Every finding on record at Bolivia Rehabilitation and Healthcare Center

Based on record review and staff interviews, the facility failed to implement a facility-wide system to monitor the use of antibiotics. This was evident for 8 of 9 months (July 2025, August 2025, September 2025, October 2025, November 2025, December 2025, February 2026, March 2026) that surveillance data was reviewed. This practice had the potential to affect all residents in the facility. Findings included: The facility's Antibiotic Stewardship Program policy last revised on December 2016, indicated that all clinical infections treated with antibiotics will undergo review by the Infection Preventionist or designee. The Infection Preventionist will review antibiotic utilization as part of the antibiotic stewardship program and identify specific situations that are not consistent with the appropriate use of antibiotics. The antibiotic stewardship program will review essential data including antibiotic orders, clinical documentation, infection surveillance logs, microbiology testing, other tests to confirm infections, and trends in data including a listing of antibiotic orders, clinical documentation confirming the infection, surveillance logs and trending of infections. The facility was unable to provide any infection control data including no listing of antibiotic orders, clinical documentation confirming the infection, surveillance logs or trending of infections for July 2025, August 2025, September 2025, October 2025, November 2025, and December 2025.A review was conducted of resident infections reported in January 2026. The list included residents who exhibited symptoms and were treated with antibiotics during the month. The facility did not utilize a structured tool to track infection rates, antibiotic use, or to monitor, conduct surveillance, or identify trends related to infections or possible infections among residents during this period.The facility was unable to provide any infection control data including no listing of antibiotic orders, clinical documentation confirming the infection, surveillance logs or trending of infections for February 2026 and March 2026. An interview with the Director of Nursing (DON) on 4/22/26 at 11:50 AM revealed that she assumed the position on 4/13/26, following a period in which several interim Directors of Nursing had served. The current DON stated that she was unable to locate Infection Control reports, surveillance records, or infection tracking data for the period of July 2025 through April 2026 except for the January list of residents that received antibiotics. The DON acknowledged that she was expected to function as the Infection Preventionist in addition to fulfilling her responsibilities as the DON. She explained that she had just begun reviewing the infection control information for April 2026 and stated that moving forward, she would implement a system to ensure infection surveillance data was compiled and reviewed monthly.An interview with the Administrator on 4/22/26 at 4:30 PM revealed that the facility had multiple interim Directors of Nursing since she started in her position at the facility in July 2025. The Administrator stated that the tracking of infection control data, including infection trends and antibiotic use, had not been completed. The Administrator explained that the Infection Control Program was intended to be a comprehensive system that included surveillance, tracking, and trend analysis. She stated that she had been in her role only a short time and had not had a consistent Infection Preventionist in place. The Administrator further noted that her expectation was for the Infection Preventionist to follow facility protocols and complete all tasks related to the antibiotic stewardship program, including surveillance and tracking of infection and antibiotic use trends.

Based on record review, and interviews with facility staff, the Nurse Practitioner, Pharmacy Consultant and the Pharmacy Director, the facility failed to 1) have effective safeguards and systems in place to prevent drug diversion of discontinued Oxycodone (narcotic pain medication), Hydrocodone/Acetaminophen (narcotic pain medicine with Tylenol) and Lorazepam (an antianxiety medication); and 2) failed to have an effective tracking system to monitor declining count sheets and remove discontinued controlled substances from the medication cart for 5 of 6 residents reviewed for drug diversion (Residents #9, #41, #69, #94, and #95). These failures resulted in inaccurate narcotic counts and had the potential for residents being administered incorrect medications, and receiving narcotics that were not physician ordered. Findings included: 1a. A physician's order was written on 07/18/25 to discontinue Lorazepam 0.5mg every 8 hours as needed for anxiety for Resident #9. The declining count sheet (an inventory log used to record a running total for each controlled medication) for 90 Lorazepam 0.5mg tablets with prescription #979977 for Resident #9 revealed the Lorazepam 0.5 mg was documented having a total of 83 tablets remaining on the count sheet. An undated note written on the count sheet revealed 82 tablets were returned, one tablet was missing. An interview with the Regional Clinical Director on 04/24/26 at 10:17 AM revealed according to the investigation that she, the previous DON and the Administrator initiated on 12/30/25 it was found that Resident #9 had one tablet missing from the declining count sheet. The documented number of tablets left should have been 83 but the total count was 82 tablets. The Regional Clinical Director stated a total of 82 tablets were returned to the pharmacy. Review of the Prescriptions Returned To Pharmacy Log revealed the prescription for Resident #18 with prescription #979977 for Lorazepam 0.5 mg had a quantity of 82 tablets recorded as returned on 01/17/26. A phone interview was conducted with the Pharmacy Director on 04/24/26 at 3:17 PM. The Pharmacy Director reviewed the Prescriptions Returned to Pharmacy Log that was sent back to the pharmacy. He confirmed that 82 tablets of Lorazepam were returned 01/17/26. He stated there were no documented discrepancies and added when the pharmacy received medications back from the facility, the medications were reviewed to verify contents and quantity returned. An interview with the current Director of Nursing (DON) on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance had been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located on the medication cart. The DON stated at the time of the investigation (12/30/25) it was the responsibility of all the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the controlled substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and verify the serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the system failure was that the controlled medication was discontinued on 07/18/25 and should have been returned back to the pharmacy when the order was discontinued. 1b.) A physician's order written on 04/23/25 which was discontinued on 07/24/25 for Resident #41 revealed Oxycodone 5 milligrams (mg) tablets, one tablet by mouth every 8 hours for pain as needed. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 04/28/25 a total of 90 Oxycodone 5 mg tablets for Resident #41 with prescription #991627 were delivered to the facility. The delivery receipt was signed off as received by night shift Nurse #12 on 04/28/25. The declining count sheet for 90 Oxycodone 5mg tablets with prescription #991627 that were delivered to the facility on [DATE] for Resident #41 revealed the first dose was signed off as removed on 09/14/25 at 12:00 PM leaving 89 pills remaining. The second dose was signed off as removed on 09/21/25 at 4:00 PM leaving 88 pills remaining, the third dose was signed off as removed on an illegible date at 5:10 AM leaving a total of 87 tablets remaining. There was no signature recorded indicating which nurse removed the medication on each day that the medications were removed. On 12/30/25 at 1:13 PM the count was noted to be 90 tablets and a note on the declining sheet indicated the count was corrected by the Regional Clinical Director and the previous Director of Nursing for 90 tablets. An undated note on the declining count sheet also revealed 87 pills returned and 3 pills did not match. A phone interview with the previous Director of Nursing on 04/24/26 at 12:37 PM revealed on 12/30/25 there were multiple incidents where blister packs were perforated and taped back up. She stated an investigation began due to the tampering of the narcotic blister packs and it was discovered that the narcotics were being replaced with other medications such as blood pressure medications. The DON could not recall if the Oxycodone blister pack she identified as being taped up and tampered with on 12/30/25 belonged to Resident #41, but she knew it was Oxycodone and that the replacement tablets that were noted in the blister packs were Metoprolol (a blood pressure medication) which made the count remaining look as though there were 90 tablets. An interview with the Regional Clinical Director on 04/24/26 at 10:17 AM revealed according to the investigation she, the previous DON and the Administrator initiated on 12/30/25 it was found that Resident #41 had 3 pills that were removed from the blister pack of Oxycodone 5mg and were replaced with 3 Metoprolol tablets. She stated when she and the previous DON did the count there were 90 tablets left, but it was realized 3 of the tablets were Metoprolol and were removed leaving a remainder of 87 tablets of Oxycodone which were returned back to the pharmacy. Review of the Prescriptions Returned To Pharmacy Log revealed the prescription date of 04/28/25 for Resident #41 with prescription #991627 for Oxycodone 5 mg had a quantity of 87 tablets recorded as returned on 01/17/26. An interview was conducted with the Nurse Practitioner on 04/24/26 at 1:30 PM and confirmed Resident #41 did not have a physician's order for Metoprolol. The Nurse Practitioner stated if Resident #41 had received the Metoprolol in error due to being replaced in the Oxycodone blister pack it may have lowered his blood pressure and heartrate and could have caused a syncopal event (a temporary loss of consciousness known as fainting or passing out caused by a sudden drop in blood pressure). A phone interview was conducted with the Pharmacy Director on 04/24/26 at 3:17 PM. The Pharmacy Director reviewed the Prescriptions Returned to Pharmacy Log that was sent back to the pharmacy. He confirmed that 87 Oxycodone tablets were returned 01/17/26. He stated there were no documented discrepancies and added when the pharmacy received medications back from the facility, the medications were reviewed to verify contents and quantity returned. The Pharmacy Director stated had Resident #41 received the Metoprolol in error it would have had the potential to lower his blood pressure and heartrate. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance had been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box on the medication cart. The DON stated at the time of this investigation (12/30/25) it was the responsibility of the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the secured controlled substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and verify the serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the system failure was that the controlled medication for Resident #41 was discontinued on 07/24/25 and should have been returned back to the pharmacy when the order was discontinued. 1c.) A physician's order written on 06/18/25 and discontinued on 11/12/25 for Resident #69 revealed Hydrocodone/Acetaminophen (Tylenol) 10mg/325mg one tablet by mouth every six hours as needed for pain. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 09/10/25 a total of 60 Hydrocodone/Acetaminophen 10mg/325mg tablets for Resident #69 with prescription #1144328 were delivered to the facility. The delivery receipt was not signed off as received by a nurse. The declining count sheet for 60 Hydrocodone/Acetaminophen 10mg/325 mg tablets that were delivered to the facility on [DATE] for Resident #69 with prescription #1144328 revealed the remaining count was recorded at 43 tablets. The declining count sheet had 17 doses signed out as being removed. An undated note on the declining count sheet indicated 42 pills were returned and 1 pill did not match. A phone interview with the previous Director of Nursing on 04/24/26 at 12:37 PM revealed she could not recall if the Hydrocodone/Acetaminophen 10mg/325mg blister pack she identified as being taped up and tampered with on 12/30/25 belonged to Resident #69, but she knew it was Hydrocodone/Acetaminophen and the replacement tablet was replaced with a lower dose of Hydrocodone/Acetaminophen 5mg/325mg. An interview with the Regional Clinical Director on 04/24/26 at 10:17 AM revealed according to the investigation she, the previous DON and the Administrator initiated on 12/30/25 it was found that Resident #69 had a blister pack of Hydrocodone/Acetaminophen 10mg/325mg but that there was one tablet removed and was replaced with Hydrocodone/Acetaminophen 5mg/325mg. She stated the remaining 42 tablets were returned back to the pharmacy. Review of the Prescriptions Returned To Pharmacy Log revealed the prescription date of 09/10/25 for Resident #69 with prescription #1144328 Hydrocodone/Acetaminophen 10mg/325mg had a quantity of 42 tablets recorded as returned on 01/17/26. A phone interview was conducted with the Pharmacy Director on 04/24/26 at 3:17 PM. The Pharmacy Director reviewed the Prescriptions Returned to Pharmacy Log that was sent back to the pharmacy. He confirmed that a total of 42 tablets of Hydrocodone/Acetaminophen 10mg/325mg were returned 01/17/26. He stated there were no documented discrepancies and added when the pharmacy received medications back from the facility, the medications were reviewed to verify contents and quantity returned. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance has been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located on the medication cart. The DON stated at the time of this investigation (12/30/25) it was the responsibility of the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the secured controlled substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and verify the serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the Hydrocodone/Acetaminophen 10mg/325mg was discontinued on 11/12/25 and should not have still been in the controlled substance box on the medication cart. The DON stated the system failure was that the controlled medication was not returned back to the pharmacy when the medication was discontinued. 1d.) A physician's order written on 12/05/25 and discontinued on 12/08/25 for Resident #94 revealed Oxycodone 5 mg one tablet by mouth every 4 hours as needed for pain for up to 7 days, and a physician's order written on 12/05/25 for Hydroxyzine (anti-itch medication) 25 mg one tablet every 8 hours for itching for 15 days; which was discontinued on 12/19/25. Resident #94 did not have physician orders in place for Seroquel (a medication to treat psychiatric diagnoses) or Metoprolol (a medication to treat high blood pressure). A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 12/06/25 a total of 30 Oxycodone 5 mg tablets for Resident #94 with prescription #1268757 were delivered to the facility. The delivery receipt was received by Nurse #14 on 12/06/25. The declining count sheet for 30 Oxycodone 5 mg tablets that were delivered on 12/06/25 with prescription #1268757 for Resident #94 revealed the remaining count was recorded as 18 tablets remaining. A total of 12 doses were signed out as removed from the declining count sheet. An undated handwritten note on the declining count sheet indicated 12 pills were returned with 6 pills that did not match. A phone interview with the previous Director of Nursing on 04/24/26 at 12:37 PM revealed she could not recall if the Oxycodone blister pack she identified as being taped up and tampered with on 12/30/25 belonged to Resident #94, but she knew it was Oxycodone and there were other medication pills that were replaced in the blister pack, but she could not recall how many or what the pills were. An interview with the Regional Clinical Director on 04/24/26 at 10:17 AM revealed according to the investigation she, the previous DON and the Administrator initiated on 12/30/25, Resident #94 had 3 pills that had been replaced with Seroquel, 2 pills were replaced with Metoprolol and one pill was replaced with Hydroxyzine. She stated that a total of 12 tablets of Oxycodone 5 mg were returned back to the pharmacy. Review of the Prescriptions Returned To Pharmacy log revealed the prescription date of 12/05/25 for Resident #94 with prescription #1268757 Oxycodone 5 mg had a quantity of 12 tablets returned on 01/17/26. A phone interview was conducted with the Pharmacy Director on 04/24/26 at 3:17 PM. The Pharmacy Director reviewed the Prescriptions Returned to Pharmacy Log that was sent back to the pharmacy. He confirmed that a total of 12 tablets of Oxycodone 5 mg were returned on 01/17/26. He stated there were no documented discrepancies and added when the pharmacy received the medications back from the facility, they were reviewed to verify contents and quantity returned. The Pharmacy Director stated had Resident #94 received the Metoprolol in error it would have had the potential to lower his blood pressure and heartrate and had he received the Seroquel it could have caused Resident #94 to be lethargic (sleepy). An interview with the Nurse Practitioner on 04/24/26 at 1:30 PM confirmed that Resident #94 did not have a physician's order for Seroquel or Metoprolol, but he did have an order for Hydroxyzine which was discontinued on 12/15/25. The Nurse Practitioner stated had Resident #94 received the Metoprolol or Seroquel he could have had syncopal event and increased lethargy as result. The Nurse Practitioner stated there was no allergy listed for either medication for Resident #94. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance has been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located on the medication cart. The DON stated at the time of this investigation (12/30/25) it was the responsibility of the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the box located in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and verify the serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the Oxycodone 5mg medication was discontinued on 12/08/25 and should not have still been in the controlled substance box on the medication cart. The DON added that the system failure was not returning the controlled medication back to the pharmacy when it was discontinued. 1e.) A physician's order written on 12/19/25 for Resident #95 revealed Oxycodone 5mg; give 5mg every 6 hours as needed for pain for 3 days. This order was discontinued on 12/22/25. Resident #95 did not have an order in place for Metoprolol. A packing slip and proof of delivery receipt from the dispensing pharmacy revealed on 12/19/25 a total of 12 Oxycodone 5mg tablets for Resident #95 with prescription #1294991 were delivered to the facility. The delivery receipt was signed off with an illegible name on 12/20/25. The declining count sheet for Oxycodone 5mg one tablet by mouth every 6 hours as needed for pain for Resident #95 with prescription #1294991 revealed the remaining count was 9 tablets. There were three doses signed out as removed by a nurse. An undated handwritten note on the declining count sheet indicated that 8 pills were returned and one pill did not match. A phone interview with the previous Director of Nursing on 04/24/26 at 12:37 PM revealed she could not recall if the Oxycodone blister pack identified as being taped up and tampered with on 12/30/25 belonged to Resident #95, but she knew it was Oxycodone and there were other medication pills that were replaced in the blister pack. An interview with the Regional Clinical Director on 04/24/26 at 10:17 AM revealed according to the investigation she, the previous DON and the Administrator initiated on 12/30/25, Resident #95 had one pill that had been replaced with Metoprolol. Review of the Prescriptions Returned To Pharmacy log revealed the prescription date of 12/19/25 for Resident #95 with prescription #1294991 Oxycodone 5mg had a quantity of 8 tablets recorded as returned on 01/17/26. A phone interview was conducted with the Pharmacy Director on 04/24/26 at 3:17 PM. The Pharmacy Director reviewed the Prescriptions Returned to Pharmacy Log that was sent back to the pharmacy. He confirmed that a total of 8 tablets of Oxycodone 5mg were returned 01/17/26. He stated there were no documented discrepancies and added when the pharmacy received the medications returned back from the facility, they were reviewed to verify contents and quantity returned. The Pharmacy Director stated had Resident #95 received the Metoprolol in error it would have had the potential to lower his blood pressure and heartrate. An interview was conducted with the Nurse Practitioner on 04/24/26 at 1:30 PM and confirmed Resident #95 did not have a physician's order for Metoprolol. The Nurse Practitioner stated if Resident #95 had received the Metoprolol in error due to being replaced in the Oxycodone blister pack it may have lowered his blood pressure and heartrate and could have caused a syncopal event. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance had been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located in the medication cart. The DON stated at the time of this investigation (12/30/25) it was the responsibility of the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the controlled substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and verify the serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the Oxycodone 5mg medication was discontinued 12/22/25 and should not have still been in the controlled substance box on the medication cart. The DON added that the system failure was not returning the controlled medication back to the pharmacy when it was discontinued. A phone interview was conducted with Nurse #5 on 04/23/26 at 7:38 PM. Nurse #5 stated on the morning of 12/30/25 when she arrived for her shift, she noticed that Nurse #6 was doing the narcotic count with Nurse #7 and Nurse #6 stated she was not taking the keys to cart because there were some narcotic blister packs that were tampered with on the 300 hall medication cart. Nurse #5 stated she worked on the 400 hall medication cart and thought it best to look through her cart to see if there were any tampered narcotic blister packs on her cart. Nurse #5 stated she identified a few (could not recall how many or for which residents) and notified the Nurse Supervisor. Nurse #5 stated some of the blister packs were taped up and some had the tiniest little sliver break noted on the back of the blister pack. She stated the Administrator saw that there were different pills replaced in the blister packs and the previous Director of Nursing did a narcotic count on the 400 hall medication cart and there were no other discrepancies. Nurse #5 stated she had to complete a drug test and it was negative for opioids (narcotic pain medications). A phone interview was conducted with Nurse #7 on 04/24/26 at 11:27 AM. Nurse #7 reported when she arrived for her shift 7:00 PM to 7:00 AM on 12/29/25 she had begun to do her narcotic medication count for 300 hall medication cart with Nurse #1. Nurse #7 stated the narcotic count appeared to be accurate; however, it was noted there were two blister packs for Oxycodone that had tape on the back side of the packs. Nurse #7 stated she did not remember which resident the blister packs belonged to or the dose of the medication. Nurse #7 stated, at that time, she told Nurse #1 that they should waste the medications that were taped up in the blister pack and Nurse #1 stated no. Nurse #7 stated the tablets that were taped up were noted to be on the bottom right hand corner of the blister pack. Nurse #7 stated she should have reported this to the supervisor and not taken over the medication cart keys until it was investigated. Nurse #7 stated she did not see tape on any of the other narcotic cards but she knew that having tape on the blister packs was not right and the integrity of the blister pack had been tampered with. Nurse #7 stated when she did the shift change count off on 12/30/25 with Nurse #6 and showed her the taped up Oxycodone blister packs, Nurse #6 stated they needed to call the Director of Nursing immediately and she would not accept the keys to the 300 hall medication cart. Nurse #7 stated she was asked to do a drug screening test and it was negative for opioids. A phone interview was conducted with Nurse #6 on 04/24/26 at 12:07 PM. Nurse #6 reported on the morning of 12/30/25 she arrived for her shift and had begun to do her narcotic medication count with Nurse #7 who worked the night shift. Nurse #6 stated while they were doing the count, Nurse #7 pointed out that there were two narcotic blister packs of Oxycodone that had tape covering the back of the blister pack. Nurse #6 stated when Nurse #7 showed her the blister packs, it looked as though the Oxycodone pills had been popped out of the blister pack but there were different pills in place in the blister packs that were taped up. Nurse #6 stated she did not remember which resident the blister packs belonged to or what the dose of the medication was. Nurse #7 stated to Nurse #6 that the pills that were in the blister pack did not match the description of an Oxycodone tablet and both Nurse #7 and Nurse #6 looked up the description of the tablets that were replaced on the internet to check and see what medications were put in place. She stated the medication was Metoprolol which was a blood pressure medication for one of the blister packs and the other blister pack had been replaced with a lower dose of Oxycodone. Nurse #7 stated she reported the concern to the Weekend Supervisor and she called the Administrator and the previous Director of Nursing. Nurse #6 stated she was not asked to do a drug screening test. A phone interview was conducted with Nurse #1 on 04/24/26 at 7:30 PM. Nurse #1 stated she was nurse doing the shift change with Nurse #7 on the evening of 12/29/25. She stated she recalled Nurse #7 showing her the taped up narcotic blister packs and asked if they should waste the medications that were taped up. Nurse #1 stated she told Nurse #7 not to waste it. Nurse #1 stated sometimes medications would accidentally pop out and she would tape them back up if she saw them falling out. Nurse #1 stated she did not know that the narcotics were replaced with other medications. Nurse #1 stated the DON asked her to do a drug test and she refused to do a drug test that day because she was not feeling well and then was terminated for not doing the drug test. An interview was conducted with the current Director of Nursing on 04/24/26 at 5:10 PM. The DON stated the system failure was that controlled substances were not being returned to the pharmacy when they were discontinued and that resulted in the misappropriation of the narcotics. The DON stated education was initiated when this occurred to be sure when doing the controlled substance count at shift change, both nurses should be checking for accuracy of the right medication and checking the blister packs for any signs of being tampered with, but she would reinforce that education along with providing education for making sure all discontinued narcotics were returned to the pharmacy according to the procedure. 2a. A physician's order was written on 07/18/25 to discontinue Lorazepam 0.5mg every 8 hours as needed for anxiety for Resident #9. The declining count sheet for 90 Lorazepam 0.5mg tablets with prescription #979977 for Resident #9 revealed the Lorazepam 0.5mg was documented as removed on 09/10/25, 09/30/25, 10/03/25, 10/05/25, and 12/03/25 by Nurse #1. On 11/19/25, one (1) tablet was documented as removed by Nurse #20. There was no active physician order for this medication during these dates. Review of the Medication Administration Record for September 2025, October 2025, and December 2025 revealed there was no active order for Lorazepam 0.5mg recorded on the Medication Administration Records for Nurse #1 and Nurse #20 to sign off as administered. An interview was attempted with Nurse #20 via phone on 04/24/26 at 12:33 PM. A voice mail message was left but Nurse #20 but did not return the phone call. A phone interview was conducted with Nurse #1 on 04/24/26 at 7:30 PM. Nurse #1 stated my system was not good and clarified that she knew which medications her residents' received and she would administer them without looking at the order. Nurse #1 stated she should have reviewed the physician order on the electronic medication administration record (eMAR) to be sure there was an order before she administered the medication. Nurse #1 stated whenever she removed the Lorazepam for Resident #9, she administered the medication to him. An interview was conducted with the Nurse Practitioner on 04/24/26 at 1:30 PM and confirmed Resident #9's Lorazepam order for 0.5mg was discontinued on 07/18/25 and there was no active order to administer this medication after that date in 2025. The Nurse Practitioner stated the medication should not have been removed to be administered if there was no active order for it. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance has been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located on the medication cart. The DON stated in 2025, it was the responsibility of the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the secured controlled substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag with a serial number. She stated two nurses were required to verify the tote was sealed and serial numbers of the tags. She stated the declining count sheet and the proof of delivery receipt should be attached together and kept on file. The DON stated the system failure was that the controlled medication was discontinued on 07/18/25 and should have been returned back to the pharmacy when the order was discontinued. The DON added that Nurse #1 and Nurse #20 should not have documented the removal of the Lorazepam tablets since there was not an active order. She stated before nursing staff removed a medication from the blister pack, they should be confirming there was a physician's order, check the order against the controlled substance blister pack, sign and date the declining count sheet with the number of tablets remaining after removal, and then sign off the administration of the medication on the Medication Administration Record. 2b. A physician's order written on 04/23/25 for Resident #41 and discontinued on 07/24/25 for Oxycodone 5mg tablet, one tablet by mouth every 8 hours for pain as needed. There was no active physician order for Oxycodone 5mg to be given from 07/25/25 through 09/10/25. The declining count sheet for 90 Oxycodone 5mg tablets with prescription #909487 for Resident #41 revealed the Oxycodone 5mg was documented as removed on 08/08/25 and 09/06/25 by Nurse #1. There was no active physician order for this medication at this time. Review of the Medication Administration Record for August 2025, revealed there was no order for Oxycodone 5mg recorded on the Medication Administration Records for Nurse #1 to sign off as given on 08/08/25 and 09/06/25. An interview was conducted with Nurse #1 on 04/24/26 at 7:30 PM. Nurse #1 stated my system was not good and clarified that she knew which medications her residents' received and she would administer them without looking at the order. Nurse #1 stated she should have reviewed the physician order on the electronic medication administration record (eMAR) to be sure there was an active order before she administered the medication. Nurse #1 stated whenever she removed the Oxycodone for Resident #41, she administered the medication to him. An interview was conducted with the Nurse Practitioner on 04/24/26 at 1:30 PM and confirmed Resident #41's Oxycodone 5mg order was discontinued on 07/24/25 and there was no active order to administer this medication on 08/08/25 and 09/06/25. The Nurse Practitioner stated the medication should not have been removed to be administered if there was no active order for it. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM revealed when a narcotic or controlled substance has been discontinued, the procedure was that the discontinued blister pack should be removed from the controlled substance box located on the medication cart. The DON in 2025, it was the responsibility of all the floor nurses who were on the medication cart to be sure any discontinued controlled substances were removed from the control substance box in the medication cart and sent back to the dispensing pharmacy utilizing the Prescriptions Returned to Pharmacy Log. The controlled substances were to be placed in a tote with a secured zip tie tag [TRUNCATED]

Based on observations, record review and staff interviews the facility failed to treat a resident in a respectful and dignified manner when Resident #19 was seated in his geriatric wheelchair (a special medical recliner with a wheeled base designed for older adults and individuals with mobility issues) and Nurse Aide #1 pulled the wheelchair down the hall with the resident positioned behind her resulting in the resident being unable to see where he was going. A reasonable person would have had the expectation of being treated with dignity and would have wanted to be wheeled facing forward. In addition, the facility failed to promote dignity during meals when Nurse Aide #1 and Nurse Aide #4 were observed standing over the bedside feeding Resident #19 and Resident #33 who required total dependent care with eating. A reasonable person would have the expectation of being treated with dignity while dining. This occurred for 2 of 6 residents reviewed for dignity (Resident #19 and Resident #33). Findings included: 1. Resident #19 was admitted to the facility on [DATE] with diagnoses of dementia and anxiety. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #19 had severe cognitive impairment. An observation of Resident #19 on 04/20/26 at 1:30 PM revealed the resident was seated in a geriatric wheelchair, slumped over with his head hanging over the chair and with his eyes opened. Resident #19 was noted to be moaning as Nurse Aide #1 was pulling the geriatric wheelchair down the hall. Resident #19 was facing the opposite direction of travel and was not able to see where he was being taken by NA #1. An interview was conducted with Nurse Aide #1 on 04/20/26 at 1:30 PM. Nurse Aide #1 stated she had been educated and in-serviced on treating residents with dignity and respect and realized that she should not have been pulling the resident from behind her and instead should have pushed him in front of her. NA #1 stated the wheelchair was hard to push and that was why she was pulling it. Nurse Aide #1 stated she was not aware he was slumped over the chair or that he was moaning and if he had been in front of her, she would have visualized and heard Resident #19. At this time, Nurse Aide #1 turned Resident #19's geriatric wheelchair around so that he was being pushed in front of her and repositioned him. An interview with the Director of Nursing (DON) on 04/24/26 at 3:30 PM revealed that the Nurse Aide should have been pushing the resident in front her and not pulling him. The DON stated it was a dignity issue, and staff should be treating all residents with dignity and respect. The Director of Nursing added that had the nurse aide been pushing the resident in front of her she would have seen that he was slumped over and perhaps he was moaning due to his positioning. 2. Resident #33 was admitted to the facility on [DATE] with a diagnosis of traumatic brain injury. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #33 had severely impaired cognition. He was dependent on staff assistance with eating.During an observation of the lunch meal on 4/22/26 at 1:20 PM. Resident #33 was observed in bed in his room with the head of the bed elevated. Resident #33 was assisted with eating by Nurse Aide #4 who was standing at the bedside over Resident #33 and was not at eye level. A chair was observed in Resident #33's room. During an interview on 4/22/26 at 1:20 PM Nurse Aide #4 stated she was an agency nurse aide and had been a nurse aide for 10 years and had never heard of having to sit down to feed a resident. She asked if she needed to pull up a chair to continue assisting Resident #33 with eating. Nurse Aide #4 then placed a chair that was in the room at the bedside and sat down at eye level and continued to assist Resident #33 with his meal. During an interview on 4/24/26 at 1:30 PM the Director of Nursing (DON) stated staff should be providing care to residents while promoting and maintaining dignity. She stated staff were to sit down with residents while assisting them with eating to promote dignity. The DON stated Nurse Aide #4 was an agency Nurse Aide and she was uncertain of what type of education on resident rights and promoting dignity that agency staff had received. 3. Resident #19 was admitted to the facility on [DATE]. Review of an annual Minimum Data Set assessment dated [DATE] revealed Resident #19 had severely impaired cognition and was dependent on staff for all activities of daily living. During the lunchtime meal on 04/24/26 at 1:01 PM Nurse Aide #1 was observed standing over Resident #19 while feeding him his meal in the dining room. Resident #19 was positioned in a geriatric chair, semi-reclined, with his eyes closed as he was fed. An empty chair was observed in the dining room that was available for Nurse Aide #1 to use. Nurse Aide #1 was interviewed at the completion of the observation on 04/24/26 and stated she did not have a chair to sit on during the meal but realized as she looked around the room that there was a chair available across the room for her to sit on as she fed the resident. She also stated that she needed to stand as she fed Resident #19 because she had to keep an eye on the other 3 residents seated at another table in the dining room who were feeding themselves. She reported she was the only staff member in the dining area. In an interview with the Director of Nursing on 04/24/26 at 2:20 PM she stated that she expected staff to sit when assisting a resident during a meal.

Based on record review, and staff and Nurse Practitioner interviews, the facility failed to follow a physician's order when nursing staff administered the wrong dose of a prescription opioid pain medication 5 times for 1 of 6 residents reviewed for medications (Resident #69). Findings included: Resident #69 was admitted to the facility on [DATE]. Diagnoses included peripheral vascular disease (narrowed or blocked blood vessels, typically affecting legs and feet, that can cause pain and cramping in the leg muscles) and status post above the knee amputation of left leg. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #69 was moderately cognitively impaired. Resident #69 did not receive scheduled pain medication but did receive as needed pain medication for a pain rating of 6 out of 10. Resident #69 was coded as receiving opioids (narcotic pain medication) during this assessment. A physician's order written on 06/18/25 and discontinued on 11/12/25 for Resident #69 revealed Hydrocodone/Acetaminophen (Tylenol) 10mg/325mg one tablet by mouth every 6 hours as needed for pain. A physician's order written on 11/12/25 and discontinued on 11/19/25 for Resident #69 revealed Hydrocodone/Acetaminophen 5mg/325mg one tablet by mouth every 6 hours as needed for pain. Review of the November 2025 Medication Administration Record (MAR) revealed there were two orders on the MAR. One order was for documenting the administration of the Hydrocodone/Acetaminophen 10mg/325mg. This order was in effect until 11/12/25. There was no documentation to support that 10mg/325mg was given from 11/01/25 thru 11/12/25. On the same page of this November 2025 MAR, revealed an order for Hydrocodone/Acetaminophen 5mg/325mg starting on 11/12/25. The following days were noted that the discontinued order of Hydrocodone/Acetaminophen 10mg/325mg were removed from the declining count sheet: On 11/16/25 Nurse #17 documented on the MAR at 10:00 PM she administered Hydrocodone/Acetaminophen 5mg/325mg, but the declining count indicated Nurse #17 removed one tablet of Hydrocodone/Acetaminophen 10mg/325mg. On 11/17/25 Nurse #17 documented on the MAR at 10:00 PM she administered Hydrocodone/Acetaminophen 5mg/325mg, but the declining count indicated Nurse #17 removed one tablet of Hydrocodone/Acetaminophen 10mg/325mg. On 11/18/25 Nurse #17 documented on the declining count sheet at 5:00 AM she removed one tablet Hydrocodone/Acetaminophen 10mg/325mg. There was no documentation on the MAR that the narcotic pain medication was given at this time. On 11/18/25 Nurse #15 documented on the MAR at 2:08 PM she administered Hydrocodone/Acetaminophen 5mg/325mg, but the declining count indicated Nurse #15 removed one tablet of Hydrocodone/Acetaminophen 10mg/325mg. On 11/18/25 Nurse #20 documented on the declining count sheet at 9:00 PM she removed one tablet Hydrocodone/Acetaminophen 10mg/325mg. There was no documentation on the MAR that the narcotic pain medication was given at this time. An interview was attempted via phone with Nurse#20 on 04/24/26 at 12:30 PM. Nurse #20 did not return the call. An interview was attempted via phone with Nurse #17 on 05/04/26 at 4:22 PM. Nurse #17 did not return the call. An interview was attempted via phone with Nurse #15 on 05/04/26 at 4:23 PM. Nurse #7 did not return the call. An interview with the Nurse Practitioner on 04/24/26 at 1:30 PM confirmed that from 11/12/25 through 11/19/25 Resident #69 had an order for Hydrocodone/Acetaminophen 5mg/325mg. The Nurse Practitioner stated the nurses removed the 10mg/325mg tablet instead of 5mg/325mg resulting in Resident #69 receiving the wrong dose. The Nurse Practitioner reviewed her progress notes during this time frame and reported there was no negative outcome as a result of Resident #69 receiving the wrong dose. An interview was conducted with the Director of Nursing on 04/24/26 at 4:00 PM. The Director of Nursing stated that the order for the Hydrocodone/Acetaminophen 10mg/325mg was discontinued on 11/12/25 and the declining count sheet and the blister pack for that dose should have been removed from the controlled substance box on the medication cart when it was discontinued. The DON stated had the nurses removed the discontinued Hydrocodone/Acetaminophen 10mg/325mg it could have prevented Resident #69 from getting the wrong dose.

Based on observations, record review, and resident and staff interviews, the facility failed to assist a resident who was dependent on staff for feeding assistance with a meal. This resulted in Resident #2, who was cognitively impaired, waiting for assistance with eating after the meal tray was placed within view at the bedside. This occurred for 1 of 3 residents reviewed for assistance with activities of daily living (Resident #2). Findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury and diabetes. A care plan dated 2/28/26 revealed Resident #2 had activities of daily living (ADL) self-care deficit related in part to; failure to thrive, lack of coordination, and muscle weakness. Interventions included to assist with ADL's including eating. Resident #2 was totally dependent on staff with eating her meals. The Minimum Data Set (MDS) comprehensive assessment dated [DATE] revealed Resident #2 had moderately impaired cognition. She was dependent on staff for feeding assistance. Resident #2 received Hospice services. During an observation on 4/22/26 at 9:20 AM Resident #2 was observed in her room seated upright in bed. The breakfast tray was on the bedside table in view of Resident #2. During an interview on 4/22/26 at 9:20 AM Nurse Aide #5 stated she was an agency nurse aide and today was her third day in the facility. She stated she had 16 residents on her assignment, and she had two residents that needed assistance with eating. She stated the assignment was busy since she was not familiar with the residents, but she was getting ready to start assisting the residents that needed assistance with eating. Nurse Aide #5 stated she was assisting other residents and had not had time to sit and assist Resident #2 with eating yet. Nurse Aide #5 stated the cart with the breakfast trays came out on the hallway around 9:00 AM. During an interview on 4/22/26 at 9:25 AM Nurse #8 stated she was the assigned nurse for the 200 hall. She stated there were two residents including Resident #2 on the 200 hall that needed assistance with eating. She stated Resident #2 was dependent on staff with eating. A continuous observation conducted on 4/22/26 from 9:20 AM until 9:45 AM revealed no staff member entered Resident #2's room to assist her with eating breakfast. During an observation on 4/22/26 at 9:45AM Nurse #8 was observed sitting at the nurses' station. When asked if she knew Resident #2 still had not been fed her breakfast meal, she stated that Nurse Aide (#5) had not asked her for help. Nurse #8 stated she was not aware Resident #2 had not been fed her breakfast yet. Nurse #8 stated she would go assist Resident #2. During an observation on 4/22/26 at 9:50 AM Nurse #8 was observed in Resident #2's room assisting her with eating her breakfast meal. During an interview on 4/22/26 at 9:50 AM Resident #2 was asked by the Surveyor if her food was warm enough to eat. Resident #2 stated yes. During an interview on 4/22/26 at 10:30 AM the Unit Manager stated Resident #2 was dependent on staff assistance with ADL care including eating. She stated Resident #2's appetite varied, she has had weight loss and was currently on Hospice services. During an interview on 4/22/26 at 11:00 AM the Director of Nursing (DON) stated she was new to the facility and had been the DON for three weeks. She stated Resident #2 should not have waited 45 minutes to be assisted with eating her breakfast meal. The DON stated the Nurse on the hallway should assist the Nurse Aides during meals to ensure that the residents that needed assistance with eating didn't have to wait for that length of time to be assisted by staff.

Based on record review and staff and Nurse Practitioner interviews, the facility failed to obtain weights as ordered by the physician and failed to verify the accuracy of weights after significant weight changes for 1 of 3 residents reviewed for weight monitoring (Resident #32).Findings included: Resident #32 was admitted to the facility on [DATE] with diagnoses including end stage renal disease with dependence on hemodialysis, and congestive heart failure (CHF). A physician's order dated 1/29/26 for Resident #32 revealed to obtain daily weights for CHF. Record review revealed the following documented weights for Resident #32 for February 2026: 02/01/26 - 190.6 lbs. (pounds) 02/03/26 - 193.6 lbs.02/09/26 - 194.0 lbs.02/10/26 - 194.4 lbs.02/11/26 - 194.6 lbs.02/16/26 - 194.1 lbs.02/17/26 - 194.8 lbs.02/18/26 - 194.0 lbs.02/19/26 - 195.4 lbs.02/20/26 - 195.4 lbs.02/21/26 - 203.2 lbs. Review of Resident #32's progress notes from 2/1/26 through 2/21/26 revealed no documentation explaining why weights were not obtained on days when no weight was recorded. There was no notation of Resident #32's refusal. Record review revealed Resident #32 was hospitalized from late February through 03/04/2026. A care plan dated 3/9/26 revealed Resident #32 was at risk for nutritional compromise due to end stage renal disease and dependence on hemodialysis, chronic obstructive pulmonary disease (COPD) and chronic respiratory failure. Resident #32 was at risk for weight fluctuations secondary to hemodialysis. The care plan included an intervention to obtain weights per the physician's order. Record review revealed the following documented weights for Resident #32 for March 2026: The weight was scheduled to be obtained daily at 6:00 AM: 03/05/26 - Refused03/07/26 - Refused03/08/26 - 197 lbs. 03/09/26 - 222 lbs., documented by Nurse #2403/10/26 - 221 lbs.03/13/26 - 223.4 lbs.03/14/26 - 222 lbs.03/19/26 - Refused03/22/26 - 218.8 lbs.03/23/26 - 220.2 lbs.03/24/26 - 245 lbs., documented by Nurse #2503/24/26 - 187.2 lbs., documented by Nurse #16 Review of Resident #32's progress notes from 3/5/26 through 3/24/26 revealed no documentation explaining why weights were not obtained on days when no weight was recorded. There was no documentation indicating a reweigh was completed on 3/9/26 that showed a 25 pound weight gain. There was no documentation on 3/24/26 that the Unit Manager or Director of Nursing were notified of the weight difference. Record review revealed Resident #32 was hospitalized [DATE] through 4/2/26 for evaluation of shortness of breath with coughing and wheezing. A physician's order dated 4/2/26 for Resident #32 revealed to obtain weekly weights for CHF. Record review revealed the following documented weights for Resident #32 for April 2026: 04/06/26 - 193.0 lbs.04/10/26 - 189.9 lbs.04/17/26 - 185.6 lbs.04/20/26 - 183.3 lbs.04/21/26 - 193.2 lbs., documented by Nurse #26 Review of Resident #32's progress note dated 4/21/26 revealed no documentation indicating a reweigh was completed or any follow up to verify accuracy for the 10 lb. weight increase in 24 hours. There were no further weights recorded after 4/21/26. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #32 had moderately impaired cognition. Resident #32 received diuretics, oxygen, and dialysis. She had no rejection of care. During an interview on 4/24/26 at 10:00 AM the Administrator indicated that nursing staff should obtain weights according to the physician's order and document accurate weights. She stated Nurse #24 (who documented the 3/9/26 weight of 222 lbs.) was no longer employed at the facility. Attempts were made on 4/24/26 to contact Nurse #25 who documented the 3/24/26 weight of 245 lbs. which was a 25 lb. weight gain. There was no response. During a phone interview on 4/24/26 at 5:10 PM Nurse #16 who documented the 3/24/26 weight of 187.2 lbs., a 57.8 lb. weight difference stated she was most likely told by another Nurse or the Unit Manager to get a reweigh on Resident #32 and entered the weight without reviewing the previous weight. Nurse #16 had no further comment. Attempts were made on 4/24/26 to contact Nurse #26 who documented the 4/21/26 weight of 193.2 lbs. which was a 10-pound weight gain in a 24-hour period. There was no response. During an interview on 04/23/26 at 10:53 AM Nurse Aide #6 stated nurse aides obtained weights and recorded them on a weight list posted at the nurses' station. She stated the Unit Manager, or nurse would notify them if a reweigh was needed. During an interview on 4/24/26 at 10:00 AM the Unit Manager indicated Resident #32 had orders for daily weights that was changed to weekly weights. She stated the assigned nurse aide obtained the weights and she or the assigned nurse would enter the weights into the resident's record. The Unit Manager stated weights should be obtained as ordered and residents should be reweighed the same day if there was a significant change. She stated she was not aware that daily weights were missed or that significant weight discrepancies occurred for Resident #32. During an interview on 4/24/26 at 1:00 PM, the Nurse Practitioner (NP) stated Resident #32 had multiple comorbidities, including end stage renal failure and end stage congestive heart failure, and required accurate weights. She stated a 20 to 25 lb. weight gain in 24 hours was unlikely and may indicate failure to subtract wheelchair weight or scale variance, and the 57 lb. weight loss was inaccurate. The NP indicated nursing staff should also compare facility weights with dialysis center weights. She stated she should be notified only after a significant weight change was verified. During an interview on 4/24/26 at 2:00 PM the Director of Nursing (DON) stated she expected weights to be obtained according to the physician's order, and residents reweighed the same day if significantly different from the previous weight and reported to her or the Unit Manager so accuracy could be verified and communicated to the Physician.

Based on record review, resident and staff, and the Nurse Practitioner's interviews the facility failed to administer an as needed antihypertensive medication (Clonidine 0.2 milligrams) according to the physician's order and withhold the medication Isosorbide Mononitrate (a vasodilator that relaxes and dilates blood vessels and can lower blood pressure) according to the physicians order when blood pressure parameters were met. This occurred for 1 of 6 residents reviewed for medication administration (Resident #60). Findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses including hypertension, congestive heart failure, and coronary artery disease. a. A physician's order dated 12/13/25 for Resident #60 revealed to administer Clonidine 0.2 milligrams (mgs) every 12 hours as needed for systolic blood pressure greater than 180 or diastolic blood pressure greater than 90. Review of Resident #60's Medication Administration Record (MAR) dated December 2025 revealed the following blood pressure recorded: 12/21/25 at 9:00 AM blood pressure 248/100 documented by Nurse #15 Review of Resident #60's Medication Administration Record (MAR) dated 12/21/25 revealed no documentation that Clonidine 0.2 mgs was administered to Resident #60. Review of Resident #60's nursing progress notes on 12/21/25 revealed no documentation that Clonidine 0.2 mgs was administered, and no documented clinical rationale for withholding the medication. Review of Resident #60's Medication Administration Record dated January 2026 revealed the following blood pressures recorded: 1/07/26 at 9:00 AM blood pressure 210/87 documented by Nurse #16 1/08/26 at 9:00 AM blood pressure 235/101 documented by Nurse #15 1/13/26 at 9:00 AM blood pressure 231/90 documented by Nurse #15 1/17/26 at 9:00 AM blood pressure 187/88 documented by Nurse #15 1/21/26 at 9:00 AM blood pressure 212/87 documented by Nurse #15 Review of Resident #60's Medication Administration Record dated January 2026 revealed no documentation that Clonidine 0.2 mgs was administered to Resident #60 from 1/7/26 through 1/21/26. Review of Resident #60's nursing progress notes from 1/7/26 through 1/21/26 revealed no documentation that Clonidine 0.2 mgs was administered, and no documented clinical rationale for withholding the medication. During a phone interview on 4/24/26 at 9:30 AM Nurse #15 stated that she had not been assigned to Resident #60 for a while prior to the times she recorded the elevated blood pressures. Nurse #16 stated she was not aware during that time that Resident #60 had an order for Clonidine as needed if her blood pressure was elevated. During a phone interview on 4/24/26 at 5:10 PM Nurse #16 stated she could not speak on a medication issue that occurred in January. She had no further comment. b. A physician's order dated 4/6/26 for Resident #60 revealed Isosorbide Mononitrate extended release 60 milligrams (mg). Give 1 tablet by mouth once a day for angina (chest pain or discomfort that occurred when the heart muscle does not receive enough oxygen rich blood). Hold for systolic blood pressure less than 120. Review of Resident #60's Medication Administration Record (MAR) dated April 2026 revealed Isosorbide Mononitrate extended release 60 mg tablets were administered on the following dates and time as evidence by the nurses signature with the following blood pressures recorded: 4/09/26 at 8:30 AM Nurse #8 signed as administered with blood pressure 112/76. 4/22/26 at 8:30 AM Nurse #8 signed as administered with blood pressure 118/70. 4/23/26 at 8:30 AM Nurse #8 signed as administered with blood pressure 118/75. Review of Resident #60's nursing progress notes on 4/9/26, 4/22/26, and 4/23/26 revealed no documentation or clinical justification for administering the medication. During an interview on 4/23/26 at 3:30 PM Nurse #8 stated she has not had to hold Resident #60's Isosorbide Mononitrate any time including today. She stated she didn't realize the medication had hold parameters. Nurse #8 stated when she viewed the electronic Medication Administration Record (eMAR) the hold parameters weren't noticeable which was why it was overlooked. Nurse #8 stated she would go check Resident #60's blood pressure to ensure her blood pressure was not too low. Nurse #8 stated Resident #60 had been resting quietly this afternoon with no complaints. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #60 had moderately impaired cognition. During an interview on 4/24/26 at 9:00 AM Resident #60 who was alert and oriented to person, and place stated she was on blood pressure medications, but she did not know what medications or when they were to be given. She stated she would get headaches and felt dizzy at times but otherwise felt okay at this time. During an interview on 4/24/26 at 1:00 PM the Nurse Practitioner stated Resident #60 had elevated blood pressures and received scheduled antihypertensive medications and had the Clonidine order in place for increased blood pressure. She stated Resident #60's blood pressure continued to run high at times and then would run low at times, and she has had to adjust her medications. The Nurse Practitioner indicated that the as needed Clonidine was ordered for a reason and the blood pressure parameters should be followed and as needed medications administered when indicated. She stated nitrates dilated blood vessels, and can lower blood pressure, which is why the hold parameters were ordered for the Isosorbide Mononitrate. She stated the ordered parameters should be followed and the medication held if the systolic blood pressure was less than 120. The Nurse Practitioner stated she would only need to be notified of Resident #60's blood pressure if the Clonidine had been administered and the blood pressure had remained significantly elevated. The Nurse Practitioner indicated Resident #60 has had no significant outcome related to the medication errors. During an interview on 4/24/26 at 2:30 PM the Director of Nursing (DON) stated the nurses were expected to read the medication orders and follow the ordered parameters and administer or withhold medications when it was indicated when the parameters were met.

Based on record review and interviews with the Nurse Practitioner and staff, the facility failed to accurately document the administration of controlled substances for 4 of 6 residents reviewed for accurate medical records (Residents #41, #69, #94 and #95).Findings included: a.) Resident #41 was admitted to the facility 03/23/23. A physician's order written on 09/11/25 for Resident #41 and discontinued on 11/19/25 for Oxycodone (opioid pain medication) 5 milligrams (mg) tablet, one tablet by mouth every 8 hours as needed for pain. Review of Resident #41's declining count sheet (an inventory log used to record a running total for each controlled medication) revealed Nurse #1 documented the removal of Oxycodone 5 mg on 09/11/25 at 4:00 PM, 09/12/25 at 2:00 PM and 6:00 PM, 09/19/25 at 9:00 AM and 4:00 PM, 09/20/25 at 9:00 AM and 4:00 PM, and 09/21/25 at 1:00 PM. The Medication Administration Record (MAR) for September 2025 for Resident #41 revealed on 09/11/25 at 4:00 PM, 09/12/25 at 2:00 PM and 6:00 PM, 09/19/25 at 9:00 AM and 4:00 PM, 09/20/25 at 9:00 and 4:00 PM, and 09/21/25 at 1:00 PM, Nurse #1 did not document that she administered the Oxycodone 5 mg on the MAR. b.) Resident #69 was admitted to the facility on [DATE]. A physician's order written on 11/12/25 and discontinued on 11/19/25 for Resident #69 revealed Hydrocodone/Acetaminophen (opioid pain medication) 5 mg / 325 mg one tablet by mouth every 6 hours as needed for pain. Review of Resident #69's declining count sheet revealed on 11/14/25 at 9:00 AM and 11/15/25 at 4:00 PM, Nurse #1 documented the removal of Hydrocodone/Acetaminophen 5 mg/325 mg. The MAR for November 2025 for Resident #69 revealed on 11/14/25 at 9:00 AM and 11/15/25 at 4:00 PM, Nurse #1 did not document that she administered Hydrocodone/Acetaminophen 5 mg / 325 mg on the MAR. c.) Resident #94 was admitted to the facility on [DATE]. A physician's order written on 12/05/25 and discontinued on 12/08/25 for Resident #94 revealed Oxycodone 5 mg one tablet by mouth every 4 hours as needed for pain for up to 7 days. A physician's order written on 12/14/25 for Resident #94 revealed Oxycodone 5 mg one tablet by mouth every 6 hours as needed for pain until 12/16/25. Review of Resident #94's declining count sheet for Oxycodone 5 mg revealed on 12/08/25 at 8:00 AM and 12:00 PM, and 12/14/25 at 8:00 AM and 12:00 PM, Nurse #1 documented the removal of Oxycodone 5 mg. The MAR for December 2025 for Resident #94 revealed on 12/08/25 and 12/14/25 at 8:00 AM and 12:00 PM, Nurse #1 did not document that she administered Oxycodone 5 mg on the MAR. d.) Resident #95 was admitted to the facility on [DATE]. A physician's order written on 12/19/25 for Resident #95 revealed Oxycodone 5 mg; give 5 mg every 6 hours as needed for pain for 3 days. Review of Resident #95's declining count sheet for Oxycodone 5 mg revealed on 12/22/25 at 8:00 AM, Nurse #1 documented the removal of Oxycodone 5 mg. The MAR for December 2025 for Resident #94 revealed on 12/22/25 Nurse #1 did not document that she administered Oxycodone 5 mg on the MAR. A phone interview was conducted with Nurse #1 on 04/24/26 at 7:30 PM. Nurse #1 stated my system was not good and clarified that she knew which medications her residents' received and she would administer them without looking at the order. Nurse #1 added that she did not sign off the medication as given on the MAR because she was too busy at the time and she forgot to go back and sign the MAR. A phone interview with the previous Director of Nursing (DON) on 04/24/26 at 12:37 PM revealed that she would expect the nursing staff to sign off on the MAR whenever administering pain medications and added it was important to document on the MAR to determine if the pain was being managed for the resident. An interview with the Nurse Practitioner on 04/24/26 at 1:30 PM revealed she utilized the MAR to determine how residents were responding to their as needed pain medication, so it was important for the nursing staff to accurately document the administration of the medication. An interview with the current Director of Nursing on 04/24/26 at 4:00 PM stated she expected her nursing staff to be accurately documenting the administration of pain medications on the MAR. She stated the system failure was that this nurse did not follow the process of medication administration which included the documentation of administration.

Based on observations, record review, and staff interviews, the facility failed to implement their infection control policy and procedures for Contact Precautions when cleaning a resident's room (Resident #37) who was on Contact Precautions for suspicion of Norovirus (a highly contagious group of viruses that cause inflammation of the stomach and intestines and can survive on surfaces for weeks) and Rotavirus (a highly contagious virus that causes gastrointestinal symptoms). This occurred with 2 of 5 staff members who were observed for infection control practices (Housekeeping Aide #1 and Housekeeping Aide #2). Findings included: The Infection Control Policy dated January 2026 revealed Contact Precautions were implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident care items in the residents environment. Staff and visitors are to wear gloves and a gown when entering the room and remove before leaving the room when a resident is on Contact Precautions. During an observation on 4/22/26 at 9:35 AM Resident #37 was observed lying in bed. A Contact Precautions sign was observed on the door of Resident #37's room. A PPE (personal protective equipment) supply bag with supplies including gloves and gowns were hanging on the door of Resident #37's room. Housekeeping Aide #1 was observed in Resident #37's room, cleaning the room including wiping down the bedside table and handling trash. Housekeeping Aide #1 was wearing gloves but no gown. She removed her gloves and performed hand hygiene before leaving the room.During an interview on 4/22/26 at 9:35 AM Housekeeping Aide #1 stated she did not see the sign on Resident #37's door because the door was open. She stated she saw the gloves and gowns hanging on Resident #37's door but did not see the Contact Precautions sign. Housekeeping Aide #1 then read the sign and stated she should have put on a gown and gloves before going into Resident #37's room. She stated she had received infection control training on Contact Precautions.During an observation on 4/23/26 at 11:05 AM Resident #37 was observed lying in bed. A Contact Precautions sign was observed on the door of Resident #37's room. A PPE supply bag with supplies including gloves and gowns were hanging on the door of Resident #37's room. Housekeeping Aide #2 was observed in Resident #37's room cleaning the room including the bathroom, and handling trash. Housekeeping Aide #2 was wearing gloves but no gown. He removed his gloves and performed hand hygiene before leaving the room.During interview on 4/23/26 at 11:05 AM Housekeeping Aide #2 stated he wasn't sure what it meant to be on Contact Precautions. Housekeeping Aide #2 stated he had received infection control training.During an interview on 4/23/26 at 11:20 AM the Housekeeping Manager stated Housekeeping Aide #1 and Housekeeping Aide #2 had received infection control training. She stated housekeeping staff had been instructed to read the precaution signs on the door of the residents' room before entering and wear the appropriate PPE.During an interview on 4/24/26 at 3:50 PM the Assistant Director of Nursing (ADON) stated she was also the Infection Preventionist, but she was new to the facility and had only worked here for three weeks. She indicated that all staff should have received infection control training and should wear the appropriate PPE when going into resident rooms that are on transmission-based precautions.During an interview on 4/24/26 at 4:00 PM the Director of Nursing (DON) stated she was new to the facility and had worked here for three weeks. She stated staff were to follow the guidelines and wear the appropriate PPE when entering resident rooms that were on any type of precautions. She stated Resident #37 was on Contact Precautions and the Housekeeping Aides (#1 and #2) should have had on gloves and a gown before entering Resident #37's room.

Based on record review, and staff, Nurse Practitioner, and Physician interviews, the facility failed to notify the Physician, or the Nurse Practitioner of a resident's blood pressure medication Carvedilol 3.125 milligrams prescribed for hypertension and scheduled for administration twice a day was held 34 times during a period of 77 days or that Midodrine (prescribed to increase blood pressure) was being administered outside of the prescribed parameters. This occurred for 2 of 5 residents (Resident #54) reviewed for medication administration and notification to the physician. Findings included. This tag is cross referenced to: F760: Based on record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.)administer the antihypertensive medication Carvedilol 3.125 milligrams prescribed twice a day for hypertension. Resident #54 experienced no significant outcome by not receiving the medication. 2.) hold the blood pressure medication Midodrine (prescribed to increase blood pressure) when the systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Resident #43 experienced no significant outcome from receiving the additional doses. This occurred for 2 of 5 residents (Resident #54 and Resident #43) reviewed for medication administration.

Based on record review, observations, Administrator, and Maintenance Director interviews, the facility failed to remove the black greenish substance from the commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411), failed to repair resident's overhead lights that were non-functioning in resident rooms (202 and 411). These failures occurred on 3 of 5 hallways (200, 300, and 400 Halls) observed for a safe, clean, homelike environment and failed to maintain hot water temperatures in 2 of the 2 shower rooms on the 300-hall (Spa #1 and Spa #2) reviewed for hot water. Findings included: 1. An observation of the two 300-hall shower rooms was completed during a round on 02/17/25 which started at 9:45 AM with the Maintenance Director. The shower hot water temperature in Spa #1 fluctuated from 85 degrees Fahrenheit (F) to 89 degrees F, and the shower in Spa #2 hot water temperature fluctuated from 83 degrees F to 101 degrees F. Both shower water temperatures were obtained using the calibrated thermometer provided by the Maintenance Director and the temperatures were obtained after 5-minutes of continuous hot water monitoring in both shower rooms. The Maintenance Director stated during the observation the water was too cold for showers, which should have been around 114 degrees F. The Maintenance Director said he would try to adjust the faucets and mixing valve to bring the hot water temperature up to around 114 degrees F. An interview was conducted on 02/21/25 at 12:00 PM with the Administrator and he stated as of September 2024, their paper water temperature logs were no longer being used, since they updated to the electronic Maintenance TELS (The Equipment Lifecycle System) (an online system used to help manage maintenance in a facility). The Administrator explained he had their new electronic TELS water testing log did not include testing water temperatures in the shower rooms. The Administrator further explained he hired a new Maintenance Director and because the 3 shower rooms were inadvertently not added in the TELS water testing log, the Maintenance Director did not track the shower water temperatures which resulted in the 3 shower rooms water temperatures not being monitored. The Maintenance Director said another reason the water in the shower rooms might be cold was due to the hot water having to travel all the way from the boiler to the shower rooms and staff were not waiting 3-5 minutes for the water to heat up. 2. An observation on 02/18/25 at 12:00 PM revealed resident commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411), were noted to have black greenish substance located around the base of the commodes. An interview and observation were conducted on 02/18/25 at 1:30 PM with the Maintenance Director. He stated there were areas on the 200, 300, and 400 halls that needed to be addressed, repaired, or replaced. He stated he was new to the building and had no assistant but was slowly keeping up with facility repairs. He said he did not know what the black greenish substance was around some of the commodes commode base caulking in resident rooms (200, 201, 205, 207, 208, 209, 305, and 411). He said maintenance was responsible for repairing or replacing items in the facility, and that some of the commodes caulking needed to be replaced. 3. An observation on 02/18/25 starting at 12:15 PM revealed overhead lights that were non-functioning, in rooms (202 and 411). All four alert and oriented residents in the two rooms said they told their nurses about the non-functioning lights, but nothing had been done. They said they primarily use the lighting from the outside window and keep the hallway door open. An interview was conducted on 02/18/25 at 1:30 PM with the Maintenance Director. He stated there were still areas on the 200, 300, and 400 halls that still needed to be addressed, repaired, or replaced. He said maintenance was responsible for repairing or replacing items in the facility, and that some of the overhead lights were not working and needed new ballasts. An interview was conducted with the Administrator on 02/18/25 at 1:50 PM. He revealed they were making progress and were improving residents' living environment to make it more home-like, and that it would take time. He said there were still areas in the facility that still needed to be addressed, and they were actively putting plans in place to address areas concern observed during the survey. The Administrator stated it was his expectation for all the residents to have a safe and homelike environment that was clean and in good repair.

Based on observations, record review, and staff interviews, the facility failed to provide bathing and showers (Resident #39, Resident #53, and Resident #60) and incontinence care (Resident #7) to residents who were dependent on staff assistance with activities of daily living (ADL). This occurred for 4 of 5 residents reviewed for ADL care. Findings included. 1a.) Resident #39 was admitted to the facility on [DATE] with diagnosis including Alzheimer's disease. The Minimum Data Set (MDS) admission assessment dated [DATE] revealed Resident #39 was severely cognitively impaired. She had no rejection of care. She had impaired range of motion in her bilateral upper and lower extremities and was dependent on staff for activities of daily living (ADL). A care plan dated 1/16/25 revealed Resident #39 had ADL self-care performance deficit related to her diagnosis of Alzheimer's disease, primary osteoarthritis, diabetes, and hypertension. Interventions included to encourage participation in tasks. During an interview on 2/16/25 at 5:00 PM Nurse #5 stated Resident #39 did not receive her scheduled shower last night on Saturday 2/15/25. She stated it was reported to her this morning when she came on duty by the night nurse and Resident #39 still had not had a shower as of now. She indicated she did not know why the showers weren't done by the Nurse Aides. She stated Resident #39 was scheduled for showers to be given on night shift on Wednesday and Saturday nights. During a phone interview on 3/4/25 at 8:30 PM Nurse Aide #9 stated he was the assigned Nurse Aide on 2/15/25 from 7:00 AM until 7:00 PM. He stated baths were not given to any residents during his shift on 2/15/25 because he was the only Nurse Aide assigned on the locked unit that day and there was no time to give baths. During an interview on 2/18/24 at 3:00 PM Nurse Aide #7 stated he worked Saturday night 2/15/25 on the locked unit from 7:00 PM until 7:00 AM. He stated he was an agency nurse aide, and he was made aware of who needed showers when he came on shift. He stated three residents were supposed to get showered that night but stated he was busy during the shift and just didn't get the showers done on any of the three residents which included Resident #39. He stated there were two nurse aides on duty and assigned to the locked unit along with the nurse on Saturday night from 7:00 PM until 7:00 AM which was the usual number of staff on the locked unit. During an interview on 2/16/25 at 2:51 PM Nurse Aide #5 stated she was the assigned Nurse Aide on the locked unit today and was scheduled to work from 7:00 AM until 7:00 PM. She stated the second Nurse Aide who was scheduled this shift called out this morning, so it was just her and the nurse until approximately 10:00 AM. She stated Resident #39 had not been given a bath today at this point because there was no time this morning to give baths. b.) Resident #53 was admitted to the facility on [DATE] with diagnoses including dementia. A care plan dated 11/25/24 revealed Resident #53 had an ADL self-care deficit related to dementia. Interventions included assistance by staff with bathing and showering. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #53 had severely impaired cognition. She required extensive assistance by staff with activities of daily living. During an interview on 02/16/25 at 5:00 PM Nurse #5 stated Resident #53 did not receive her scheduled shower last night (Saturday 2/15/25). She stated that was reported to her this morning when she came on duty by the night nurse. She stated Resident #53 still had not had a shower as of now. She stated she did not know why the showers weren't done by the Nurse Aides. She stated Resident #53 was scheduled for showers to be given on night shift on Wednesday and Saturday nights. During a phone interview on 3/4/25 at 8:30 PM Nurse Aide #9 stated he was the assigned Nurse Aide on 2/15/25 from 7:00 AM until 7:00 PM. He stated baths were not given to any residents during his shift on 2/15/25 because he was the only Nurse Aide assigned on the locked unit that day and there was no time to give baths. During an interview on 2/18/24 at 3:00 PM Nurse Aide #7 stated he worked Saturday night 2/15/25 on the locked unit from 7:00 PM until 7:00 AM. He stated he was an agency nurse aide and stated he was made aware of who needed showers when he came on shift. He stated he was busy during the shift and just didn't get the showers done on any of the three residents who were scheduled which included Resident #53. During an interview on 2/16/25 at 2:51 PM Nurse Aide #5 stated she was the assigned Nurse Aide on the locked unit today and was scheduled to work from 7:00 AM until 7:00 PM. She stated Resident #53 had not been given a bath today at this point because there was no time this morning to give baths. c.) Resident #60 was admitted to the facility on [DATE] with diagnoses including dementia. A care plan revised 11/25/24 revealed Resident #60 had an ADL self-care deficit related to dementia with agitation. Interventions included to encourage resident to participate to the fullest extent. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #60 had moderately impaired cognition. She required extensive assistance by staff with activities of daily living. She had no rejection of care. During an interview on 02/16/25 at 5:00 PM Nurse #5 stated Resident #60 did not receive her scheduled shower last night (Saturday 2/15/25). She stated Resident #60 still had not had a shower as of now. She stated she did not know why the showers weren't done by the Nurse Aides. She stated Resident #60 was scheduled for showers to be given on night shift on Wednesday and Saturday nights. During a phone interview on 3/4/25 at 8:30 PM Nurse Aide #9 stated he was the assigned Nurse Aide on 2/15/25 from 7:00 AM until 7:00 PM. He stated baths were not given to any residents during his shift on 2/15/25 because he was the only Nurse Aide assigned on the locked unit that day and there was no time to give baths. During an interview on 2/18/24 at 3:00 PM Nurse Aide #7 stated he worked Saturday night 2/15/25 on the locked unit from 7:00 PM until 7:00 AM. He stated he was an agency nurse aide and stated he was made aware of who needed showers when he came on shift. He stated he was busy during the shift and just didn't get the showers done on either of the three residents who were scheduled which included Resident #60. During an interview on 2/16/25 at 2:51 PM Nurse Aide #5 stated she was the assigned Nurse Aide on the locked unit today and was scheduled to work from 7:00 AM until 7:00 PM. She stated Resident #60 had not been given a bath today at this point because there was no time this morning to give baths. During a phone interview on 2/18/24 at 4:00 PM Nurse #7 stated she was the assigned nurse on the locked unit on Saturday night 2/15/25. She stated she was an agency nurse, and it was her very first night working in the facility. She indicated she was aware showers were scheduled on night shift but did not know why the nurse aides on duty Saturday night didn't do them. She indicated she reported this to the oncoming nurse the next morning. During the survey three attempts were made to contact Nurse Aide #8 who was on duty in the locked unit from 7:00 PM until 7:00 AM on Saturday night 2/15/25. There was no response. During an interview on 02/19/25 at 11:24 AM the Director of Nursing (DON) stated she was made aware of the three residents who did not get showered on their scheduled shower day on Saturday night 2/15/25. She stated she did confirm after talking with Nurse Aide #7 and Nurse Aide #8 who were the nurse aides on duty that showers weren't given. She stated they chose not to do the showers, and they received disciplinary action and were pulled from the locked unit. She stated they typically had two nurse aides assigned to each shift on the locked unit and there were two nurse aides on duty from 7:00 AM until 7:00 PM. She stated the showers should have been given. 35173 2) Resident #7 was admitted to the facility on [DATE]. Diagnoses included history of urinary tract infections, muscle wasting and atrophy, and need for assistance with personal care. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #7 was cognitively intact and was coded for impairments to both sides of upper and lower extremities and dependent with one staff physical assistance for ADL care. Resident #7 was always incontinent of bowel and bladder. A care plan updated on 02/11/25 for Resident #7 revealed a plan of care was in place for incontinent care and required staff assistance with toileting and bowel and bladder incontinence. The goal of care was to receive the appropriate level of staff assistance for toileting and incontinence care. Interventions included providing one person assistance with toileting and incontinence care. A plan of care was in place for limited physical mobility related to weakness, impaired mobility and incontinence with a goal that resident would be free of complications related to immobility to include skin breakdown. Interventions included observing for any signs or symptoms of skin breakdown. A plan of care updated on 02/13/25 revealed the resident had a Stage IV pressure ulcer to her coccyx (a small bone at the base of the spinal column above the buttocks) related to immobility and incontinence with a goal that the pressure ulcer would show signs of healing and remain free from infection. Interventions included observing any changes in skin status. An observation and interview with Resident #7 on 02/16/25 at 10:30 AM revealed an alert and oriented resident lying in bed on her back. Resident #7 reported that her brief had not been changed since early this morning and stated it was well before breakfast. Resident #7 stated she was wet with urine at this time and wanted to be changed. Resident #7 stated she would ring her call bell to get assistance. A follow up observation and interview was conducted with Resident #7 on 02/16/25 at 1:15 PM. Resident #7 stated she rang her call bell and told the Nurse Aide (NA) #2 that she needed her brief to be changed. The call light was not sounding upon entry to Resident #7's room. Resident #7 reported NA #2 stated she would be right back but she did not come back. Resident #7 stated she believed it was about 10:30 AM or so when she pressed her call bell, but she could not remember the actual time. Resident #7 stated she wanted her brief to be changed, but she did not want to keep bothering the nurse aide. An interview was conducted with Nurse Aide (NA) #2 on 02/16/25 at 1:15 PM. NA #2 was asked when the last time was that she checked on and changed Resident #7's brief. NA #2 responded I don't know, I don't keep track of that. I am so busy with the 18 residents on my hall. NA #2 stated she did not recall Resident #7 ringing her call bell to ask for assistance or telling Resident #7 she would be back. NA #2 stated she would check Resident #7 at this time. An observation of NA #2 was conducted on 02/16/25 at 1:15 PM. NA #2 was noted to have checked Resident #7's brief and it was noted to be saturated with a significant amount urine. NA #2 was observed changing Resident #7's brief at this time. Resident #7's dressing to her coccyx was noted to be intact. A follow up interview was conducted with NA #2 on 02/16/25 at 1:45 PM. NA #2 stated she was doing the best the could with keeping up with changing her residents. NA #2 stated she tried to check her residents every 2 - 3 hours per the facility protocol to see if the residents needed to be changed, but that Resident #7 had gone over 4 hours before she was changed again. NA #2 stated she did not remember when she first changed Resident #7 but she thought it was at the start of her shift around 7:30 AM. NA #2 stated she should have checked her for incontinence again after 2-3 hours since she was one of her residents known to urinate a lot. An interview was conducted with the Administrator on 02/21/25 via phone at 1:35 PM. The Administrator stated he would have expected the nurse aides to check and change all residents on their assignment every 2 - 3 hours to ensure they were kept dry and clean to maintain the resident's skin integrity.

Based on record review, and staff, Registered Dietician and Physician interviews, the facility failed to provide a nutritional supplement ordered twice a day for 30 days for wound healing to a resident who was at risk for malnutrition and had a facility acquired unstageable deep tissue injury of the right heel and a deep tissue injury to the left heel that developed into a Stage IV pressure wound. This occurred to 1 of 10 residents (Resident #60) reviewed for nutrition. Findings included. Resident #60 was admitted to the facility on [DATE] with diagnoses including muscle wasting with atrophy, dysphagia, and dementia. A wound physician's report dated 11/20/24 revealed Resident #60 had bilateral deep tissue injuries to her left and right heels. A care plan revised 11/25/24 revealed Resident #60 was at nutritional risk due to cognitive decline associated with dementia, dysphagia with a modified diet order, age-related physiological decline and debility, skin breakdown, diabetes, and aphasia. She was at risk for malnutrition, and for hydration alterations and weight fluctuations secondary to diuretic use. Interventions included in part: to observe for signs of malnutrition and provide and serve supplements as ordered. The Registered Dietician will evaluate and make diet change recommendations as needed. The Registered Dietician review note dated 12/17/24 revealed that she evaluated Resident #60. The head-to-toe skin review indicated that Resident #60 had a suspected deep tissue injury on the right and left heel. The current weight on 12/4/24 was 111 pounds, which was up over the past month. The Registered Dietician recommended for wound healing Arginaid twice a day for 30 days. (Arginaid is a nutritional supplement in a powder or drink mix that contains arginine. Arginine is an amino acid that's essential for wound healing. It stimulates the release of growth hormone and insulin-like growth factor, which can improve wound healing.) Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated December 2024 revealed no documentation that Arginaid nutritional supplement was administered to Resident #60. Review of Resident #60's progress notes from 12/17/24 through 12/31/24 revealed no documentation as to why Arginaid was not administered. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated January 2025 revealed no documentation that Arginaid nutritional supplement was administered to Resident #60. Review of Resident #60's progress notes from 1/1/25 through 1/17/25 revealed no documentation as to why Arginaid was not administered. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #60 had moderately impaired cognition. She had two deep tissue injuries. She had no rejection of care. A wound physician's report dated 2/12/25 for Resident #60 revealed the deep tissue injury to the left heel had now revealed itself to be a Stage IV pressure injury. The right heel wound remained unstageable due to necrosis. The Registered Dietician review note dated 2/13/25 revealed that she evaluated Resident #60 for pressure areas and weight loss. The wound report indicated Resident #60 had wounds to the left and right heel. The Registered Dietician recommended for wound healing and weight stability Arginaid twice a day for 90 days. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated February 2025 revealed no documentation that Arginaid was administered to Resident #60. Review of Resident #60's progress notes from 2/1/25 through 2/28/25 revealed no documentation as to why Arginaid was not administered. Review of the Medication Administration Record (MAR) and the Treatment Administration Record (TAR) dated March 2025 revealed no documentation that Arginaid was administered to Resident #60 as of 3/5/25. During an interview on 2/17/25 at 2:30 PM Nurse #8 stated she was consistently assigned to care for Resident #60. She stated Resident #60 had pressure wounds, but she did not recall Resident #60 receiving Arginaid at any time since December 2024. She stated she did not see the order on the MAR or the TAR for Arginaid for Resident #60 in December 2024, or January 2025 or through today 2/17/25. During an interview on 02/18/25 at 2:44 PM the Registered Dietician stated she last evaluated Resident #60 on 2/13/25. The progress notes indicated Resident #60 continued with deep tissue injuries and Stage III and Stage IV pressure wounds. She stated she was not aware that the Arginaid recommendation for wound healing was not implemented in December 2024, but a new recommendation was made for Arginaid on 2/13/25. She stated she did not enter her recommendations as orders. She stated when she wrote the recommendations, she emailed them to the Director of Nursing, then the physician would sign off on the order then the nursing staff would enter it into the resident's electronic medical record to be implemented. During an interview on 02/20/25 at 1:04 PM the Director of Nursing (DON) stated that when the Registered Dietician made recommendations following her evaluations, she emailed the recommendations to her. She stated she would then forward the email to the Unit Manager to complete the order process. She indicated that she gave the recommendations made by the Registered Dietician to Unit Manager #1 following the December 2024 evaluation of Resident #60. During a phone interview on 02/21/25 at 2:05 PM Unit Manager #1 stated she gets the Registered Dietician recommendations from the DON. She stated once she gets the recommendation, she sends it to the Nurse Practitioner or the Physician to be signed off, then she would enter the order into the electronic medical record, and it would flow to the Medication Administration Record. She stated she looked back for the recommendation for Resident #60 from December 2024 for Arginaid and she could not find where the recommendation was sent to her. She indicated it was missed and was never implemented. During a phone interview on 3/4/25 at 2:00 PM the Physician stated Resident #60 had an unstageable deep tissue injury on her right heel and a Stage IV pressure wound on her left heel. She stated Resident #60 had multiple comorbidities that contributed to her wound development and the wounds were unavoidable. She stated she was made aware of the Arginaid order not getting entered for Resident #60 following the onsite survey period. She stated Arginaid had not been used in the facility for several years, however if it was recommended by the Registered Dietician then she would have signed off on the recommendation and expected the order to be entered and administered to the resident. A phone interview was conducted on 3/5/25 at 2:00 PM with the Registered Dietician, along with the Administrator and the Corporate Nurse. The Registered Dietician stated her recommendations had to have approval by the Physician before they were entered as an order. She stated she made another recommendation for Arginaid for Resident #60 during her last evaluation on 2/13/25 to aid in wound healing. The Corporate Nurse stated there had been an issue with the Registered Dieticians emails getting transmitted to the DON. The Administrator stated they just ordered the Arginaid for Resident #60, and it arrived at the facility on Monday 3/3/25. He stated Resident #60 would get the Argnaid by tomorrow 3/6/25.

Based on record review and staff interviews, the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 13 of 275 days reviewed for staffing (04/6/24, 04/20/24, 04/21/24, 07/13/24, 07/27/24, 08/17/24, 09/07/24, 09/08/24, 09/28/24, 09/29/24, 10/05/24, 10/28/24, and 12/03/24). Findings included: The PBJ (Payroll Based Journal) Staffing Data Report Fiscal Year - Quarter 1, 2024 (October 1 - December 31) documented the facility had no RN Coverage on 10/08/24, 11/19/24, 12/03/24, and 12/31/24. In addition, the PBJ Staffing Data Report Fiscal Year - Quarter 3, 2024 (April 1 - June 30) documented the facility had no RN Coverage on 04/06/24, 04/07/24, 04/20/24, and 04/21/24. In an interview with the Human Resources Director on 02/18/25 at 1:50 PM she stated she verified by reviewing the daily employee timecard punches that an Agency RN had worked 8 hours on the following dates: 04/07/24,10/08/24, 11/19/24, 12/31/24. She could not explain why the PBJ report did not recognize the hours worked by the Agency RN because she did punch the time clock. The Human Resources Director verified by reviewing the timecard punches that the facility did not have 8 hours of RN coverage on the following dates: 04/06/24, 04/20/24, 04/21/24, 07/13/24, 07/27/24, 08/17/24, 09/07/24, 09/08/24, 09/28/24, 09/29/24, 10/05/24, 10/28/24, and 12/03/24. She explained the facility advertised through the internet and social media, participated in local college skills fairs, and placed a sign in facility yard in an effort to hire RN's. In an interview with the Administrator on 02/20/25 at 9:56 AM he explained the facility had a hard time hiring RNs and the Agency also had trouble supplying licensed RNs for the facility. He felt the facility offered a competitive wage. He noted a new scheduler had been hired on 12/06/24 and the scheduling had improved.

Based on record review, and Physician and Consultant Pharmacist's interviews, the Pharmacist failed to identify and address during the monthly medication regimen review that a residents Carvedilol 3.125 milligrams prescribed for hypertension was held 17 out of 31 days during December 2024. This occurred for 1 of 5 residents (Resident #54) reviewed for medication administration. Findings included. Resident #54 was admitted to the facility on [DATE] with diagnoses to include hypertension. A physician's order dated 6/10/24 for Resident #54 revealed Carvedilol (antihypertensive) 3.125 milligram tablets. Give one tablet orally two times a day for hypertension. There were no parameters on the order to hold the medication. Review of the Medication Administration Record (MAR) dated December 2024 for Resident #54 revealed Carvedilol 3.125 milligram tablets. Give one tablet orally two times a day for hypertension to be administered at 8:00 AM and 8:00 PM. There were no parameters on the MAR to hold the medication. The medication was signed off on the following dates and times with either a chart code of 4 meaning vital signs were outside of the parameters or a chart code of 5 meaning the medication was held: 12/3/24 at 8:00 AM the blood pressure was 120/51 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/6/24 at 8:00 AM the blood pressure was 103/57 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/7/24 at 8:00 AM the blood pressure was 108/63 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/8/24 at 8:00 AM the blood pressure was 108/63 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/8/24 at 8:00 PM the blood pressure was 105/50 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. 12/11/24 at 8:00 AM the blood pressure was 110/51 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/11/24 at 8:00 PM the blood pressure was 105/57 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. 12/12/24 at 8:00 AM the blood pressure was 100/55 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/14/24 at 8:00 PM the blood pressure was 110/70 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/16/24 at 8:00 AM the blood pressure was 108/78 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/19/24 at 8:00 PM the blood pressure was 118/60 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/23/24 at 8:00 AM the blood pressure was 128/60 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/23/24 at 8:00 PM the blood pressure was 104/64 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/24/24 at 8:00 AM the blood pressure was 110/56 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/25/24 at 8:00 AM the blood pressure was 105/93 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/26/24 at 8:00 AM the blood pressure was 116/54 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/30/24 at 8:00 PM the blood pressure was 106/90 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. Review of the monthly Pharmacy medication regimen review for January 2025 revealed no recommendations to address Resident #54's Carvedilol 3.125 milligrams being held 17 times during the previous month of December 2024. During a phone interview on 2/21/25 at 10:00 AM the Physician stated she was not aware that Resident #54's Carvedilol was being held so many times. She stated she did not usually put hold parameters on blood pressure medications. She stated Resident #54 has had no significant outcome from not receiving the medication. During a phone interview on 02/21/25 at 11:54 AM the Consultant Pharmacist stated the facility made her aware of the medication error today regarding the Carvedilol. She indicated the medication should not have been held unless the resident was symptomatic. She stated the physician should have been notified after the first held dose since there were no parameters and there was enough concern to hold the medication. She indicated she did not realize the number of times the Carvedilol was held during the month of December 2024 and didn't make recommendations to address Resident #54's Carvedilol being held frequently during the January 2025 monthly medication review.

Based on record review, and staff, Physician, Nurse Practitioner, and the Consultant Pharmacist interviews the facility failed to 1.)administer the antihypertensive medication Carvedilol 3.125 milligrams prescribed twice a day for hypertension. Resident #54 experienced no significant outcome by not receiving the medication. 2.) hold the blood pressure medication Midodrine (prescribed to increase blood pressure) when the systolic blood pressure was greater than 130 millimeters of mercury (mmHg). Resident #43 experienced no significant outcome from receiving the additional doses. This occurred for 2 of 5 residents (Resident #54 and Resident #43) reviewed for medication administration. Findings included. 1.) Resident #54 was admitted to the facility on [DATE] with diagnoses to include hypertension. A physician's order dated 6/10/24 for Resident #54 revealed Carvedilol (antihypertensive) 3.125 milligram tablets. Give one tablet orally two times a day for hypertension. There were no parameters on the order to hold the medication. Review of the Medication Administration Record (MAR) dated December 2024 for Resident #54 revealed Carvedilol 3.125 milligram tablets. Give one tablet orally two times a day for hypertension to be administered at 8:00 AM and 8:00 PM. There were no parameters on the MAR to hold the medication. The medication was signed off on the following dates and times with either a chart code of 4 meaning vital signs were outside of the parameters or a chart code of 5 meaning the medication was held: 12/3/24 at 8:00 AM the blood pressure was 120/51 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/6/24 at 8:00 AM the blood pressure was 103/57 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/7/24 at 8:00 AM the blood pressure was 108/63 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/8/24 at 8:00 AM the blood pressure was 108/63 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/8/24 at 8:00 PM the blood pressure was 105/50 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. 12/11/24 at 8:00 AM the blood pressure was 110/51 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/11/24 at 8:00 PM the blood pressure was 105/57 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. 12/12/24 at 8:00 AM the blood pressure was 100/55 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/14/24 at 8:00 PM the blood pressure was 110/70 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/16/24 at 8:00 AM the blood pressure was 108/78 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/19/24 at 8:00 PM the blood pressure was 118/60 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/23/24 at 8:00 AM the blood pressure was 128/60 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/23/24 at 8:00 PM the blood pressure was 104/64 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/24/24 at 8:00 AM the blood pressure was 110/56 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 12/25/24 at 8:00 AM the blood pressure was 105/93 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 12/26/24 at 8:00 AM the blood pressure was 116/54 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 12/30/24 at 8:00 PM the blood pressure was 106/90 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #11. Review of the progress notes for Resident #54 from 12/1/24 through 12/31/24 revealed no documentation as to why the Carvedilol was held or that the physician was notified that the medication was held. Review of the Medication Administration Record (MAR) dated January 2025 for Resident #54 revealed Carvedilol 3.125 milligram tablets. Give one tablet orally two times a day for hypertension to be administered at 8:00 AM and 8:00 PM. The medication was signed off on the following dates and times with either a chart code of 4 meaning vital signs were outside of the parameters or a chart code of 5 meaning the medication was held: 1/3/25 at 8:00 PM the blood pressure was 100/60 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 1/12/25 at 8:00 AM the blood pressure was 128/58 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #8. 1/14/25 at 8:00 AM the blood pressure was 108/54 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 1/18/25 at 8:00 AM the blood pressure was 112/58 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 1/19/25 at 8:00 AM the blood pressure was 108/59 millimeters of mercury (mmHg) and signed off with chart code of 5 by Nurse #5. 1/21/25 at 8:00 AM the blood pressure was 112/58 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 1/22/25 at 8:00 AM the blood pressure was 108/54 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. Review of the progress notes for Resident #54 from 1/1/25 through 1/31/25 revealed no documentation as to why the Carvedilol was held or that the physician was notified with the exception of 1/5/25. A progress note dated 1/5/25 during the day shift, Nurse #5 documented Carvedilol 3.125 milligrams was held, and the Nurse Practitioner was notified. There was no documentation that Resident #54 was symptomatic. Review of the Medication Administration Record (MAR) dated February 2025 for Resident #54 revealed Carvedilol 3.125 milligram tablets. Give one tablet orally two times a day for hypertension to be administered at 8:00 AM and 8:00 PM. The medication was signed off on the following dates and times with either a chart code of 4 meaning vital signs were outside of the parameters or a chart code of 5 meaning the medication was held: 2/5/25 at 8:00 AM the blood pressure was 94/54 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/7/25 at 8:00 AM the blood pressure was 112/56 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/9/25 at 8:00 AM the blood pressure was 104/62 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/10/25 at 8:00 PM the blood pressure was 107/56 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/11/25 at 8:00 AM the blood pressure was 90/52 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/12/25 at 8:00 AM the blood pressure was 120/52 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/14/25 at 8:00 AM the blood pressure was 104/66 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/15/25 at 8:00 AM the blood pressure was 92/58 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/17/25 at 8:00 AM the blood pressure was 108/64 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. 2/18/25 at 8:00 AM the blood pressure was 114/58 millimeters of mercury (mmHg) and signed off with chart code of 4 by Nurse #5. Review of the progress notes for Resident #54 from 2/1/25 through 2/18/25 revealed no documentation as to why the Carvedilol was held or that the physician was notified of the medication being held. During an interview on 2/20/25 at 2:00 PM Nurse #5 stated Resident #54 had an order for Carvedilol twice a day. She stated she did hold the medication if his blood pressure was low. She stated there were no parameters on the MAR to hold the medication if the blood pressure was low but thought it was the right thing to do. She stated she thought she did notify the Nurse Practitioner once or twice that she had held Resident #54's Carvedilol but that was over a month ago. She indicated she should not have held the Carvedilol without parameters to hold it without notifying the Nurse Practitioner or the Physician for instructions on whether to hold it or administer the medication. During an interview on 2/20/25 at 12:27 PM the Nurse Practitioner indicated there were no hold parameters on the Carvedilol for Resident #54. She stated she was not aware the medication had been held so frequently. She stated Resident #54 had no outcome due to the medication not being administered and had not been symptomatic for low blood pressure. She stated she would have expected to be notified after one or two doses of the medication being held. During a phone interview on 2/21/25 at 10:30 AM Nurse #8 stated she would hold Resident #54's Carvedilol if his blood pressure was low. She stated she was not sure if there were hold parameters on the order or not. She stated she didn't recall Resident #54 being symptomatic, such as weakness or lethargy. She stated she did not notify the physician when the residents' blood pressure was low to get orders on whether or not to give the medication or hold it. During a phone interview on 2/21/25 at 1:40 PM Nurse #11 stated she has held Resident #54's Carvedilol if his blood pressure was low. She stated she did not call the physician to get further instructions to hold it or give the medication. During an interview on 2/20/25 at 3:00 PM the Director of Nursing (DON) stated she was not aware the Carvedilol was held so frequently by the nurses. She stated if there were no hold parameters on the order then the physician should have been notified that the medication was held so that further instruction or orders could have been given. She stated there was no protocol as to when to call the physician if medications were being held. She stated education would be provided. During a phone interview on 2/21/25 at 10:00 AM the Physician stated she was not aware that Resident #54's Carvedilol was being held so many times. She stated she did not usually put hold parameters on blood pressure medications. She stated Resident #54 has had no significant outcome from not receiving the medication. The Physician stated she should have been notified that the medication was being held so frequently. During a phone interview on 02/21/25 at 11:54 AM the Consultant Pharmacist stated the facility made her aware of the medication error today regarding the Carvedilol. She indicated the medication should not have been held unless the resident was symptomatic. She indicated the physician should have been notified after the first held dose since there were no parameters and there was enough concern to hold the medication. She indicated typically there were no parameters on Carvedilol unless the resident was symptomatic. 2.) Resident #43 was admitted to the facility on [DATE] with diagnosis including hypotension and end stage renal disease. A physician's order dated 1/3/25 for Resident #43 revealed Midodrine Hydrochloride oral tablet 5 milligrams (mg). Give 1 tablet by mouth two times a day for hypotension. Hold for systolic blood pressure greater than 130 mmHg. Review of the Medication Administration Record (MAR) dated January 2025 for Resident #43 revealed Midodrine 5 mgs with instructions to hold for systolic blood pressure greater than 130 mm/Hg was administered on the following dates and times when the systolic blood pressure was greater than 130 mmHg. 1/06/25 at 8:00 AM blood pressure 146/82 (systolic/diastolic) administered by Nurse #8 1/09/25 at 8:00 PM blood pressure 140/70 administered by Nurse #11 1/10/25 at 8:00 AM blood pressure 146/88 administered by Nurse #8 1/11/25 at 8:00 PM blood pressure 132/76 administered by Nurse #10 1/15/25 at 8:00 AM blood pressure 140/86 administered by Nurse #8 1/16/25 at 8:00 AM blood pressure 146/82 administered by Nurse #8 1/16/25 at 8:00 PM blood pressure 140/80 administered by Nurse #10 1/19/25 at 8:00 AM blood pressure 142/89 administered by Nurse#5 1/19/25 at 8:00 PM blood pressure 142/89 administered by Nurse#11 1/20/25 at 8:00 AM blood pressure 138/92 administered by Nurse#8 1/20/25 at 8:00 PM blood pressure 142/78 administered by Nurse#10 1/21/25 at 8:00 AM blood pressure 142/88 administered by Nurse#8 1/21/25 at 8:00 PM blood pressure 140/80 administered by Nurse#10 1/22/25 at 8:00 AM blood pressure 142/86 administered by Nurse#5 1/23/25 at 8:00 AM blood pressure 150/88 administered by Nurse#5 1/24/25 at 8:00 AM blood pressure 144/88 administered by Nurse#8 1/24/25 at 8:00 PM blood pressure 136/80 administered by Nurse#10 1/25/25 at 8:00 AM blood pressure 138/84 administered by Nurse#8 1/26/25 at 8:00 AM blood pressure 144/84 administered by Nurse#8 1/26/25 at 8:00 PM blood pressure 132/82 administered by Nurse#10 1/27/25 at 8:00 AM blood pressure 135/85 administered by Nurse#5 1/29/25 at 8:00 AM blood pressure 162/86 administered by Nurse#8 1/30/25 at 8:00 AM blood pressure 144/84 administered by Nurse#8 1/30/25 at 8:00 PM blood pressure 138/78 administered by Nurse#10 Review of the Medication Administration Record (MAR) dated February 2025 for Resident #43 revealed Midodrine was administered on the following dates and times when the systolic blood pressure was greater than 130 mmHg. 2/2/25 at 8:00 PM blood pressure 140/72 administered by Nurse #11 2/9/25 at 8:00 PM blood pressure 140/78 administered by Nurse#10 A physician's order dated 2/13/25 for Resident #43 revealed to discontinue Midodrine Hydrochloride oral tablet 5 milligrams (mg). Give 1 tablet by mouth two times a day for hypotension. Hold for systolic blood pressure greater than 130 mmHg. Review of the progress notes from 1/6/25 through 2/9/25 for Resident #43 revealed no documentation as to why the Midodrine was administered outside of the prescribed parameters or that the Physician was notified. During an interview on 2/18/25 at 11:28 AM Nurse #8 stated Resident #43 received dialysis three times a week. He was prescribed Midodrine for low blood pressure. She stated if she signed off on the MAR that the medication was administered then she did give it. She reported it was done in error. During an interview on 2/19/25 at 11:00 AM Nurse #5 stated she was aware that there were hold parameters on the Midodrine. She stated if she signed off that the Midodrine was administered to Resident #43 then it was given in error. During a phone interview on 2/19/25 at 12:50 PM Nurse #10 stated she was aware there were hold parameters on the Midodrine. She stated if she signed off that Midodrine was administered to Resident #43 outside of the parameters then it was administered in error. During a phone interview on 2/19/25 at 4:00 PM Nurse #11 stated if she signed off on the MAR that she administered Midodrine to Resident #43 outside of the parameters then it was given in error. During an interview on 2/18/25 at 3:36 PM the Physician stated she was not aware that the Midodrine was not being held according to the prescribed parameters. She stated Resident #43 received dialysis three times a week and has had no significant outcome from receiving the medication. The Physician stated staff should follow the physician orders. She indicated that she had not been notified when the Midodrine was given outside of the parameters. During an interview on 2/20/25 at 12:27 PM the Nurse Practitioner stated Resident #43 has had no effects of receiving the Midodrine outside of the parameters. She stated she was made aware of the medication error on 2/13/25 and the Midodrine was discontinued. She indicated staff should follow the hold parameters according to the order. During an interview on 2/20/25 at 3:00 PM the Director of Nursing (DON) stated she was made aware of the medication error regarding Resident #43 and medication parameters should be followed. She stated education would be provided. During a phone interview on 02/21/25 at 11:54 AM the Consultant Pharmacist stated the facility made her aware today of the medication error regarding the Midodrine for Resident #43. She stated the medication was discontinued on 2/13/25 by the time she completed the monthly medication regimen review so therefore no recommendations were made. She stated that receiving an antihypotensive medication when it was not needed would increase the blood pressure unnecessarily. She stated they had planned for in-service education with nursing staff in March 2025 and would review medication administration.

Based on observations and staff interviews the facility failed to ensure that food items that were stored for use in 1 of 1 walk-in refrigerator, 1 of 1 reach-in refrigerator and the dry goods storage pantry were labeled, dated, or discarded when expired. This deficient practice had the potential to affect food served to residents. Findings included: An observation on [DATE] at 10:20 AM of the kitchen's walk-in refrigerator with the Dietary Manager in training revealed: a. (2) small glasses of nectar orange juice with no opened date b. (1) partially used plastic bucket of pears with no opened date c. (4) hot dogs in a zip lock bag with an expiration date of [DATE] d. (1) partially used container of apple juice with an open date of [DATE] (expired on [DATE]) e. (1) tub of chocolate pudding partially used with no opened date f. (1) pitcher of partially used fruit punch with an expiration date of [DATE] g. (1) partially used container of thickened sweet tea with lemon with no opened date h. (1) partially used small bowel of apple sauce with no opened date i. (1) partially used bowl of pudding with no opened date j. (1) white tubular package of thawed ground meat with no label and no opened date. k. (3) bowls of mixed fruit with no opened date l. (1) bowl of green Jello with no opened date Additionally, an observation of the reach in refrigerator revealed (1) partially used tub of pimento spread with an expiration date of [DATE]. An observation of the dry storage pantry on [DATE] at 11:00 AM revealed: a. (1) partially used container labeled yellow cake mix with no expiration date b. (1) partially used zip lock bag labeled breadcrumbs with no expiration date In an interview with the Dietary Manager in training on [DATE] at 11:10 AM she stated it was her first day as the Dietary Manager. She could not explain why foods had not been labeled and expired foods had not been discarded. She stated the kitchen staff were supposed to inventory all food storage areas daily to ensure food was properly labeled and expired foods were discarded. In an interview with the Certified District Manager on [DATE] at 12:10 PM he stated that all stored foods were to be labeled, dated, and discarded when expired. He explained the current CDM had resigned (effective [DATE]) and that he would be working full time at the facility until the Dietary Manager in training completed the food safety course and became certified. In an interview with the Administrator on [DATE] at 9:56 AM he stated he did not know why foods were stored with no labels and expired foods had not been discarded. He expected all foods to be properly labeled and expired foods to be discarded daily.

Based on record review and staff interviews, the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) program established and implemented effective systems to monitor and evaluate action plans previously developed to correct identified deficiencies. This failure resulted in the facility being unable to sustain compliance at F584, F677, F727, F732, and F812. During a complaint investigation and follow up survey of [DATE], the facility failed to maintain hot water temperatures in a shower room used by residents (F584). During a complaint investigation survey of [DATE], the facility failed to provide incontinent care to dependent residents (F677). During a recertification and complaint investigation survey of [DATE], failed to provide 8 hours of a Registered Nurse (RN) coverage (F727), accurately document the Daily Nursing Hours staff postings (F732), and ensure that food items that were stored for use were labeled (F812). On the current recertification and complaint investigation survey these identical deficient practices were repeated. The continued failure during three federal surveys of record showed a pattern of the facility's inability to sustain an effective QAPI program. Findings included: a. On the current recertification and complaint investigation survey the facility failed to maintain hot water temperatures in two shower rooms used by residents. During the complaint investigation and follow up survey of [DATE] the facility failed to maintain hot water temperatures in a shower room used by residents. An interview was conducted on [DATE] at 12:00 PM with the Administrator. The Administrator confirmed he was responsible for providing a safe and homelike environment for all residents, and for making sure the plan of correction (POC) that was in place for the cold shower citation of F584 was effective for sustaining compliance. The Administrator stated both he and the Maintenance Director were responsible for reassessing the POC for F584 to see if the plan that was implemented was working. The Administrator stated he believed the POC was not working because as of [DATE], their paper water temperature logs were no longer being used since they updated to the electronic maintenance system and hired a new Maintenance Director who was not tracking the shower water temperatures. The Administrator added that their new electronic maintenance water testing log did not include testing water temperatures in the shower rooms which resulted in the shower room water temperatures not being monitored and, because of this, they inadvertently forgot to add the 3 shower rooms to the electronic maintenance weekly water temperature testing form. He stated once they realized the water temperatures in the showers were not monitored during this recertification survey, they added shower rooms #1, #2, and #3 onto the electronic water temperature tracking form on [DATE] to document shower room water temperatures. The Administrator stated they were not aware of the cold-water concerns in the showers. 35173 b. On the current recertification and complaint investigation survey the facility failed to provide incontinence care to a resident who required assistance with activities of daily living (ADLs). During the complaint investigation survey of [DATE] the facility failed to provide incontinence care to 4 residents who were unable to carry out activities of daily living without staff assistance that were reviewed for needing assistance with ADLs. An interview with the Administrator conducted via phone on [DATE] at 1:30 PM revealed the Director of Nursing was responsible for making sure rounds were being completed to ensure residents were being changed if they were incontinent as part of the plan of correction (POC) that was written for F677. The Administrator stated he was responsible for reviewing the results of the audits to ensure the care was being provided and that the audits may have needed to be in place for a longer period of time. The Administrator stated after the initial audits were completed for the previous citation, there was no further assessing done to see if the plan of correction for providing incontinence care was working. He indicated there should have been further assessing. The Administrator stated he was not aware that incontinence care was delayed for a resident. The Director of Nursing was not available for an interview on [DATE]. 37673 c. On the current recertification and complaint investigation survey the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 13 of 275 days reviewed. During the recertification and complaint investigation survey of [DATE] the facility failed to provide 8 hours of Registered Nurse (RN) coverage for 28 of 45 days reviewed. An interview with the Administrator on [DATE] at 9:56 AM revealed that the facility had a hard time hiring full and part time RN's and the Agency they used also had trouble providing licensed RNs for the facility. Additionally, the Administrator stated that the facility had several as needed (PRN) RNs but those nurses were not scheduling any days to work. The Administrator stated he was not sure why there were days in [DATE] that had no RN coverage because the new POC was in effect and the schedule was being reviewed every morning in the daily staff meeting. The Administrator stated when it was discovered that there was no RN on the schedule, himself and the DON should have been notified immediately, but they were not. The Administrator added, he and the DON even reviewed the weekend schedules every Friday in the morning meeting to ensure there was an RN on the schedule and discussed that in the event of a last minute call out, himself and the DON should have been notified immediately. The Administrator stated he could not understand how this continued to happen because the schedule was also scrutinized daily to ensure they were within the budget and stated that a RN weekend supervisor was hired on [DATE] and this had helped. d. On the current recertification and complaint investigation survey the facility failed to accurately document the Daily Nursing Hours postings on 4 of 324 days reviewed. During the recertification and complaint investigation survey of [DATE] the facility failed to accurately document the Daily Nursing Hours staff postings for 2 days. An interview with the Administrator on [DATE] at 9:56 AM revealed that he stated there was no excuse for the two postings that were blank. The Administrator explained he had assigned himself to review the daily postings to ensure accuracy but had quit checking them 3 or 4 months after their last recertification survey. The Administrator stated he had not done his due diligence as the reviewer and needed to do better to fix the problem. The Administrator added he spent 2 weeks training a new scheduler that was hired on [DATE] and there had been no errors on the Daily Nursing Hours Report since then. e. On the current recertification and complaint investigation survey the facility failed to ensure that food items that were stored for use in a walk-in refrigerator, a reach-in refrigerator and the dry goods storage pantry were labeled, dated, or discarded when expired. During the recertification and complaint investigation survey completed on [DATE] the facility failed to ensure refrigerated food items that were stored for use in the walk-in refrigerator were dated and sealed. An interview with the Administrator on [DATE] at 9:56 AM revealed that the Dietary Manager was responsible for visually inspecting the kitchen freezer and cooler for open, undated items twice daily, 5 days per week Monday through Friday. He stated the Dietary Manager had quit abruptly giving him less than a week's notice. The Administrator stated the previous plan of correction was not working and he believed it was due to poor leadership in the kitchen.

Based on observations, record review, and staff interviews, the facility failed to implement the facility's infection control policy and procedures for Enhanced Barrier Precautions (EBP) when 1.) Nurse #5 provided direct care for Resident #60's Stage IV and unstageable chronic foot wounds without applying the necessary personal protective equipment (PPE) and; 2.) when two nurse aides (Nurse Aide #1 and Nurse Aide #2) provided care to Resident #7 without applying the necessary PPE who had a stage IV pressure ulcer and tube feeding port. This occurred for 3 of 3 staff (Nurse #5, Nurse Aide #1 and Nurse Aide #2) observed for infection control practices. Findings included: Review of the facility's policy for Enhanced Barrier Precautions updated October 2024 revealed Enhanced Barrier Precautions (EBP) requires the use of gown and gloves only for high contact resident care activities. High contact resident care activities in the residents' rooms included dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as central lines, urinary catheters, feeding tubes, tracheostomy/ventilator use, and wound care. 1.) During an observation on 02/16/25 at 4:50 PM Resident #60 was observed sitting up in her wheelchair in the common area of the locked dementia unit. Resident #60 was not oriented to person, place, or time. Heel protector boots were in place on both feet. Nurse #5 sat down on the floor in the common area and removed the bilateral heel boots from Resident #60's feet. The gauze dressing on both feet were observed not intact and hanging from the wounds. The wounds to her bilateral heels were not completely covered and revealed a Stage IV wound on the left heel and unstageable wound on the right heel. Nurse #5 lifted the left heel and removed part of the soiled dressing with her bare hand. She lifted the right heel and removed part of the soiled dressing with her bare hand. The surveyor stopped Nurse #5 at that point and told her that she needed to wear gloves while handling soiled dressings, and that gowns were also to be worn when providing direct care to a wound. Nurse #5 stopped and stated she would apply gloves and gown before removing more of the soiled dressing and proceeding with her wound care. During an interview on 2/16/25 at 4:50 PM Nurse #5 stated she was aware that Resident #60 had a chronic Stage IV wound, and an unstageable heel wound to her feet. She stated that she thought that she was only going to look at the wounds and not complete the dressing change and that was why she did not apply gloves or a gown prior to handling the wounds. She stated once she removed the heel protectors and saw that the dressing was soiled and falling off, she should have applied gloves and gown prior to removing part of the dressing on Resident #60's feet. She stated she had received infection control training and was aware of the requirement for Enhanced Barrier Precautions. During an interview on 2/20/25 at 1:00 PM the Infection Control Preventionist Nurse stated staff had been trained on Enhanced Barrier Precautions and were aware that gloves and gown were to be applied prior to providing direct care to residents with chronic wounds. During an interview on 2/20/25 at 2:00 PM the Director of Nursing (DON) stated Resident #60 had chronic heel wounds. She stated staff were aware that gloves and gown were to be worn when providing direct care to a resident with chronic wounds. She stated education would be provided to all nursing staff including Nurse #5. 35173 2a) An observation of Resident #7's room door revealed a sign posted on the front of the door Enhanced Barrier Precautions. Additionally, a storage cart was located outside the resident's room beside her door containing PPE to include gloves and gowns. An observation of Nurse Aide (NA) #2 was conducted on 02/16/25 at 1:15 PM. NA #2 was noted to apply gloves and no gown upon entering the resident's room. NA #2 proceeded to remove Resident #7's brief and began to provide incontinence care. The brief was noted to be saturated with a significant amount urine. NA #2 was observed changing Resident #7's brief at this time with the use of gloves only. An interview with NA #2 on 02/16/25 at 1:25 PM revealed she thought she was only suppose to wear gloves. She stated she did not think she had to wear a gown. NA #2 read the sign on the door and stated she knew Resident #7 had a wound and had a g-tube (gastrectomy tube inserted in the abdomen to provide nutrition). NA #2 stated she would wear the appropriate PPE to include gown and gloves whenever she entered the room from now on. 2b) An observation of NA #1 was conducted on 02/18/25 at 11:30 AM. NA #1 was observed completing incontinence care for Resident #7 while she secured the resident's brief and disposed of the soiled brief and was noted to have on gloves only. An interview was conducted with NA #1 on 02/18/25 at 11:30 AM. NA #1 was asked if she wore a gown while she provided incontinence care to Resident #7 and she stated No, I thought I was only suppose to wear gloves. NA #1 stated she was aware that Resident #7 had a pressure ulcer and a g-tube (gastrectomy tube inserted in the abdomen to provide nutrition). An interview was conducted with the Administrator via phone on 02/21/25 at 1:30 PM. The Administrator stated all staff needed to follow the policy and the signage on the door for residents with Enhanced Barrier Precautions in order to protect themselves and other residents from the potential of getting an infection. He stated education was given to every staff member regarding EBP upon hire and when the EPB was first initiated, but that more education was needed to be provided regarding enhanced barrier precautions.

Based on observation, record review, and resident and staff interviews, the facility failed to provide a resident with their preferred number of showers a week for 1 of 1 residents reviewed for choices (Resident #38). The findings included: Resident # 38 was admitted to the facility on [DATE] with diagnoses that included spondylosis, muscle weakness, venous thrombosis, and anxiety. Resident #38's most recent Minimum Data Set (MDS) dated [DATE] revealed the resident had no cognitive impairments. Resident #38 needed extensive to total assistance with activities for daily living: bed mobility, transfers, eating, toilet use, dressing, personal hygiene, and bathing. Resident #38's care plan dated 02/03/25 revealed Resident #38 was unable to participate in the usual daily routine and needed modified activities or some assistance when using her hands. Resident #38 had an Activities for Daily Living (ADL) self-care performance deficit related to diabetes, spondylosis with myelopathy, osteoarthritis, and muscle weakness. Resident #38 had limited physical mobility and required two-person total assistance utilizing a mechancial lift for transfers and showers. Review of the ADL record for January 2025 and February 2025 documented Resident #38 received one bath on 02/11/24 and no showers and was not noted to have refused a shower during those months. A review of Resident #38's electronic activities for daily living (ADL) bath/shower sheets from 01/21/24 through 02/18/25 revealed one bath on 02/11/25 and no showers during the 30-day look back period. Review of the shower schedule revealed Resident #38's was scheduled for a shower on Tuesdays. An interview and observation was conducted on 02/16/25 at 12:00 PM with Resident #38. She stated she had only received one shower since her admission on 12/06/24. She stated she would like to have 2 showers a week, but staff told her it took too much of their time to take her to the shower room and back, and they could not accommodate her request. Resident #38 was observed sitting up in bed, had a gown on, and her face and hair appeared oily. A follow-up interview was conducted on 02/17/25 at 12:00 PM with Resident #38. She stated since her admission she had only received one shower. Resident #38 stated she did not refuse showers and wanted 2 showers a week, but the NAs refused to give her one, with only a partial bed bath now and then. She said she let the nurses know, but still received no showers. An interview was conducted on 02/17/25 at 9:15 AM with Nurse #1. Nurse #1 stated she did not know when Resident #38 last had a shower and that Resident #38 should be getting two showers a week or more if she wants them. Nurse #1 stated all residents should be scheduled for 2 showers per week and on the other days they should receive a bed bath. A review of Resident #38's shower calendar with Nurse #1 revealed Resident #38's shower day was Tuesday. Nurse #1 stated Resident #38 should have had 2 shower days posted per week on the calendar (Tuesday and Saturday), not Just Tuesday. When Nurse #1 checked the electronic shower/bath 30-day look back tracking log from 01/21/25 through 02/18/25, it revealed Resident #38 received no showers and one bath on 02/11/25 at 1:00 PM. An interview was conducted on 02/17/25 at 9:20 AM with NA #1. NA #1 stated Resident #38 told her that she had only had one shower since her admission. NA #1 stated she never gave the resident a shower, and that Resident #38 needed 2 NAs with a mechanical lift to take her to and from the shower room, and that it was easier for the NAs to just to give the resident a bed bath. An interview was conducted on 02/18/25 at 12:15 PM with the Director of Nursing (DON). The DON stated Resident #38 should be getting daily bed baths and 2 showers per week per her preference. But it was currently scheduled for one shower weekly on Tuesday, and she was not getting that and should have been. The DON revealed all residents should have a shower twice a week and whenever they request a shower. An interview was conducted on 02/17/25 at 10:35 AM with the Administrator. He stated he had not heard any complaints about residents not receiving showers.

Based on observations, record review, staff and Nurse Practitioner interviews, the facility failed to protect residents' right to be free from sexual abuse (Resident #2) and intentional inappropriate touching (Resident #6) perpetrated by Resident #1. In the evening of 11/26/23 the facility was made aware Resident #1 entered another resident's room (Resident #6) uninvited and Resident #6 reported to Nurse #1 that a strange man (identified as Resident #1) woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what Resident #1 was doing in the room and told him he did not belong in her room. Resident #6 required Ativan (a medication to treat anxiety) 4 days later because she was still upset. On 11/27/23, the day following the incident with Resident #1 and Resident #6, Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 lay in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) Resident #2's penis. Due to the inappropriate act initiated by Resident #1 toward Resident #2, a reasonable person would have experienced intimidation and fear. This was for 2 of 3 residents reviewed for abuse. Immediate Jeopardy began on 11/27/23 at 4:15 PM when Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 was lying in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) Resident #2's penis. Immediate Jeopardy was removed on 12/08/23 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy were effective. Findings included: 1a. Resident #1 was admitted to the facility on [DATE]. Diagnoses included pervasive developmental disorder (delay in development of multiple basic functions including socialization and communication), dysarthria (speech disorder), and cognitive communication deficit. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and demonstrated no behaviors. He was independent with bed mobility, transfers, walking in his room and corridor and with all activities of daily living ADLs. He had no impairments and did not use a mobility device. There was no care plan for behaviors for Resident #1 and there was no documentation to support Resident #1 had any prior behaviors. Resident #6 was admitted to the facility on [DATE]. Diagnoses included, in part, anxiety, age related physical debility, tremors, difficulty in walking, and depression. The MDS admission assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance with two person physical assistance with bed mobility and transfers. She had impairment to both sides of lower extremities and used a wheelchair. A nursing progress note written on 11/26/23 at 10:47 PM by Nurse #1 revealed Nurse #1 answered the phone around 7:00 PM and the caller identified herself as the responsible party for Resident #6, stating that the resident had called her and reported a strange man in her room. Went to resident's room and a male resident was sitting in a chair beside her bed. Informed male resident that he was in the wrong room and assisted him back to his room. Reported incident to the nurse and the nurse aide on the 400 hall about the male resident being in the room of Resident #6 and that the nurse should inform the Director of Nursing immediately of incident and to notify the responsible party that the male resident had been removed from room. A nursing progress note written on 11/26/23 at 11:26 PM by Nurse #3 revealed at 7:00 PM was told by a Nurse #1 that Resident #1 was sitting in Resident #6's room. Was also told that Resident #6 was upset and the responsible party called to report the incident. This nurse went to speak with Resident #6. Upon entering the room, the resident was tearful and speaking with her responsible party on a cell phone. Resident #6 stated, A man sat on the side of my bed and told me he loved me and said he will take care of me. He kissed me on the cheek. Resident #6 stated she was scared and made it clear that his advances were unwelcome so she pushed the call button and called her responsible party and the responsible party contacted the facility. A nursing progress note written by Nurse #3 on 11/27/23 at 3:04 AM revealed at 8:00 PM, Resident #6's responsible party came to the facility. Discussed incident with Resident #6 and her responsible party. Resident #6 was aware that she could move to another room. This nurse would be included in all care for this shift and provided Resident #6 with nurse's personal cell phone number. A Social Service Note written by the Social Worker on 11/27/23 at 1:21 PM revealed he met with Resident #6 in her room and discussed a room change. Resident #6 stated she did not wish to move rooms at this time. A physician's progress note written by the Nurse Practitioner on 11/27/23 at 6:00 PM revealed Resident #6 was requesting Ativan (a medication to relieve anxiety) to help with her anxiety caused by the man coming into her room. A nursing progress note written on 11/27/23 at 6:22 PM revealed Nurse #2 notified responsible party and left message on voicemail to make her aware Resident #6 had a new order for Ativan 0.5 milligrams every 8 hours as needed for anxiety for the next 14 days. Review of Resident #6's physician orders revealed there were no orders for any antianxiety medications prior to 11/27/23. A review of the medication administration record revealed Resident #6 received the ordered Ativan one time on 11/30/23. An interview was conducted with Nurse #1 on 12/07/23 at 11:15 AM via phone. Nurse #1 stated she responded to a phone call that the responsible party of Resident #6 put into the facility. She stated the responsible party reported to her that some strange man was in Resident #6's room. Nurse #1 stated after she spoke with the responsible party, she went to Resident #6's room and she saw Resident #1 sitting in a chair at the bedside talking with Resident #6. Nurse #1 reported she asked Resident #1 what he was doing in the room and he had replied that Resident #6 told him to get out and that was not his room. Nurse #1 stated she then took Resident #1 to his room. Nurse #1 stated Resident #6 appeared to be upset, but she was not crying. Nurse #1 stated Resident #1 was normally confused. She stated she reported to the Medication Aide and Nurse #3 on the hall what had happened to make sure Nurse #3 followed up with the responsible party and the Director of Nursing. An interview was conducted with Medication Aide (MA) #1 via phone on 12/06/23 at 4:22 PM. MA #1 reported she was assigned to the hall Resident #1 and Resident #6 resided on the night of 11/26/23 and she arrived on her hall at 7:00 PM. When she first arrived on the hall she noticed Resident #1 sitting across the hall from Resident #6 in Resident #'2's room. She stated she did not think much about him visiting with Resident #2 and when she observed them they were just talking. MA #1 stated after about 5 minutes or so, she noticed Resident #6's call light go off and saw Nurse #1 go into Resident #6's room and saw her bring Resident #1 out of Resident #6's room. MA #1 stated she went into the room to see Resident #6 and the resident shared with her that a strange man had come into her room and was holding her hand and telling her he loved her and he was going to take care of her and he kissed her on the cheek. MA #1 stated Resident #6 stated she was scared. MA #1 stated Resident #1 remained in his bed in his room for the remainder of the night. MA #1 stated she had never seen Resident #1 go into Resident #2's room or any other room until 11/26/23. An interview was conducted with Nurse #3 via phone on 12/06/23 at 2:38 PM. Nurse #3 reported Nurse #1 told him she received a call from the responsible party of Resident #6 with concerns that a strange man was in her room. Nurse #3 stated Nurse #1 went into Resident #6's room at the time of the phone call to investigate and had Resident #1 leave the room. Nurse #3 went and spoke with Resident #6 and she stated she was sleeping and she woke up to see this strange man who she did not know and she was upset and scared. Nurse #3 stated she said her responsible party was on the way to the facility. Nurse #3 stated he had asked Resident #6 if she wanted to move to a different hall but she said she was okay and she declined to move. Nurse #3 stated he had explained to Resident #6 that Resident #1 was confused and once he had explained that to her, she did not believe he was trying to hurt her or anything. Nurse #3 stated Resident #6 expressed she did not want him to come into her room again and he made sure to follow up with her through the remainder of the shift to be sure she felt safe. Nurse #3 stated he called the DON and reported what happened between Resident #1 and Resident #6. The DON instructed him to speak with both families regarding the incident and he (DON) would move the resident in the morning. Nurse #3 reported Resident #6 stated she was fine knowing that Resident #1 was not going to be moved until the next morning. Nurse #3 reported he checked on Resident #1 through the night and he seemed to have his normal baseline confusion and he was not presenting with any signs and symptoms of a urinary tract infection (UTI). Nurse #3 reported he spoke with Resident #1 after the incident and Resident #1 had no recollection at all of what happened. Nurse #3 stated he told him to say in his room and stay out of residents' rooms. He was very agreeable and he seemed very innocent. He added, shortly after the incident, Resident #1 went to bed and remained in his bed through the remainder of the night. Nurse #3 stated he had never known Resident #1 to wander into other resident's rooms. Nurse #3 reported he reviewed the nursing notes a few days later and saw that he had been sent to the hospital for a psychiatric evaluation and it was discovered in the emergency room he had UTI. Nurse #3 reported it made a little more sense that he would have this very out of character behavior if he had a UTI. An interview was conducted with Resident #6 on 12/06/23 at 2:45 PM. Resident #6 reported a strange man came into her room while she was sleeping on 11/26/23. She stated she had never seen him before and he woke her up when he sat on the bed and was holding her hand. He began to tell her he loved her and he was going to take care of her and she told him he did not belong in this room and needed to leave. She stated he remained in the room and continued to say he would take care of her and he kissed her on the cheek. Resident #6 stated she was scared and did not know what this man was going to do to her. She continued to tell him he had to leave. She stated he moved to the other side of the bed and sat on a chair beside the bed. Shortly after he moved, a nurse came in and she took him out of the room. She stated she called her responsible party because she as scared. She added, the staff asked her if she wanted to move to another room, but she declined. She stated she just did not want him to come back in her room again. She stated Nurse #3 checked on her frequently throughout the night and she felt safe. A follow up interview was conducted with Resident #6 on 12/07/23 at 10:35 AM. Resident #6 revealed she was told Resident #1 would be moved in the morning on 11/27/23 and she was glad to hear that he would be getting moved and that that made her feel safer. An interview with the Director of Nursing on 12/06/23 at 3:43 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1 we would monitor him to be sure he did not enter Resident #6's room. He stated we did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated we completed an incident report but we did not initiate an abuse investigation. He stated he should have implemented a measure to protect all the residents from Resident #1 after that incident occurred with Resident #6. An interview was conducted with the Nurse Practitioner (NP) on 12/07/2023 at 10:00 AM. The NP stated she was notified on 11/27/23 when she reviewed the physician's book which was located at the nurse's station. She stated she went to speak to Resident #6 and she reported Resident #1 was on her bed and he kissed her cheek. The NP stated Resident #6 told her it really scared her and she asked for something for anxiety because it was making her very anxious. The NP added, Resident #6 was not on any antianxiety medications in the past but had asked for something to see if it would help her. The NP could not definitively say his behavior was as a result of the urinary tract infection, but that it could have possibly caused the increased confusion. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. 1b. Resident #2 was admitted to the facility on [DATE]. Diagnoses included, in part, Alzheimer's Disease, cognitive communication deficit, and anxiety. The MDS quarterly assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and demonstrated no behaviors. He required extensive assistance with 2 staff physical assistance with bed mobility and dressing and was totally dependent with 2 staff physical assistance with toileting and transfers. A review of Resident #2's care plan dated 09/06/23 revealed a plan of care for decision making related to difficulty making his own decisions. Interventions included, in part, validate thoughts/feelings when confused or anxious and provide an environment that respects privacy. A nursing progress note written by Nurse #2 on 11/27/23 at 7:09 PM revealed at approximately 4:15 PM, Resident #2 was noted by a staff member that Resident #1's hand was down the front of Resident #2's brief. Nurse #2 was notified by the staff member and observed Resident #1 was sitting in a chair beside Resident #2's bed and Resident #1 had his arms crossed and his hands tucked under his arms. Nurse #2 asked Resident #1 to, please go to assigned room. The Assistant Director of Nursing and Administrator were made aware. A skin assessment was performed on Resident #2 and there were no noted injuries or impairments. Every 15 minutes safety checks were ordered. Review of the initial allegation report submitted to the Health Care Personnel Registry on 11/27/23 at 5:38 PM per fax transaction report indicated Resident #1 was observed in another resident's room with his hands down another resident's brief. There was no apparent physical or mental harm. Review of a hand written statement dated 11/27/23 by Nurse Aide (NA) #1 revealed About 4:15 PM on 11/27/23, as I was walking to get ice, passing resident's [Resident #2] room, another resident [Resident #1] had his hand in resident's [Resident #2] brief manually stimulating him. When the other resident [Resident #1] saw me he quickly removed his hand. Notified nurse. Review of a hand written statement dated 11/27/23 by NA #2 revealed I am the aide on the 400 hall. I did not see anything out of the norm with the residents [Resident #1 or Resident #2]. [Resident #1] had been in his own room today until they had movie day on the 100 hall. Around 2:00 PM he was walking around. Review of a hand written statement dated 11/27/23 by Nurse #2 revealed At approximately 4:15 PM, [NA #1] notified of [Resident #1] with his hand down [Resident #2's] brief in the front of his brief. This nurse walked down and [Resident #1] was sitting in a chair at bedside of [Resident #2] with both hands crossed tightly under his arms. When this nurse went in the room and asked Hey, [Resident #1] what are you doing? Resident said nothing and [Resident #2] stated He's just talking junk [Resident #1] said No I'm not. This nurse asked [Resident #1] to please go to his assigned room until this nurse could come and speak with resident. [Resident #1] got up, closed his right hand to a fist, and went to his room. This nurse notified the Assistant Director of Nursing and Administrator and the Administrator implemented every 15 minute safety checks until further advisement. A nursing progress note written by ADON on 11/27/23 at 7:54 PM revealed at 5:00 PM notified Psychiatric provider on call regarding sexually inappropriate incident with resident this evening who stated they have 24 hours to do an evaluation and will notify the supervisor on call and contact our Nurse Practitioner to discuss plan of care for resident and will call facility back. A nursing progress note written by the Assistant Director of Nursing (ADON) written on 11/27/23 at 7:32 PM revealed she notified Resident #2's responsible person regarding a situation earlier this evening where a resident from another room was observed by the Nurse Aide inappropriately touching Resident #2 by reaching under his brief. The ADON informed the responsible party no injuries were noted and the other resident was moved to another hall. The ADON explained to the responsible party she had attempted to process this incident with Resident #2 but was unable due to his confusion. A nursing progress note written by the ADON on 11/27/23 at 7:48 PM revealed at 6:20 PM notified Resident #1's responsible party regarding an incident that happened this evening where resident was observed by a nurse aide in another resident's room with his hand under the other resident's brief. Explained that this resident will be moved to another room closer to the nurse's station with no roommate and be placed on every 15 minute safety checks as well as be evaluated by Psych Services on call in the next 24 hrs. A nursing note written by Nurse #4 on 11/28/23 at 1:49 AM revealed Resident #1 continued on 15 minute safety checks; resident moved to room on the 200 hall per management without any issue. Oriented resident to new room location, bathroom, call light, and remote. Resident had been in room all shift with no behaviors noted. A nursing note written by Nurse #5 on 11/28/23 at 5:18 PM revealed a physician order was received to send resident to hospital for psychiatric evaluation. Emergency Medical Services (EMS) called at 3:30 PM. EMS arrived at 3:41 and exited facility with resident via stretcher at 3:49 PM. The emergency room (ER) progress note dated 11/29/23 revealed Resident #1 was seen and evaluated by psychiatry. He was cleared for disposition (dismissed) back to the facility at this time. Resident was started on antibiotics due to moderate leukocytes (elevate white blood cells indicative of infection) on urinalysis. Will continue with antibiotics at facility. A nursing progress note written by Nurse #4 on 11/29/23 at 7:51 PM revealed Resident #1 returned from hospital at 3:30 PM on 11/29/23 with orders for an antibiotic to treat a urinary tract infection. A physician's order written on 11/29/23 revealed an order for Cephalexin (antibiotic to treat urinary tract infections) 500 milligrams 3 times daily for 7 days. A review of the medication administration record revealed Resident #1 received the ordered antibiotic three times daily starting on 11/29/23 and finished on 12/06/23. Review of the 5 Day investigation report submitted on 12/01/23 at 2:27 PM per fax transaction report to Health Care Personnel Registry indicated Resident #1 was observed in another resident's (Resident #2) room with his hands down his brief. Resident #1 was cognitively impaired and had a diagnosis of pervasive developmental disorder. Resident #1 was observed inappropriately touching Resident #2. Resident #1 was sent for psychiatric evaluation. Findings negative. Medical evaluation revealed presence of urinary tract infection (UTI). Resident #2 who was recipient of touching showed no physical harm or mental anguish related to incident. Resident #1's room moved to different unit and resident was placed on every 15 minute safety checks. No further inappropriate behaviors have been observed at this time. Resident #1 placed on antibiotics for UTI. An interview was conducted with Nurse Aide (NA) #1 via phone on 12/06/23 at 1:02 PM. NA #1 reported as she was walking by to get ice on the 400 hall she noticed Resident #1 sitting in a chair beside Resident #2's bed and noticed Resident #1 had his hand under the brief of Resident #2 and was manually stimulating (moving hand in an up and down motion) on Resident #2's penis. NA #1 stated Resident #1 noticed that she saw him and he quickly pulled his hand out of the brief. NA #1 stated she went into the room and asked what Resident #1 what he was doing in the room and replied nothing. She added, she went straight to Nurse #2. NA #1 stated Resident #2 had a surprised look on his face when she entered the room and was calm. She stated Resident #2 was not observed being upset or showing signs of refusing to have Resident #1 touch him. She added he was just laying back in his bed. NA #1 stated she had never seen this behavior before from Resident #1 and that their rooms have always been near each other. NA #1 reported when he was asked to leave the room he kept his hand balled up and tucked in. An interview was conducted with Nurse #2 on 12/06/23 at 1:33 PM. Nurse #2 reported NA #1 quickly had approached her and told her Resident #1 was in Resident #2's room and Resident #1 had his hand down Resident #'2s brief and was stimulating him. Nurse #2 stated she went straight to Resident #2's room and Resident #2 was lying down on his back in his bed and Resident #1 was sitting in a chair right beside Resident #2's bed with his arms tucked under him. Nurse #2 stated she asked what he was doing and Resident #1 replied nothing, and Resident #2 replied He's just talking junk and Resident #1 said No I'm not. Nurse #2 stated she asked Resident #1 to go to his room and she would be in to speak with him. Nurse #2 stated she did a complete head to toe assessment on Resident #2. She added, Resident #2 did not speak about Resident #1 having his hand down his brief and acted as though it did not happen. Nurse #2 stated she did not see any erection or semen or any signs of stimulation at the time of the assessment. Nurse #2 stated once the residents were separated, she initiated every 15 minute safety checks until Resident #1 could be further evaluated and every 15 minutes safety checks continued after Resident #1's return from the hospital until he finished his antibiotic treatment. She stated his room was moved to the 200 hall as well. Nurse #2 added Resident #2 remained in his room as he usually would not come out of his room and he was monitored as well with every 15 minute safety checks. An interview was conducted with the ADON on 12/06/23 1:41 PM. The ADON reported that after she was made aware of the incident between Resident #1 and Resident #2 by Nurse #2 she went into Resident #2's room to assess his mental state. The ADON reported that his confusion was at his baseline and it was difficult to process the incident with him because he did not seem to understand what was going on. The ADON reported Resident #2 was not upset or recalling any of the incident. The ADON reported she then went to see Resident #1 who was in his bathroom at the time. She stated it seemed he knew he had done something wrong but that he did not understand; he seemed embarrassed. The ADON spoke to him and told him that that behavior was not acceptable and he needed to stay out of residents' rooms and to keep his hands to himself. An interview was conducted with Nurse Practitioner (NP) on 12/07/2023 at 10:00 AM. The NP reported she had seen Resident #1 on the morning of the 11/27/23 in his room. She stated he had no signs or symptoms of a urinary tract infection and his confusion seemed at baseline. The NP stated she received a call later on 11/27/23 as to what had happened with Resident #1 and Resident #2 and that the facility was waiting for a psychiatric evaluation. The NP stated a psychiatric provider was unable to come to the facility and it was decided to send Resident #1 to the ER for a psychiatric evaluation. The NP stated he was cleared after the psych evaluation but it was determined he had a urinary tract infection and was started on antibiotics and discharged back to the facility and continued with every 15 minutes safety checks until the antibiotic was completed. The NP stated she assessed Resident #2 and his assessment was benign and he did not share any information of the incident with her nor did he seem to have any recollection. An interview with the Director of Nursing on 12/06/23 at 3:45 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 by Nurse #3. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1, the facility would monitor him to be sure he did not enter Resident #6's room. He stated he did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated he completed an incident report, but that he should have implemented a measure to protect all the residents from Resident #1 after the first incident occurred with Resident #6 because if he had followed the abuse policy and procedure the sexual abuse with Resident #2 could have been prevented. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. The Administrator stated if he had further investigated the incident with Resident #6, the incident that occurred with Resident #1 and Resident #2 could have been avoided. An observation of Resident #1 on 12/06/23 at 12:42 PM revealed Resident #1 was an alert resident who was sitting in his room on the 200 hall. He was pleasant and cheerful but confused. An observation of Resident #2 on 12/06/23 at 12:53 PM revealed Resident #2 was an alert resident lying on his bed in his room on the 400 hall. He was pleasant and cheerful but confused. The Administrator was notified of Immediate Jeopardy on 12/06/23 at 6:30 PM. F600 Identify those residents who suffered, or are likely to suffer a serious adverse outcome because of the non-compliance: The facility failed to protect Resident #6 from inappropriate touching on 11/26/23 and Resident #2 from sexual abuse on 11/27/23 perpetrated by Resident #1. Resident #1 was evaluated 11/29/23 at the hospital emergency room and was diagnosed with a urinary tract infection and was treated with antibiotics. The hospital completed a psychiatric evaluation and was cleared to return to the facility. He was relocated to be closer to the nurse's station to ensure closer observation on 11/29/23. No further complaints from other residents have been received to date. Resident #1 has been a resident at this facility since 03/31/21 and this was a newly identified behavior for this resident. The facility has scheduled a neurology consult for 12/07/23, to evaluate any current changes to the plan of care. A review of the updated care plan for Resident #1 revealed on 11/28/23 revealed a plan of care for wandering into other's residents' room with a goal that wandering would not contribute to injury through the next review with interventions to include move resident close to nurse's station, follow up with psychiatry, and implement every 15 minute safety checks. Resident #2 has a diagnosis of Alzheimer's Disease and a Brief Interview Mental Status (BIMS) score of 6. Upon interview by the Regional Clinical Consultant on 12/06/23, he had no recollection of the event and had demonstrated no new behaviors. Resident #6 was alert and oriented with a BIMS of 15. Upon interview by the Regional Nurse Consultant on 12/06/23, she recalled the event and was fearful at the time of the incident because she was asleep and was awakened by a man kissing her cheek. On 12/06/23, during the interview with the Regional Nurse, she affirmed that she felt safe in the facility and has had no further incidents of this type. A review of Resident #6's care plan dated 12/07/23 revealed Resident #6 had experienced a trauma in this facility related to another resident entering her room uninvited with a goal that Resident would feel safe through next review and interventions included, in part, resident to be assessed by Physician or Practitioner, offer to change room for resident, provide assurance that she was safe at this facility and monitor resident. On 12/06/23, the Regional Nurse Consultant completed a review of progress notes for the last 30 days to identify any incidents that could be interpreted as abuse. As a result of this review, two additional initial reports were filed to the state agency on 12/07/23 and investigations initiated at that time. One report was for the incident of inappropriate sexual touching with Resident #6 and Resident #1 on 11/26/23. The other report was filed as a precautionary measure for a resident-to-resident verbal yelling incident on the memory care unit. The facility Social Worker and the Admissions Coordinator completed trauma care assessments on current residents on 12/07/23 to identify any existing trauma affecting the psychosocial well-being of the resident. The facility Social Worker and the Admissions Coordinator interviewed current alert and oriented residents on 12/07/23 to determine if they felt safe in the facility. There were no other residents who were identified as feeling unsafe. For those residents who were unable to be interviewed, their responsible party would be contacted on 12/07/23 by the Social Worker and Admissions Coordinator to ensure they felt their resident was safe in the facility. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete: The facility Administrator and Director of Nursing received re-training from the Director of Operations and Regional Clinical Nurse on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention, screening, and the possible psychosocial effects of sexually inappropriate behavior on a resident. This training was completed on 12/07/23. The DON and Regional Clinical Nurse began education with current facility staff, including contract Housekeeping/Laundry and Rehabilitation, on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention and screening abuse, the reporting of abuse, types of abuse and the possible psychosocial effects of sexually inappropriate behavior on a resident. This training was completed as of 12/07/23. Any current employee who had not receive [TRUNCATED]

Based on record review, and staff interviews, the facility failed to protect Resident #2 from sexual abuse when the Administrator was made aware of Resident #1 entering Resident #6's room uninvited on 11/26/23. Resident #6 reported to Nurse #1 that Resident #1 woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Resident #6 was upset and scared and was not sure what he was doing in the room and told him he did not belong in her room. The following day 11/27/23, Resident #1 was found by Nurse Aide #1 in Resident #2's room sitting at his bedside while Resident #2 lay in bed. Resident #1 had his hand down Resident #2's brief and was manually stimulating (moving hand in an up and down motion) his penis. Additionally, the facility failed to identify abuse, to report the allegation of abuse to the state agency and to conduct a thorough investigation for Resident #6. This was for 2 of 3 residents observed for abuse. Immediate Jeopardy began on 11/26/23 when the facility failed to implement measures to protect other residents from sexual abuse after Resident #1 entered Resident #6's room uninvited on the evening of 11/26/23 where it was reported to Nurse #1 by Resident #6 that Resident #1 woke her up and was holding her hand, telling her he was going to care for her and kissed her on the cheek. Immediate Jeopardy was removed on 12/08/23 when the facility provided and implemented an acceptable credible allegation of Immediate Jeopardy removal. The facility will remain out of compliance at a lower scope and severity level D isolated with potential for more than minimal harm to correct the deficient practice and to ensure that the education and monitoring systems put in place to remove the Immediate Jeopardy were effective. Findings included: The facility's abuse policy dated February 2021 titled Abuse Prevention, intervention, reporting and investigation read, in part, as follows: #5 Identification: (a) It is our policy that all staff monitor residents and will know how to identify potential signs and symptoms of abuse and (d) identifying possible indicators of abuse in residents (injuries, fearfulness, behavioral or social changes). #6 Investigation: (a) It is our policy that reports of abuse are promptly and thoroughly investigated. #8 Protection: (a) It is our policy that the residents will be protected from the alleged offender. #9 Reporting: (a) It is our policy that abuse allegations are reported per Federal and State Law and all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involve abuse to the Executive Director of the facility and other officials including the State Survey Agency and Adult Protective Services where state law provides for jurisdiction in long term care facilities. 1. Resident #1 was admitted to the facility on [DATE]. Diagnoses included pervasive developmental disorder (delay in development of multiple basic functions including socialization and communication), dysarthria (speech disorder), and cognitive communication deficit. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and demonstrated no behaviors. a. Resident #6 was admitted to the facility on [DATE]. The MDS 5 day assessment dated [DATE] revealed Resident #6 was cognitively intact. A nursing progress note written on 11/26/23 at 11:26 PM by Nurse #3 revealed at 7:00 PM was told by a Nurse #1 that Resident #1 was sitting in Resident #6's room. Was also told that Resident #6 was upset and the responsible party called to report the incident. This nurse went to speak with Resident #6. Upon entering the room, the resident was tearful and speaking with her responsible party on a cell phone. Resident #6 stated, A man sat on the side of my bed and told me he loved me and said he will take care of me. He kissed me on the cheek. Resident #6 stated she was scared and made it clear that his advances were unwelcome so she pushed the call button and called her responsible party and the responsible party contacted the facility. An interview was conducted with Nurse #1 on 12/07/23 at 11:15 AM via phone. Nurse #1 stated she was assigned to another hall and she responded to a phone call that the responsible party of Resident #6 put into the facility. She stated the responsible party reported to her that some strange man was in Resident #6's room. Nurse #1 stated after she spoke with the responsible party, she went to Resident #6's room and she saw Resident #1 sitting in a chair at the bedside talking with Resident #6. Nurse #1 reported she asked Resident #1 what he was doing in the room and he had replied that Resident #6 told him to get out and that that was not his room. Nurse #1 stated she then took Resident #1 to his room. Nurse #1 stated Resident #6 appeared to be upset, but she was not crying. Nurse #1 stated Resident #1 was normally confused. She stated she reported to the Medication Aide and Nurse #3 on the hall what had happened to make sure Nurse #3 followed up with the responsible party and the Director of Nursing. Nurse #1 reported she recognized Resident #1's action as being abuse and that was why she told Nurse #3 to be sure to call the Director of Nursing immediately. Nurse #1 stated she has been in serviced on abuse annually through the facility's computer program. An interview was conducted with Nurse #3 via phone on 12/06/23 at 2:38 PM. Nurse #3 went and spoke with Resident #6 and she stated she was sleeping and she woke up to see this strange man who she did not know and she was upset and scared. Nurse #3 stated he had asked Resident #6 if she wanted to move to a different hall but she said she was okay and she declined to move. Nurse #3 stated Resident #6 expressed she did not want him to come into her room again and he made sure to follow up with her through the remainder of the shift to be sure she felt safe. Nurse #3 stated he called the DON right after Nurse #1 had informed him and he had spoken with Resident #6 on 11/26/23 and informed the DON of the abuse. Nurse #3 stated the DON instructed him to speak with both families regarding the incident and he (DON) would move the resident in the morning. Nurse #3 reported Resident #6 stated she was fine knowing that Resident #1 was not going to be moved until the next morning. Nurse #3 reported Resident #1 was brought to his room and remained in his room the remainder of the night and he and Medication Aide did frequent checks on both residents throughout the shift. Nurse #3 stated he also gave Resident #6 his personal cell phone number to call him if she needed him through the rest of the shift. Nurse #3 reported he called the DON because he felt what Resident #1 did to Resident #6 was abuse and it needed to be reported. Nurse #3 stated he got training annually regarding abuse. An interview with the Director of Nursing on 12/06/23 at 3:43 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23. He stated during morning meeting on 11/27/23 it was decided since this was a new behavior for Resident #1 we would monitor him to be sure he did not enter Resident #6's room. He stated we did not feel the need to change his room at this time because Resident #6 said she felt safe. He stated we completed an incident report but we did not initiate an abuse investigation because it was a new behavior for Resident #1 and Resident #6 stated she felt safe. He stated he should have implemented a measure to protect all the residents from Resident #1 after that incident occurred with Resident #6. b. Resident #2 was admitted to the facility on [DATE]. The MDS quarterly assessment dated [DATE] revealed Resident #2 was severely cognitively impaired and demonstrated no behaviors. A nursing progress note written by Nurse #2 on 11/27/23 at 7:09 PM revealed at approximately 4:15 PM, Resident #2 was noted by a staff member that Resident #1's hand was down the front of Resident #2's brief. Nurse #2 was notified by the staff member and observed Resident #1 was sitting in a chair beside Resident #2's bed and Resident #1 had his arms crossed and his hands tucked under his arms. Nurse #2 asked Resident #1 to, please go to assigned room. The Assistant Director of Nursing and Administrator were made aware. A skin assessment was performed on Resident #2 and there were no noted injuries or impairments. Safety checks every 15 minutes were ordered. An interview was conducted with Nurse Aide (NA) #1 via phone on 12/06/23 at 1:02 PM. NA #1 reported as she was walking by to get ice on the 400 hall she noticed Resident #1 sitting in a chair beside Resident #2's bed and noticed Resident #1 had his hand under the brief of Resident #2 and was manually stimulating (moving hand in an up and down motion) his penis. NA #1 stated Resident #1 noticed that she saw him and he quickly pulled his hand out of the brief. NA #1 stated she went into the room and asked what Resident #1 was doing in the room and replied nothing. She added, she went straight to Nurse #2. NA #1 stated she received annual training on abuse and knew she needed to report this immediately to a supervisor. An interview was conducted with Nurse #2 on 12/06/23 at 1:33 PM. Nurse #2 reported NA #1 quickly had approached her and told her Resident #1 was in Resident #2's room and Resident #1 had his hand down Resident #'2s brief and was stimulating him. Nurse #2 stated she went straight to Resident #2's room and Resident #2 was lying down on his back in his bed and Nurse #2 stated she asked Resident #1 to go to his room and she would be in to speak with him. Nurse #2 stated she did a complete head to toe assessment on Resident #2. She added, Resident #2 did not speak about Resident #1 having his hand down his brief and acted as though it did not happen. Nurse #2 stated once the residents were separated, she initiated 15 minute safety checks until Resident #1 could be further evaluated and the safety checks continued after Resident #1's return from the hospital. She stated his room was moved to the 200 hall on 11/28/23. Nurse #2 added Resident #2 remained in his room as he usually would not come out of his room and he was monitored as well with every 15 minute safety checks. Nurse #2 stated she reported the sexual abuse to the Assistant Director of Nursing and the Administrator. Nurse #2 stated she received annual training regarding abuse. An interview was conducted with the ADON on 12/06/23 1:41 PM. The ADON reported that after she was made aware of the incident between Resident #1 and Resident #2 by Nurse #2 on 11/27/23 at about 4:15 PM she went into Resident #2's room to assess his mental state. The ADON reported that his confusion was at his baseline and it was difficult to process the incident with him because he did not seem to understand what was going on. The ADON reported Resident #2 was not upset or recalling any of the incident. The ADON reported she then went to see Resident #1 who was in his bathroom at the time. She stated it seemed he knew he had done something wrong but that he did not understand; he seemed embarrassed. The ADON spoke to him and told him that that behavior was not acceptable and he needed to stay out of residents' rooms and to keep his hands to himself. The ADON reported she received annual training regarding abuse through the facility's computer program. An interview with the Director of Nursing on 12/06/23 at 3:45 PM revealed he should have implemented a measure to protect all the residents from Resident #1 after the first incident (11/26/23) occurred with Resident #6 because if he had followed the abuse policy and procedure the sexual abuse with Resident #2 could have been prevented. An interview with the Administrator on 12/06/23 at 4:00 PM revealed he was made aware of Resident #1 entering Resident #6's room on 11/26/23 and was told that Resident #1 kissed Resident #6 on the cheek and she told him not to do that and he left the room. The Administrator stated he was not aware Resident #6 was scared. He stated on Monday he interviewed her and since she stated she felt safe and did not want her room changed he did not investigate further. The Administrator stated if he had further investigated the incident with Resident #6, the incident that occurred with Resident #1 and Resident #2 could have been avoided. The Administrator was notified of the Immediate Jeopardy on 12/06/23 at 6:30 PM. F607 FAILURE TO IMPLEMENT THE ABUSE POLICY Identify those residents who suffered, or are likely to suffer a serious adverse outcome because of the non-compliance: The facility failed to follow their abuse policy and procedure to investigate allegations of abuse and to protect other residents from abuse following an incident of inappropriate touching, kissing, and unwanted advancements by Resident #1 into the personal space of Resident #6 on 11/26/23. The Regional Clinical Nurse completed an interview 12/07/23 with Resident #6. Resident #6 stated Resident #1 did enter her room on 11/26/23 and gave her a kiss. She told him to go sit in the chair across the room until someone came for him. He did comply. She added that she felt safe in the facility and has had no further incidents. An initial report was completed and filed with the state agency on 12/07/23. Adult Protective Services (APS) and police were called on 12/07/23 by the Administrator. This investigation was opened and completed on 12/07/23 by Regional Clinical Nurse. Resident #1 was moved closer to the nurse's station on 11/27/23. He was transferred to the emergency department on 11/28/23 for medical and psychiatric evaluation where he was diagnosed with a urinary tract infection. Antibiotics were prescribed for 7 days. Resident #1 completed his course of antibiotics on 12/07/23. The Regional Clinical Nurse completed a review of current resident electronic medical records, including progress notes and incident reports for the last 30 days to determine if there were any other incidents that would require further investigation and reporting of abuse on 12/06/23. The results of the audit identified one incident that had occurred on 11/29/23. This investigation was opened and completed on 12/07/23 by the Regional Clinical Nurse. The facility Administrator completed an initial report on 12/07/23, including notification of law enforcement, APS, and report to the State Agency on 12/07/23. This was related to a yelling incident between two residents. The facility Social Worker and the Admissions Coordinator interviewed current alert and oriented residents on 12/07/23 to determine if they felt safe in the facility. There were no other residents who were identified as feeling unsafe. For those residents who are unable to be interviewed the responsible party will be contacted on 12/07/23 by the Social Worker and Admissions Coordinator to ensure they felt their resident was safe in the facility. Specify action the facility will take to alter the process or system failure to prevent a serious outcome from occurring or recurring and when the action will be completed: The facility Administrator and Director of Nursing received re-training from the Director of Operations and Regional Clinical Nurse on Abuse/Neglect policy and procedure, including identification of abuse, types of abuse, investigation, protection, reporting/respond, prevention, screening, and the possible psychosocial effects of sexually inappropriate behavior on a resident. The Administrator and DON were trained in the steps to follow in a facility investigation. This training was completed on 12/07/23. The 24-hour report will be reviewed by the oncoming nurse and shared with the nursing assistants at the beginning of the shift. The nursing assistants will sign the 24-hour report indicating that they have been informed of the previous day's events. The 24-hour report was a review of the last 24 hours any resident change in condition, behaviors, or other acuities. This will be a new process for the nursing assistants. The DON and /or Administrative Nurse will be completing education with current licensed nurses and nursing assistants on the use of the 24-hour report sheet. Any current licensed nurse and nursing assistant who does not receive this training by 12/07/23 will not be able to work without the training from the DON and/or Administrative Nurse. Newly hired licensed nurses and nursing assistants will receive this training at orientation by DON or ADON. The DON and Regional Clinical Nurse began education with current facility staff, including contract Housekeeping/Laundry and Rehabilitation on Abuse/Neglect policy and procedure, including identification of abuse, investigation, protection, reporting/respond, prevention and screening. abuse, the reporting of abuse and the possible psychosocial effects of sexually inappropriate behavior on a resident. Staff were also educated that the cognitive status of the resident does not rule out abuse. This training was completed as of 12/07/23. Any current employee who has not received this education as of 12/07/23 will not be allowed to work until education was completed by the facility DON. All newly hired employees will receive this education during orientation and prior to assignment. The DON will be responsible for the education. The DON is responsible for the tracking of the education to ensure completion. The facility does not utilize agency staff. The facility alleges the removal date of the Immediate Jeopardy was 12/08/23. The removal plan of the Immediate Jeopardy was validated on 12/08/23. A sample of staff including the Administrator, Director of Nursing, nurses, nurse aids, therapists, housekeeping staff, and dietary aides were interviewed regarding in services they received related to the deficient practice. All staff interviewed stated they had been in serviced regarding identifying, reporting, and investigating abuse. Additionally, nurses and nurse aides were interviewed regarding the in-services they received for the new process of the 24 hour report sheet which was a tool used to communicate daily events when reporting off or on shift. The removal date of 12/08/23 was validated.

Based on observation, record review and staff, Resident, Medical Director interviews, the facility failed to provide care in a safe manner for 1 of 3 residents (Resident #1) reviewed for accidents. On 5/8/23 the Nurse Aide raised the level of the bed to provide incontinence care and change bed linens for Resident #1. Resident #1 was positioned on her right side while the bed linens were being changed and fell out of bed landing face down on the floor. The resident was sent to the Emergency Department (ED) for evaluation and diagnosed with a subdural hematoma (blood collection between the skull and surface of the brain), scattered skin tears, skin lacerations to the left forearm and right knee that required sutures, forehead abrasion, closed fracture of the right orbit (eye) with right periorbital hematoma (black eye) and premaxillary hemorrhage (bleeding) and a minimally displaced right nasal bone fracture. Resident #1 was admitted to the trauma service step down unit for wound care, antibiotics, and post operative pain control. Findings included: Resident #1 was admitted on [DATE] with diagnoses that included vascular dementia without behaviors, atrial fibrillation, chronic obstructive pulmonary disease (COPD), debility, bowel and bladder incontinence and bed bound. Review of physician orders revealed Resident #1 was prescribed Xarelto 2.5 milligrams (mg) daily for atrial fibrillation on 4/21/22 and scheduled oxycodone IR (immediate release) 5 mg 1 tablet every 8 hours for generalized osteoarthritis pain and was also prescribed oxycodone IR 5 mg 1 tablet every 4 hours as needed for generalized osteoarthritis pain on 3/29/23. Resident #1 was admitted into hospice on 10/14/22 with diagnoses that included moderate vascular dementia without behaviors, atrial fibrillation, chronic obstructive pulmonary disease (COPD), debility, bowel and bladder incontinence, and bedbound. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed moderately impaired cognition and required 2-person assistance with bed mobility and transfers. Resident #1 was always incontinent of bowel and bladder. Resident #1 had bilateral lower extremity impairment in range of motion and was receiving opioid pain medication daily. The MDS indicated no falls since admission/reentry/prior assessment. Review of Care Plan dated 4/26/23 identified a focus of at risk for falls related to history of falls with impaired mobility contributing of vascular dementia, insomnia, and muscle spasm. The goal was for the resident to not sustain falls that will create injury over the next review period and the interventions were to refer to physical therapy for evaluation, monitor for changes in condition that may warrant increased supervision/assistance and notify the physician, and floor mat next to bed when resident was in bed. The Nurse Aide care guide (Kardex) updated 10/06/22 revealed Resident #1 required extensive assistance of 2 with positioning and mobility. The care guide revealed that the resident required 1 assist with dressing, 2 assist with positioning, and 2 assist with mechanical lift. Interview with NA #1 on 5/24/23 at 8:30 am revealed incontinence care was being provided to Resident #1 on 5/8/23 when Resident #1 fell out of the bed. NA #1 stated he typically provided incontinence care and bed linen changes for this resident without assistance and the fall was not expected. NA #1 explained Resident #1 was heavily soiled requiring a full bed change and after incontinence care had been provided Resident #1 was rolled onto her right side while the dirty sheets were being removed. Resident #1 changed the position of her top leg by sticking it out and rolled off the side of the bed onto the floor. The interview further revealed NA #1 had raised the level of the bed to provide care and the fall mat was in place at the time of the fall, but the resident fell off the opposite side of the bed. NA #1 observed Resident #1 lying on the floor face down with her right arm underneath her body after the fall. NA #1 notified Nurse # 3 who came and assessed Resident #1. Phone interview with NA#1 on 6/2/23 at 9:42 am revealed when Resident #1 fell out of bed she yelled out Oh, oh and initially did not express pain but when she was being assessed by Nurse #3, she would say oh, that hurts when being moved. Skin tears were noted to both arms and legs, and she had bleeding on her face, but NA#1 did not know where the bleeding was coming from but stated there was a considerable amount of blood. Resident #1 was alert and oriented the entire time and seemed fully aware that she had fallen out of bed. Resident Incident Report dated 5/8/23 at 3:15 pm revealed that Resident #1 went over the side of the bed toward the window during incontinence care with a bed change. The fall resulted in injuries including right lip small laceration, bump to the left side of forehead, nose fracture with black right eye, large skin tear to left forearm, large skin tear to right lower leg, skin tear to left knee and right forearm. Resident #1 was transported to the Hospital by Emergency Medical Services (EMS). It further revealed that at the time of the incident the resident had received analgesics/narcotics in the past 8 hours. This report was documented by Nurse #3. A nurse's notes written by Nurse #3 dated 5/8/23 at 6:46 pm revealed that the Resident #1 fell from the bed during a full bed linen change and was face down next to the bed after the fall. Bleeding was noted from the head, leg, and nose. It further revealed that the resident reported pain everywhere. Resident was alert. Emergency Medical Services (EMS) was notified and due to resident injuries and being on blood thinners. Resident #1 was transported to hospital emergency department (ED) where she was admitted for subdural hematoma. A telephone interview with Nurse #3 on 5/23/23 at 2:50 pm revealed she was on duty on 5/08/23 when Resident #1 fell and was called to the room by Nurse Aide (NA) #1. Resident #1 was found on the floor next to her bed in the prone position. She indicated that NA #1 had been changing Resident #1 to include a full bed change and Resident #1 was a fairly big person for one aide to do but, only one aide would typically be assigned. Nurse #3 revealed that the resident was sent out with Emergency Medical Services. Nurse #3 stated that the resident could stabilize herself a little, but you had to always keep a hand on her. The interview further revealed the fall mat was in place at the time of the fall but was on the other side of the bed. A follow up phone interview with Nurse #3 on 6/2/23 at 9:55 am revealed she was on duty on 5/8/23 when Resident #1 had a fall from the bed and was called to the room by NA #1. She observed Resident #1 on the side of the bed closest to the window face down on the floor, she described seeing a large amount of blood in her mouth, and bleeding noted from the nose. She added that she had injuries to her head, face and that her nose looked broken, and she could observe that blood was going to the back her throat, so she kept her on her side while awaiting Emergency Medical Services (EMS) to arrive. Nurse #3 revealed there was a lot of blood mostly from the face and Resident #1 had 2 deep skin tears, one on the left forearm and one on the right knee, and an abrasion to the forehead. Nurse #3 added that Resident #1's left arm may have come into contact with hardware from the a nearby chest of drawers when she fell causing the deep skin tear. When asked about pain Resident #1 indicated she had pain everywhere. Nurse #3 revealed that she worked with the resident after she was readmitted from the hospital after the fall. On return to the facility Nurse #3 described Resident #1 as bruised on her face and was in more pain than before the fall and when staff moved her to change her, she was vocal about the discomfort and pain and would grimace. Resident #1 would tell them it hurt. Nurse #1 stated that Resident #1 returned to the facility with a PRN (as needed) pain medication ordered but the pain medicine was changed to scheduled after the first few days after admission because of the pain. She described Resident #1's pain prior to the fall as more general discomfort and after the fall as being more related to the injuries from the fall. She added Resident #1 would not give you a number on a pain scale but would just say real bad so that is how they knew she was in a lot of pain. On return Resident #1 was described as having more real bad pain, especially in the first few days after return, and more lethargic and tired and it took about 10 days to get back to her baseline. Nurse #3 indicated that Resident #1 had anxiety and after the fall had to be reassured when she was changed because she was afraid she would fall again, but that was getting better now. Resident Incident Report dated 5/8/23 at 3:45 pm revealed that Resident #1 fell out of bed while incontinence care was provided. The fall resulted in injuries including upper right lip laceration, raised bump to left forehead, possible nose fracture, bruise to right eye, multiple skin tears - left upper arm, left forearm, right upper arm, right forearm, and bilateral knees. Resident #1 was transported to the Hospital by Emergency Medical Services (EMS). It further revealed that at the time of the incident the resident had received analgesics/narcotics in the past 8 hours. This report was documented by Nurse # 2. Phone interview with Nurse #2 on 6/1/23 at 3:55 pm revealed that she was the wound nurse and had assessed Resident #1's skin tears, bruises, and lacerations that she received from the fall on 5/8/23 and provided wound care to the Resident #1 after her readmission from the hospital after the fall. She added that Resident #1 was like her normal self even though she was all cut up, happy and talking to staff and no different from before the fall, other than her injuries. Nurse # 2 reported that Resident #1 denied pain and did not have non-verbal expressions during wound care. The interview further revealed that Nurse #2 would at times assist the NAs with brief changes and Resident #1 would say ow, that hurts or don't touch me there when they were rolling her over and added that Resident #1 had bruises on the backs of her arms and if touched there would say ouch and that Resident #1 did not do that prior to the fall and didn't complain of pain prior to the fall during care. Nurse #2 described Resident #1's skin condition after the fall and stated that she had multiple skin tears on both upper and lower extremities on both sides and bruising on the face, arms and legs with sutures in her right knee. Review of hospital records dated 5/8/23 revealed Resident #1 presented to the emergency department (ED) after a fall from bed during a transfer that impacted her face. No report of loss of consciousness. The ED Provider's review of systems noted numerous skin avulsions, right periorbital ecchymosis and the resident reported a headache. The CT scan of the face noted closed fracture of the right orbit (eye) with right periorbital hematoma and premaxillary hemorrhage, a minimally displaced right nasal bone fracture. The CAT scan of the head noted a right frontal subdural hematoma. The history and physical completed by a Trauma Surgeon on 5/8/23 revealed the resident reported pain in her left shoulder, extremities and skin tears and rated the pain level as a 4 out of 10. History and physical further noted right periorbital ecchymosis and the lacerations to the left forearm and right knee were repaired with dissolvable sutures. The x-ray of the left shoulder was negative for fracture. Resident #1 was admitted to the trauma service step down unit for wound care, antibiotics and post operative pain control. It was determined that the subdural hematoma did not require surgical intervention. Resident #1 was discharged from the hospital back to the facility on [DATE] with orders that included Oxycodone 5 mg every six hours as needed for pain and to stop Xarelto 2.5 mg. Review of a progress note dated 5/11/23 written by the Family Nurse Practitioner revealed Resident #1 was readmitted to the facility with a diagnosis of fall resulting in nasal bone fracture, fracture of right orbital floor, subdural hematoma and multiple skin tears. The progress note review revealed Resident #1 was readmitted with orders for Oxycodone 5 mg every four hours as needed for pain and an order for alprazolam 0.5 mg 1 tablet every eight hours and 1 tablet every 4 hours as needed for anxiety for 4 months. The physical exam revealed Resident #1 had bruising to the forehead, nasal and orbital area, and neck and bruising and multiple skin tears to upper and lower extremities. Resident #1 was oriented to person, not place and time. The review further revealed that anticoagulants were being held. Review of nurses note dated 5/10/23 7:15 pm Nurse # 1 revealed that Resident #1 returned from the hospital to the facility alert and oriented and noted to have numerous facial bruises (eye area) color observed to be reddish purplish. Resident #1 was noted to have dressings to bilateral arms and bilateral lower extremities and returned with a prescription for a narcotic pain pill that was faxed to a pharmacy. On 6/1/23 at 4:06 pm phone interview with Nurse #1 revealed that she was the nurse on duty when the resident was readmitted from hospital on 5/10/23. Nurse #1 indicated that she worked with Resident #1 on a routine basis and was familiar with her. She did not recall complaints or signs of pain on readmission. Nurse #1 described her condition as being bruised, to include on her face with dressings on the injuries from the fall. She was described as happy to be back home and was laughing and smiling. Review of a progress note dated 5/11/23 written by the Family Nurse Practitioner revealed Resident #1 was readmitted to the facility with a diagnosis of fall resulting in nasal bone fracture, fracture of right orbital floor, subdural hematoma and multiple skin tears. The progress note review revealed Resident #1 was readmitted with orders for Oxycodone 5 mg every four hours as needed for pain and an order for alprazolam 0.5 mg 1 tablet every eight hours and 1 tablet every 4 hours as needed for anxiety for 4 months. The physical exam revealed Resident #1 had bruising to the forehead, nasal and orbital area, and neck and bruising and multiple skin tears to upper and lower extremities. Resident #1 was oriented to person, not place and time. The review further revealed that anticoagulants were being held. After the fall Resident #1 was initially prescribed oxycodone 5 mg 1 tablet every 6 hours as needed for pain. This regime was ordered on 5/10/23 and discontinued on 5/11/23. Review of nurse's notes dated 5/11/23 12:24 pm Nurse #5, unit manager, revealed that she received a new physician order for Resident #1 to discontinue oxycodone 5 mg as needed (PRN) every 6 hours and to start Oxycodone 5 mg every 4 hours as needed for pain. Review of the Medication Administration Record (MAR) on 5/11/23 oxycodone 5 mg 1 tablet every 4 hours as needed for pain was started. This order was discontinued on 5/12/23 after receiving 3 doses with a pain scale of 8 reported on a scale of 1 to 10 with 10 being the worst pain. Review of a progress note dated 5/12/23 written by Adult-Gerontology Nurse Practitioner revealed nursing staff reported Resident #1 moaned when repositioned and the family requested oxycodone 5 mg be scheduled. An order for oxycodone 5 mg every 4 hours written and an order for oxycodone 5 mg every 6 hours as needed for pain written. Review of nurses note dated 5/12/23 at 6:40 pm revealed that Nurse #4 received new pain medication orders for Resident #1. The new order was to discontinue Oxycodone 5 mg every 6 hours and to start Oxycodone 5 mg every 4 hours. A phone interview with Nurse #4 on 6/1/23 at 5:15 pm revealed that after Resident #1 was readmitted to the facility from the hospital that she was very bruised with skin tears on each extremity, bruising to her face and in a lot of pain. Nurse #4 further revealed that she did a pain assessment on Resident #1 the day after she returned (5/11/23) and she couldn't give a number on a pain scale but was moaning and grimacing. Resident #1's pain medication was prescribed as PRN (as needed) at that time and her son wanted it scheduled and the order was changed to scheduled every 4 hours since she was in pain but would not ask for anything. Nurse #4 further revealed that you could tell that she was hurting, and Resident #1 told her that her left arm was hurting but would not ask for pain medication. The interview further revealed that Resident #1's pain was worse after the fall, and she had non-verbal signs of pain. Nurse #4 described Resident #1 as more confused after the fall and that she could not insert a urinary catheter because Resident #1 was in too much pain and if you tried to open her legs it was too painful for her because of her injuries to her legs. On 5/12/23 a physician order for oxycodone 5 mg 1 tablet every 6 hours as needed for pain was started in addition to the scheduled every 4-hour dose. She received this as needed dose 3 times between 5/19/23 and 5/26/23. Review of the May MAR further revealed that Resident #1 reported pain (on a pain scale of 0-10) consistently as a 1-7 prior to the fall. After the fall Resident #1 reported pain (on a pain scale of 0-10) consistently as a 3-8. On 5/11/23 and 5/12/23 Resident #1 reported pain as an 8 (on a pain scale of 0-10). Review of Resident #1's MAR from 5/10/23 through 5/31/23 revealed that Resident #1 continued to receive scheduled oxycodone 5 mg every four hours and oxycodone 5 mg every 6 hours as needed for pain. MAR review further revealed that between the dates of 5/11/23 and 5/31/23 the resident had a total of 5 days where pain was documented as a 0 (on a pain scale of 0-10) all other dates had pain scale ratings ranging from a 3 to 8 (on a pain scale of 0-10). Interview with NA #2 on 5/23/23 at 12:30 pm revealed Resident #1 could communicate needs and was a 2 person assist. NA #2 stated she would always get help when providing incontinence care and linen changes for Resident #1. NA #2 indicated that she followed a care guide that was in a book on the unit and the care guide listed the resident as a 2 assist with positioning and mobility with a mechanical lift, and a 1 assist with dressing. Interview and observation of Resident #1 on 5/23/23 at 10:45 am revealed the resident did not report concerns of pain. Resident #1 was noted to have bandages to her left lower forearm and right upper arm and an abrasion to the left side of the forehead. Yellowing bruising was noted below the left eye and to the left side of the forehead. When asked Resident #1 describes her injuries and bruising as occurring from being in a wreck and did not respond when asked if she had pain. Review of Medical Director progress notes dates 5/16/23 revealed Resident #1 was diagnosed with a nasal bone fracture, fracture of the right orbital floor, subdural hematoma, multiple skin tears, laceration of the left forearm and laceration of the knee. She was evaluated by neurosurgery and after a follow-up CT it was determined that she did not require surgical intervention for the subdural hematoma. Once stable Resident #1 was discharged back to the facility to continue long-term care with the help of hospice. The review revealed that upon physical examination by the facility Medical Director that Resident #1 had decreased range of motion in both lower extremities, a decrease of range of motion of both hands, but she was able to feed herself, and Resident #1 had hematomas all over her face. The review indicated that Resident #1 was back to her baseline and required total care. The Medical Director noted a concern that since the subdural hematoma Resident #1 would most probably have more cognitive impairment and would not be able to do the inhaler prescribed for her chronic obstructive pulmonary disease. Additionally, the report revealed that after several skin tears and nasal-orbital floor fracture that Resident #1 would continue on Tylenol (acetaminophen) 650mg three times a day and oxycodone every 6 hours as needed for pain. The review further revealed that Resident #1 was at significant risk of worsening medical and neurobehavioral status. An interview on 5/24/23 at 9:55 am the Medical Director indicated she was aware of Resident #1's fall from the bed on 5/08/23 and participated in the post incident care plan review. She was aware of the injuries sustained by the resident from the fall. She indicated that the resident was large, and the amount of assistance required during care would be determined by the facility. The interview revealed that Resident #1 would easily bruise and always had skin issues related to blood thinners. The Medical Director stated that the resident had returned to her baseline. Interview with the Director of Nursing (DON) on 5/23/23 at 5:30 pm revealed that the DON was aware of the injuries of Resident #1 from the fall. He stated that on the Kardex she was a 2 person assist with positioning, but based on her condition it was appropriate for a 1 person assist at the time of the fall. He further indicated that the fall was caused by the resident unexpectedly changing position. He stated the fall was unexpected for her. Interview with Administrator on 5/24/23 at 11:00 am revealed that a Plan of Correction (POC) had been done for the incident that involved Resident #1. 5/24/23 at 11:30 am interview with the DON and Administrator revealed both indicated that they would not expect a resident to fall from the bed during an occupied full bed linen change. The DON stated the fall and injuries obtained by Resident #1 were determined as caused by the resident changing position unexpectedly and the Administrator agreed. The Administrator was notified of Immediate Jeopardy on 5/31/23 at 5:27 pm. The Administrator provided the following corrective action plan with a compliance date of 5/11/23. Address how corrective action will be accomplished for resident(s) found to have been affected: Resident #1 is a [AGE] year-old female, who has been a resident at the facility since 7/25/2016 and admitted to Hospice services 10/14/2022. She was admitted to the facility with the following diagnosis: GERD, Dysphasia, COPD, Candidiasis (skin, nail, vulva, and vagina), Allergic Rhinitis, Insomnia, Hypertension, Heart Failure, A. Fibrillation, Anxiety D/O, Hypothyroidism, Diabetes Mellitus, Vascular Dementia w/o behaviors, Depression D/O, Obstructive Sleep Apnea, Dyspnea and Obesity. Resident #1 is currently on Eliquis twice a day for the diagnosis of Arial Fibrillation. Nurse Aide #1 was providing ADL/Incontinent care to the resident. While positioned on her side Resident #1 kicked out her leg from the bed causing her to roll off the bed onto the floor between the bed and the window. Nurse Aide #1 immediately notified the residents' assigned nurse. Licensed Nurse #3 came to the room and completed a head-to-toe evaluation of the resident. Licensed Nurse #3 identified injuries to the residents' upper lip, left side of her forehead, nose, bilateral arms/legs and her right eye. First aid was initiated immediately, the Director of Nursing was informed, who immediately came to assist, and 911 emergency services were contacted. Licensed Nurse #3 and the Director of Nursing provided first aid while awaiting 911 emergency services. Resident #1 was transported to New [NAME] Regional Medical Center where she was admitted with a diagnosed of subdural hematoma. Nurse Aide #1 received retraining on bed mobility to include appropriate positioning of resident during care and safe bed mobility practices with return demonstrations on 5/11/23 by the Asst. Director of Nursing. Resident #1 returned to the facility on [DATE] and has been changed to requiring 2 persons to assist her with bed mobility and positioning. A care plan meeting was held with resident #1 representatives, resident #1, Administrator, Director of Nursing, and hospice services on 5/12/23. Address how corrective action will be accomplished for resident(s) having potential to be affected by the same issue needing to be addressed: All residents in the facility have the potential to be affected. An audit was completed of all current resident's positioning/bed mobility status by the Director of Nursing, Asst. Director of Nursing and Director of Rehabilitation Services to determine their current functional status and care needs. Current residents care plans have been reviewed and updated with any changes in functional mobility status by the MDS coordinator. Completed 5/11/23. Address what measures will be put in place and systemic changes made to ensure that the identified issue does not occur in the future. Current licenses nurses and CNA's including agency nurses received retraining on appropriate positioning/bed mobility status with a return demonstration. This included reviewing the 24-hour report daily in the morning clinical meeting to identify changes in condition. All newly hired licensed nursing staff and CNA's will be educated on the functional mobility evaluation by the Director of Nursing or designee during orientation. Any nurse or CNA including agency personnel not in-serviced by 5/11/23 will not be able to work until completion of education. Resident #1 has been changed to requiring 2 persons to assist her with bed mobility and positioning. Indicate how the facility plan to monitor its performance to make sure that solutions are sustained. The facility must develop a plan for ensuring that correction is achieved and sustained. The plan must be implemented, and the corrective action evaluated for its effectiveness. The Director of Nursing and Assistant Director of Nursing conduct a random observation audit of 5 residents per week for 12 weeks to ensure appropriate positioning/bed mobility status. Also, the Director of Nursing and Asst. Director of Nursing will review the 24-hour report daily in the morning clinical meeting to identify changes in condition, 5 days a week for 12 weeks. The results of all observations and audits will be reported to the Quality Assurance Performance Improvement Committee by the Director of Nursing for 3 months to determine the effectiveness of this plan. Negative findings will be addressed by the committee. Additional interventions will be developed, implemented, and monitored by the Committee to ensure sustained compliance. Date of Compliance 5/11/2023 *This QAPI Action Plan must be discussed at your next QAPI meeting and Medical Director should review and sign. The QAPI Action Plan was signed and dated 5/12/23 by the Administrator and Department Managers On 5/24/23 at 12 pm, the corrective action plan with a compliance date of 5/11/23 was validated. The survey team confirmed the facility addressed the resident involved and acted to mitigate the risk of the other residents. The facility re-educated all staff on safety transfers and repositioning. The facility implemented an audit to update all care guides. The facility initiated a process to review resident's transfer capabilities and updated the care guides of all residents including new admissions. The facility also implemented the monitoring process, and it was to be included in the Quality Assurance and Performance Improvement Committee meeting. The facility's compliance date of 5/11/23 was validated.

Based on record review and staff interviews, the facility failed to safely transfer 1 of 1 sampled resident who required assistance of two staff for transfers.(Resident # 1) Findings included: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) completed on 7/14/2010 revealed Resident #1 had short and long term memory loss with moderate impaired decision making. Resident #1 required extensive assistance with two person assist in bed mobility, transfer, dressing, toileting use and personal hygiene. The MDS indicated ambulation in the room/corridor did not occur and the mode of locomotion for resident #1 was wheelchair. The MDS also indicated Resident #1's range of motion was limited on one side with partial loss of voluntary movement of the arm, hand, leg and foot. Review of the ADL (Activities of Daily Living) sheet from 10/1/2010- 10/11/2010 revealed Resident # 1 was transferred from bed, chair, wheelchair , and standing with one Nurse Assistant ( NA). Review of the nurse ' s note dated 10/15/2010 revealed Resident #1 was being moved from wheel chair to the bed by NA ( Nurse Assistant) # 1 when popping sound was heard coming from Resident # 1. Review of the Incident Report dated 10/15/2010 indicated the resident " knee popped and twisted. NA # 1 was pivoting resident into bed and heard a popping sound. She then lowered down the resident in bed. Resident cried out in pain. MD (Medical Doctor) was called and mobile X- ray. " The incident report further indicated the result of the X- ray was the resident had a femor fracture. The incident report also indicated NA #1 used a gate belt to pick the resident when she had a popping sound three times. Review of Resident # 1 ' s current Closet Care Plan which was generated on 4/8/2010 revealed the resident needed two person assist when being transferred. Review of the nurse note dated 10/15/2010 revealed that Resident # 1 was transferred to the hospital following the result of the X- ray. The Review of x-ray results dated 10/15/2010 revealed the resident had a femoral fracture. During the interview on 12/1/2010, at 1:00 PM, Nurse # 1 who was assigned to Resident # 1 on 10/15/2010 indicated that NA # 1 reported to her that she heard a popping sound while transferring the resident from wheel chair to bed. Nurse #1 was asked whether it was appropriate for NA # 1 to have transferred Resident # 1 without assistance. Nurse # 1 answered she did not know whether it was appropriate for NA # 1 to transfer Resident #1 alone because it was her first time working with Resident # 1. NA #1 who transferred Resident # 1 was not available for interview as she was no longer working at this facility. During the interview on 12/1/2010 at 1:25 PM, NA # 2 who had worked with Resident # 1 before being sent to hospital reported that she always sought assistance before transferring Resident # 1 from wheel chair to bed. She (NA #2) also added per Resident # 2 ' s current Closet Care Plan, the resident required 2 person assist for transfers. During the interview with MDS nurse on 12/1/2010 at 1:40 PM, she stated she was not aware that Resident # 1 needed two person assist with the transfers because she did not assess the resident herself when she was completing the current quarterly assessment of 10/11/2010 (four days prior to the residents being sent out to the hospital with a fracture on 10/15/2010). The MDS nurse further indicated she was new and was behind with residents ' assessments at the facility during the time she was completing Resident # 1 ' s MDS quarterly assessment of 10/11/2010. During the interview with Administrator on 12/1/2010 at 2:00 PM, she reported that she was working on making sure the staff communicates better at the facility about the residents ' care. The Administrator further indicated she was not aware that Resident # 1 needed 2 person assist from the beginning of October 1, 2010 to 10/15/2010 per 7/14/2010 MDS assessment.