Every finding on record at Bostick Nursing Center

Based on observations, staff interviews, and review of the facility policies titled Equipment and Warewashing, the facility failed to ensure that dishware was not stored wet. In addition, the facility failed to ensure sanitary conditions in the kitchen. These deficient practices had the potential to place the 213 residents receiving nutrition and hydration from the kitchen at risk of a foodborne illness. Findings include: Review of the facility's policy titled Equipment, revised 9/2017, revealed the Policy Statement section included, All foodservice equipment will be clean, sanitary, and in proper working order.Review of the facility's policy titled Warewashing, revised 12/2024, revealed the Procedures section included, . 4. All dishware will be air dried and properly stored.During a tour of the kitchen on 9/22/2025 at 9:50 am with the Certified Dietary Manager (CDM), observation revealed that washed plates stacked in the plate storage had water between them. Continued observation revealed that a fan mounted on the wall, and directed toward the clean section of the kitchen, had a buildup of gray and black debris. Further observation revealed the ceiling vent over the exit side of the dishwasher had a buildup of grey material. In an interview on 9/22/2025 at 10:25 am, Dietary Aide (DA) FF confirmed that her duties include drying and storing dishware and utensils, and using the high-temperature dishwasher. DA FF confirmed that the plates had water on them in the storage rack. She stated she should leave them on racks to dry, and was uncertain as to why she did not.In an interview on 9/22/2025, at 10:44 am, the Maintenance Director confirmed he was responsible for cleaning the fan and vent in the dishwashing area. The Maintenance Director explained that he planned to clean the vents every six months across the building, although he did not maintain any logs or documentation. He stated that the fan was cleaned as necessary.

Based on observations, staff interviews, and review of the facility's pest control contract and service records, the facility failed to maintain effective pest control in the kitchen. This facility practice had the potential to place the 213 residents who received nutrition and hydration from the kitchen. Findings include:Observation on 9/22/2025 at 10:07 am revealed flies in the kitchen, with one fly landing on a four-ounce (oz) serving bowl with pudding. Observation on 9/22/2025 at 10:16 am revealed flies in the kitchen, hovering around the steam table, and two landing on the pole that supports the table.Observation on 9/23/2025 at 12:30 pm, during lunch meal pass, revealed flies hovering around the steam table and prepared food, with one fly landing on a four-oz serving bowl of assorted fruits. In an interview on 9/22/2025 at 10:10 am, the Certified Dietary Manager confirmed the presence of the flies in the kitchen area. In an interview on 9/24/2025 at 11:03 am, the Maintenance Director stated that the prolonged summer resulted in the continued presence of flies, and he had not thought to put out fly bait. Review of the Pest Control contract revealed that services began with the facility on 5/26/2020 and included one service per month. The contract stated pests to be managed by this service program included German roaches, ants, American roaches, mice/rats, silverfish, fire ants, Oriental roaches, and Smoky brown banded cockroaches. Review of the Pest Control monthly appointment record from January 2025 to August 2025 revealed there were no targeted services identified for flies.

Based on observation, staff interviews, record review, and review of the facility policy titled Weight Monitoring Policy and Procedures, the facility failed to identify and implement interventions in a timely manner to aid in the prevention of potential weight loss for one of two sampled residents (R) (R39) reviewed for weight loss out of a total sample of 36 residents. R39 had a recorded severe weight loss of 5.23 percent in one month. Findings include: Review of the facility's undated policy titled Weight Monitoring Policy and Procedures revealed, . Resident with a SWL [Significant Weight Loss] will be weighed and reviewed weekly for a minimum of 4 (sic) weeks until weight is stable or increasing. Review of R39's Admission Record, located under the Profile tab of the electronic medical record (EMR), revealed R39 was admitted to the facility on [DATE] with diagnoses that included major depressive disorder, anxiety disorder, and unspecified protein-calorie malnutrition. Review of R39's Physician Orders, dated 9/1/2023, located under the Orders tab of the EMR, revealed R39 was to receive a high-caloric drink after meals and at bedtime. Review of R39's Care Plan, last reviewed on 4/11/2024 and located under the Care Plan tab of the EMR, revealed a focus, . history of unplanned/unexpected weight loss. The goal was for R39 to consume 50-70 percent twice a day of the three meals served. Interventions included alert dietician if consumption is poor for more than 48 hours. Review of R39's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 5/6/2024 and located under the MDS tab of the EMR, revealed R39 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated R39 was cognitively intact. It was recorded that R39 weighed 153 pounds (lbs.) and had no weight loss. Review of R39's Weights, located under the Weights & Vitals tab of the EMR, revealed R39's weight on 4/2/2024 was 153.0 lbs. It was recorded that R39 weighed 145.0 lbs. on 5/8/2024. This represented an 8-lb. weight loss, indicating a severe weight loss of 5.23 percent in one month. Review of R39's Progress Notes located under the Progress Notes tab of the EMR, revealed a dietary note, dated 5/28/2024, that documented RD [registered dietician] note: 5/8[/24] - 145# (pounds), BMI (Body Mass Index) 22 (normal). -8# [lbs.] x 30 days (5.2% severe weight loss .Rec(commend) weekly weight x4, DBL (double) portions at meals. Monitor weight, appetite, PO intake, skin, labs, RD will follow per protocol. There were no other notes written by the RD when the severe weight loss was discovered on 5/8/2024. An attempt to interview R39 was unsuccessful due to the resident not responding to questions. During an interview on 5/29/2024 at 2:52 pm, the RD said she came to the facility on ce a month and communicated with nursing staff often. She said she also had online access to all residents' medical records. She said they have a weekly meeting where they review residents who have had weight loss. The RD said R39 had not been reviewed in the weekly meeting since his last weight and she was unsure why. She said she was uncertain who should notify her if there was a resident who had lost weight. She said if she had known earlier, she would have implemented weekly weights. She said she would expect an email from nursing when there was a weight loss. She agreed she should keep track of residents who have had weight loss so they can be reviewed in the meeting. During an interview on 5/29/2024 at 3:25 pm, the Restorative Aide (RA) stated she entered all resident weights into their EMR. She stated if there was a weight loss, she would re-weigh the resident and notify the RD. She stated they also had a weekly meeting where residents who had weight loss would be discussed. The RA stated she was not sure why R39 had not been discussed in any meeting since the weight loss was identified. During an interview on 5/29/2024 at 3:53 pm, the Director of Nursing (DON) and the Administrator confirmed they both attended the weekly meeting where weight loss was discussed. The DON said the RD should provide a list of who should be reviewed in the meeting, and it should include any resident who lost weight since the last meeting. During an interview on 5/30/2024 at 12:46 pm, the Medical Director said he knew the facility had a weekly resident-at-risk meeting and residents who had weight loss should be reviewed. He said he was not aware of R39's weight loss but said as the Medical Director it was important he was made aware of any resident's weight loss.

Based on staff and resident interviews, record review, and a review of the facility policy titled, Abuse, Neglect, Exploitation, or Misappropriation- Reporting and Investigating, the facility failed to protect the resident's right to be free from misappropriation of funds/property for one of four residents (R) (R 1) by a staff member. Findings: A review of the facility policy titled Abuse, Neglect, Exploitation, or Misappropriation- Reporting and Investigating revised date September 2022 under Policy Statement revealed: All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings od all investigations are documented and reported. Under Corrective Action: 2. If the investigation reveals allegations of abuse are found, the employee(s) is terminated. Record review revealed R#1 was admitted to the facility with multiple diagnoses of, but not limited to hemiplegia and hemiparesis following cerebral infarction infecting non-left dominant side, aphasia, major depressive disorder, expressive language disorder, and Hypertension. Record review of the Minimum Data Set (MDS) Section C- cognitive patterns revealed R#1 had a Brief Interview for Mental Status (BIMS) score of 12, indicating he had minimal cognitive impairment. Record review of the admission record (Face Sheet) revealed R#1 was his own responsible party. Review of the investigation report provided by the local Police Department dated 10/3/2023 case number 202300048417 revealed an interview with R1 dated 10/6/2023 with the following: On 10/6/2023, R1 stated that he made arrangements with CNA EE for her to get $500 out for him and $500 out for herself at $1,000 each time. He stated that he allowed this to occur three times totaling $3,000. He state that he learned that over $5,000 had been taken out via Cash app (an additional way to make money transfers). After learning of the money being missing, he notified the facility. During an interview on 11/1/2023 at 11:00 am Detective FF revealed R#1's total loss was $8,117.22. The detective revealed the first $3,000.00 was justified; all funds after that would be a felony. Interview on 11/1/2023 at 3:12 pm with R1 reported he messed up and gave the Certified nursing Assistant (CNA) his security number to his debit card; R1 reported he gave her $1,500.00 to help her get her car fixed. She was supposed to get $500.00 out at a time. Continued interview also revealed that CNA EE took $5,000.00 from his account and was not sure if there would be charges pressed against the staff member. During the interview R1 also stated that he called the customer service number to report the fraud to the bank and that his card was returned to him by the staff member. Interview on 11/11/2023 at 4:44 p.m. with CNA EE revealed that she was working on unit three to help out on the unit. R1 asked her to help him out with something and stated he had money on another card that the facility did not know about that he wanted to retrieve. Further interview revealed that she accepted the bank card and security pin code from R#1 and transferred funds from R#1's Cash App account (an additional way to make money transfers), to her Cash App account. Continued interview with CNA EE revealed R#1 told her the total amount on the debit card was about $10,000.00, and she transferred $5,000.00 from the account. Interview on 11/2/2023 at 4:45 pm with the Administrator revealed that all staff to include agency staff receive abuse training prior to employment. Further interview also revealed that R1 reported to them that he wanted to help the CNA get her car fixed and was not sure when the card was returned to R1. CNA EE was terminated from the facility prior to R1 reporting the incident.

Based on interviews, record reviews, and review of policy titled Abuse Prevention Program, the facility failed to maintain an environment free from physical abuse for two residents (R) (R#1 and R#3), and sexual abuse for three residents (R#1, R#4, and R#8), from a total sample of 27 residents. On 4/25/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: The facility had an Abuse Prevention Program policy, with a revision date of December 2016. The policy statement included that the residents had the right to be free from abuse, neglect, misappropriation of resident property and exploitation. That included, but was not limited to, freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse. However, the facility failed to implement this policy regarding abuse effectively, resulting in the physical abuse of one resident (R#1) by a facility staff member and the sexual abuse of three residents (R#1, R#4, and R#8) by other residents. 1. Review of the clinical record for R#8 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, Chronic Obstructive Pulmonary Disease (COPD), metabolic encephalopathy, Parkinson's Disease, dementia, hypertension, major depressive disorder, ataxia and dysphagia. Review of the 10/13/22 Quarterly MDS assessment revealed that R#8 was assessed as having severe cognitive impairment with a Brief Interview of Mental Status (BIMS) score of 00 out of 15. He was also assessed on the MDS assessment as being provided with limited assistance for Activities of Daily Living (ADL's) including ambulation. He was also assessed as using a wheelchair. He resided on Unit 6 in the facility. Review of the clinical record for R#9 revealed that he resided at the facility from 7/20/20 through 12/8/22 and had diagnoses that included, but were not limited to, prostate cancer, open angle glaucoma, anemia, right knee contracture, vitamin D deficiency, and vitamin B12 deficiency. Review of the 9/21/22 Quarterly MDS assessment revealed that R#9 was assessed as being cognitively intact (BIMS score of 15 out of 15) and being independent and/or being provided with supervision for ADL's, including ambulation. He was also assessed as using a wheelchair. He resided on Unit 6 in the facility. R#9 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 11/6/22, that documented an allegation of resident-to-resident abuse had occurred on 11/6/22 at 8:00 p.m. The form included that LPN TT reported an inappropriate act between R#8 and R#9, with R#9 being listed as the perpetrator. A further review of the form revealed that the residents were separated, and skin assessments were completed on both residents with no injuries noted. The physician, responsible parties and law enforcement were notified. A review of the accompanying investigation that included employee and resident interviews, police reports, and the facility's follow-up summary conclusion revealed evidence that the allegation had occurred. The investigation revealed that when LPN TT entered R#8's room to administer medication, she observed R#9 at R#8's bedside sexually abusing R#8. R#8 and R#9 were not roommates. A review of the 11/6/23 police department Incident Report revealed that an officer responded to the facility at 9:14 p.m. in reference to a sexual assault. LPN TT alleged in the police report that she entered R#8's room to administer his medication and observed R#9 at R#8's bedside in his wheelchair. LPN TT observed R#9 leaned over R#8, performing a sexual act on him. The report included that LPN TT and R#9 left R#8's room and that the residents had remained separated. Further review of the police report revealed that LPN TT stated that she initially thought the act was consensual, but due to R#8's cognitive state, it was not. During an interview on 4/13/23 at 2:20 p.m., when the Administrator was questioned if R#8 had the capacity to consent, she responded that she did not think so, because of his BIMS score. Following R#8 and R#9's initial separation, review of security guard logs revealed that R#9 was placed on 1:1 supervision with security on 11/6/22 at 8:59 p.m. A review of census information revealed that R#9 was also moved to a different unit of the facility on 11/7/22. He was transferred from Unit 6 to Unit 7. He was subsequently discharged from the facility on 12/8/22. Further review of the facility's follow-up summary revealed that R#9 was considered a parolee with the Department of Correction and had the potential to be returned to the Department of Correction, once determined by the parole board. A review of R#9's clinical record revealed a 12/8/22 Health Status Progress Note that documented R#9 was transferred back to prison; escorted by his parole office. During an interview on 4/12/23 at 4:30 p.m., the Administrator confirmed that R#9 was discharged from the facility to prison on 12/8/22. 2. Review of the clinical record for R#3 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, hemiplegia and hemiparesis, bipolar disorder, major depressive disorder, a history of traumatic brain injury, hypertension, unspecified speech disturbance, hyperlipidemia, arthropathy, and mood disorder. He utilized a communication device due to impaired speech. Review of the 3/14/23 Quarterly MDS assessment revealed that R#3 was assessed as having moderately impaired cognition (BIMS score of 12 out of 15) and using a wheelchair and walker for mobility. R#3 resided on Unit 7 in the facility. A review of facility reported incidents revealed a Facility Incident Report Form, dated 1/31/23, that documented an allegation of staff to resident abuse. The form included that the allegation involved R#3 and LPN AA and had occurred on 1/31/23 at 8:00 p.m. A further review of the form revealed that R#3 had minor scratches to his face and hands and that the police, responsible party, and physician were notified. LPN AA was placed on administrative leave pending the investigation. A review of the accompanying investigation that included staff and resident interviews, police report, and a follow-up summary revealed evidence that the allegation had occurred. LPN AA's agency nurse contract was terminated on 1/31/23. The investigation revealed that R#3 was physically assaulted by LPN AA after a verbal altercation that escalated with R#3 throwing a phone at LPN AA. LPN AA removed R#3 from his wheelchair and began hitting, kicking, and punching him while he lay on the floor, causing injuries to R#3's upper body. A review of the 1/31/23 police department Incident Report revealed that an officer responded to the facility at 8:37 p.m. in reference to an assault that occurred between R#3 and LPN AA. R#3 alleged in the police report that prior to the physical assault, he and LPN AA had cursed at each other earlier in the hallway. R#3 alleged that he thought about what LPN AA said to him, went to the desk to call his social worker, saw LPN AA, and became upset and threw the phone at him. R#3 then alleged that LPN AA came from around the desk, flipped R#3 out of his wheelchair, and stomped on his arm. Another resident, RB, attempted to intervene. The police report documented that the officer observed a bruise on R#3's left shoulder and a laceration on his right hand. Further review of the police report revealed that camera footage was available and viewed by the police officer on 1/31/23 following the incident. The report documented that the footage revealed that the incident at the nurses' station took place at 7:20 p.m. R#3 came around the corner yelling at LPN AA. Once R#3 got to the desk, he picked up the phone and put it back on the receiver. R#3 picked up the phone again and slammed it down in the direction of LPN AA. LPN AA was observed on camera, getting up out of his chair and R#3 pushing himself into the left-hand side of the desk. LPN AA kicked a chair out of his way and flipped R#3 out of his wheelchair by grabbing for R#3's feet and pulling up. The officer observed on the camera footage, R B and other residents gather around LPN AA and R#3 with R B trying to get between the two (LPN AA and R#3). LPN AA was observed striking R#3 with a closed fist. The officer also documented in the report that he observed LPN AA raise one of his legs up as if was going to stomp on R#3. Following the incident, the police report detailed that the police officer contacted LPN AA, and he was subsequently arrested. During an interview on 3/27/23 at 2:45 p.m., RB confirmed he had witnessed the alteration between LPN AA and R#3. He also stated he heard them arguing in the hall prior to it happening. RB said that he heard R#3 and LPN AA exchange words in the hall. R#3 was trying to apologize to LPN AA for something he previously said, but the nurse wasn't having it and they exchanged words. RB stated that after the argument in the hall, LPN AA was at the nursing station and R#3 came up to the nursing station and was hollering. R#3 picked up the phone and banged the phone on the counter and it flew up at LPN AA. LPN AA went ballistic and went at R#3 and got him out of the wheelchair onto the floor. RB stated that LPN AA hit, kicked, punched R#3. RB said he got in between LPN AA and R#3 and tried to keep R#3 from getting hurt and get the nurse to stop. When RB was questioned if he got hit by the nurse also when he was in between LPN AA and R#3, RB responded yes, but he did not get hurt. During an interview on 3/30/23 at 3:02 p.m. LPN PP confirmed she witnessed the altercation between LPN AA and R#3. LPN PP stated she was going off shift and LPN AA was coming on-shift. LPN AA was seated at the nursing station, and she was standing by him and showing him something on the computer screen and was giving report. R#3 rolled up yelling and yelling. R#3 then picked up the phone and threw it at LPN AA and it struck him. LPN PP stated that LPN AA tried to ignore R#3 at first and that she had never seen LPN AA act that way before. LPN PP stated she got on the phone to notify security. A review of R#3's clinical record revealed documentation of the assault. A 1/31/23 Nurse's Note documented that R#3 was assaulted by a nurse and sustained bruises on the right wrist, back of right hand, left thumb, and redness on the left upper arm. R#3 refused treatment. During an interview on 3/30/23 at 1:07 p.m. LPN DD stated that she did not witness the incident between LPN AA and R#3, but she responded afterwards and assessed R#3. LPN DD stated that R#3 had a big bruise on his left shoulder and redness on his chest and shoulders area. She stated that R#3 was angry and upset. Although R#3 initially refused medical treatment and evaluation on 1/31/23, a review of the facility's investigation summary revealed that the following day, on 2/1/23, he was observed to be in a manic state. A 1013 emergency transfer order was initiated. R#3 was sent to the emergency roiagnom on [DATE] for evaluation and medical clearance and admitted to a behavioral health unit from 2/2/23 through 2/16/23. During an interview on 3/30/23 at 3:52 p.m., the Administrator confirmed that R#3 had refused assessment attempts and a hospital transfer on 1/31/23, but he became manic over the next day and was sent out to the hospital, as ordered by the psychiatrist. A review of hospital emergency room documentation from 2/1/23 documented that R#3 was sent to the emergency roiagnom on a 1013 for aggression with medical clearance requested. R#3 presented with back pain. The physical exam documented ecchymosis with linear demarcation at the upper border of the left arm. The emergency room assessment included clinical impressions of 1) aggression 2) bipolar disorder, current episode mixed, severe, without psychotic features 3) history of traumatic brain injury. R#3's psychiatrist was consulted, and the resident was accepted for transfer to a behavioral health unit. R#3 completed a stay at behavioral health unit and returned to the facility on [DATE]. 3. Review of the clinical record for R#1 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, cerebral infarction, occlusion and stenosis of left carotid artery, seizures, atrial fibrillation, aphasia, diabetes, Parkinson's, schizophrenia, mood disorder, anemia, and major depressive disorder. Review of the 1/17/23 Quarterly MDS assessment revealed that R#1 was assessed as having moderately impaired cognition (BIMS score of 12 out of 15). He was also assessed on the MDS assessment as being ambulatory with a rolling walker. Further review of the clinical record revealed that R#1 wore a soft helmet for protection from falls and/or seizures. R#1 resided on Unit 4. His roommate was R#2. Review of the clinical record for R#2 revealed that he resided at the facility from 11/13/19 to 4/26/23 and had diagnoses that included, but were not limited to, congested heart failure, peripheral vascular disease, cystic disease of liver, atrial fibrillation, hypertension, dementia, dyspnea, polyneuropathy, intellectual disabilities, and diabetes. Review of the 12/22/22 Quarterly MDS assessment revealed that R#2 was cognitively intact (BIMS score of 15 out of 15) and ambulatory with a rolling walker. R#2 resided on Unit 4 of the facility and was R#1's roommate. R#2 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/9/23, that documented an allegation of resident-to-resident abuse. The form included that the allegation involved R#1 and R#2 and had occurred on 3/9/23 at 10:50 a.m. R#1 reported that R#2 had inappropriately touched his private area. Further review of the form revealed that the residents were separated, a skin assessment was completed on R#1, and he was sent to the emergency room for a forensic physical exam. R#2 was placed on 1:1 supervision. The physician, responsible parties and law enforcement were also documented as being notified. A review of the accompanying investigation that included employee and resident interviews, police reports, and the facility's follow-up summary conclusion revealed evidence that abuse had occurred. The investigation revealed that on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. Both were clothed, but R#1 was holding his groin area. R#1 alleged that he had been touched inappropriately by R#2. He also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment dated [DATE]. A review of the 3/9/23 police department Incident Report revealed that an officer responded to the facility at 11:30 a.m. in reference to sexual misconduct between two residents, one of which had bruises on his bottom. The report documented that CNA BB responded to loud screaming coming from R#1 and R#2's room and entered the room to find both residents on the window side of the room. R#1 was visually upset and had placed his hands over his private parts. Both residents were clothed. R#2 alleged he was trying to prevent R#1 from falling. Further review of the police report revealed that the Administrator reported that R#1 alleged that R#2 had also sexually abused him previously, but that today was the first time R#1 had reported the allegations. During an interview on 3/22/23 at 1:48 p.m. Detective NN stated he had taken out two warrants on R#1, one for false imprisonment and one for battery. The results of the sexual assault examination, completed on 3/9/23, were pending. During an interview on 3/23/23 at 2:21 p.m., CNA BB stated that on 3/9/23, she was in a room next door to R#1 and R#2's room and heard R#1 scream. She went to his room and knocked on the door then entered. She stated she was making sure he had not fallen because he was a fall risk. She observed R#1 and R#2 coming from behind the privacy curtain together from R#2's side of the room, with R#1 coming out first like he was scurrying away from R#2. Both had their clothes on. Review of the 3/9/23 Skin Observation Tool revealed that R#1 refused an assessment by LPN treatment nurse OO and was guarded and uncooperative. However, he allowed an assessment to be completed by LPN DD. The 3/9/23 skin observation tool documented bruising to the coccyx and left and right hips. During an interview on 3/30/23 at 1:07 p.m. LPN DD stated that after the incident between R#1 and R#2, she brought R#1 to the conference room. She was the only one he would let talk to him and see him. She stated he was upset and crying and scared to return to his room. She reassured him that R#2 had been moved and encouraged him to go back to his room with her, to complete a skin assessment. However, she said he stood up and began taking his clothes off on his own in the conference room, so she assessed him there. LPN DD stated that R#1 had a dark black bruise right at his sacral area and bruising to his left and right buttocks and hips. LPN DD stated that the bruising on his right was in the shape of a cupped hand; the bruises were dark black and not yellow or green to indicate they were old. LPN DD stated that she had not seen bruising like that on him before. She stated that they looked at his skin a lot because he had seizures and falls. Record review revealed R#1's last fall was on 2/9/23 during a seizure, at which time he was hospitalized and returned to the facility on [DATE]. Further record review of skin assessments completed (prior to 3/9/23) for R#1 on 2/23/23, and 3/7/23 revealed no documentation of bruising. Following the alleged assault by R#2, R#1 was sent to the emergency roiagnom on [DATE]. Review of hospital emergency department documentation revealed that R#1 complained that his roommate had been raping him for the past 3 months. He was noted with bruising of the left hip and sacrum as well as anal pain. R#1 was also noted as very tearful. The clinical impression section documented sexual assault of adult, initial encounter and traumatic hematoma of lower back, initial encounter. Following the exam, R#1 returned to the facility on [DATE]. Following R#1 and R#2's initial separation on 3/9/23, review of security guard logs revealed that R#2 was placed on 1:1 supervision with security on 3/9/23 at 12:15 p.m. A review of census information revealed that R#2 was also moved to a different unit of the facility on 3/9/23. He was transferred from Unit 4 to Unit 7 and remained on routine security checks every two hours. Review of an Appearance Bond form, dated 4/4/23, revealed that R#2 had been charged with misdemeanor battery and felony false imprisonment. During an interview on 4/11/23 at 10:52 a.m. the Administrator stated that R#2 had been arrested and was holding at the facility until his court date, which was undetermined at that time. On 4/26/23, R#2 was discharged from the facility. Review of R#2's clinical record revealed a 4/26/23 Nurse's Note that documented R#2 was escorted by three police officers out from the unit. During an interview on 4/27/23 at 4:10p interview, the Administrator stated that R#2 went to prison until his court date. She confirmed he was discharged from the facility. 4. Review of the clinical record for R#4 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, seizures, schizophrenia, aphasia following nontraumatic intracranial hemorrhage, and major depressive disorder. Review of the 3/14/23 Quarterly MDS assessment revealed that R#4 was assessed as having severe cognitive impairment (BIMS score of 3 out of 15). Further review of the clinical record revealed that R#4 was ambulatory with impaired balance at times. He wore a soft helmet for seizure and fall protection. R#4 resided on Unit 2 in the facility. Review of the clinical record for R#5 revealed that he was admitted to the facility on [DATE] and had diagnoses that included, but were not limited to, deafness, vitamin D deficiency, glaucoma, hypertension, hyperlipidemia, and major depressive disorder. Review of the 1/27/23 Quarterly MDS assessment revealed that R#5 was assessed as being cognitively intact (BIMS of 15 out of 15) and being provided with supervision and set up assistance with ADL's. Further review of the clinical record revealed that R#5 communicated via written word and hand gestures. R#5 resided on Unit 2 in the facility. R#5 is a registered sex offender. A review of facility reported incidents revealed a Facility Incident Report Form, dated 3/16/23 that documented an allegation of resident-to-resident abuse had occurred on 3/16/23. The form included that R#5 made contact with R#4's private area, and this was witnessed by CNA CC. Further review of the form revealed that the residents were separated, and R#5 was moved to another unit in the facility (unit 6) and placed on 1:1 supervision. A skin assessment was completed on R#4 with no injuries noted. The physician, responsible parties and law enforcement were notified. A review of the accompanying investigation that included employee and resident interviews, police report, and the facility's follow-up summary conclusion revealed evidence that the allegation of sexual abuse had occurred. The investigation revealed that when CNA CC entered R#4's room to pick up his meal tray, she observed R#5 at R#4's bedside sexually abusing him, while R#4 was asleep. R#4 and R#5 were not roommates. A review of the 3/16/23 police department Incident Report revealed that an officer responded to the facility at 5:38 p.m. in reference to a sexual assault. The report documented that CNA CC entered R#4's room on 3/16/23 and observed R#5 touching R#4's genital area, head, shoulders, and buttocks. She got R#5's attention and she and R#5 exited R#4's room. The report includes that CNA CC reported the incident to LPN QQ, who then notified the Administrator. Further review of the police report revealed that both residents, R#4 and R#5, declined medical attention. During an interview on 3/30/23 at 11:45 a.m., Detective NN confirmed they were moving forward with charges against R#5. Investigator QQ stated R#5 was charged with sexual battery, which was a misdemeanor. During an interview on 3/30/23 at 1:54 p.m., CNA CC stated that on 3/9/23, she went into R#4's room to pick up his supper tray. She stated R#4 was asleep, and she knew he must be asleep because he did not eat his supper. The privacy curtain near his bed was open just a little bit at the sink area and she looked and saw R#5 at R#4's bedside. CNA CC observed R#5 put his hand under the bed covers at R#4's groin area and then take his hand out. CNA CC stated she was not even sure what she was seeing at first, so she looked further and saw R#5 rub R#4's head, shoulder, and squeeze his buttocks. CNA CC stated that R#5 smiled when he squeezed R#4's buttocks. CNA CC stated she yelled out and it scared R#5 and he threw his hands up. R#5 followed CNA CC out of R#4's room and CNA CC reported the incident to the charge nurse. They kept the residents separated and R#5 was moved to a different unit. CNA CC stated that R#4 was asleep when R#5 touched him, and R#5 was standing up from his wheelchair over R#4 when he touched him. Review of R#4's clinical record revealed a 3/16/23 Nurse's Note entry from LPN QQ that documented the LPN was notified by the CNA that R#5 was observed touching and rubbing R#4's genital region while he was in the bed resting. A head-to-toe assessment was completed with no injuries noted. Further review of the clinical record revealed that a Skin Observation Tool was also completed the following day, on 3/17/23, with no skin abnormalities noted. Following R#4 and R#5's initial separation on 3/16/23, review of security guard logs revealed an entry on 3/16/23 at 5:20 p.m. that documented R#5 was placed on 1:1 supervision. During an interview on 4/18/23 at 3:50 p.m., the Administrator confirmed R#5 was placed on 1:1 supervision, then transferred to another unit and remained on 1:1 supervision for 72 hours. Review of census information revealed that R#5 was moved to a different unit of the facility on 3/16/23. He was transferred from Unit 2 to Unit 6. Review of a Policy: Involuntary Transfer and Discharge letter, dated 3/23/23, revealed that the facility had also issued a discharge notice to R#5 with an effective date of 4/3/23. However, R#5 remained in the facility. Review of an Appearance Bond form, dated 4/3/23, revealed that R#5 had been charged with misdemeanor sexual battery. Review of a Stay Away Order Addendum to Appearance Bond, dated 4/3/23, revealed R#5 was ordered to have no further contact of any nature with R#4. During an interview on 4/11/23 at 10:52 a.m., the Administrator stated that R#5 had been arrested and was being held at the facility until his court date. Further review of the Appearance Bond form revealed that his court date was 5/18/23. During an interview on 4/12/23 at 10:55 a.m. the facility's Head of Security stated that R#5 remained on routine (every 2 hour) security rounds.

Based on interviews and record reviews, the facility failed to develop care plans for four residents (R) (R#2, R#5, R#8, and R#9) with a known inappropriate sexual behavior background to address the behavior and the potential risk to reoffend. The sample size was 27. On 4/25/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: Review of the Georgia Bureau of Investigation's (GBI) Georgia Sex Offender Registry online revealed that R#2, R#5, R#8, and R#9 were registered sex offenders. During an interview on 4/18/23 at 12:33 p.m. the Minimum Data Set (MDS) Director, when questioned if a resident's registered sex offender status would be included in their care plan, she responded that they used to include the sex offender status and other crimes residents committed in the care plan, but they had to do some cleaning up of those care plans because it did not pertain to their care at the facility. The MDS Director stated that they could include the registered sex offender status in the care plan because those residents would continue to have to report to an external entity. When the MDS Director was questioned if a history of sexually inappropriate behavior be care planned, she responded that they would include that information if the resident had a diagnosis related to it or if they were receiving medication related to the behavior issue. They would also care plan a behavior if it was displayed at the facility. However, the facility failed to develop care plans to address the current sex offender registry status and thus a history of sexually inappropriate behavior, to ensure interventions were in place to prevent reoccurrence for R#2, R#5, R#8 and R#9. 1. R#2 was registered as a sex offender with the GBI since 3/13/2000. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#2 physically and sexually abused R#1 on 3/9/23. R#1 and R#2 were roommates. Based on staff interviews, record review and review of the police report and investigation, on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. The CNA stated that R#1 appeared to be scurrying away from R#2. Both were clothed, but R#1 alleged that R#2 touched him inappropriately on his groin area. R#1 also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment. R#1 was also emotionally upset following the incident. Following the incident, R#1 was sent to the emergency room for evaluation on 3/9/23. R#2 was arrested on 4/4/23 and charged with misdemeanor battery and felony false imprisonment. He was discharged from the facility on 4/26/23. Cross reference to F600 2. R#5 was registered as a sex offender with the GBI since 8/9/22. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#5 sexually abused R#4 on 3/16/23. Based on staff interviews, record review, and review of the police report and facility investigation information, on 3/16/23, CNA CC entered R#4's room to pick up his meal tray. She witnessed R#5 (who was not R#4's roommate) in the room, touching R#4's groin, head, shoulders, and buttocks. R#4 was asleep in his bed at the time and R#5 was standing up from his wheelchair over R#4. R#5 was arrested and charged with misdemeanor sexual battery on 4/3/23 and remained in the facility until the pending court date. Cross reference to F600 3. R#8 was registered as a sex offender with the GBI since 8/14/19. Review of the clinical record revealed that a care plan was developed on 2/28/20 for a history of the potential to be physically and sexually aggressive towards females/staff. A 4/13/23 revision to a trauma care plan problem included that R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan did not include that R#8 was currently a registered sex offender. Cross reference to F600 4. R#9 was a registered as a sex offender with the GBI since 7/20/20. Review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#9 sexually abused R#8 on 11/6/22. R#9 was assessed as being cognitively intact on the 9/21/22 Quarterly MDS assessment with a Brief Interview for Mental Status (BIMS) score of 15. R#8 was assessed as having severe cognitive impairment on the 10/13/22 Quarterly MDS assessment with a BIMS score of 00. On 11/6/22, LPN TT entered R#8's room to administer mediation and observed R#9 at R#8's bedside sexually abusing R#8. R#8 and R#9 were not roommates. Based on staff interview and record review, R#8 did not have the capacity to consent. R#9 was discharged from the facility on 12/8/22 and returned to prison. Cross reference to F600

Based on interviews and record reviews the facility failed to ensure care plans were revised to include occurrences of abuse with the interventions implemented for six residents (R#1, R#2, R#4, R#5, R#8 and R#9). The sample size was 27. On 4/25/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: During an interview on 4/18/23 at 12:33 p.m. the MDS Director, when questioned if a history of sexually inappropriate behavior would be care planned, she responded that they would include that information if the resident had a diagnosis related to it or if they were receiving medication related to the behavior issue. They would also care plan a behavior if was displayed at the facility. When questioned about whose responsibility it was for updating a care plan after abuse occurrences, the MDS Director stated that it would be the person who witnessed the incident or the person completing the incident report, such as the charge nurse. The MDS Director stated that they (the MDS staff) reviewed the care plans every three months and if they were aware of an incident, they would review to see if the care plan had been updated correctly. However, there was no evidence that the care plans were thoroughly and timely revised after occurrences of abuse for resident (R)#1, R#2, R#4, R#5, R#8, and R#9. 1. Review of the clinical record for R#1 revealed a care plan problem, dated 2/8/22, for having a history of Post Traumatic Stress Disorder (PTSD) but not experiencing any symptoms currently. R#1 was sexually and physically abused by R#2 on 3/9/23. Based on staff interviews, record review and review of the police report and investigation, on 3/9/23, Certified Nursing Assistant (CNA) BB responded to screams from R#1 in his room. She observed R#1 and R#2 coming from around the privacy curtain from R#2's side of the room. The CNA stated that R#1 appeared to be scurrying away from R#2. Both were clothed, but R#1 alleged that R#2 touched him inappropriately on his groin area. R#1 also alleged that he had previously been sexually abused by R#2 on other occasions. A skin assessment on 3/9/23 revealed bruising to R#1's sacrum, hips, and buttocks that was not there on the previous skin assessment. R#1 was also emotionally upset following the incident. Following the incident, R#1 was sent to the emergency room for evaluation on 3/9/23. R#2 was arrested on 4/4/23 and charged with misdemeanor battery and felony false imprisonment. He was discharged from the facility on 4/26/23. Following the sexual and physical abuse of R#1 by R#2 on 3/9/23, R#1's care plan problem was revised on 4/4/23 to include that R#1 had a history of trauma but was not experiencing any symptoms at this time. However, the care plan revision was not thorough to include the 3/9/23 sexual and physical abuse R#1 sustained, with injuries, from R#2. After surveyor inquiry about care plan revisions on 4/18/23, further record review revealed that R#1's care plan was revised to include that he sustained bruising to his buttocks related to an alleged assault by a peer. Cross reference to F600 2. Based on staff interviews, record review and review of the police report and investigation information, R#2 physically and sexually abused R#1 on 3/9/23. Review of the clinical record revealed that his care plan was revised on 3/23/23 to include a care plan problem for the potential to be physically aggressive related to a history of harm to others. However, the care plan revision was not thorough to include the 3/9/23 abuse he inflicted on R#1 until after surveyor inquiry on 4/18/23. Following surveyor inquiry on 4/18/23, further record review revealed that the care plan was revised to include that R#2 was alleged to have physically abused a peer. Cross reference to F600 3. Review of the clinical record revealed that R#4 had a care plan problem, dated 8/29/22, for having a history of PTSD but not experiencing any symptoms. R#4 was sexually abused by R#5 on 3/16/23. Based on staff interviews, record review, and review of the police report and facility investigation information, on 3/16/23, CNA CC entered R#4's room to pick up his meal tray. She witnessed R#5 (who was not R#4's roommate) in the room, touching R#4's groin, head, shoulders, and buttocks. R#4 was asleep in his bed at the time and R#5 was standing up from his wheelchair over R#4. R#5 was arrested and charged with misdemeanor sexual battery. Following the sexual abuse of R#4, the care plan was revised on 4/4/23 and documented that R#4 had a history of trauma but was not experiencing any symptoms at this time. However, the care plan revision was not thorough to include the 3/16/23 sexual abuse R#4 sustained, from R#5, until after surveyor inquiry on 4/18/23. Following surveyor inquiry, R#4's care plan was revised to include that R#4 was groped in his private area by a peer. Cross reference to F600 4. Based on staff interviews, record review, and review of the police report and facility investigation information, R#5 sexually abused R#4 on 3/16/23. Review of the clinical record revealed that his care plan was revised on 3/23/23 to include a care plan problem for the potential to be physically aggressive related to a history of harm to others. However, the care plan revision was not thorough to include the sexual abuse he inflicted on R#4 until after surveyor inquiry on 4/18/23. Following surveyor inquiry on 4/18/23, the care plan was revised to include that R#5 groped a peer's private area. Cross reference to F600 5. Review of the clinical record revealed that R#8 had a care plan problem, dated 7/16/20, for not having a history of PTSD. Based on staff interviews, record review and review of the police report and facility investigation information, R#8 was sexually abused by R#9 on 11/6/22. R#9 was assessed as being cognitively intact on the 9/21/22 Quarterly MDS assessment with a Brief Interview for Mental Status (BIMS) score of 15. R#8 was assessed as having severe cognitive impairment on the 10/13/22 Quarterly MDS assessment with a BIMS score of 00. On 11/6/22, LPN TT entered R#8's room to administer mediation and observed R#9 at R#8's bedside sexually abusing R#8. Based on staff interview and record review, R#8 did not have the capacity to consent. R#9 was discharged from the facility on 12/8/22 and returned to prison. Following the sexual abuse R#8 experienced on 11/6/22, record review revealed that no revisions were made to the care plan until 3/21/23. On 3/21/23 the PTSD care plan was revised to include that the resident did not have any history of trauma. Further record review revealed a 4/13/23 care plan revision that documented R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan revisions were not thorough to include the 11/6/22 sexual abuse R#8 sustained from R#9. Cross reference to F600 6. Based on staff interviews, record review and review of the police report and facility investigation information, R#9 sexually abused R#8 on 11/6/22. Review of the clinical record revealed no evidence his care plan was revised to include the sexual abuse he inflicted on R#8 on 11/6/22. R#9 was discharged from the facility on 12/8/22 and returned to prison. During the interview on 4/18/23 at 12:33 p.m. the MDS Director stated she did not have any additional care plan information on R#9. Cross reference to F600

Based on record review and staff interview, the facility failed to conduct and document a facility wide assessment that included and documented all required components of the resident population and facility resources. The facility census was 211. On 4/25/23 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. The facility Administrator and the Minimum Data Set (MDS) Director were informed of the Immediate Jeopardy (IJ) on 4/25/23 at 1:25 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 11/6/22. At the time of exit on 5/1/23, an acceptable Immediate Jeopardy Removal Plan had not been received, therefore, the Immediate Jeopardy remained ongoing. Findings include: Review of the Facility Assessment Tool revealed a 19-page document with an assessment and assessment review date of 1/28/23. Although the facility listed common diagnoses and conditions to determine the resources necessary to meet the needs of the residents it failed to include that the facility admitted a large percentage of justice involved residents, including 88 registered sex offenders. Further review, the Facility Assessment Tool did not include an evaluation of the care required by that specific resident population. 1. R#2 was registered as a sex offender with the Georgia Bureau of Investigation (GBI) since 3/13/2000. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#2 physically and sexually abused R#1 on 3/9/23. 2. R#5 was registered as a sex offender with the GBI since 8/9/22. However, a review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#5 sexually abused R#4 on 3/16/23. 3. R#8 was registered as a sex offender with the GBI since 8/14/19. Review of the clinical record revealed that a care plan was developed on 2/28/20 for a history of the potential to be physically and sexually aggressive towards females/staff. A 4/13/23 revision to a trauma care plan problem included that R#8 was at risk for recurring thoughts and behaviors related to past events. However, the care plan did not include that R#8 was currently a registered sex offender. 4. R#9 was a registered as a sex offender with the GBI since 7/20/20. Review of the clinical record revealed that a care plan had not been developed to address his current sex offender status and history of inappropriate sexual behavior. R#9 sexually abused R#8 on 11/6/22. During an interview with the Administrator on 5/1/23 at 1:40 p.m., she stated she was the person responsible for completing the Facility Assessment. She confirmed parts of the assessment were incomplete.

Based on the observation, interviews, and review of facility documents, the facility failed to ensure residents were not served meals on disposable dishware. The facility census was 205. Findings include: During an interview on 11/2/22 at 9:45 a.m. with the Dietary Manager revealed the kitchen was using the all-disposable trays, Styrofoam boxes, and prepackaged cutlery. During observation and interviews in the dining room on the three hundred hall on 11/3/22 at 12:47 p.m., several residents voiced concerns about receiving their meals on paper goods. Review of facility documentation revealed they had been using paper goods since 3/17/20.

Based on observation, record review and staff interview, and review of the facility policy titled Care Plans, Comprehensive Person-Centered the facility failed to develop and implement a care plan for the use of an indwelling urinary catheter for one resident (R) (R#156) and for oxygen therapy for one resident, R#146. The sample size was 46. Findings include: Review of the facility policy titled Care Plans, Comprehensive Person-Centered dated revised December 2016 revealed: a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 1. Review of R#156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#156's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13 indicating minimum cognitive deficit. Section G-Functional Status: extensive assistance with most activities of daily living (ADL's); Section H-Bowel and Bladder: has a catheter. Review of R#156's care plans revealed no care plan in place for the use of an indwelling urinary catheter. An observation of R#156 on 11/1/22 at 10:00 a.m. and 11/2/22 at 10:23 a.m. revealed resident was observed in his room. Resident had an indwelling urinary catheter. An observation of R#156 on 11/2/22 at 2:35 p.m. revealed resident up in a wheelchair, in the hallway participating in therapy. An indwelling urinary catheter was noted attached to his wheelchair with dignity flap in place. An interview with the resident revealed he has had the catheter since May of this year. An interview held on 11/2/22 at 3:10 p.m. with the Director of Nursing (DON) revealed she would expect the resident to have a care plan for the catheter. An interview held on 11/3/22 at 10:13 a.m. with the DON revealed the Charge Nurse or the Unit Manager (UM) should have written the order for the catheter and put in the care plan. 2. Review of the clinical record for R#146 revealed resident was admitted on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS of 15 (indicating was cognitively intact). Section G - Functional Status revealed the resident required set-up assist with all ADLs. Section J - Health Conditions revealed no shortness of breath during the seven-day assessment period. Section O - Special Treatments and Programs revealed no respiratory therapy in the seven-day assessment period and oxygen was provided in the past fourteen days. Review of the care plan dated 9/20/22 revealed R#146 had shortness of breath (SOB) related to history of pneumonia, [CONDITION(S)] [CONDITION(S)] and [CONDITION(S)]. Interventions include: Resident to maintain a clear airway by encouraging resident to clear secretions with effective coughing, suction as needed. Monitor changes in orientation, restlessness, anxiety, and air hunger. Monitor breathing patterns and report abnormalities to physician. Review of physician's orders revealed an order on 12/1/20 - Oxygen (O2) at two liters per minute (LPM) as needed for SOB. Review of physician notes revealed notes dated 7/13/22: He suffers from [CONDITION(S)] and bronchiectasis and is on continuous O2 therapy at five LPM. Observation on 11/1/22 at 11:00 and 11/2/22 at 10:00 a.m. revealed R#146 had oxygen on at seven LPM. Interview on 11/2/22 at 9:40 a.m. with CNA CC revealed the Licensed Practical Nurses manage oxygen and the CNAs report any concerns with oxygen to the floor nurse. Interview on 11/2/22 at 9:45 a.m. with LPN DD revealed she had observed R#146 to adjust oxygen flow as he desires. Interview on 11/2/22 at 2:20 p.m. with the Director of Nurses (DON) revealed her expectations are for physician's orders to be followed, including oxygen orders. She further revealed it is her expectation for continuous oxygen to be included on the care plan.

Based on observation, resident and staff interviews, record review and review of the facility policy titled Safety and Supervision of Residents, the facility failed to ensure the environment was free from potential accident hazards by not ensuring that a heating element, specifically a clothes iron, was kept in a secured location and not in a resident (R) room (R#149). The sample size was 46. Findings include: Review of the facility policy titled Safety and Supervision of Residents revealed the policy statement is to make the environment as free from accident hazards as possible. Record review revealed that R#149 had diagnoses that included [CONDITION(S)], primary open-angle [CONDITION(S)] bilateral, combined forms of age-related cataract bilateral, and cystoid [CONDITION(S)] left eye. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R#149 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating cognitively intact). Section G - Functional Status indicated resident was independent for mobility, dressing, toileting, personal hygiene and required supervision for locomotion. Record review revealed no assessment for R#149 to use the clothes iron unsupervised. Observation on 11/1/22 at 9:30 a.m. revealed R#149 standing in room at bedside ironing a pair of jeans with a clothes iron on his bedside table. The doorway to the room was open and R#149 was observed with the clothes iron from the hallway. Clothes iron was plugged in, turned on and was hot to touch. Observation on 11/2/22 at 9:20 a.m. revealed R#149 sitting on the side of his bed. Interview of R#149 revealed he keeps the clothes iron in a closet when not in use. He revealed he has had the clothes iron for about one week and has used it a few times. Interview on 11/2/22 at 9:25 a.m. with Certified Nursing Assistant (CNA) CC revealed she had received training to include accident prevention and that she reports any concerns to the floor nurse or the unit manager. She revealed she is unaware if residents have clothes iron or heating elements in the rooms. Interview on 11/2/22 at 9:30 a.m. with Licensed Practical Nurse (LPN) DD revealed she had worked at the facility for three days. She revealed she is unsure if any residents have clothes irons or heating elements in the room. Interview on 11/2/22 at 9:40 a.m. with the Administrator revealed residents are not allowed to keep any type of heating elements in their rooms and are allowed to use items such as clothes irons with staff supervision if the resident is assessed to be able to safely do so. Observation of R#149 room with the Administrator verified the clothes iron in R#149's room. Administrator discussed safety concerns and explained to R#149 he may use the clothes iron with supervision only and R#149 agreed for Administrator to remove the clothes iron and keep it in a secure area.

Based on observation, record review and staff interview, and review of the facility policy titled Catheter Care, Urinary the facility failed to obtain a Physician's order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of the facility policy titled Catheter Care, Urinary dated revised 2014 revealed the purpose of this procedure is to prevent catheter-associated urinary tract infections. Review of R#156's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of R#156's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of 13 indicating minimum cognitive deficit; Section G-Functional Status: extensive assistance with most activities of daily living (ADL's); Section H-Bowel and Bladder: has a catheter. Review of R#156's Physician's Orders revealed no order for the use of [MEDICAL RECORD OR PHYSICIAN ORDER] An observation of R#156 on 11/1/22 at 10:00 a.m. and 11/2/22 at 10:23 a.m. revealed resident was observed in his room, in bed, appeared asleep. No concerns identified. Resident had an indwelling urinary catheter with catheter bag noted covered with dignity flap. An observation of R#156 on 11/2/22 at 2:35 p.m. revealed resident up in a wheelchair, in the hallway participating in therapy. An indwelling urinary catheter was noted attached to his wheelchair with dignity flap in place. An interview with the resident revealed he has had the catheter since May of this year. An interview held on 11/2/22 at 2:40 p.m. with Certified Nursing Assistant (CNA) CNA AA revealed the resident has a catheter and she does catheter care on him every day. An interview held on 11/2/22 at 2:50 p.m. with Licensed Practical Nurse (LPN) LPN BB revealed the resident does have a catheter. She looked at his orders and indicated there was not an order in place for the use of an indwelling urinary catheter. An interview held on 11/2/22 at 3:10 p.m. with the Director of Nursing (DON) revealed she would expect the resident to have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview held on 11/3/22 at 10:13 a.m. with the DON revealed the Charge Nurse or the Unit Manager (UM) should have written the order for the catheter. Review of a Progress Note dated 10/15/2022 revealed: Resident's Foley catheter was changed during Urology visit yesterday, 10/14/22, with no problems noted. Foley catheter was intact and patent with clear yellow urine draining to bedside drain.

Based on observations, record review, staff interview, and review of the policy titled, PRN [CONDITION(S)] Notification and PRN Anti-Psychotic Notifications the facility failed to ensure that [CONDITION(S)] medications including an antipsychotic and an antianxiety medication were not ordered as needed (PRN) for more than 14 days unless clinically indicated for one of five residents (R) (R#88) reviewed for unnecessary medications. Findings include: Review of the documents titled PRN [CONDITION(S)] Notification not dated revealed PRN psychotropics (excluding antipsychotics): 14-day limitation on all PRN orders and PRN Anti-Psychotic Notification not dated revealed 14-day limitation on all PRN orders. Order may not be extended beyond 14 days. Review of R#88's diagnoses included but not limited to [CONDITION(S)], [CONDITION(S)] disorder, anxiety disorder, and obsessive-compulsive disorder. Review of R#88's quarterly Minimum Data Set (MDS) dated [DATE] revealed Section C-Cognition: Brief Interview of Mental Status (BIMS) score of three indicating very poor cognition; Section D-Mood: score of 0; Section E-Behavior: no behaviors; Section N-Medications: Antianxiety. Review of R#88's Physician orders revealed: [MEDICATION(S)] solution two (2) milligrams (MG)/Milliliter (ML) ([MEDICATION(S)]) inject 1 MG intramuscularly (IM) every (Q) eight (8) hours as needed (PRN) for agitation-start date 10/06/2022. No stop date indicated. [MEDICATION(S)] solution 5 MG/ML ([MEDICATION(S)]) inject 5 MG IM Q 8 hours PRN for agitation, give with [MEDICATION(S)] and Benadryl-start date 10/06/2022. No stop date indicated. Observations of the resident on 11/01/22 at 11:54 a.m. and 11/02/22 at 7:58 a.m. revealed the resident was in his room, appeared asleep, bed in low position, and up against the wall and fall matt in place. He had a sheet pulled over his head. An interview held on 11/03/22 at 10:00 a.m. with the Director of Nursing (DON) revealed when a resident receives an order for a [CONDITION(S)] medication that is ordered as needed it should have a stop date. She verified the orders for the [MEDICATION(S)] and the [MEDICATION(S)] did not have a stop date.

Based on observation and staff interviews, the facility failed to wash/sanitize hands and change gloves during wound treatment for one resident (R) (#16) reviewed for pressure ulcers. The sample size was 46 residents. Findings include: During an observation on 11/2/22 at 9:30 a.m., revealed wound care was not performed in accordance with accepted standards of treatment. Wound nurse removed gloves but did not decontaminate hands between glove change. Nurse washed her hands with soap and water prior to wound care. Nurse washed her scissors with soap and water at R#16 sink. With ungloved hands, wound nurse cut the dressing from R#16 right heel and placed the contaminated scissors on R#16 bed next to his right foot. Nurse removed the soiled dressing and placed it in a clear trash bag, and she placed the bag on R#16 bed. Nurse donned gloves, cleaned the area to right heel and applied a [MEDICATION(S)]-soaked gauze to his right heel. Nurse removed gloves and donned gloves. Nurse did not sanitize hands between glove change. Nurse wrapped right leg with a Kerlix wrap, dated the dressing, and removed the contaminated scissors from R#16 bed and placed the scissors on the table. Interview with wound nurse on 11/02/22 at 9:57 a.m. revealed wound nurse stated that she got off track when the restorative nurse entered the room. Wound nurse stated she normally washes and sanitizes her hands between glove change. Wound nurse further stated she had been in-serviced on hand hygiene. Interview with the Director of Nursing (DON) on 11/02/22 at 10:18 a.m. revealed Certified Nursing Assistants (CNAs) and Nurses are in-serviced weekly on hand hygiene. DON stated she expects the treatment nurse to perform hand hygiene between every glove change. DON stated that the wound nurse was checked off on hand hygiene competency on 1/13/22 and 5/13/22.

Based on observations, staff interview and review of the Cleaning and Disinfecting Resident's Rooms policy, the facility failed to maintain three of four sampled units (Unit 100, 200, and 300) in a clean and sanitary manner. Findings include: Review of the policy Cleaning and Disinfecting Resident's Rooms: General Guidelines (Revised August 2013) revealed the following: 1. Housekeeping surfaces (e.g., floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled. 4. Walls, blinds, and window curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled. An observation on 6/8/21 at 9:19 a.m. revealed room 305 Bed D (door), there was paint missing on the wall. An observation on 6/8/21 at 9:23 a.m. revealed room 205 Bed D (door), there were multiple brown substance and white stains on the wall. The side rail next to the wall had splattered brown substance on it. The privacy curtain had stains and dried particles. An observation on 6/9/21 at 9:49 a.m. with the Housekeeping Supervisor revealed room 202 Bed D (door), there were several brownish tan stains on the privacy curtain. An observation on 6/9/21 at 9:50 a.m. with the Housekeeping Supervisor revealed room 203 Bed W (window), there was dried white substance and brown substance on the privacy curtain. An observation on 6/9/21 at 9:53 a.m. with the Housekeeping Supervisor revealed room 205 Bed D (door), there was brown substance smeared on the wall and on the bed rail next to the wall. There were scuff marks on the wall. The privacy curtain had multiple dried substance areas. An observation on 6/9/21 at 10:07 a.m. with Housekeeping Supervisor revealed room 305 Bed D (door), there were black scuff marks on wall, and paint missing. There were tan-brown substances on the privacy curtain. An observation on 6/9/21 at 10:10 a.m. with Housekeeping Supervisor revealed room 102 Bed D (door), there were scuff marks and dried pink substances on wall. There was brown substance on the privacy curtain. An observation on 6/9/21 at 10:12 a.m. with Housekeeping Supervisor revealed room 105 Bed D (door), there was a dried urine stain with a brown ring on the sheet. There were food particles in the bed. The privacy curtains had a brown substance on it. During an interview on 6/9/21 at 10:17 a.m. the Housekeeping Supervisor revealed that in the past, there was a daily cleaning schedule for the rooms. When covid came, the facility started doing deep cleaning in the rooms, mostly on the covid unit. Housekeeping Supervisor stated that during covid a lot of the staff left but now she has a full-time regular employee. The privacy curtains are to be checked daily for cleanliness. If the privacy curtains are dirty, the staff are to tie them is a knot, so that maintenance would know to take those curtains down for laundry.

Based on record review and staff interview, the facility failed to implement a care plan intervention for weekly skin assessments for one resident (R) (#1) and failed to implement a care plan intervention for weekly wound documentation for one resident (R#3) of three residents with pressure ulcers. Findings include: 1. Review of the Admission Record revealed R#1 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 3/9/21 Significant Change Minimum Data Set (MDS) revealed the R#1 had a Brief Interview of Mental Status (BIM) score of 14 indicating that he was cognitively intact and had one unstageable pressure ulcer. Review of the care plan for R#1 dated 6/8/21 revealed resident had a pressure ulcer to his right upper buttock with an intervention to complete weekly skin assessments. There was no documented evidence of weekly skin assessments prior to 6/6/21. An interview on 6/9/21 at 4:15 p.m. with LPN GG revealed the skin assessment are set up weekly in the User Define Assessment (UDA) and that if the resident was not in the UDA system for a skin assessment, she would not know to complete a skin assessment. 2. Review of the Admission Record revealed R#3 has the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 4/14/21 Quarterly MDS revealed the R#3 had a BIMS score of 12 indicating moderate cognitive impairment and had one unstageable pressure ulcer. Review of the care plan dated revised 5/8/21 revealed R#3 has a stage 3 pressure wound to the left ischium related to diabetes mellitus and immobility. The interventions included weekly treatment documentation to include measurement of each area of the skin breakdown with width, length, depth, type of tissue and exudate. Review of the Progress Notes dated 4/10/21 through 6/8/21 revealed no evidence that wound measurements and wound description was completed on 4/23/21 and 5/22/21. Cross reference F686

Based on observation, record review and staff interview, the facility failed to perform weekly skin assessments for three residents (R) (R#1, R#2, and R#3); failed to obtain wound treatment orders timely for one resident (R#1); failed to document wound treatment administration for two residents (R#2 and R#3); and failed to document weekly wound description for one resident (R#3). The sample size was three residents with pressure ulcers. Findings include: Review of the policy titled Prevention of Pressure Ulcers/Injuries, (revision date of July 2017) revealed under Risk Assessment 4. b. Inspect pressure points (sacrum, heels buttocks, coccyx, elbow, ischium, trochanter, etc.). 1. Review of the Admission Record revealed R#1 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation on 6/8/21 at 9:23 a.m., Licensed Practical Nurse (LPN) EE treatment nurse washed her hands and donned gloves. She removed the wound dressing dated 6/7 and there was mild serosanguinous drainage without odor on the pad. She washed her hands and donned gloves. LPN EE then obtained measurements of 2.0 centimeters (cm) x 1.8 cm and the wound bed was 100% red granulation. She cleansed the wound with normal saline, then applied Santyl ointment, then calcium alginate, placed a dry folded 4 x 4 gauze over the calcium alginate and then covered with an adhesive dressing. Review of the Skin/Wound Note dated 6/3/21 revealed R#1 had a stage 3 pressure wound measuring 1.5 cm x 1.5 cm x 0.1 cm. The wound consultant physician was notified. The resident remains under hospice services. Review of the June 2021 Order Summary report revealed an order to complete weekly skin assessment every dayshift with an order date of 7/18/20. There was an order dated 6/8/21 to clean wound to right upper buttock with normal saline, blot dry, apply skin prep to peri-wound. Apply Santyl and then calcium alginate and cover with a dressing every day shift related to pressure ulcer of right buttock stage 3. The facility failed to obtain wound treatment orders to the right upper buttocks until 6/7/21. There was no documented evidence of weekly skin assessments prior to 6/6/21. An interview on 6/9/21 at 3:49 p.m. with LPN EE treatment nurse revealed that the assigned nurses are responsible for the weekly skin assessment. 2. Review of the closed medical record revealed R#2 admitted to the facility on [DATE] and discharged on [DATE]. R#2 had the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Skin and Wound Weekly Re-assessment dated [DATE] documented R#1 deep tissue injury to the right medial heal measuring 2.3 cm x 2.0 cm. Review of the Order Summary report revealed an order to completed weekly skin assessment with an order date of 7/19/20. There was an order dated 5/27/21 to apply skin prep to a deep tissue injury (DTI) on the right medial heel. The Treatment Administration Record (TAR) dated 6/1/21 through 6/30/21 revealed no evidence that the treatment to the DTI was completed on 6/1/21 and 6/2/21. Review of the Skin Observation Tool dated 4/15/21 revealed that the resident's skin was intact. There was no documented evidence that weekly skin assessments were completed before 3/25/21 or after 4/15/21. An interview on 6/9/21 at 4:15 p.m. with LPN GG revealed the skin assessment are set up weekly in the User Define Assessment (UDA) and that if the resident was not in the UDA system for a skin assessment, she would not know to complete a skin assessment. 3. Review of the Admission Record revealed R#3 has the following diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . R#3 refused wound observation. Review of the Order Summary report revealed an order to complete weekly skin assessments every day shift every Tuesday with order date of 7/21/20. An order dated 4/17/21 revealed to clean wound to left ischium with normal saline, apply Medi-honey and calcium alginate then cover with dry protective dressing daily every dayshift. Review of the TAR dated 4/1/21 through 4/30/21 revealed there was no evidence that the wound treatment to left ischium was completed on 4/17/21, 4/21/21 and 4/28/21 as indicated by blank boxes and no initials. The TAR dated 5/1/21 through 5/31/21 revealed there was no evidence that the wound treatment to left ischium was completed on 5/9/21, 5/17/21 and 5/19/21 as indicated by blank boxes and no initials. The TAR dated 6/1/21 through 6/30/21 revealed there was no evidence that the wound treatment to left ischium was completed on 6/1/21 as indicated by blank boxes and no initials. Review of clinical record revealed no evidence that R#3 refused wound treatments. Review of the Progress Notes dated 4/10/21 through 6/8/21 revealed no evidence that wound measurements and wound description was completed on 4/23/21 and 5/22/21. Review of the Skin Observation Tool dated 6/1/21 revealed no new skin issue. There was no documented evidence that weekly skin assessments were completed before or after 6/1/21. An interview on 6/9/21 at 4:29 p.m. with the Assistant Director of Nursing (ADON) revealed that the Unit Managers are to follow-up and make sure that the weekly skin assessments are entered into the UDA. She continued to explain that it was possibly a computer issue, or the nurses missed the assessment. An interview on 6/10/21 at 10:19 a.m. with the Administrator revealed that the Director of Nursing (DON) was responsible for oversight of the wound program. She could not state why the staff did not follow the facility policy for wound care.

Based on record review, review of the facility policy titled Change in a Resident's Condition or Status and Notification, and family and staff interviews, the facility failed to notify the physician and family in a timely manner of the significant change in condition for one resident (A) of five residents sampled for the provision of hospice services. Findings include: A review of the policy Change in a Resident's Condition or Status and Notification last updated in 2015 revealed the facility shall promptly notify the resident, his or her attending physician, and representative of changes in the resident's medical/mental condition. This includes a significant change or deterioration in the resident's physical, mental, psychosocial status in either life-threatening conditions or clinical complications. A review of the banner area under the resident's profile in the electronic health records revealed staff were instructed to notify the resident's Forensic Community Coordinator and family with all emergent situations. A review of the clinical records for Resident (R)A revealed he was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A further review of the clinical records revealed the resident was readmitted to the facility under the care of hospice services on [DATE] after a brief hospital stay. A review of the progress notes revealed a nurses' note dated [DATE] at 7:35 a.m. which documented that the resident was lethargic and weak, and continued to refuse meds and fingerstick blood sugar checks. The note also documented that hospice was notified and hospice staff would come to the facility that morning to evaluate the resident. A further review of the progress notes for R A on [DATE] revealed the next documented activity were four notes from the social worker and charge nurse at 5:02 p.m., 5:04 p.m., 5:22 p.m., and 6:30 p.m., respectively. The first documented that the social worker spoke with hospice personnel regarding the status of the resident and was advised by the hospice clinical manager that hospice staff would be out to assess the resident shortly. The second noted documented that the social worker had returned a call to the resident's sister and left a message informing her that hospice was called. The third note documented that the social worker had called hospice again to obtain a specific time in which hospice staff would visit. This time, a message was left with the on-call operator who promised to have someone from hospice contact the facility within 15 minutes. The fourth note was written by the charge nurse who documented that she found the resident in bed with eyes fixed, no respirations, and no blood pressure, and that she planned to contact hospice regarding this change in status. During an interview with Licensed Practical Nurse (LPN) DD on [DATE] at 3:13 p.m. she revealed when she arrived for her shift around 7:00 a.m. on [DATE], the nurse on the previous shift (7:00 p.m. to 7:00 a.m.) informed her that nurse had called hospice the night before to notify them that R A had a change in condition. The nurse on the previous shift also informed LPN DD that the hospice personnel said they would send someone on the on the morning of [DATE] to assess the resident. LPN DD said she did not know whether the nurse on the previous shift had notified the facility physician or the family of the change in condition during her shift. The hospice chaplain called around 11:00 a.m. on [DATE] and left a message with the nursing staff for her to call him. The hospice nurse had not called or visited when she returned his call sometime between 12:30 p.m. and 1:30 p.m. When she spoke with the chaplain he explained that the resident's family member had called and asked that he enquire as to the resident's condition and relay this information to her because she could not get this information from the facility staff. After speaking with the chaplain, she spoke to the Nurse Practitioner who advised her to monitor the resident until hospice came. LPN DD said she was aware during her shift that day that R A was actively dying. She also said for residents on hospice service who experiences a significant change in condition, the nurse in charge of the resident should notify hospice and hospice will come to assess the resident. The charge nurse then follows whatever directives that are given by hospice. Hospice should notify the next of kin of the resident's change in condition. If hospice does visit after they are notified, then the charge nurse should contact the facility physician. LPN said she was not sure but felt that charge nurse should also contact the family about the resident's change in status if the hospice staff does not. During an interview on [DATE] at 3:46 p.m., the Assistant Director of Nursing (ADON) said the care of residents on hospice is a collaborative effort between the facility and hospice. Hospice is first contacted if there is any change in the resident's condition such as if the resident is actively dying or has died . After hospice is notified, the facility physician is also notified. Hospice is responsible for notifying the family of such changes, but the facility should also ensure that the family has is made aware. During an interview on [DATE] at 4:51 p.m. with LPN FF it was revealed she was the nurse in charge of R A on [DATE], the night before he died . Soon after her shift began at 7:00 p.m. she observed that, he appeared to be transitioning. She called hospice between 7:00 p.m. and 8:00 p.m. and spoke with the staff who answered the phone, informing him that the resident had experienced a change in condition. The hospice person said he would have someone call her back. Someone (she thinks it was one of the hospice nurses) called her within the next hour and she advised that person that the resident was very weak and not taking his medicine. The hospice person on the phone said they would send a hospice nurse the following morning to assess the resident. LPN FF said she passed this information on to the day shift nurse, LPN DD and documented the situation on a progress note before she left the next morning. LPN FF also said the proper process for residents on hospice who experiences a change in conditions is for the nurse in charge to notify the hospice staff, the facility physician, and the family. She did not inform the facility physician, nor did she call the family during her shift starting at 7:00 p.m. on [DATE] and ending at 7:00 a.m. on [DATE]. When she next returned to work, she learned that R A had died . During an interview on [DATE] at 12:42 p.m., Family of R A said the family had not seen R A in-person after the facility restricted visitors in [DATE] in response to the [MEDICAL CONDITION] pandemic. However, the family spoke with him on the phone an almost daily basis. Family of R A said she called the facility around 8:30 a.m. on [DATE] after she received a call from the resident's mother who was upset because she had called the facility and staff would not let her speak with him. Family of R A said staff informed her the resident was tired and weak and could not come to the phone. Family of R A said she called the facility about an hour later and left her name and number with the receptionist and asked for the director and social worker to return her call. Soon after this call to the facility, Family of R A said she called the hospice chaplain to ask if he could call the facility to find out what was going on with the resident. She called the chaplain again about an hour later, but he did not have any information for her. She called the facility again and asked for the social worker (SW). She was told the SW was in a meeting and would call her back. She called the facility nurse again around 4:00 p.m. and spoke with one of the charge nurses. She suggested to the charge nurse that the facility staff should call 911 if R A was too weak to come to the phone. She felt if he went to the hospital, she could visit him there. She said the nurse told her that hospice staff would need to make the decision to send the resident out to the hospital. Sometime after that, Family of R A said she left her home to travel to the facility. On her way there, she called the Forensic Coordinator. The Forensic Coordinator said she too had called the facility that day and was unable to obtain information on the resident. Family of R A told the Forensic Coordinator that she was on her way to the facility because she could not get the facility staff to tell her what was going on. When she arrived, she spoke to a hospice nurse who said she had arrived a few minutes before and was told that the resident had died not long before she arrived. Family of R A said at no time that day during her several conversations with nurses at the facility did the facility staff notify her that R A was gravely ill or dying. She was never told that he was in the end stage of his life. He was placed on hospice so that hospice staff would assist him with his Activities of Daily Living and encourage him to take his medications. The resident was his usual self when family last spoke with him on the phone about two days before. During an interview on [DATE] at 2:48 p.m., SW EE revealed that she returned a call from Family of R A between 4:00 p.m. and 5:00 p.m. on the afternoon of [DATE]. During this telephone conversation, the family member said she was concerned because she had not heard from the resident in a couple of days. SW EE said she did not inform Family of R A of the resident's significant change in condition during this telephone conversation because she had not seen the resident that day. After speaking with Family of R A however, she went to the resident's unit to speak with the charge nurse. While on the unit, the charge nurse, LPN DD, informed her that the resident's condition had worsened. LPN DD also informed her that the hospice service was contacted the night before, but hospice had not come out. SW EE said she called hospice after this conversation with the nurse. SW EE said she called the hospice clinical manager and told her that the facility needed someone from hospice to come out to assess the resident because his condition had worsened. She then called the family again but could not reach them. She left a voice message just asking the family to call her back. She did not provide any further information about the resident's condition in that voice message. During an interview on [DATE] at 2:27 p.m. with the behavioral health Forensic Coordinator assigned to R A it was revealed that she too had called the facility on [DATE] (did not document time) to check on the status of the resident. During this call, she spoke with SW EE who said she could not report on the resident's status because she had not seen him for some time. The Forensic Coordinator was transferred to speak to the charge nurse on the resident's unit, but no one answered the phone on the unit and she called again and was transferred to the medical clerk who promised to send a monthly status update. Soon after,(the FC said it was around 5:00 p.m.), Family of R A called the Forensic Coordinator to say she had spoken with the facility about 15 minutes before and the staff there said they had notified hospice since the day before that the resident was not doing well, he was weak and had not eaten in a couple of days. A review of an assessment note by the hospice nurse dated [DATE] revealed the hospice nurse arrived at the facility and was informed of the resident's death by facility staff at 7:00 pm and verified the death at 7:20 p.m. The note also documented this nurse notified the next of kin, the physician, and funeral home. During an interview on [DATE] at 2:45 p.m. with the Nurse Practitioner, she said, when a resident on hospice experiences a significant change in condition, the facility staff should contact the resident's provider (physician) and also contact the hospice. Hospice notifies the family of the change in condition in most instances. If the resident is near death, the hospice should come immediately to assess the resident. Under those circumstances either hospice or the facility staff should notify the resident's family. She knew R A was not doing well when he was readmitted to the facility in March and was aware that he was placed on hospice. However, she was not informed that he was near death on [DATE]. She was away from the facility, but an on-call physician was available that day. Although she was informed of his death afterward, staff did not contact her to inform her of a change in his status before he died . She spoke with the on-call physician for that day and he had no recollection of staff calling to notify him of the resident's change in condition that day.

Based on record review and staff interviews, the facility failed to follow the care plan related to [MEDICAL CONDITION] medications for one resident (#7) from a sample of five residents reviewed for medications. Findings include: Review of the clinical records for Resident (R)#7 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. Further review of the clinical records revealed physician orders [REDACTED]. A review of the care plan records for R#7 revealed a plan of care for [MEDICAL CONDITION] medications initiated 12/5/19. Interventions included directives for staff to administer [MEDICAL CONDITION] medications as ordered by the physician, and to administer for side effects and effectiveness. A review of the Medication Administration Record [REDACTED]. A review of the progress notes revealed the nurse documented on those occasions that the medication was not available for administration. A review of the Rx History Report from January 2020 to June 2020 revealed the [MEDICATION NAME] ER 150 mg was first dispensed to the resident on 2/19/20. A review of the MAR for January 2020 through June 2020 revealed that Ingrezza 80 mg was not administered due to unavailability as follows: February - 6 occasions March - 14 occasions April - 19 occasions May - 17 occasions June - 9 occasions Cross-Refer to F755

Based on record review, review of the facility policy titled Pharmacy Services Overview, and staff interviews, the facility failed to obtain two medications in a timely manner for one resident (#7) of five residents reviewed for medications. Findings include: A review of the policy titled, Pharmacy Services Overview dated 2001 revealed that the facility is responsible for providing or obtaining pharmacy services for its residents. The facility is to contract with a licensed pharmacist who will collaborate with the facility and medical director to help the facility assure that medications are requested, received, and administered in a timely manner, as ordered by authorized prescribers. If multiple pharmacy services are utilized, the pharmacist is to coordinate those pharmacy services. The pharmacist is also responsible for helping to develop policy and procedures about when to contact a prescriber about mediation issues, and to give the DON, Medical Director, and staff feedback about performances and practices related to med administration, and med errors. A review of the clinical records for Resident (R)#7 revealed she was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the physician's order sheet for the months of January 2020 through June 2020 revealed orders for the resident to receive the antidepressant medication [MEDICATION NAME] ER (extended release formulation) 150 milligrams (mg) daily (beginning 1/22/20) for OCD. This order was changed to [MEDICATION NAME] (the immediate release formulation) with effect from 3/27/20. The physician's order sheets also documented an order for [REDACTED]. A review of the Medication Administration Record [REDACTED]. A review of the progress notes revealed the nurse documented on those occasions that the medication was not available for administration. A further review of the progress notes revealed a nurse's note on 1/27/20 which documented that the nurse spoke with the pharmacist, a prior authorization was needed, and that the necessary form had been faxed since 1/21/20. A review of the Rx History Report from January 2020 to June 2020 revealed the [MEDICATION NAME] ER 150 mg was first dispensed to the resident on 2/19/20. In a written statement dated 6/29/20, pharmacist, AA wrote: The medication needed a Prior Authorization. Once we received the new order, we immediately sent a PA form to notify the Facility and ask how to handle. We called and resent the form several times within the next several days and had no response. The Facility responded and accepted the cost to pay themselves on 02/19/20 and we sent it out. A further review of the MAR for January 2020 through June 2020 revealed that Ingrezza 80 mg was not administered due to unavailability as follows: February - 6 occasions March - 14 occasions April - 19 occasions May - 17 occasions June - 9 occasions In a written statement dated 6/29/20, pharmacist, BB, said: in this case the drug comes directly from the GA Approved Specialty Pharmacy to the Nursing Center and we are not allowed to dispense it. During an interview on 6/25/20 at 3:46 p.m. with the Assistant Director of Nursing (ADON) it was revealed that the charge nurse who has administered the last prescribed dose of a resident's medication or becomes aware that the resident has only a few remaining doses is responsible for contacting the pharmacy staff to let them know that the medication is out or almost out. If the pharmacy cannot send the medication before the next (or current) administration, that nurse should call the physician for authorization to miss a dose or for some other directive. The charge nurse is responsible for contacting the physician for an order to hold the dose(s) that is being missed and for notifying the nursing supervisor of the circumstances. If the medication needs a prior authorization, the pharmacy normally sends a prior authorization form and the ADON is responsible for contacting the insurance company to obtain this authorization. Sometimes the insurance company will not pay for certain dosage amount or the medication may not be part of the formulary allowed. Whatever the issue is, beyond immediate unavailability, the ADON is responsible for contacting the physician so he can make any necessary adjustments. During an interview on 6/26/20 at 10:32 a.m., Licensed Practical Nurse (LPN) CC revealed that the Ingrezza 80 mg at bedtime prescribed for R#7 had been unavailable for administering for several periods of time. In the past, LPN CC said, this medication had been unavailable for a day or so. However, this last period of unavailability had stretched for several weeks. She was not aware of the reason for the latest unavailability of this medication, but said, if a resident runs out of a scheduled medication, the charge nurse should contact the pharmacy. If the pharmacy does not have the medicine available to be sent over or if there will be delay in sending it, the nurse is to notify the physician. LPN CC said the first time she became aware that the Ingrezza was not available for administering she called the contracted pharmacy, they said they did not carry the medication. However, she knew that the contracted pharmacy sometimes obtained medications from other pharmacies and, since they were the only pharmacy she knew to contact, she called them each time she worked on the resident's unit and was aware that the Ingrezza was not available for administering. She also notified the nurse practitioner, the unit manager, and the Director of Nursing (DON). LPN CC said R#7 was prescribed the Ingrezza 80 mg daily for Extrapyramidal Symptoms (EPS). She has witnessed no such symptoms since she has worked with the resident in the last six months or so. She could not recall the period during which the [MEDICATION NAME] ER 150 mg was not available to be administered to R#7. During an interview with the consultant pharmacist BB on 6/30/20 at 2:01 p.m. it was revealed that he reviews all the residents' medications including the [MEDICAL CONDITION] medications during his monthly review to see if the resident is getting the correct dosages, if the medication is associated with an appropriate diagnosis, if the facility is monitoring the use of the medication. He also makes recommendations as to dose reductions. He verified that the [MEDICATION NAME] ER 150 mg prescribed for R#7 in January 2020 needed prior authorization. When the order was received, the prior authorization form was sent to the facility several times with no response. Once the facility accepted responsibility for paying for the medication themselves, it was immediately sent to them. The pharmacist also verified that the Ingrezza 80 mg was not supplied by his pharmacy but through an arrangement the facility had with a specialty pharmacy. Many of the residents are admitted on medications that the facility pays for out of pocket until the resident is approved for Medicaid or if Medicaid refuses to pay. Pharmacist BB said he should have been aware from reviewing the MAR indicated [REDACTED]. However, some nurses documented that the medicine is given and some document that it was not. The facility's MAR indicated [REDACTED]. This is an issue that he continues to notify the administrator and DON about. During an interview on 7/1/20 at 2:45 p.m. with the Nurse Practitioner (NP), she said if a resident is prescribed a medication that is not available from the pharmacy for formulary or other reasons, the nursing staff should let the prescribing physician know so he/she can change the medication to an equivalent medication or have the facility pay for the medication that is prescribed. They have done so in the past. If the resident is prescribed a medication that is not part of the formulary, the pharmacy sends a form to the facility with options the facility can take to ensure the resident receives the medication. This process was followed when, on March 26, she was informed by that the pharmacy that the ER version of the [MEDICATION NAME] was not part of the formulary and she immediately changed the order for R#7 to receive the regular version. She was not made aware by staff in January or February that the resident's prescribed medication, [MEDICATION NAME] ER 150 was not available. R#7 was already prescribed the Ingrezza 80 mg upon her admission in May 2019 and she continued this medication. The Ingrezza was provided to the resident as part of a patient assistance program. The NP said she received a call from the patient assistance program on 4/30/20 saying they had made repeated calls to the previous medical director (who last worked in January) to verify the resident's information before they would send any further Ingrezza. She provided the requested information, but the program wanted to speak directly with the resident to verify other information The NP said she told the resident to expect a call from the patient assistance program, and on 5/3/20 the resident confirmed to her that she spoke with the program and they promised to send the medication. In speaking with a program representative on the day of this interview, the NP said she learned that the resident informed them on 4/30/20 she no longer wanted the medication and no further doses were sent. The program representative confirmed to the NP that the last 30-day supply of the Ingrezza was sent to the resident in January 2020 (not sure the exact date). However, the nursing staff failed to inform her then and after her conversation with the patient assistance program on 4/30/20 that the medication was not and continued to not be available for administering to R#7 until 6/17/20. At that time, she immediately contacted the physician who changed the prescription to another medication that was available. The NP said the resident was prescribed the Ingrezza to address EPS of Tardive Dyskinesia. The resident does not have frank EPS but would sometimes lick her lips. These symptoms have been stable. She has not seen any worsening of her symptoms or any changes. She also did not recall any negative effects suffered by the resident during January and February 2020 or any documented behavioral issues during that time related to her not receiving the prescribed [MEDICATION NAME] ER.