed to independently contact the physician or the NP to request a psychiatric consultation and that her responsibility was to pass the information to the nursing staff. She indicated the nursing staff had a notebook at the nurse ' s station where they kept a list for the PNP of whom she was supposed to see when she came to the facility. The DON reviewed this notebook and stated that there was not any information in the notebook related to Resident #163 ' s report of [MEDICAL CONDITION] on 7/2/18. This interview with the DON continued. She was asked what her expectation was related to a timely psychiatric consultation for a resident who reported multiple depressive symptoms as well as passive suicidal thoughts. The DON indicated she expected a resident with voiced passive suicidal thoughts and multiple depressive symptoms to be referred for a psychiatric consultation and to be documented in the PNP notebook to alert her to see the resident on her next scheduled visit to the facility. She stated that the PNP came to the facility about once every 2 weeks. An interview was conducted with the NP on 11/16/18 at 10:00 AM. The note dated 7/2/18 in which Resident #163 reported passive suicidal thoughts to SW #2 was reviewed with the NP. She stated she was unable to recall with certainty if she had been informed of Resident #163 ' s self-reported suicidal thoughts, but she felt he was not sincere stating that she believed, he just said that like I would say ' oh I ' d rather be dead than have to do this today ' . She indicated that when she wrote the order dated 8/1/18 for a psychiatric consultation that it wasn ' t even related to Resident #163 ' s depressive symptoms or suicidal thoughts. She indicated this was related to Resident #163 ' s increased agitation and behaviors. A phone interview was conducted with Resident #163 ' s physician/the facility ' s Medical Director on 11/16/18 at 6:10 PM. The note dated 7/2/18 in which Resident #163 reported passive suicidal thoughts to SW #2 was reviewed with the physician. He stated that he was unable to recall if he had been informed of this information related to Resident #163. He indicated that his expectation was for any statement of suicidal thoughts to be taken seriously and for a psychiatrist to be consulted to make their own determination of the sincerity of the resident ' s expressed thoughts as this was their specialty.

Based on observations, resident, staff, Nurse Practitioner (NP) and Medical Director (MD) interviews and record review, the facility failed to evaluate and treat a resident with continued complaints of left rib pain following a fall on 10/17/18. A diagnostic x-ray dated 10/30/18 revealed fractures to the 3rd through 7th ribs on the left side. This was for 1 (Resident #30) or 1 residents reviewed for pain management. The findings included: Resident #30 was admitted on [DATE] with cumulative [DIAGNOSES REDACTED]. Resident #30's quarterly Minimum Data Set ((MDS) dated [DATE] indicated moderate cognitive impairment with a Brief Mental Status (BIMS) score of 12. She was coded with no behaviors and limited assistance with ambulation. Resident #30 was coded with no impairments to her upper or lower extremities. She was coded for scheduled and as needed (PRN) pain medications. Resident #30 was coded as reporting no pain and as having no falls since previous MDS assessment. Review of the nursing 24 Hour Report dated 10/16/18 read Resident #30 slid to the floor on first shift with the Physician and Responsible Party (RP) notified. The 24-Hour Report indicated Resident #30 received Tylenol 2 tablets on second shift. Review of an incident report and nursing note dated 10/17/18 at 10:43 AM read Resident #30 had an unwitnessed fall in her room. She was ambulating on her own from her wheelchair to her closet when she fell . The report and nursing note read no injury, but Resident #30 complained of left rib pain. The nursing note read a correspondence was left for the NP and Medical Director. The intervention was a therapy screen. Review of a Physician Fax Communication sheet dated 10/17/18 read Resident #30 did not fall but sat on the floor and caught herself using her walker and recliner. Resident #30 complained of left rib pain. The Nurse Practitioner (NP) wrote the word monitor with her initials. The NP documentation was undated. Review of the nursing 24 Hour Report dated 10/17/18 read Resident #30 received Tylenol 2 tablets at 6:00 PM. Review of the (MONTH) (YEAR) Physician order [REDACTED]. There were also orders for [MEDICATION NAME] (opioid used to treat pain) 1 tablet as needed for pain. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Review of the Rehabilitation screen dated 10/18/18 read Resident #30 was not interested in participating in therapy. Review of the nursing 24 Hour Report dated 10/22/18 read Resident #30 complained of rib pain and received Tylenol on third shift. Review of a nursing 24 Hour Report dated 10/23/18 read Resident #30 went out of the facility with her RP on first shift. Review of a Physician Fax Communication dated 10/23/18 read Resident #30 continues to complain of left upper rib pain and stated she was going to have her RP drop her off at the hospital for evaluation if something was not done. The NP documented per Nurse #4, no complaints with the date 10/24/18 and her initials. Review of a nursing note dated 10/29/18 at 4:56 PM read Resident #30 was complaining of soreness to her left side and left arm. Resident #30 requested an x-ray and the NP was notified. Review of an x-ray report dated 10/30/18 read as follows: Minimal displaced fractures of the third through seventh posterior lateral ribs left side suggested. The x-ray was undated but initialed by the NP. Review of Resident #30's MAR indicated [REDACTED]. Review of a NP note dated 10/30/18 at 2:11 PM, read in part as follows: Resident #30 had a fall approximately 2 weeks ago and continues to have left lower rib cage pain that worsens with coughing, deep breaths or with repositioning in bed. Resident #30 stated her pain medications do help alleviate the pain somewhat, but she is still very concerned since it is ongoing. Resident #30 stated otherwise, she is doing okay and has no complaints. Review of the (MONTH) (YEAR) MAR indicated [REDACTED]. In an interview on 11/13/18 at 4:49 PM, Resident #30 reported she fell in (MONTH) and immediately experienced left side pain. She stated she broke her ribs and she received no x-ray and saw no NP or MD until two weeks after the fall. She stated the pain was bad but has improved. She stated she continues to have pain with movement in bed and on transfers. She reached to guard her left side with facial grimacing. Resident #30's care plan last revised on 11/14/18 indicated she was at risk for pain related to complaints of soreness and discomfort to her left side and left arm on 10/29/18. The care plan revised 11/14/18 also read her x-ray dated 10/30/18 indicated fractures of her left 3rd through 7th ribs. Interventions included listening to her complaints of pain, medications as ordered, documenting verbal and non-verbal indicators of pain and notification of the physician if pain management was not effective. In an interview on 11/14/18 at 2:35 PM, Nurse #4 stated she was assigned Resident #30 most days and assigned to her the day she fell . She stated the NP was in the building that day and spoke to the NP about Resident #30's complaints of left side pain. She stated the NP told her to monitor Resident #30 and administer the prn Tylenol if she needed it for pain. Nurse #4 stated about a week later, Resident #30 was still complaining of pain to her left side so Nurse Supervisor #3 requested an x-ray order from the NP. Nurse #4 confirmed she did not report Resident #30's continued complaints of pain until she sent the NP the Physician Fax Communication form dated 10/23/18. In an interview on 11/14/18 at 2:45 PM, Nursing Assistant (NA) #10 stated Resident #30 complained of left side pain after the fall and she reported it to Nurse #4. She confirmed Resident #30 continues to complain of occasional pain with transfers. In an interview on 11/14/18 at 3:05 PM, Nurse Supervisor #3 stated she was aware that Resident #30 had a fall and was experiencing left side pain. She stated the NP wanted nursing staff to monitor her for continued or worsening of the pain. She stated the NP wanted nursing staff to monitor her for continued or worsening of the pain but confirmed there was little documentation to suggest the nurses were monitoring Resident #30's continued complaints of pain to her left side. She stated she contacted the NP on 10/29/18 and requested an x-ray because Resident #30 requested it. In an interview on 11/15/18 at 8:50 AM, NA #11 stated Resident #30 has complained of pain to her left side with care. NA #11 stated when Resident #30 complained of pain, she would report it to her assigned nurse. In an interview on 11/15/18 at 9:00 AM, the NP stated it was her expectation that when she directed the nursing staff to monitor Resident #30, they would have contacted her if she got worse, but she was likely going to be sore from the fall. The NP stated staff reported to her that Resident #30 was going out with her RP and she was able to function at her baseline. The NP stated when the Nurse #4 faxed her on 10/23/18, she stopped in to see Resident #30, but she was out of the facility with her RP and she was not notified again until 10/29/18 by Nurse Supervisor #3. The NP stated that was when she ordered the x-ray. The NP confirmed the x-ray results of 5 fractured left side ribs. She stated there was no need for additional treatment and that Resident #30 was already taking [MEDICATION NAME] twice daily for pain and Tylenol as needed. The NP stated she did not routinely review the nursing notes but rather relied on the staff calling her for sending her a Physician Communication Fax form. The NP confirmed she was at the facility daily Monday through Friday and available by phone when she was not at the facility. In a second interview on 11/15/18 at 10:40 AM, Resident #30 was sitting up in her wheelchair with NA #11 present in the room. Resident #30 complained of left side pain where she broke her ribs. She was guarded of her left side with facial grimacing. NA #11 heard Resident #30's complaint of pain and stated she would notify her nurse. In an interview on 11/15/18 at 5:40 PM, Nurse #6 confirmed she was assigned Resident #30 and had cared for her since beginning her shift at 7:00 AM on 11/15/18. She stated NA #11 did not inform her that Resident #30 voiced left side pain earlier today after breakfast and that Resident #30 had not complained of pain to her, but she was due her scheduled [MEDICATION NAME] and would assess Resident #30. A telephone call was made to Resident #30's RP at both phone numbers listed with messages left to call surveyor. At time of exit, there had been no return call from RP. In an interview on 11/16/18 at 8:20 AM, Resident #30 stated she was feeling better today. She stated her RP told her to take it easy and rest. In a second interview on 11/16/18 at 10:20 AM, the NP stated it was her expectation that when NA #11 heard Resident #30 complain of left side pain on 11/15/18, she would have reported it to Resident #30's nurse. A telephone call was made to NA #11 on 11/16/18 at 11:18 AM with a message left to call the surveyor regarding not reporting Resident #30's complaints of pain on 11/15/18. At the time of exit, there had been no return phone call. In a telephone call on 11/16/18 at 11:35 AM, NA #12 confirmed she was assigned Resident #30 on 10/19/18 and 10/22/18 for second shift. She stated she recalled Resident #30 complaining of left rib pain especially when toileting and that she could not use her left arm to reach due to the pain. NA #12 stated she reported the pain the Resident #30's nurse on both days. In a telephone call on 11/16/18 a 11:42 AM, NA #13 confirmed she was assigned Resident #30 on 10/18/18 for third shift. She stated she recalled Resident #30 stated she was sore from the fall, but NA #13 could not recall if she reported anything to the nurse. In a second interview on 11/16/18 at 11:55 AM, NA #10 confirmed she was assigned Resident #30 first shift on 10/17/18, 10/18/18, 10/19/18, 10/20/18, 10/21/18, 10/23/18, 10/24/18, 10/26/18 and 10/30/18. NA #10 stated Resident #30 did complain of left side pain on occasion, but she always reported the complaints to the nurse. In an interview on 11/16/18 at 12:30 PM, Nurse #7 confirmed he was assigned Resident #30 on 10/19/18, 10/26/18, 10/27/18 and 10/28. He stated he worked those days from 7:00 AM to 7:00 PM. Nurse #7 stated he received no notification that Resident #30 complained of pain and that she never complained of pain when he went in to give her medications. In a telephone interview on 11/16/18 at 5:00 PM, the MD stated it was his expectation that there would have been assessment completed by the NP at the time when Resident #30 first complained of pain on 10/17/18 and x-ray would have been ordered at that time to rule out injury. He further stated it was his expectation there were timely interventions for pain management. Review of the medical record indicated new orders dated 11/16/18 for Resident #30 to have a pain assessment completed three times daily while awake for 2 weeks and to administer the prn [MEDICATION NAME] for pain as ordered.

Based on record review, observation and resident and staff interview, the facility failed to follow their facility procedure in dealing with physically/verbally aggressive residents for 1 (Resident #1) of 3 sampled residents causing skin tears and bruises to a resident. Findings included: Resident #1 was admitted to the facility on [DATE] and was readmitted on [DATE] with multiple [DIAGNOSES REDACTED].#1 had severe cognitive impairment and with verbal and other behavioral symptoms. The nurse aide's care guide for Resident #1 dated 6/22/15 was reviewed. The non - pharmacological behavioral interventions listed were explain each activity/care procedure prior to beginning and re-approach resident after refusal. The physician's orders [REDACTED].#1 was started on [MEDICATION NAME] (antipsychotic drug) 0.25 milligrams (mgs) daily for behavior on 6/22/15. On 7/1/15, the [MEDICATION NAME] was discontinued and [MEDICATION NAME] (drug for convulsions and mood stabilizing drug) 250 mgs at night for behavior was started. The nurse's notes for Resident #1 were reviewed. The notes dated 6/27/15 at 3:04 AM indicated that Resident #1 attempted to hit the staff and refused to go back to bed. On 6/30/15 at 4:51 PM, the notes indicated that Resident #1 continued to be agitated, calling roommate by names and roommate family members and tried to smack the nurse. On 7/2/15 at 10:36 PM, the notes indicated that Resident #1 played in feces and was resisting to care. On 7/14/15 at 9:44 AM, the notes revealed that on 7/13/15 at 11:00 PM, the 3-11 shift nurse aides reported to the 11-7 shift nurse that while they were giving care to Resident #1 and changing her soiled clothing, the resident was resistive to care, combative and verbally abusive. The nurse aides reported that while removing soiled clothing, they were holding onto the resident's arms and she was fighting and flailing arms and sustained 2 skin tears, one on the left arm and one on right arm. The nurse observed some light bruising on hands and forearm. The skin tear on the right forearm was 1 centimeter (cm) and on the left forearm was 2.5 cm in size. Treatment was provided per protocol. On 7/14/15 at 5:45 AM, the nurse observed the resident lying in bed alert and awake. The nurse observed bruising purplish in color on back of left hand and left forearm. The resident was unable to give information regarding the incident. The flow sheets of non - ulcer skin condition assessments dated 7/14/15 were reviewed. The assessment indicated that on left lower arm with very small open area with small amount of bleeding and large area purple/maroon colored bruising to lower arm and hand. The assessment also indicated that on the right lower arm a small open area with scant bloody exudate, and purple/maroon bruising to entire lower arm and hand. The incident report dated 7/14/15 read on 7/13/15 at 11:00 PM, two certified nurse aides (CNAs) giving care to resident. Reported to 11-7 shift nurse that while giving patient care and changing resident's clothes, resident resistive to care and combative. CNA reported that resident was kicking and arguing with them. CNA reported that they were holding onto resident's arms in order to change soiled clothing and resident sustained [REDACTED]. At this time, nurse noted no bruising. On 7/14/15 at 5:45 AM, Nurse observed resident lying in bed, alert and awake. Observed large bruising on right hand and forearm up to antecubital area and left back of hand and forearm up to the elbow. The writer was Nurse #1. On 8/4/15 at 4:20 PM, Resident #1 was observed sitting at the side of bed having snacks. Resident #1 was confused as she was answering to questions inappropriately. Her roommate (Resident #2) was in the room at this time. On 8/4/15 at 4:22 PM, Resident #2 was interviewed. Resident #2's cognition was intact. She stated that more than 2 weeks ago, a nurse aide (name of NA #2) and a new girl (name of NA #3) came in the room around 11 PM to care for (name of Resident #1). The curtain was pulled between the bed and she can't see the resident and the aides. She heard NA #2 yelling at the resident be still. The resident was struggling and was yelling quit, quit. After the incident the resident was noted to have bruises and skin tears on her arms/hands. Resident #2 indicated that she reported the incident to the administrator and she was interviewed. Resident #2 added that both aides were no longer at the facility. She indicated that the resident was hard of hearing and can be combative at times during care. On 8/5/15 at 9:05 AM, Nurse #1 was interviewed. She stated that she came in before 11 PM on 7/13/15. She started counting narcotics with the 3-11 shift nurse when NA #2 informed her to check Resident #1 as she was fighting during care. NA #2 also informed her that the resident had a skin tear on her arm. Nurse #1 stated that after counting, she went to check on Resident #1. She noticed skin tears and bruises on her right and left arm. She indicated that she didn't bother the resident at that time. Early morning, an aide assigned to Resident #1 informed her to look at the resident. She went to check on Resident #1 and it scared her, the resident had big bruises on her left and right arm, from the middle of her hand to the elbow. The dressing on her skin tears had bled through, so she had to change the dressings. Nurse #1 indicated that NA #2 had been working at the facility for a long time and NA #3 was still on orientation. She indicated that when a resident was combative during care I would quit and would leave the resident alone. On 8/5/15 at 11:23 AM, tried to call NA #2 for interview but was not available. On 8/5/15 at 11:24 AM, NA #3 was interviewed. She stated that she was new to the facility. She indicated that around 10:45 PM on 7/13/15, she helped NA #2 cleaned up Resident #1. Resident #1 was soiled with urine and feces. She stated that Resident #1 was cooperative when they started the care. She was sitting in the chair while they changed her bed. Then, they cleaned the resident, put her shirt on and put her back to bed. They were about to put the brief on when the resident started to be combative. The resident started fighting with NA #2 telling her I don't like you. She continued putting the brief on her while NA #2 holding on both arms. NA #3 indicated that normally when the resident was combative during care, she would stop and walk away and come back later but she didn't do it because she didn't want the resident exposed with no brief and pajama on. She indicated that she was suspended and then terminated for not following the facility's procedure in dealing with aggressive resident. NA #3 indicated that she didn't notice the bruises or the skin tears on the resident's arms before the care. The facility's abuse investigation was reviewed. The resident was assessed and treatment was provided to the skin tears. The 24 hour and 5 day reports were sent to the state. NA #2 and NA #3 were suspended immediately and were terminated. All staff were in -serviced on the facility's procedure in dealing with combative residents. The procedure included if giving care to combative resident, make sure resident is safe, walk away. Tell the nurse. Nurse to document that resident was combative during care, resident was left safely and the nurse aide left and will re-approach to provide care at a later time. Nurse needs to call family and let them know about the combative resident and care will be provided a later time. All alert and oriented residents were interviewed if they were abused or heard/seen another resident abused. One resident (Resident #2) had answered yes have heard/seen another resident being verbally/physically abused at the facility in the last 2 weeks. The statement from Resident #2 dated 7/14/15 written by a staff member read (name of Resident #2) feels her roommate was abused on Saturday night (July 11th) around 11 PM. She states staff was in to get (name of Resident #1) ready for bed and she was not ready. There were 2 staff members (NA #2 and the second girl she didn't know her name because she was new (NA #3)). She stated that NA #2 was yelling at the resident. She was not able to recall everything but stated that NA #2 was yelling for the resident to be still and roll over. She hurt her arms, they were black and blue. There is a skin tear on her left arm and right. I wish I could remember what was said. The written statement of NA # 2 was reviewed. The statement read on last night at (name of Resident #1) room, I (NA#2) went into her room to change her. She already had dark bruises on her arms when I got in there. The bed was all wet and with feces. We got her up and put her in the chair. While I was in there she was scratching at me and kicking at me and she told me she wasn't going to do anything unless I tell her who sent me in there. I was on the side of the bed to the wall, the skin tear on her left arm did occur while I was in there but the bruises to her arms was already there. She was still fighting at me. She said I'm going to slap your face. So I backed up so she would not grab my glasses. I was trying to hold her hands but that didn't do much good because she was still fighting and saying I am a human not a horse. And after we change her clothes and got her pulled up in the bed she was still fighting but the bruises on her arms was from her elbow to her wrist was already there but the skin tear on the left arm happened while I was in there. The written statement of NA #3 dated 7/14/15 was reviewed. The statement read around 10:45 PM, I (NA #3) was asked by (name of NA #2) to help change Resident #1. When we walked into the room, you could visibly see the sheets were soiled. NA #2 got out the resident's night clothes and new brief and wipes. Then she told me to wait until she got back with new sheets. The resident was up sitting on the side of the bed at this point. She was lying down when we first walked in. We explained that we need to get her some clean clothes on. The resident was really confused and we talked to her a few minutes. We helped the resident stand up and sit in her chair for a few minutes while we changed the bed. She was okay with sitting in the chair but still did not want to get changed. She was soaked and had a large bowel movement so we had to get her changed. We got her back to the bed and changed her shirt so she would have clean clothes that was not soiled. She didn't want to change clothes but because they were soiled we needed to get her in some clean clothes. I took her old shirt off by pulling the shirt over her head and off her arms. This was when she started hitting. When we put the new shirt on, I guided one arm through and NA #2 guided the other one through. When we got the shirt on we explained that we were going to lay her down and roll her to change her. When we opened the brief you could see the poop in front of the brief. NA #2 rolled the resident to her first and I wiped the resident, cleaned and replaced the brief with a clean one. Then we rolled the resident towards me so NA #2 could get the other side of the brief out from under the resident. When the resident went to hit NA #2 I put my arm in the way so she would hit me instead. The resident was holding my hands until she slipped her hands off of mine and swung at NA #2. Then NA #2 was holding the resident while I hooked the brief and pulled her pants. While I was hooking the brief, the resident tried to hit NA #2 again. NA #2 said ouch. And after we were done, I was told the resident had a skin tear on her left arm. On 8/5/15 at 1:48 PM, administrative staff #1 was interviewed. She indicated that the abuse allegation was unsubstantiated because there was no intent to harm the resident, both aides just wanted to clean the resident up and ready for bed. She indicated that both NAs (NA #2 and NA #3) were trained on abuse and in dealing with aggressive/combative residents prior to the incident. She added that her expectations were for the aides to leave the resident alone when she started to be combative and inform the nurse and the oncoming shift of the resident's behavior. On 8/5/15 at 1:53 PM, administrative staff #2 was interviewed. The staff indicated that the abuse allegation was unsubstantiated because we felt like it was not intentional. The staff stated that all staff were in-serviced on how to deal with aggressive residents on a yearly basis. The staff added that both NAs were terminated for not following the procedure in dealing with an aggressive resident. His expectation was for the aides to secure the resident, make sure she was safe, walk away, re-approach the resident later or try with another staff member. The administrative staff indicated that there was no monitoring done except for the monitoring of staff during showers which was done on a quarterly basis. On 8/5/15 at 2:46 PM, Resident #1 was observed during the incontinent care. NA #4 was observed to explain to the resident what she was about to do. The resident was hard of hearing and NA #4 has to explain to the resident repeatedly until she was able to hear and understand what the aide was saying. The resident was cooperative during the procedure. NA #4 stated that she had no problem with the resident as long as you let her know what you are going to do. NA #4 indicated that when a resident started to be combative during care, she would leave the resident alone and come back later.