Every finding on record at Beverly Park Place Health and Rehab

Based on facility policy review, medical record review, observations, and interview, the facility failed to maintain infection control practices for 1 resident (Resident #204) of 4 residents reviewed for urinary catheters. The findings include: Review of the facility policy titled, Catheter Care, dated 8/2022, revealed .The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections .Be sure the catheter tubing and drainage bag are kept off the floor .Review of the medical record revealed Resident #204 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Anxiety Disorder, and Neuromuscular Dysfunction of Bladder. Review of the admission Minimum Data Set (MDS) assessment (scheduled) dated 5/15/2026 revealed, .in progress .During an observation on 5/11/2026 at 3:53 PM, in Resident #204's room revealed the resident was resting in the bed with eyes closed. Further observation revealed the bed was in the lowest position with the urinary drainage bag clipped to the side of the bed and the bottom of the urinary drainage bag resting on the floor.During an observation on 5/12/2026 at 2:48 PM, in Resident #204's room revealed the resident resting in the bed with eyes closed. Further observation revealed the bed was in the lowest position with the urinary drainage bag clipped to the side of the bed and the bottom of the urinary drainage bag resting on the floor.During an observation on 5/13/2026 at 10:01 AM, in Resident #204's room revealed the resident resting in the bed with eyes closed. Further observation revealed the bed was in the lowest position with the urinary drainage bag clipped to the side of the bed and the bottom of the urinary drainage bag resting on the floor.During an interview on 5/13/2026 at 10:05 AM, in Resident #204's room the Assistant Director of Nursing (ADON) observed and confirmed the bottom of the urinary catheter drainage bag was resting on the floor. The ADON confirmed the urinary drainage bag should not be touching the floor. The ADON stated her expectation was for the staff to secure the drainage bag to the bed, off the floor, or to have a barrier in place to maintain proper infection control practices.

Based on facility policy review, facility investigation documentation review, observation, and interview the facility failed to protect 1 Resident (Resident #13) from physical abuse of 7 residents reviewed for abuse. The findings include: Review of the facility's policy titled, Abuse, Neglect, Exploitation, and Misappropriation Prevention Program, revised 9/2021, revealed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation, and misappropriation of resident property .Abuse includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraints not required to treat the residents' medical symptoms .Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation . Medical record review revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Dementia with Mood Disturbance, and Cognitive Communication Disorder. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 had severe cognitive impairment. No behaviors noted. Review of a comprehensive care plan for Resident #13 dated 9/25/2023, revealed .has outbursts and name-calling directed at staff . Medical record review revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including End Stage Renal Disease, Dementia without Mood Disturbance, and Need for Assistance with Personal Care. Review of an annual MDS assessment dated [DATE], revealed Resident #14 had mild cognitive impairment. No behaviors noted. Review of a comprehensive care plan for Resident 14 dated 1/7/2024, revealed .History of Altercation with another resident, physical contact made, Date Initiated: 12/23/2023 .has the potential to be physically/verbally aggressive with others r/t [related to] cognitive impairments/Poor impulse control . Review of a Sheriff's Office report dated 12/23/2023 at 5:36 PM revealed .Prior to my arrival on scene dispatch advised .suspect [Resident #14] had been transported to [local hospital] for a mental status change and the victim [Resident #13] was still on scene .I spoke with another patient who was near by and she stated [Resident #13 and Resident #14] were in a verbal argument over sharing food .The witness stated the argument continued and [Resident #14] did in fact walk over to [Resident #13] and strike her once in the face causing a loud noise .[Resident #13] did not have any visible injuries .she refused medical treatment . Review of a Telephone Physicians' Order for Resident #14 dated 12/23/2023, revealed .1 on 1 sitter now .send to [local hospital] ER [emergency room ] mental status changes . Review of a Nursing Progress Note for Resident #14 dated 12/23/2023, revealed .Allegation of physical aggression initiated, with residents separated, 1:1 sitter placed until resident sent to ER . Review of a Nursing Progress Note for Resident #13 dated 12/23/2023 at 7:24 PM, revealed .Allegation Physical aggression received. Immediate separation of residents, physical exam, notification of family and MD [Medical Doctor], Psych [Psychiatric] NP [Nurse Practitioner], LCSW [Licensed Clinical Social Worker] to increase visits . Review of a Nursing Progress Note for Resident #13 dated 12/23/2023 at 11:58 PM, revealed .Head to toe skin assessment .Denies pain. No redness or bruising to entire body. States she feel safe, and isn't afraid . Review of a Nursing Progress Note for Resident #14 dated 12/24/2023 at 2:56 AM, revealed .Room change .for better placement [upon return] . Review of a Nursing Progress Note for Resident #14 dated 12/24/2023 at 7:25 AM, revealed .Alert Note .Resident returned from the ER, no new orders noted. 1:1 sitter in place . Review of a Psychotherapy Progress Note for Resident #14 dated 12/27/2023, revealed .Pt presented with a stable mood .He discussed how he lashed out at another resident, over the weekend, stating she was cussing me, and I asked her to stop but she didn't and then I tapped her on her shoulder [shoulder], if I hurt her, please tell her I'm sorry. We discussed how it is inappropriate to touch anyone without their consent, especially hitting them for any reason, and how he can better handle his reactions in the future . Review of a Physicians' Progress Note for Resident #14 dated 12/27/2024, revealed .had altercation with another resident and struck her. He doesn't remember striking her but does recall [the] verbal assault . Review of a Nursing Progress Note for Resident #13 dated 1/1/2024, revealed .Alleged incident .Resident does not recall having an altercation with another resident. She reports that she feels safe .She does not appear to be in any acute distress. Residents were separated immediately. Continue current plan of care . Review of the facility's investigation titled, Summary of Investigation, dated 1/3/2024, revealed .Brief summary of incident .Both residents in dining room. [Resident #13] was asking [Resident #14] for food. He [Resident #14] stated he did not have food and she continued to ask, he told her to shut up and asked if she wanted him to come over and smack her in the face. [Resident #14] went over to her and used the back of his hand and hit her in the face and returned to his table . Further review revealed .residents immediately separated .1 on 1 sitter placed with [Resident #14] .actions taken .[Resident #14 was sent to [the] ER for [a] mental status change .returned to [a] private room on a different unit with a 1 on 1 sitter .psych NP and medical to eval [evaluate] . During an interview on 7/15/2024 at 11:50 AM, Resident #13 was asked by the surveyor if anyone at the facility had ever done anything mean or hurtful to her, Resident #13 denied abuse and stated, .No .I'm doing ok .I'm fine . During an interview on 7/15/2024 at 11:55 AM, Resident #14 was asked by the surveyor about the allegation of physical abuse that allegedly occurred between himself and Resident #13 on 12/23/2023; Resident #14 stated .I don't think so .no .I don't believe I did [physically abuse Resident #13] . Resident #14's multiple accounts of the incident were inconsistent with investigation and witness statements of Resident #32 and Resident #33. Medical record review revealed Resident #32 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Subsequent Encounter for Closed Fracture with Routine Healing, Hypertensive Chronic Kidney Disease, and Need for Assistance with Personal Care. Review of a quarterly MDS assessment dated [DATE], revealed Resident #32 was cognitively intact. Medical record review revealed Resident #33 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Chronic Obstructive Pulmonary Disease, and Essential Tremor. Review of a quarterly MDS assessment dated [DATE], revealed Resident #33 was cognitively intact. During an interview on 7/15/2024 at 2:50 PM, Resident #32 stated she was present during the altercation on 12/23/2023 and heard both residents (Resident #13 and Resident #14) arguing. Further interview revealed Resident #32 had seen Resident #14 go over to Resident 13's table and hit her in the face with the back of his right hand. During an interview on 7/15/2024 at 3:05 PM, Resident #33 stated she was in the dining room when Resident #14 had struck Resident 13 in the face after a verbal argument. Resident #33 stated .she did not recall if [Resident #13] provoked him [Resident #14] or not, but he hit her . During a telephone interview on 7/15/2024 at 3:10 PM, Licensed Practical Nurse (LPN) A stated she was the weekend supervisor when the allegation of physical abuse occurred on 12/23/2023. LPN A stated she responded to the incident promptly and the residents had already been separated by the staff ( LPN A was unable to provide additional names). LPN A stated she interviewed Resident #14 and was told by him Resident #13 had .ran her mouth to where it was annoying .stated he [Resident #14] said to her [Resident #13] .Do you want to see what this [racial expletive] can do .Resident #13 dared him .and he [Resident #14] went over and hit [Resident #13] . LPN A stated there were 2 other residents' present [Resident #32 and Resident #33] who were eyewitnesses the incident. LPN A stated she had conducted interviews with the 2 other residents [Resident #32 and Resident #33] their recollection of the event was collaborated with the altercation. LPN A stated she assessed both residents [Resident #13 and Resident #14] and no injuries were observed to either resident. During an interview on 7/16/2024 at 9:29 AM, the Director of Nursing (DON) confirmed an act of physical abuse occurred on 12/23/2023. A verbal exchange resulted in physical contact when Resident #14 left his table, propelled over to Resident #13, and struck Resident #13 in the face with the back of his hand. The DON stated .he hit her .

Based on facility policy review, medical record review, and interview the facility failed to report the suspicion of a crime for 1 resident (Resident #1) of 1 resident reviewed to the State Survey Agency, local law enforcement, adult protective services, and other officials (where state law provides for jurisdiction in long-term care facilities) in accordance with State law. The findings included: Review of the facility policy titled, Investigating Incidents of Assault, Rape or Other Violent Crime, dated 4/2021, showed .If a resident .is thought to be the victim of .crime the victim is stabilized and the scene of the crime is preserved for evidence. The following actions must be taken .Call .911 .Do not disturb the area where the incident is thought to have occurred .Do not .clean the area so as not to disturb evidence .Notify appropriate agencies .to include DOH, APS, Ombudsman . Review of the facility policy titled, Opioid Overdose Response (Naloxone), dated 10/2023, showed .Follow state department of health requirements for opioid overdose reporting . Resident #1 was admitted to the facility on [DATE] with diagnoses including Anoxic Brain Damage, Acute Kidney Failure, Psychoactive Substance Abuse, Human Immunodeficiency Virus, and Cerebral Infarction. Review of the comprehensive care plan dated 11/15/2023, showed .hx [history] of drug abuse and could be prone to drug seeking behaviors . Review of a Nursing Note dated 12/7/2023, showed .post visitor/mother this evening this nurse and staff cont [continued] frequent room checks per admin req [request] as precaution . Review of a Psychotherapy Progress Note dated 12/8/2023, showed .goal for the weekend will be to not contact anyone who can bring her drugs. [Resident #1] admitted to having thoughts of calling someone but knows what will happen if she does . During an interview on 12/18/2023 at 2:26 PM, Nursing Supervisor #1 stated she recalled an incident where a white powdery substance was confiscated from Resident #1's room (unsure of the date), during a supervised visit with the resident's mother. Nursing Supervisor #1 stated she was informed of the incident during verbal shift report from Licensed Practical Nurse (LPN) #1. During an interview on 12/19/2023 at 9:28 AM, the Psychiatric Nurse Practitioner (Psych NP) stated she was very familiar with Resident #1. She was made aware of a white powdery substance discovered in resident's room by the Director of Nursing (DON). She was informed the mother had dropped the white substance during a supervised visitation and that is how it was discovered. During interviews on 12/19/2023 at 2:40 PM, with the Administrator (ADM) and DON stated they recalled the event that occurred on 12/7/2023 with Resident #1. An unknown white powdery substance was confiscated by LPN #1, during a supervised visit between Resident #1 and her mother. The DON stated the mother of Resident #1 was questioned and denied knowing about the unknown substances retrieved from the cell phone wallet. The DON stated she put the paper with the unknown substance in a denture cup, covered with a lid, and took it to the ADM's office. The ADM stated the denture cup containing the unknown substance sat on her desk from 12/7/2023 until 12/11/2023, when she threw it in the trash. She stated, I didn't know what else to do with it. The ADM and DON both confirmed they did not report the incident to the state agency or local law enforcement, they didn't feel it met the criteria of a reportable event. The unknown substance was confiscated prior to reaching the resident.

Based on facility policy review, review of the facility's 2567 dated 9/18/2019 and 9/22/2021, medical record review, observations, and interviews, the facility's Quality Assurance Performance Improvement (QAPI) program failed to have an effective system in place to sustain compliance with ensuring residents were free from abuse and reporting allegations of abuse for 1 resident (#58) of 24 residents reviewed for abuse. The QAPI committee's failure to effectively monitor previously identified deficient practices and corrective actions to ensure residents were free of abuse and reporting allegations of abuse had the potential to affect all 162 residents in the facility. The findings include: Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020 revealed .The objectives of the QAPI Program are to .Provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators .Implementation .The QAPI Committee oversees implementation of our QAPI Plan .The QAPI plan describes the process for identifying and correcting quality deficiencies .Key components .Tracking and measuring performance .Identifying and prioritizing quality deficiencies .Developing and implementing corrective action/performance improvement activities .Monitoring or evaluating the effectiveness of corrective action/performance improvement activities and revising as needed . Review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Design and Scope, dated 2/2020 revealed .The facility QAPI Program is ongoing, comprehensive and addresses all care and services provided by the facility .The QAPI program is designed to address all systems and practices in this facility that affect residents, including clinical care, quality of care, quality of life, resident choice and safety . Review of the facility's 2567 dated 9/18/2019 revealed during a recertification survey conducted on 9/22/2021, the facility was cited F600 Free from Abuse and Neglect. Review of the facility's 2567 dated 9/22/2021 revealed during a complaint survey conducted on 9/22/2021, the facility was again cited at F600 Free from Abuse and Neglect and also F609 Reporting of Alleged Violations. Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review revealed Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an interview with Resident #58 on 10/25/2022 at 9:54 AM, the resident stated, .my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out .He says [expletive] you and stuff like that He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. During an interview on 10/26/2022 at 7:25 PM, with the Administrator, Director of Nursing, and the Director of Clinical Services, the QAPI program was discussed including review of findings from the recertification survey dated 9/18/2019, and complaint survey dated 9/22/2021 related to abuse. The Administrator discussed the QAPI interventions put in place by the facility to address F-600 and F-609 from the complaint survey on 9/22/2021. The Administrator stated a Performance Improvement Plan (PIP) had been developed for the monitoring of abuse. The PIP developed included reviewing all new admission referrals for a history of violence and aggressive behaviors. The Administrator revealed the facility had tracked and trended abuse in the facility and no concerns were noted. The Administrator stated, We try to find compatible roommates. The Administrator stated, .We have allegations (of abuse) we can't prevent . The Administrator confirmed the facility's QAPI program was not effective in preventing the allegation of abuse between resident #58 and #67. The Administrator revealed the facility developed a PIP related to the Facility's deficiency related to failure to report an allegation of abuse. The Administrator stated all allegations of abuse are to be reported by staff. The Administrator confirmed the QAPI program was unable to sustain compliance with failure to prevent abuse and was unable to sustain compliance with notifying the appropriate authorities of the allegation of abuse for Resident #58.

Based on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #58) from abuse of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Residents have the right to be free from abuse .Protect residents from abuse including other residents . Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan dated 9/6/2022, revealed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of an admission MDS dated [DATE], showed Resident #67 had a BIMS score of 3 indicating the resident had severe cognitive impairment. Review of Resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/2022 at 9:54 AM, he stated, my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that . Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:17 PM, Licensed Practical Nurse (LPN) #3 stated she had heard Resident #67 yell at Resident #58 to tell staff something for him, and the staff redirected him. She stated Resident #67 cusses and calls the facility staff names but she had not heard him call Resident #58 names. LPN #3 stated Resident #58 had not reported incidents of verbal abuse to her. During an interview on 10/25/2022 at 2:27 PM, Certified Nursing Assistant (CNA) #2 stated Resident #67 .is sweet sometimes and other times lashing out and aggressive. I have never heard [Resident #67] lash out at his roommate, but he does lash out at the staff . During an interview on 10/25/2022 at 2:36 PM, CNA #3 stated, Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an[OBSCENITY] .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator stated she had not been notified of any incidents between Resident #58 and Resident #67. I was not aware of any behaviors, cursing or abuse. If the staff member had made me aware and I thought there was a problem, we would have separated them. I would have investigated immediately. The CNA should have immediately reported it and made us aware . The Administrator confirmed she was the Abuse Coordinator for the facility.

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of abuse after a resident-to-resident altercation for 2 residents (Resident #58 and Resident #67) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Abuse includes but is not limited .verbal, mental, sexual or physical abuse .Any employee .who becomes aware of abuse .shall immediately report it per 483.12 Freedom from Abuse, Neglect, and Exploitation .report any allegations within timeframes required by federal requirements . Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of an admission MDS dated [DATE] showed Resident #67 had a BIMS score 3 indicating the resident had severe cognitive impairment. Review of a care plan dated 9/6/2022, showed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/22 at 9:54 AM, he stated,my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that . Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:36 PM, Certified Nursing Assistant [CNA] #3 stated, Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an[OBSCENITY] .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator stated she had not been notified of any incidents between Resident #58 and Resident #67. I was not aware of any behaviors, cursing or abuse .The CNA should have immediately reported it and made us aware. The CNA should have reported it to her supervisor and then it would have been reported to me . The Administrator confirmed she was the Abuse Coordinator for the facility. The Administrator confirmed the allegation should have been reported to the State Survey Agency within 2 hours of the occurrence and was not.

Based on facility policy review, medical record review, and interview, the facility failed to investigate an allegation of abuse for 1 resident (Resident #58) of 24 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Investigate .any allegations within timeframes required by federal requirements . Resident #58 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #58 had a Brief Interview for Mental Status (BIMS) score of 10 indicating the resident had moderate cognitive impairment. Review of a care plan revised 9/30/2022, revealed Resident #58 .may be depressed or anxious .Encourage talking about problems initiated .When restless or anxious, provide calm, quiet atmosphere, [Resident #58] has a history of experiencing Suicidal Ideation (SI) .[Resident #58] will be administered medications as directed .[Resident #58] will be referred to by Psych NP [Psychiatric Nurse Practitioner], provide a calm, quiet atmosphere when restless or anxious. Document and report any changes in mood status . Resident #67 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Care Plan dated 9/6/2022 revealed Resident #67 .can be uncooperative. May on occasion shout or physically resist care. May use foul or abusive language during care or tx [treatment] . Review of an admission MDS dated [DATE], showed Resident #67 had a BIMS score 3 indicating the resident had severe cognitive impairment. Review of Resident #67's Psychiatric Progress Note dated 10/6/2022 showed .staff is interviewed, and they report resident has increased resistance to care. They [staff] report that during these episodes he is hard to redirect . Review of progress notes showed Resident #58 and #67 shared a room and there were no documented issues between the residents. During an interview with Resident #58 on 10/25/2022 at 9:54 AM, he stated, .my roommate [Resident #67] is verbally abusive towards me .What my roommate says don't make sense then he gets mad at me .He curses me and calls me names .I try to block what he says out. He says [expletive] you and stuff like that Resident #58 stated he had not reported the verbal abuse to staff. He stated staff were aware because they had overheard Resident #67 cursing at him. Resident #58 stated that staff tell Resident #67 to stop cursing him. Resident #58 stated he did not remember the names of the staff who overheard the cursing. During an interview on 10/25/2022 at 2:17 PM, Licensed Practical Nurse (LPN) #3 stated she had heard Resident #67 yell at Resident #58 to tell staff something for him, and the staff redirected him. She stated Resident #67 cusses and calls the facility staff names but she had not heard him call Resident #58 names. LPN #3 stated Resident #58 had not reported incidents of verbal abuse to her. During an interview on 10/25/2022 at 2:36 PM, CNA #3 stated Resident #67 .has behaviors. I think he [Resident #67] doesn't understand, and he gets loud. Sometimes he [Resident #67] says inappropriate things, cusses and I heard him [Resident #67] call [Resident #58] an[OBSCENITY] .He curses at his roommate and then apologizes. I told [Resident #67] he could not say things like that . The CNA thought she reported the incident to a nurse but was unable to remember the nurse's name. The CNA was unable to recall the date the incident occurred but thought .it was a couple of weeks ago . During an interview on 10/26/2022 at 9:39 AM, the Administrator confirmed the allegation of verbal abuse had not been investigated. I was not aware of any behaviors, cursing or abuse. If the staff member had made me aware and I thought there was a problem, we would have separated them. I would have investigated immediately . The Administrator confirmed the allegation of abuse should have been investigated.

Based on facility policy review, medical record review, and interview, the facility failed to revise the care plan after the code status (Resident's wishes for treatment if the heartbeat or breathing stops) changed for 1 resident (Resident #63) of 32 residents reviewed for care plans. The findings include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered, dated ,d+[DATE], showed .Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary team reviews and updates the care plan .when the resident has been readmitted to the facility from a hospital stay . Record review revealed Resident #63 was admitted to the facility on [DATE] and readmitted from the hospital on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan updated [DATE], showed, .Advance Directive in place to include Code Status: DNR [Do Not Resuscitate-No Cardiopulmonary Resuscitation-CPR] with Comfort Measures .Interventions Ensure Advance Directives are accurate and up to date. Review at least quarterly . Review of Resident #63's Tennessee Physician Orders for Scope of Treatment (POST Form) dated [DATE], showed .Resuscitate (CPR) .Full Treatment . indicating the resident wanted Full Code status (Resident wished to receive CPR if the heartbeat or breathing stopped). Review of a physician's order dated [DATE], showed .Full Code- Full Treatment . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #63 had a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident was cognitively intact. During an interview on [DATE] at 2:03 PM, Licensed Practical Nurse (LPN) #3 confirmed Resident #63's POST form dated [DATE] showed the Resident wished to be Full Code status. The LPN confirmed the Resident's care plan dated [DATE] showed DNR with comfort measures. The LPN stated the Resident's care plan had not been updated to reflect the full code status after an updated POST form had been received. During an interview on [DATE] at 2:22 PM, the Administrator confirmed the POST form and physician's order both showed Full Code with Full treatment. She confirmed the care plan had not been revised to reflect the Resident's wishes for Full Code status after she returned from the hospital on [DATE].

Based on medical record review, observation, and interview, the facility failed to assist with care of a [CONDITION(S)] according to the resident's preferences for 1 resident (Resident #446) of 32 residents reviewed for activities of daily living (ADLs). The findings include: Resident #48 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a quarterly Minimum Data Set assessment dated [DATE] showed Resident #446 had moderate cognitive impairment and required supervision of 1 staff with bed mobility, limited assistance of 1 staff with transfers, limited assistance of 1 staff with toileting, and had an ostomy. Review of a care plan showed Resident #446 had a [CONDITION(S)] for bowel elimination with interventions including assist the resident with emptying of [CONDITION(S)] bag as needed. During an observation on 10/24/2022 at 12:25 PM, in Resident #446's room, Certified Nursing Assistant (CNA) #1 responded to the resident's call light, and the resident stated she wanted her [CONDITION(S)] bag emptied. CNA #1 responded, It doesn't need it right now, you'll have to wait til after lunch. During an interview on 10/24/2022 at 12:30 PM, CNA #1 confirmed Resident #446 was told to wait until after lunch and it should be the resident's choice when the ostomy bag was emptied. During an interview on 10/26/2022 at 6:03 PM, the Director of Nursing (DON) stated it was expected that the CNA help with Resident #446's [CONDITION(S)] when the resident requested. The DON confirmed the CNA had not honored the resident's wishes and helped her with ADLs.

Based on review of the facility policy, medical record review, observation, and interview, the facility failed to administer medications through a Percutaneous Endoscopic Gastrostomy (PEG) enteral tube (tube inserted into the abdomen used for nutrition and medications) as ordered by the physician for 1 resident (Resident #40) of 8 residents with enteral tubes. The findings include: Review of the facility policy Administering Medications through an Enteral Tube dated 11/2018, showed .provide guidelines for the safe administration of medications through an enteral tube .remove the syringe and clamp tubing .reattach syringe (without plunger) .when the last of the medication begins to drain from the tubing, flush the tubing with 15 ml [milliliters] of warm purified water (or prescribed amount) .clamp the tubing when the flush is complete . Medical review revealed Resident #40 was initially admitted [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #40 was readmitted to the facility following a Cerebral Vascular Accident ([CONDITION(S)]) with a PEG tube inserted in his left upper quadrant for enteral feeding and medications. Orders revealed NPO (nothing by mouth) diet NGT [nasogastric tube] for nutrition/meds, check for residual every shift and prior to medication administration, and flush PEG via syringe with 30 ml water before and after medication administration. [MEDICATION(S)] 1.5 (nutritional supplement) at 65 ml per hour with a water flush of 50 ml/hour was ordered for nutrition. Review of the Care Plan, revised 8/23/2022, showed Resident #40's PEG tube interventions included .check PEG tube placement prior to initiating TF [tube feed] and medication administration by checking gastric residual volume .flushes and hydration as directed . Observation on 10/26/2022 at 8:19 AM, with Licensed Practical Nurse (LPN) #1 during a medication administration pass for Resident #40 showed LPN #1 placed the tube feeding on hold; failed to disconnect the feed tubing, and attached the 60 ml syringe with 30 ml of water with the plunger inserted into the side balloon port, which is not an port to the stomach for administration of feedings, water, or medications. When the water did not free flow into the PEG tubing, she restarted the TF and exited the room. The Unit Manager/LPN entered with LPN #1, disconnected the tubing, flushed the insertion site with the 30 ml of water, and exited the room. LPN #1 attached the 60 ml syringe and plunger with the crushed medications and water to the correct TF insertion port. When the medications did not free flow into the tubing, LPN #1 again exited the room. The Director of Nursing (DON) entered the room and checked the residual content, withdrawing 48 ml of stomach contents. The DON exited the room. LPN #1 attached the 60 ml syringe with the crushed medications and water without removing the plunger. After the medications eventually were administered, LPN #1 flushed with 5 ml of water and later with 30 ml of water. During an interview on 10/26/2022 at 9:00 AM, LPN #1 confirmed she failed to check the residual before giving the enteral medications, failed to flush with 30 ml of water prior to giving the medications, and initially gave 5 ml of water after the medication administration instead of the ordered 30 ml of water. During an interview on 10/26/2022 at 5:30 PM, with the Administrator and the Director of Clinical Services, the Administrator stated the facility failed to ensure physician's orders for enteral medications via a PEG tube were followed for Resident #40.

Based on facility policy review, medical record review, hospital record review, and interview, the facility failed to ensure facility staff assessed, monitored, and provided treatments for wounds for 1 resident (Resident #1) of 4 residents reviewed for wound care. The facility's failure to ensure the Nurse Practitioner (NP) and licensed nursing staff accurately assessed, monitored, and treated Resident #1's lower extremity wounds resulted in Resident #2 being admitted to the hospital with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The findings include: Review of the facility policy Pressure Ulcers/Skin Breakdown-Clinical Protocol dated 4/2018, showed .the physician will assist as needed with the staff to identify the type (for example, arterial or stasis ulcer) and characteristics (presence of necrotic tissue [dead tissue], status of wound bed, etc.) of an ulcer .the physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue .the physician will guide the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions . Medical record review showed Resident #1 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's Comprehensive Care Plan dated 11/27/2021, showed .at risk for skin breakdown r/t [related to] Venous Stasis [inflammation of the skin in the lower legs as a result of chronic [CONDITION(S)]] .weakness, decreased mobility and incontinence . Continued review showed .weekly and as needed head to toe skin assessments by licensed nurse with interventions added as needs identified. Wound Team referral as needed. Notify MDNP [Medical Doctor/Nurse Practitioner (NP)] of concerns . Medical record review of a Podiatry note dated 4/21/2022, showed a diagram that indicated wraps were on Resident #1's bilateral lower extremities (BLE) from his knees to his ankles. Continued review showed areas of stable eschar (collection of dry, dead tissue within a wound) on Resident #1's left great toe, right great toe, and right second toe. Review of Podiatry Orders dated 4/21/2022, showed .dressing of R [right] lower leg dried to skin [and] soaked through; open wounds of R [right] lateral lower leg purulent [pus] drainage [and] strong malodor . Continued review showed the right leg was cultured, and antibiotics, a probiotic (to help reduce the risk of diarrhea), and bilateral lower extremity non-stick dressings with daily dressing changes had been ordered. Medical record review of a wound culture report obtained on 4/21/2022 and reported on 4/25/2022, showed .wound (site not specified) .result: moderate growth of Staphylococcus aureus [a type of bacteria found on people's skin] . Medical record review of a physician telephone order dated 4/26/2022, showed .[MEDICATION(S)] [antibiotic] 500 mg [milligrams] po [by mouth] daily x [times] 10 days . Medical record review of a physician telephone order dated 4/29/2022, showed .apply [MEDICATION(S)] [topical antiseptic that provides infection protection] to BLE cover with [non-stick dressing] daily x 14 days then re-eval [reevaluate] . Review of a Wound Care Progress Note dated 4/29/2022, showed .resident has current skin issues .location: BLE plaques [scaling patches caused by venous stasis] and multiple open [CONDITION(S)] wound bed: granulation [healing tissue]. Wound exudate [drainage in response to inflammation]: serosanguinous [light pink/light red drainage containing blood]. Dressing saturation: minimal .wound odor: no .note/notification/education .skin assessed .multiple open lesion from previous plaques. TX [treatment] in place, MD [Medical Doctor] notified, new orders noted. Zero other concerns . Continued review showed the Responsible Party/Person (RP) was notified of the diagnosis, plan of care, and orders. Further review showed no documentation related to the stable eschar on the resident's toes. Medical record review showed the dressing changes had been completed on 5/13/2022. Continued review showed no documentation the resident was re-evaluated by the NP, MD, or nursing staff as was ordered. Medical record review showed a weekly skin assessment had not been completed on 5/23/2022. Review of a physician telephone order dated 5/26/2022, 13 days after previous dressing change order had been completed, showed .apply [MEDICATION(S)] to lower ext [extremities] daily until resolved . Medical record review showed weekly skin assessments had not been completed on 5/30/2022 and 6/6/2022. Medical record review of a Nursing Home History and Physical dated 6/20/2022, showed .dry skin LE's [lower extremities] small eschar dorsal L [left] foot [at] base L great toe . Medical record review of Skin Only Progress Note dated 6/20/2022, 6/27/2022, and 7/4/2022, showed Resident #1 continued to have open [CONDITION(S)] and bilateral lower extremity plaques and nursing staff documented .wound care manages all skin issues . Continued medical record review showed no documentation the wound care team was treating, assessing or managing Resident #1's skin issues, including the eschar noted at the base of the resident's great left toe. Medical record review of a Nursing Progress Note dated 7/4/2022, showed .resident had a previous skin tear to left foot open back up. Supervisor and wc [wound care] notified and treated with dressing Continued record review showed no documentation the wound care team treated, assessed, or managed Resident #1's skin tear. Medical record review of a Nurse Practitioner (NP) Progress Note dated 7/15/2022, showed the NP was asked to see the resident for a cough, and sore throat. The NP ordered a chest x-ray, that was negative, and performed a physical exam. Continued review showed no documentation related to the resident's skin, left great toe eschar, lower extremity open [CONDITION(S)], or left foot skin tear. Medical record review of Skin Only Progress Note dated 7/18/2022, showed Resident #1 continued to have open [CONDITION(S)], scar tissue on bilateral lower extremities, and it was documented the wound care team had managed all wounds. However, continued record review showed no documentation the wound care team had assessed, treated, or managed Resident #1's wounds. Medical record review of a NP Progress Note dated 7/26/2022, showed the NP performed a physical exam and documented .chronic skin changes [secondary] to PVD [Peripheral Vascular Disease] . No additional documentation related to Resident #1's bilateral lower extremity open [CONDITION(S)], eschar, or skin tear was noted. Review of a Nurse Progress Note dated 7/28/2022, showed .resident declined meals today, having coffee grounds emesis denies pain or discomfort .RP notified and she stated 'he has done this before, please monitor for now and call me if he gets worse' NP notified, new orders noted . Review of an additional Nurse Progress Note dated 7/28/2022, showed .resident refused breakfast and lunch stated didn't feel well vitals WNL [within normal limits] .chest x-ray done [negative for pneumonia]. Resident had coffee ground emesis MD and family notified and requested that resident be sent to [named hospital] . From 7/4/2022 through 7/28/2022, Resident #1's medical record contained no documentation the dressing applied to Resident #1's left foot had been changed or removed. Review of emergency room (ER) documentation dated 7/28/2022, showed .Review of systems .patient has wound on left foot the bandage on it .had a date of 7/4/2022/time it was changed. The wound is draining pus .Physical exam .skin .erythematous wound to the dorsal surface of the left foot with purulent drainage .WBC [white blood cell count laboratory result indicative of infection] 20.3 [normal range 4.5-11] .diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .GI [gastrointestinal] bleeding . Review of a hospital Wound Consult Note dated 7/29/2022, showed .has a cluster of wounds to the L dorsal foot .nongranular red tissue with eschar to the L great toe that is stable .dorsal foot draining small ss [serosanguineous] exudate .no malodor .stasis [CONDITION(S)] to bilateral anterior LE [lower extremities] wounds were mechanically debrided [removing unhealthy tissue with a moving force] with gauze and no open area under flaking noted . Review of a hospital Infectious Disease consult dated 7/31/2022, showed .improving [CONDITION(S)] .did have left foot [CONDITION(S)] and patient's MRI [magnetic resonance imaging] at the time .shown some suspicion of [CONDITION(S)] [bone infection], but it was very much degraded exam because of so much movement that they did not want to comment for any [CONDITION(S)] .we did notice that there was some between the toes dermatophytes [group of fungi]/athlete's foot [group of fungi] infection .that could very well often cause further bacterial [CONDITION(S)] . Review of hospital Discharge Documentation dated 8/5/2022, showed .transferred from nursing home after developing multiple episodes of bloody and coffee ground emesis .he had pustulant discharge from his left foot and his wound had become worse .on presentation to the ER patient was found to be hypotensive [low blood pressure] .significant leukocytosis [elevated WBCs] lung opacities [gray areas indicative of pneumonia] suggestive of pneumonia and lower left extremity purulent discharge suggestive of [CONDITION(S)] .he was treated with .antibiotics and arrangements were made to DC [discharge] him to SNF [skilled nursing facility] with hospice . During an interview on 8/4/2022 at 2:31 PM, Licensed Practical Nurse (LPN) #1 stated on 7/4/2022, she told the wound care team about Resident #1's left foot skin tear. LPN #1 stated .wound care applied something . The LPN stated she performed weekly head to toe skin assessments on Resident #1 since 7/4/2022 and did not recall a dressing on the resident's left foot. During an interview on 8/4/2022 at 3:37 PM, the Wound Care (WC) LPN #1 stated she was familiar with Resident #1. WC LPN #1 stated the resident had really heavy moist plaques that nursing staff applied [MEDICATION(S)] to. When the thick yellow plaques sloughed off, it left a hyper granulated (complication of wound healing) area that was cleaned with [MEDICATION(S)] applied. The LPN stated she was working on 7/4/2022 and LPN #1 notified her about a skin tear, but the WC LPN could not recall details. When asked if she applied bandages to the resident's bilateral lower extremities, WC LPN #1 replied .no not that I recall .typically we don't .we leave them [plaques] open to air .until [MEDICATION(S)] dries .I can't honestly tell you .his skin is extremely fragile . During an interview on 8/8/2022 at 11:49 AM, the Nurse Practitioner (NP) stated Resident #1 had no skin issues other than the bilateral lower extremity plaques and [MEDICATION(S)] had been ordered .biggest issues was his legs .to my knowledge .plaques on legs . The NP stated on 7/26/2022, she performed a cursory head to toe assessment. She pulled the sheet aside and just looked at his lower legs. The NP stated for people who had PVD issues, she would look at their legs. The NP did not see bandages, did not look at his feet, and was more concerned with the plaques, which were improving a little bit. When asked if she spoke to Podiatry, nursing, or the wound care team regarding Resident #1's eschar at the base of his left great toe or left foot skin tear, the NP shook her head no .I didn't know he had a wound . The NP stated the wound care team typically sent the NP notification of wounds on a communication form, an interdepartmental memo, and would slip them under her door. If Resident #1 had wounds in July, the NP would have gotten a notification. The NP stated the resident did not complain to the NP that day. The NP stated she could not recall the assessment dated [DATE] that noted the eschar on Resident #1's left great toe, nor could she recall any Podiatry documentation. The NP stated she should have been made aware of the eschar and if she had known she would have watched it, applied [MEDICATION(S)], and skin prep. The NP stated [MEDICATION(S)] was already ordered at that time. During an additional interview on 8/8/2022 at 4:00 PM, WC LPN #1 contradicted her previous interview and stated .I have never been asked to look at his foot .one of those plaques got infected .hyper granulation of tissue .very thin .yellow thick moist .plaques .it is not considered a wound . WC LPN #1 stated Resident #1 was not followed by the wound care team in July 2022. During an interview on 8/9/2022 at 11:02 AM, Resident #1's Attending Physician and the facility's Medical Director stated Resident #1 .had some exfoliative conditions on his legs .greasy scaley areas on lower legs . The Attending Physician stated she was not aware of eschar on Resident #1's left or right toes. The Attending Physician further stated she could not recall seeing Resident #1's legs and confirmed if a bandage on an open wound was not changed for 24 days, then yes that can cause [CONDITION(S)]. During an interview on 8/9/2022 at 11:34 AM, the ER Physician stated he recalled Resident #1 and stated .[Resident #1's] foot was erythematous .lesion open on dorsal aspect of his left foot .nurse told me the bandage was dated 7/4 . During an interview on 8/9/2022 at 3:15 PM, WC LPN #2 stated in April 2022, podiatry cultured the plaques on Resident #1's legs and the resident had [CONDITION(S)]. The Wound Care team took over treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . It was a chronic issue. The Wound Care team typically didn't do skin tears For vascular, arterial, surgical, and pressure wounds, they did treatments, followed the wound, measured it. WC LPN #2 remembered at one point looking at the resident's leg. A treatment was put in place for the floor nurse to follow. Wound Care wrote that order, then it was for the nurses to continue to treat. WC LPN #2 did not remember eschar and if there was eschar, Wound Care would have followed, diagnosed as arterial or vascular, and taken care of it, making sure it healed. WC LPN #2 stated the nurses took care of skin tears. Interview confirmed Resident #1 was not followed by the wound care team in July 2022. During an additional interview on 8/9/2022 at 4:49 PM, the Director of Nursing (DON) confirmed nursing staff were expected to perform weekly head-to-toe skin assessments and document dressing changes in the medical record. Continued interview confirmed Resident #1 was missing weekly skin assessments on 5/23/2022, 5/30/2022, and 6/6/2022. Furthermore, the DON stated she was unable to provide documentation the dressing on Resident #1's left foot skin tear was changed or removed from 7/4/2022 through 7/28/2022, when the resident was transferred to the hospital.

Based on facility policy review, medical record review, and interview, the facility failed to document wound care treatments and dressing changes for 2 residents (Resident #4 and Resident #5) of 4 residents reviewed for complete and accurate medical records. The findings include: Review of the facility policy Charting and Documentation dated 7/2017, showed .All services provided to the resident .shall be documented in the resident's medical record . Medical record review showed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident left Against Medical Advice (AMA) on 7/29/2022. Medical record review of a Physician's Order dated 7/16/2022, showed .Cleanse Amputation site with NS [normal saline], apply 0.25 % Dakins [solution used to prevent and treat skin and tissue infections] wet to dry to wound bed. Cover with .gauze, wrap with Kerlix [gauze bandage wrap] and ACE [bandage] change BID [twice a day] and PRN [as needed] . Medical record review of Resident #4's 7/2022 Electronic Treatment Administration Record (ETAR) showed no documentation the resident received the ordered wound care on 7/23/2022 through 7/27/2022 at the scheduled 4:00 PM treatment time. During an interview on 8/9/2022 at 9:23 AM, the Wound Care Registered Nurse (RN) confirmed she administered the ordered wound care treatments and performed Resident #4's dressing changes at 4:00 PM on 7/23/2022 through 7/25/2022, but did not document them on the ETAR. During an interview on 8/9/2022 at 3:15 PM, Wound Care Licensed Practical Nurse (LPN) #2 confirmed she administered the ordered wound care treatments and performed Resident #4's dressing changes at 4:00 PM on 7/26/2022 and 7/27/2022, but did not document them on the ETAR .was an oversight and human error . Medical record review showed Resident #5 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Medical record review of a Physician's Order for Resident #5 dated 6/4/2022, showed .cleanse midline abdominal surgical incisions w [with] NS apply .moistened gauze [and] cover w bordered gauze qd [every day] one time a day for wound care . Medical record review of a Physician's Order for Resident #5 dated 7/1/2022, showed .cleanse midline abdominal surgical incisions w [with] NS apply calcium alginate [non-occlusive dressing] cut to fit [and] cover with 2 bordered gauze qd every shift for wound care . Medical record review of Resident #5's 6/2022 ETAR showed the wound care treatment and dressing changes were not documented as completed on 6/22/2022, 6/28/2022, and 6/30/2022. Medical record review of Resident #5's 7/2022 ETAR showed the wound care treatment and dressing changes were not documented as completed on 7/27/2022. During an interview on 8/9/2022 at 9:23 AM, the Wound Care RN confirmed she administered the ordered wound care treatments and performed Resident #5's dressing changes on 6/22/2022, 6/28/2022, 6/30/2022, and 7/30/2022 but did not document them on the ETAR. During an interview on 8/9/2022 at 2:45 PM, Resident #5 confirmed nursing staff performed daily dressing changes and wound care treatments as ordered and had no concerns with his care. During an interview on 8/9/2022 at 4:49 PM, the Director of Nursing (DON) confirmed it was expected staff document wound care treatments and dressing changes in the medical record.

Based on facility policy review, medical record review, and interview, the facility failed to protect 1 resident (Resident #4) from abuse of 5 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised ,d+[DATE], showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Residents have the right to be free from abuse . Medical record review revealed Resident #4 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #4's admission Minimum Data Set (MDS) assessment dated [DATE], showed the resident was cognitively intact. Review of a facility investigation dated [DATE], showed Resident #4's roommate (Resident #5) had came over to his side of the room, messed with his personal belongings on the bedside table, sat on the end of Resident #4's bed and then .back handed resident's [Resident #4's] left upper arm . Further review revealed there were no injuries noted. Resident #5 was moved to another room. Further review of Resident #4's statement showed .The guy came around the curtain .I told him to go back to his side. The guy then started touching my phone and things on this table .He came around and sat at the end of my bed .I told him again to go back to his bed. Then he hit me . Further review revealed Resident #4 demonstrated back handing him on the left upper arm and stated .for an old guy he got me good . Review of Resident #4's nurse's note dated [DATE], showed .Resident reported to nurse that roommate hit him on his left upper arm. They were separated immediately . Further review revealed no injuries. Review of a Nurse Practitioner note dated [DATE], showed .Asked to see resident [Resident #4] for being hit on [left] arm by another resident .[no] visible injury. Other resident moved to another room . Medical record review showed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review showed the resident died at the facility on [DATE] with hospice care. Review of Resident #5's Hospital Discharge Documentation dated [DATE], showed .[Resident #5] .presented to [name of hospital] on [DATE] with chief complaint of aggressive actions requiring geropsych evaluation. He .was aggressive .and tried to choke them .Patient was admitted for dementia with aggressive behavior .Plans to discharge to facility under comfort/hospice care when arranged . Review of Resident #5's Baseline Care Plan dated [DATE], showed .risk for psychosocial/mood/ behavior problems related to .Alzheimer's disease .I have psychosocial/mood/behavior disorder as evidenced by .Hitting/kicking others .Risk for harm to self or others will be minimized through next review date . Review of a facility investigation dated [DATE], showed .Resident [Resident #5] went over to roommate's side of the room. Messed with roommate's personal belongings on roommate's bedside table, and sat at the end of roommate's bed then backhanded roommate's left upper arm .Separated immediately . Further review showed Resident #5 was sent to the emergency room for evaluation .Refer to psych NP [Nurse Practitioner] .room [change] upon RTH [return from hospital] & [and] 1:1 [one on one sitter] initiated .sent back to hospital for possible geropsych [geriatric psychiatric] placement which was unsuccessful . Review of Resident #5's nurse's note dated [DATE], showed .CNA [Certified Nursing Assistant] went in room to change resident [Resident #5] and he became aggressive and combative with CNA. She stepped out in the hall and called for assistance and this nurse went to room to help. At that time resident [Resident #5] was found sitting on the end of room mates [Resident #4's] bed, naked and combative. Room mate [Resident #4] states had asked resident [Resident #5] several times to please go back to his bed that this wasn't his bed and resident [Resident #5] proceeded to sit on the bed and struck room mate [Resident #4] 2 times with the back of his hand on the left arm per room mate [Resident #4]. Room mate called for help and by the time pushed his call light the CNA and I were in the room. At that time we assisted resident [Resident #5] back to his bed, changed his brief and gown and .removed resident [Resident #5] from room right away to nurses station in staff view at all times . Review of Resident #5's emergency room Note dated [DATE], showed .patient supposedly punched his neighbor in the face .aggressive behavior . Review of Resident #5's nurse's note dated [DATE], showed .late entry for [DATE]- 10 am resident transferred to room .for better placement .sitter in room with resident at this time no s/s [signs or symptoms] of distress of combativeness at this time .Psych [Psychiatric Nurse Practitioner] in to eval [evaluate] resident. Orders received to transport resident to ER [emergency room ] for eval [evaluation] . Review of Resident #5's Physician's Order dated [DATE], showed .Send to .ER for psych eval and treat for behaviors . Review of Resident #5's Physician's Order dated [DATE], showed .Provide 1:1 sitter . Review of Resident #5's admission assessment dated [DATE], showed the resident had severe cognitive impairment. During an interview on [DATE] at 3:46 PM, the Director of Nursing (DON) stated Resident #5 was admitted to the facility on [DATE] with hospice care. He was placed in the room with Resident #4. Resident #5 had gone over to Resident #4's side of the room and was touching Resident #4's belongings. Resident #4 had asked him to stop, and Resident #5 then sat on Resident #4's bed. Resident #4 asked Resident #5 to get up off of the bed when Resident #5 hit Resident #4 twice on the upper arm. Resident #4 was alert and oriented and reported the incident to the staff. The DON confirmed Resident #5 did hit Resident #4 on the upper arm twice with no injuries to Resident #4. She confirmed the facility had reported the allegation of abuse to the State Agency and had completed an investigation for abuse. The DON stated the incident occurred on Resident #5's date of admission so the facility did not know a lot about his background and thought he would be a good roommate for Resident #4. The DON stated the facility had placed Resident #5 in a private room on 1 on 1 care with a sitter after the incident to prevent further occurrences due to Resident #5 did wander in the facility. She stated the 1 on 1 care was continued until Resident #5 had declined and was no longer able to wander. She stated Resident #5 had passed away at the facility on [DATE].

Based on facility policy review, medical record review, and interview, the facility failed to report an allegation of misappropriation of personal property to the State Agency for 1 resident (Resident #1) of 5 residents reviewed for abuse. The findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised 9/2021, showed .It is the policy of the facility to maintain an environment where residents are free from abuse, neglect, exploitation and misappropriation of resident property .Investigate and report any allegations within timeframes required by federal requirements . Medical record review showed Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #1's nurse's note dated 8/27/2021, showed .resident was upset after discovering a bottle of pain medication missing from her room . Review of the facility's investigation dated 8/27/2021, showed Resident #1 did not realize the medication was in the bag she took to [CONDITION(S)]. Resident #1 stated when she was putting things in the bag, she found a bottle of pain pills and 2 boxes of [MEDICATION(S)] patches. She stated she left the bag at the facility and when she got back from [CONDITION(S)], the bottle of pain medication was no longer in the bag. Resident #1 opened the bag and let the nurse look into the bag. The nurse noted 1 box of unopened [MEDICATION(S)] (narcotic pain medication) patches and 1 opened box of [MEDICATION(S)] patches with 4 patches in the box. The staff searched the room and laundry, and the bottle of pills was not located. The facility investigated the incident and was unable to verify if the bottle of pain medication had been in the bag. During a phone interview on 9/22/2021 at 10:21 AM, Resident #1 stated she had found a bottle of pain medication and some pain patches in her bag and stated she did not know she had them with her at the facility until that morning. She stated she did not take the bag with her to [CONDITION(S)] that day and when she returned the bottle of pain medication was missing. During an interview on 9/22/2021 at 11:36 AM, Physician #1 stated that on the day she saw the resident (8/27/2021) Resident #1 had come back from [CONDITION(S)] and stated some medications had been stolen from her room. The Physician stated the resident had shown her packs of pain patches she had and stated to the Physician that a bottle of pain medication was missing. During an interview on 9/22/2021 at 2:08 PM, the Director of Nursing (DON) stated she had kept the resident's pain patches after she reported the pills had been stolen. She stated she returned the pain patches to the resident upon discharge from the facility. She stated the facility had investigated the allegation but was unable to prove the bottle of pain pills had ever been in the resident's bag. During an interview on 9/22/2021 at 3:53 PM, the DON confirmed the allegation of the missing medication should have been reported to the State Agency.

Based on facility policy review, medical record review, hospital record review, and interviews, the facility failed to notify the physician of a change in the discharge plan for 1 of 3 residents (Resident #7) reviewed for discharge planning. The facility's failure to notify the physician of a change in the discharge plan resulted in Resident #7 being discharged to a motel and being admitted to the hospital 4 days after discharge (Harm). The findings include: Review of the facility's undated policy titled, Change in Resident's Condition or Status, showed, .Our facility shall promptly notify .Attending Physician .of changes in the resident's medical/mental condition and/or status . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 7/3/2020, and the Physical Therapy (PT) Evaluation and Plan of Treatment dated 7/4/2020, showed Resident #7 had a functional decline after a stroke and 2 falls resulting in a left [MEDICAL CONDITION] with a total hip replacement. Review of Resident #7's care plan for Discharge with a Start Date of 7/9/2020 showed the care plan goal was .Resident will work with facility toward appropriate discharge through next review . The care plan interventions were .Offer transition meeting to discuss post-discharge needs .Assist with obtaining community resources for discharge PRN (as needed) .Set up home health services and DME (Durable Medical Equipment) when appropriate .Explain discharge instructions to resident and significant others . Review of the Discharge Note/Summary completed by Resident #7's physician on 7/15/2020, with a discharge date of [DATE], showed .Social Services: Patient to return to community with a friend. Orders to be written for a rolling walker. Patient to follow up with (Named Primary Care Physician (PCP) practice) for primary care. No orders for home health until physician is established . Review of the Social Service note dated 7/16/2020, showed that a call was received from the resident's PCP office to notify the facility that Resident #7 had not been seen in their office since 2013 and was not a current patient. Review of physician's orders [REDACTED].#7 was to be discharged home with Friend #1 and PCP follow-up in 1-2 weeks. Review of the Social Service note dated 7/20/2020, showed that on 7/16/2020, Friend #1 voiced concerns regarding housing/helping the resident and wanted to pursue placement at a community senior housing facility before he would agree to pick up the resident. On 7/17/2020, the Medical Doctor (MD) evaluated the resident and cleared him for discharge. The social worker submitted a referral to the community senior housing facility on 7/17/2020 and made multiple attempts to contact Friend #1, but no return phone call had been received as of 4:30 PM on 7/17/2020. The resident's friend did not pick Resident #7 up from the facility. On 7/20/2020, the resident asked the social worker to contact Friend #2 to pick him up. Friend #2 refused to pick the resident up and a cab was called to take the resident to a motel. Resident #7's personal property in the amount of $495 was returned to him. It was noted that, Patient has no PCP follow up .declined DME (rolling walker) . Review of the Emergency Department (ED) Clinical Report dated 7/24/2020, showed, Arrival: 7/24/2020 .Chief Complaint: Trouble Walking .discharged from (named Long Term Care facility) rehab to a motel because he had no place to live .states he has generalized weakness .not able to ambulate .feels he cannot care for himself .will admit . Review of the hospital Admission History and Physical dated 7/24/2020, showed .Pending PCP .ED physician tried to obtain placement for him due to deconditioned state .unable to transfer today .admit the patient to the hospital until placement can be obtained . During an interview on 7/29/2020 at 8:55 AM, the Medical Director, who was also the resident's physician in the facility, stated that Resident #7 was to be discharged home with Friend #1 because he needed assistance. The Medical Director confirmed that she was not notified that Resident #7 had refused a rolling walker, did not have a PCP follow-up appointment, and was discharged alone to a motel. Further interview confirmed that had she been aware, she would have held Resident #7's discharge until arrangements could be made because the resident needed assistance. During an interview on 7/29/2020 at 1:47 PM, the Director of Nursing (DON) confirmed that the Medical Director should have been notified that Resident #7 had refused a rolling walker, did not have a PCP to follow-up with, and was discharged to a motel alone. Refer to F-660

Based on facility policy review, medical record review, hospital record review, and interviews, the facility failed to implement an effective discharge planning process to ensure a safe and effective discharge, and failed to modify the discharge plan when it was identified the resident did not have a safe discharge destination, Primary Care Physician (PCP) or caregiver support, for 1 of 3 residents (Resident #7) reviewed for discharge planning. The facility's failure to ensure the resident's discharge needs were met resulted in Resident #7 being discharged to a motel with no community support and being hospitalized 4 days after discharge because the resident could not independently manage self-care (Harm). The findings include: Review of the facility policy titled, Transfers and Discharge Process, dated 6/20/2017, showed, .discharge procedures must provide sufficient preparation, documentation and information of the resident to ensure a safe, and effective transition of care . Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan dated 7/3/2020, showed Resident #7's goal for discharge was to Home and Approaches were Community referrals prn (as needed). Review of the Occupational Therapy (OT) Evaluation and Plan of Treatment dated 7/3/2020, showed Resident #7 had a functional decline after a stroke ([MEDICAL CONDITION]) and 2 falls resulting in a left [MEDICAL CONDITION] with a total hip replacement. The resident was to be seen 6 times per week for rehabilitation in Activities of Daily Living (ADLs), self-care, and mobility activities.Prior Living Description: Chart reports pt (patient) lived alone in an apartment, and was (Independent) at prior level of function with ADL, self care .pt says he is NOT returning to that apartment. Chart notes plan is to discharge to his friend's apartment .will have 24/7 (24 hours a day/7 days a week) support; pt reports he's not quite sure yet if he will be going to this friends (or) to alternative discharge location .Transition/Discharge plan = Other (to be determined based on patient's social situation/availability of help from friends . Review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 7/4/2020, showed Resident #7 was admitted to the facility for .ongoing rehabilitative care in order to facilitate optimal quality of life in discharge setting . The PT plan included treatment 6 times per week with the goal of maximizing safety and independence with functional mobility. Review of Resident #7's care plan for Discharge with a Start Date of 7/9/2020 showed the care plan goal was .Resident will work with facility toward appropriate discharge through next review . The care plan interventions were . Offer transition meeting to discuss post-discharge needs .Assist with obtaining community resources for discharge PRN (as needed) .Set up home health services and DME (Durable Medical Equipment) when appropriate .Explain discharge instructions to resident and significant others . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed that Resident #7 was cognitively intact and needed extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene. The resident needed limited assistance of 1 person with walking in his room. Review of a Social Service note dated 7/10/2020 at 4:41 PM, showed, .Patient is alert with some confusion .Patient stated he would like to rehab (rehabilitation) and then transition back to the community at the conclusion of skilled services. Patient states he's lived 'oh here and a little bit of there.' Patient states he has lived with (Family Member #1) most recently but doesn't know if it is an option for him to return. Patient reports he was mostly independent at home prior to hospitalization .Sw (Social Worker) stated continued therapy would be based on patient's progress/(Insurance company) . Review of a Social Service note dated 7/13/2020 at 10:42 AM showed .Resident states prior to his most recent hospitalization he was living with (Family Member #2). He plans to return to this situation when therapy is complete. Social services is available as needed to assist with planning . Review of a Nurse note dated 7/14/2020 at 1:08 PM, showed Resident #7 was sent to the emergency room for persistent nausea and vomiting. The resident returned to the facility on [DATE] at 2:40 AM with a [DIAGNOSES REDACTED]. Review of the OT Discharge Summary dated 7/14/2020 at 2:24 PM, showed the resident's Modified Barthel score (score to determine independence in ADLs) was 50 at discharge from OT on 7/13/2020, and the goal was to reach 65. The resident required moderate assistance for toileting, dressing, and bathing.Patient discharge to hospital. (Patient is currently homeless. It is not known exactly at the time of this writing physical location patient will be discharging.) . Review of the Discharge Note/Summary completed by Resident #7's physician on 7/15/2020, with a discharge date of [DATE], showed .Reason for Discharge: Transition to lower level (lower level of care) .Disposition of medications: [REDACTED]. Orders to be written for a rolling walker. Patient to follow up with (named Primary Care Physician (PCP) practice) for primary care. No orders for home health until physician is established. 0 (no) residency . Review of the PT Discharge Summary dated 7/15/2020 at 1:58 PM, showed that Resident #7 was discharged from PT with goal evaluations including Tinetti score of 17/28, indicating a high risk for falls, able to stand 10 minutes with support without pain, needed Stand-By Assist (SBA) for transfers, and able to ambulate 125 feet with SBA.Patient discharged to home (with) support (assistance) from others .Prognosis to Maintain CLOF (current level of function) = Good with strong family support .Pt is discharging home with recommended SBA for all standing functional mobility secondary to persisting deficits in coordination and balance stemming from residual effects [MEDICAL CONDITION]. Review of the Social Service note dated 7/15/2020 at 4:35 PM, showed .Patient is set to discharge 7/16 to the community with a friend. Discharge is planned. NOMNC (Notice of Medicare Non-Coverage) was issued 7/13 to patient with skilled coverage concluding 7/15. Patient previously stated he was homeless prior to hospitalization . Patient asked sw to contact friends (Friend #2 and Friend #1) to ask them if they or someone they knew would house patient upon discharge .Sw received call back from friend (Friend #1) .stated he would be willing to help patient with housing. (Friend #1) stated was working with hospital staff to get patient qualified for (government) housing. Sw explained that government housing can be a lengthy process .(Insurance company) will not continue to approve skilled care. Sw called (Friend #1) and explained. (Friend #1) stated he would pick patient up tomorrow and 'figure it out'. Discharge plans were reviewed today with patient. Patient was in agreement with d/c (discharge) plans. Sw will provide patient with a list of local contact agencies. Patient stated he sees (named PCP's practice) for primary care. Sw called and left a message with nurse .to schedule a follow up appt (appointment). At present, HH (home health) will not be ordered due to patient first needing to be seen by a primary care and establish residency .Therapy staff has recommended a rw (rolling walker) @ (at) discharge . Review of Discharge Orders written by the Medical Director on 7/16/2020 showed discharge was home with Friend #1 and the resident had friend support. Medications at discharge included [MEDICATION NAME] (medication to treat high blood pressure) 5 milligrams (mg) daily, [MEDICATION NAME] (medication to treat high blood pressure) 20 mg daily, and [MEDICATION NAME] (medication to treat urinary tract infection) 300 mg twice daily for 10 days (stop date 7/25/2020). Review of the Social Service note dated 7/16/2020 at 11:58 AM, showed that Resident #7's discharge was held due to nausea and vomiting.NP (Nurse Practitioner) planned to do d/c paperwork today but asked to hold d/c .(Insurance Company) sent a new NOMNC for skilled coverage to conclude on 7/18 with d/c on 7/19 .Sw also received a call from (named PCP's office) .stated patient is not current and has not been seen in the office since 2013 . Review of Physician's Orders dated 7/17/2020, showed that Resident #7 was to be discharged home with Friend #1 and follow-up appointment with the Primary Care physician in 1-2 weeks. Review of a Physician's Verbal Order from the Nurse Practitioner (NP) dated 7/20/2020 showed .D/C (discontinue) all skilled services D/C (discharge) from facility . Review of a Social Service note dated 7/20/2020 at 12:18 PM, showed, .Patient was originally (scheduled) for d/c on 7/16 to return to the community with a friend (Friend #1). NP evaluated patient for d/c and asked d/c to be he'd (held) due to ongoing GI (gastrointestinal) issues. A new NOMNC was issued on 7/16 to patient with skilled services to conclude on 7/18 with d/c on 7/19. Sw spoke with patients friend (Friend #1) on 7/16 and informed him that patient's d/c would be delayed. (Friend #1) stated he had concerns housing/helping patient and wanted sw to pursue placement at (community senior housing facility) before he would agree to pick patient up as was previously planned. On 7/17, MD (physician) evaluated patient, completed d/c paperwork and cleared him for d/c. Sw .submitted a referral (community senior housing facility). Around 4:30 pm 7/17 sw had not received a return call from (community senior housing facility) nor from patient's friend (Friend #1) after multiple attempts. (Friend #1) did not pick patient up from facility. This AM sw received multiple calls from patient's friend (Friend #2). (Friend #2) stated patient called him over the weekend and requested that he come to facility and pick patient up .(Friend #2) stated 'Look he's been calling me and he doesn't make any sense. He keeps telling me he needs help with the block. I don't know what a block is. He can't answer any of my questions .I'm not responsible for the man. He was living in a motel before (working for Friend #2) .Sw checked with facility Admin (Adminstrator) and patient's personal property was located and accounted for. Patient has 495$ ($495). Sw gave patient's peronal (personal) property back. Patient asked sw to call (Friend #2) and tell him that he'd pay him if he can (came) to pick patient up. Patient stated if not then 'call me .cab.' Sw called (Friend #2) and relayed patient's request. (Friend #2) stated, 'I can't take this on today .I can't be responsible for him. You best just call him a cab.' Sw called (cab company) and scheduled pick up for 3pm. Patient states he will go to the (motel) for a room .Patient has no PCP follow up. Patient has no follow up orders for HH or Outpatient. MD/NP wrote orders for a rw (rolling walker). Patient declined DME (rolling walker) and stated he did not need . Review of a Nurse note dated 7/20/20 at 12:57 PM showed, .Resident self transfers and is mobile in room on his own. Orders noted for discharge home today .Discharge orders, summary, care plan and H&P (history and physical) faxed to PCP .Discharge medication faxed to (pharmacy) .All meds (medications) are 30 day supply with no refills. Resident has no hard copy prescriptions. All discharge instructions, interdisciplinary discharge summary and care plan given to resident .Resident is to be transported to hotel this afternoon by taxi . Review of Discharge Information dated 7/20/2020, showed the facility did not make a follow-up appointment with a primary care physician and Resident #7 was to make his own follow-up appointment with a primary care physician. Review of an Emergency Department (ED) Clinical Report dated 7/24/2020, showed, Arrival: 7/24/2020 at 12:24 .Chief Complaint: Trouble Walking .discharged from (named Long Term Care facility) to a motel because he had no place to live. Patient states he has generalized weakness and for the last week has not been able to ambulate. Patient is requesting help in order to get to a facility for long-term care. Patient feels that he cannot care for himself .Will admit patient to (hospital) and obtain an occupational and physical therapy consult .Clinical Impression ambulatory dysfunction . Review of the hospital History and Physical dated 7/24/2020 showed, .Per patient he was discharged from there (Long Term Care facility) to a motel. He reports difficulty ambulating and getting around and caring for himself. He was brought to the emergency department noted to have uncontrolled hypertension (high blood pressure). ED tried to obtain placement for him due to deconditioned state however he was unable to be transferred today .admit the patient to the hospital until placement can be obtained .He had a blood pressure of 200 systolic (normal systolic blood pressure is categorized as 120 or less) and was given [MEDICATION NAME] (medication to lower blood pressure) .Assessment/Plan Deconditioned state/difficulty with ambulation and self-care .Uncontrolled hypertension .Admit for further observation in the hospital we will ask PT to evaluate .Case manager assisting with placement. Monitor blood pressure closely and restart his home antihypertensives . During an interview on 7/27/20 at 8:36 AM, the Social Worker stated the facility has Interdisciplinary Team Meetings to determine if residents are able to return to the community. Once the facility determines a potential discharge date they begin making plans for discharge. Social Services makes referrals to local agencies if needed, including home health, DME, physical therapy, Adult Protective Services, and emergency housing if needed. The Social Worker stated, D/C planning is started on admission and we solidify those plans when we do our care plan meetings and D/C plan is updated as needed. During an interview on 7/27/2020 at 9:20 AM, the Social Worker stated that Resident #7 informed the facility that he didn't have a home during his care plan meeting on 7/9/2020. He gave the facility the phone numbers of 2 friends to contact about helping him at discharge. Friend #1 agreed to take the resident home at discharge but quit returning phone calls and never came to pick up Resident #7. Attempts made to obtain placement with a community senior housing facility and with Friend #2 were unsuccessful. A follow-up appointment with his PCP was unable to be made because he wasn't a current patient. Resident #7 was agreeable to discharge to a motel via cab and was discharged on [DATE]. Therapy staff recommended that he get a walker, but the resident refused a walker and stated it would hold him up. The facility called a cab for the resident on 7/20/2020 and the resident left in a cab. No staff members went with the resident to the motel. During interview on 7/27/2020 at 5:28 PM, the Director of Rehab stated that Resident #7 was using a rolling walker with standby supervision. They recommended that he be discharged with a rolling walker. During an interview on 7/29/2020 at 8:55 AM, the Medical Director who was also Resident #7's physician in the facility, stated she thought that Resident #7 was discharged home with Friend #1. She was unaware that Resident #7 had been discharged to a motel alone and that no PCP follow-up appointment had been made. The Medical Director stated it was not safe for Resident #7 to be discharged alone and without a PCP. If she had known that he was being discharged alone to a motel and was not a current patient with his PCP, she would have held his discharge. During an interview on 7/29/2020 at 1:47 PM, the Director of Nursing confirmed that the facility should have made arrangements for a follow-up appointment with a PCP at discharge. During an interview on 7/29/2020 at 4:44 PM, the Director of Rehab confirmed that Resident #7 did need assistance with ADLs and stand-by assistance for transfers and ambulation.

Based on medical record review, hospital record review, and interviews, the facility failed to provide social services by obtaining community services before transition to the community after discharge for 1 of 3 residents (Resident #7) reviewed for discharge planning. The facility's failure to ensure transition to the community with needed services was obtained resulted in Resident #7 being discharged to a motel with no community support and being hospitalized 4 days after discharge because the resident could not independently manage self-care (Harm). The findings include: Resident #7 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Baseline Care Plan dated 7/3/2020, showed Resident #7's goal for discharge was to Home and Approaches were Community referrals prn (as needed). Review of the Physical Therapy (PT) Evaluation and Plan of Treatment dated 7/4/2020, showed the resident was hospitalized after a fall, for treatment of [REDACTED]. He was admitted to the facility for ongoing rehabilitative care in order to facilitate optimal quality of life in discharge setting. PT plan included treatment 6 times per week with the goal of maximizing safety and independence with functional mobility. Review of a Care Plan Review Summary dated 7/9/2020 showed .My initial goal(s) for this admission Gain strength through therapy in order to return to prior level .My Discharge Plan Return to community with resources. Social Worker to assist patient in scheduling a follow up with the patient's primary care physician, arrange for home health/outpatient services, and order durable medical equipment if appropriate . Review of Resident #7's care plan for Discharge with a Start Date of 7/9/2020 showed the care plan goal was .Resident will work with facility toward appropriate discharge through next review . The care plan interventions were .Offer transition meeting to discuss post-discharge needs .Role(s) Social Services (Social Services responsible) .Assist with obtaining community resources for discharge PRN (as needed) .Set up home health services and DME (Durable Medical Equipment) when appropriate . Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed that Resident #7 was cognitively intact and needed extensive assistance of 1 person for bed mobility, transfers, dressing, toilet use, bathing, and personal hygiene. The resident needed limited assistance of 1 person with walking in his room. Review of a Social Service note dated 7/10/2020 at 4:41 PM, showed, .Patient is alert with some confusion .Patient stated he would like (to go to rehab) (rehabilitation) and then transition back to the community at the conclusion of skilled services. Patient states he's lived 'oh here and a little bit of there.' Patient states he has lived with his (Family Member #1) most recently but doesn't know if it is an option for him to return. Patient reports he was mostly independent at home prior to hospitalization .Sw (Social Worker) stated continued therapy would be based on patient's progress/(Insurance company) . Review of the Discharge Note/Summary written by the resident's physician on 7/15/2020, with a discharge date of [DATE], showed .Reason for Discharge: Transition to lower level (lower level of care) .Social Services: Patient to return to community with a friend. Orders to be written for a rolling walker. Patient to follow up with (named Primary Care Physician (PCP) practice) for primary care. No orders for home health until physician is established. 0 (no) residency . Review of the Social Service note dated 7/15/2020 at 4:35 PM, showed .Patient previously stated he was homeless prior to hospitalization . Patient asked sw to contact friends (Friend #2 and Friend #1) to ask them if they or someone they knew would house patient upon discharge .Sw received call back from friend (Friend #1) .stated he would be willing to help patient with housing .Discharge plans were reviewed today with patient. Patient was in agreement with d/c (discharge) plans. Sw will provide patient with a list of local contact agencies. Patient stated he sees (named PCP's practice) for primary care. Sw called and left a message with nurse .to schedule a follow up appt (appointment). At present, HH (home health) will not be ordered due to patient first needing to be seen by a primary care and establish residency .Therapy staff has recommended a rw (rolling walker) @ (at) discharge . Review of the Social Service note dated 7/16/2020 at 11:58 AM, showed that the Sw .received a call from (named PCP's office) .stated patient is not current and has not been seen in the office since 2013 . Review of a Social Service note dated 7/20/2020 at 12:18 PM, showed, .Sw spoke with patients friend (Friend #1) on 7/16 .(Friend #1) stated he had concerns housing/helping patient and wanted sw to pursue placement at (community senior housing facility) before he would agree to pick patient up as was previously planned. On 7/17, MD evaluated patient, completed d/c paperwork and cleared him for d/c. Sw .submitted a referral (community senior housing facility). Around 4:30 pm 7/17 sw had not received a return call from (community senior housing facility) nor from patient's friend (Friend #1) after multiple attempts. (Friend #1) did not pick patient up from facility. This AM sw received multiple calls from patient's friend (Friend #2). (Friend #2) stated patient called him over the weekend and requested that he come to facility and pick patient up .(Friend #2) stated 'Look he's been calling me and he doesn't make any sense. He keeps telling me he needs help with the block. I don't know what a block is. He can't answer any of my questions .He was living in a motel before .' Sw checked with facility Admin (Administrator) and patient's personal property was located and accounted for. Patient has 495$ ($495). Sw gave patient's peronal (personal) property back. Patient asked sw to call (Friend #2) and tell him that he'd pay him if he can (came) to pick patient up. Patient stated if not then 'call me a cab'. Sw called (Friend #2) and relayed patient's request. (Friend #2) stated, 'I can't take this on today .I can't be responsible for him. You best just call him a cab.' Sw called (cab company) and scheduled pick up for 3pm. Patient states he will go to the (motel) for a room .Patient has no PCP follow up. Patient has no follow up orders for HH (Home Health) or Outpatient. MD/NP wrote orders for a rw (rolling walker). Patient declined DME (rolling walker) and stated he did not need . Review of Nurse's Note dated 7/20/20 at 12:57 PM showed, .Orders noted for discharge home today .Resident is to be transported to hotel this afternoon by taxi . Review of Discharge Information dated 7/20/2020, showed Social Services did not make a follow-up appointment with a primary care physician. Review of an Emergency Department (ED) Clinical Report dated 7/24/2020, showed, Arrival: 7/24/2020 at 12:24 .Chief Complaint: Trouble Walking .discharged from (Long Term Care facility) to a motel because he had no place to live. Patient states he has generalized weakness and for the last week has not been able to ambulate. Patient is requesting help in order to get to a facility for long-term care. Patient feels that he cannot care for himself .Will admit patient to (hospital) . Review of the hospital History and Physical dated 7/24/2020 showed, .Per patient he was discharged from there (nursing home) to a motel. He reports difficulty ambulating and getting around and caring for himself. He was brought to the emergency department noted to have uncontrolled hypertension (high blood pressure) . During an interview on 7/27/20 at 8:36 AM, the Social Worker stated the facility has Interdisciplinary Team Meetings to determine if resident are able to return to the community. Once the facility determines a potential discharge date they begin making plans for discharge. Social Services makes referrals to local agencies if needed, including home health, DME, physical therapy, Adult Protective Services, and emergency housing if needed. The Social Worker stated, D/C planning is started on admission and we solidify those plans when we do our care plan meetings and dc plan is updated as needed. During an interview on 7/27/2020 at 9:20 AM, the Social Worker stated that Resident #7 informed the facility that he didn't have a home during his care plan meeting on 7/9/2020. He gave the facility the phone numbers of 2 friends to contact about helping him at discharge. Friend #1 agreed to take the resident but then said he was uncomfortable accepting responsibility and was no longer willing to take Resident #7 at discharge. The Social Worker said he sent a referral to a community senior living facility on Friday 7/17/2020. The Social Worker said he did not make a follow-up appointment with Resident #7's PCP. The Social Worker discussed discharge with the resident. Resident #7 was agreeable to discharge to a motel via cab. Therapy staff recommended that he get a walker, but the resident refused a walker and stated it would hold him up. The Social Worker stated, We called a cab for him on 7/20/20. Our staff members got him into the cab and he left. No staff members from (named Long Term Care facility) went with him in the cab to the hotel . During an interview on 7/29/2020 at 1:47 PM, the Director of Nursing confirmed that the facility should have made arrangements for a follow-up appointment with a PCP at discharge. Refer to F-660

Based on review of facility policy, medical record review, interviews, the facility failed to obtain consent for administration of a medication for 1 resident (Resident #1) of 3 residents reviewed for medication administration, resulting in Resident #1 receiving an appetite stimulant without approval from the resident or the resident's representative. The findings included: Review of the facility's policy titled, Change in a Resident's Condition or Status, dated 11/17/2017 showed .Our facility shall promptly notify the resident .and representative of changes in the resident's medical/mental condition and/or status . Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the quarterly Minimum (MDS) data set [DATE] showed the resident scored a 6 (severe cognitive impairment) on the Brief Interview Mental Status. The resident required extensive assist for bed mobility and transfers with 2 person assist and required extensive assist for Activities of Daily Living with 1 person assist. The resident was always incontinent of urine and frequently incontinent of bowel. Review of a Practitioner's Order dated 1/27/2020, not timed, showed .Orders .[MEDICATION NAME] (appetite stimulant) 7.5 mg (milligrams) PO (by mouth) q (every) hs (hour of sleep) x (times) 7 days then (increase) to 15 mg q hs . Review of the medical record showed no documentation consent for the appetite stimulant was received from the resident or the resident's representative. During an interview on 2/21/2020 at 10:00 AM Resident #1 stated the resident's daughter .takes care of everything . During an interview on 2/21/2020 at 11:55 AM, Registered Nurse (RN) #1 stated an order for [REDACTED].#1 for her to get permission from Resident #1's daughter prior to administration of the medication. During an interview on 2/21/2020 at 12:15 PM, the Nursing Supervisor stated the facility should have obtained family consent prior to administration of the appetite stimulant. During a telephone interview on 2/21/2020 at 2:15 PM, LPN #1 stated she had not been notified a signature was needed prior to administration of Resident #1's appetite stimulant. During a telephone interview on 2/21/2020 at 2:30 PM, the Assistant Director of Nursing confirmed there was no documentation to indicate consent was obtained prior to administration of the appetite stimulant to Resident #1.

Based on review of facility abuse policy, medical record review, review of facility documentation, observation and interview, the facility failed to prevent verbal abuse of 1 resident (#17) of 26 residents reviewed for abuse. The findings include: Review of the facility policy Abuse Prevention Policy and Procedure, dated 2/26/18, revealed .The purpose of this written .Prevention Program is to outline the preventive steps taken by the facility to reduce the potential for the mistreatment, neglect and abuse of residents . Medical record review revealed Resident #17 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Quarterly Minimum Data Set, dated dated [DATE], revealed Resident #17 scored an 8 on the Brief Interview for Mental Status, indicating severe cognitive impairment, with short and long term memory deficits, and was totally dependent on 2 persons to transfer. Review of the facility's documentation, dated 9/5/19, revealed 2 Certified Nursing Assistants (CNA #1 and #2) were providing care to Resident #17 when CNA #1 became upset with the resident and spoke harshly to him, using foul language. Further review revealed CNA #1 was removed from resident care. Continued review revealed CNA #1 confirmed she became upset with the resident and used the F word. Review of the Director of Nursing's (DON) summary statement revealed, Two CNA's were getting (Resident #17) up and the resident became agitated. He started to flail his arms and (CNA #1) said 'Don't you f***ing hit me.' .(CNA #1) admits to saying F***ing in front of the resident and was terminated . Observation of Resident #17 on 9/16/19 from 2:35 PM until 3:15 PM revealed he was in his wheel chair, using his arms to propel himself through the front halls of his unit. Interview with the Charge Nurse on 9/16/19 at 3:15 PM, at the nursing station, revealed .(Resident #17) is normally in the hall .always mild mannered .doesn't normally resist care . Further interview revealed Resident #17 was diagnosed with [REDACTED]. Continued interview revealed the Charge Nurse had not encountered any problems with CNA #1 prior to 9/5/19 and stated .they (referring to the facility administration) don't tolerate foul language . Interview with CNA #2 on 9/18/19 at 11:40 AM, in the conference room, revealed the facility's documentation of the events on 9/5/19 was correct. Interview with the DON on 9/18/19 at 11:50 AM, in the conference room, confirmed the verbal abuse had occurred and he stated his observation and interview of Resident #17 two hours after the incident, revealed the resident had no memory of the verbal abuse.

Based on review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, medical record review and interview, the facility failed to complete a Discharge Minimum Data Set (MDS) assessment for one resident (#19) of 3 residents reviewed for discharge MDS assessments. The findings include: Review of the RAI Version 3.0 Manual Chapter 2: Assessments for the RAI revealed .Discharge assessment .Must be completed .within 14 days after the discharge date . Medical record review revealed Resident #19 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Further review revealed the resident was discharged from the facility on [DATE]. Medical record review of the resident's MDS assessments revealed a discharge MDS assessment for Resident #19 had not been completed from the day of discharge, [DATE], to the present day, [DATE]. Interview with the MDS Coordinator on [DATE] at 5:06 PM, in the conference room, confirmed Resident #19 expired on [DATE] in the facility. Continued interview confirmed the facility had not complete a Discharge MDS assessment for Resident #19.