Every finding on record at Casa De Oro Center

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 2 (R #16 and R #17) of 3 (R #16, R #17, and R #18) residents reviewed for Percutaneous Endoscopic Gastrostomy tube (PEG, a flexible feeding tube inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly) when staff failed to document flushing R #16 and R #17's PEG tubes. This deficient practice could likely cause staff to not have the most accurate resident information and adversely impact the care staff provides. The findings are: R #16 A. Record review of R #16's Face Sheet, no date, revealed the following: 1. R #16 was admitted to the facility on [DATE]. 2. R #16 had the following diagnoses: a. Gastrostomy status (having a surgically created opening in the stomach (a PEG-tube). b. Dysphagia, oropharyngeal phase (a swallowing disorder where food or liquid cannot easily move from the mouth into the throat and esophagus). B. Record review of R #16's physician's order revealed the following: 1. An order dated 04/22/26 and discontinued on 05/18/26, for gabapentin (medication used to treat nerve pain and prevent seizures) 18 mL (900 mg) via PEG tube three times a day. 2. An order dated 04/23/26 and discontinued on 05/18/26, for melatonin (a hormone produced naturally by your brain's pineal gland in response to darkness) 5 mg via PEG tube at bedtime. 3. An order dated 04/23/26 and discontinued on 05/18/26, for olanzapine (an atypical antipsychotic medication primarily used to treat schizophrenia and bipolar I disorder) 2.5 mg via PEG tube twice a day. 4. Staff did not document orders for monitoring or flushing (pushing water through a tube to prevent blockage) R #16's PEG tube. C. Record review of R #16's Administration Record, dated May 2026, revealed staff did not document flushing R #16's PEG tube. D. Record review of R #16's Administration Record, dated June 2026, revealed staff did not document flushing R #16's PEG tube. E. On 06/08/26 at 11:58 AM, during an interview, RN #16 stated the following: 1. R #16 has not received feedings through her PEG tube since she arrived on 04/22/26. 2. R #16 had orders to receive medications through her PEG tube that were discontinued on 05/18/26. 3. R #16 received all her medications by mouth after 05/18/26. 4. After R #16's orders for medications to be administered through her PEG tube were discontinued, she flushes R #16's PEG tube twice a day to prevent blockage. 5. She confirmed she did not document in R #16's medical record that she flushed her PEG tube. R #17 F. Record review R #17's Face Sheet, no date, revealed the following: 1. R #17 was admitted to the facility on [DATE]. 2. R #17 had the following diagnoses: a. Malabsorption due to intolerance, not elsewhere classified (a digestive diagnosis for when the small intestine fails to properly absorb specific nutrients-like fats, carbohydrates, proteins, or starches-due to an adverse food reaction that is not classified elsewhere). b. Gastrostomy status. c. Dysphagia. G. Record review of R #17's physician's orders revealed the following: 1. An order dated 04/21/26 and discontinued 05/18/26, for 150 mL hydration flushes through PEG tube every 6 hours. 2. An order dated 04/21/26 and discontinued 05/18/26, for Jevity (specialized medical nutritional formulas developed by [NAME] Nutrition, primarily used for tube feeding) at 75 milliliters per hour (mL/hr) for 12 hours. 3. An order dated 01/16/26 and discontinued 05/19/26, for flush PEG tube with 30 mL of water before and after each medication pass and between each medication. 4. All medications for PEG tube administration were discontinued as of 05/19/26 and new orders were entered to be administered by mouth. 5. An order dated 04/29/26 for a regular textured diet with thin liquid consistency. 6. Staff did not document an order to flush R #17's PEG tube after her medications and diet were changed to by mouth on 05/18/26 and 05/19/26. H. Record review of R #17's Administration Record, dated May 2026, revealed staff did not document flushing R #17's PEG tube after 05/18/26. I. Record review of R #17's Administration Record, dated June 2026, revealed staff did not document flushing R #17's PEG tube. J. On 06/08/26 at 2:45 PM, during an interview, RN #17 stated the following: 1. R #17 has not received feedings through her PEG tube since her feedings were discontinued on 05/18/26. 2. R #17 had orders to receive medications through her PEG tube that were discontinued on 05/19/26. 3. R #17 received all her food and medications by mouth after 05/18/26. 4. She flushed R #17's PEG every day to prevent blockage. 5. She confirmed she did not document in R #17's medical record that she flushed her PEG tube. K. On 06/09/26 at 10:12 AM, during a joint interview, the DON and NP #16 confirmed the following: 1. Staff were expected to flush residents PEG tubes at least daily if not receiving nutrition and medications through the PEG tube. 2. Residents should have orders to flush the PEG tube at least daily to prevent blockage. 3. Staff were expected to document PEG tube flushes in the medical record. 4. R #16 and R #17 did not have orders in their medical record to flush their PEG tubes. 5. Staff did not document flushing R #16 or R #17's PEG tubes.

Based on record review and interview, the facility failed to ensure medications were administered as ordered by the physician for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for medication administration when staff failed to ensure narcotic (medication used to treat moderate to severe pain) medications were not administered earlier than ordered. This deficient practice could likely lead to adverse side effects (unwanted, harmful, or unintended reactions to medications or treatments, ranging from mild annoyances to life-threatening conditions) due to overmedication. The findings are: A. Record review of R #3's Face Sheet, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 diagnoses include: a. Polyneuropathy (condition in which multiple peripheral nerves throughout the body are damaged disrupting communication between the brain and the rest of the body leading to pain, numbness and weakness). b. Pain in left knee. B. Record review of R #3's physician's orders revealed an order dated 03/23/26 for oxycodone-acetaminophen (combination medication used to help relieve moderate to severe pain) 5-325 mg, give one tablet by mouth every eight hours as needed for moderate pain/severe pain. C. Record review of R #3's Controlled Drug Record (CDR; mandatory documentation required by the Drug Enforcement Agency [DEA]to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal) for oxycodone-acetaminophen 5-325 mg dated 03/23/26 to 03/27/26 revealed the following: 1. Staff signed out one tablet of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 3:00 PM. 2. Staff signed out one tablet of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 8:03 PM. D. Record review of R #3's MAR, dated March 2026, revealed the following: 1. Staff did not document administration of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 3:00 PM. 2. Staff documented administration of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 8:03 PM. E. On 04/09/26 at 9:56 AM, during an interview, the DON confirmed the following: 1. Staff administered R #3's oxycodone-acetaminophen 5-325 mg sooner than every eight hours when they administered a dose at 3:00 PM on 03/24/26 then again at 8:03 PM on 03/24/26. 2. The administration of R #3's oxycodone-acetaminophen 5-325 mg given prior to every eight hours was a medication error. 3. The expectation is that staff check both the CDR and MAR to determine if the PRN oxycodone-acetaminophen can be administered to the resident.

Based on record review and interview, the facility failed to ensure medical records were complete and accurate for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for medication administration when staff failed to document narcotic medication administration on the MAR for R #3. This deficient could likely cause staff to not have the most accurate resident information if the records are inaccurate or missing adversely impact the care staff provides. The findings are:A. Record review of R #3's Face Sheet, no date, revealed the following:1. R #3 was admitted to the facility on [DATE]. 2. R #3 diagnoses include: a. Polyneuropathy (condition in which multiple peripheral nerves throughout the body are damaged disrupting communication between the brain and the rest of the body leading to pain, numbness and weakness). b. Pain in left knee B. Record review of R #3's physician's orders revealed an order dated 03/23/26 for oxycodone-acetaminophen (combination medication used to help relieve moderate to severe pain) 5-325 mg, give one tablet by mouth every eight hours as needed for moderate/severe pain. C. Record review of R #3's Controlled Drug Record (CDR; mandatory documentation required by the Drug Enforcement Agency [DEA] to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal) for oxycodone-acetaminophen 5-325 mg dated 03/23/26 to 03/27/26 revealed staff signed out one tablet of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 3:00 PM. D. Record review of R #3's MAR, dated March 2026, staff did not document administering one tablet of oxycodone-acetaminophen 5-325 mg on 03/24/26 at 3:00 PM. E. On 04/09/26 at 9:56 AM, during an interview, the DON confirmed that staff were expected to document all narcotic medication administrations on the CDR and the MAR and staff did not.

Based on record review and interview, the facility failed to follow procedures in accordance with professional standards of food service safety, when staff failed to: 1. Ensure the chemical sanitation concentration was checked during dish washing machine use after each meal service. 2. Maintain refrigerator temperatures in the upright refrigerator in the kitchen. 3. Maintain freezer temperatures in the upright freezer in the kitchen. These failures have the potential to affect all 134 residents in the facility who eat food prepared in the kitchen. Residents were identified by the Resident Matrix provided by the DON on 01/26/26. If the facility fails to adhere safe food storage practices, then residents are likely to be exposed to foodborne illnesses. The findings are: A. Record review of the kitchen upright refrigerator temperature log dated January 2026, revealed the following: 1. Staff did not document the refrigerator temperature on 01/25/25 during the evening shift. 2. Staff did not document the refrigerator temperature on 01/26/25 during the morning shift. B. Record review of the kitchen upright freezer temperature log dated January 2026, revealed the following: 1. Staff did not document the freezer temperature on 01/25/25 during the evening shift. 2. Staff did not document the freezer temperature on 01/26/25 during the morning shift. C. Record review of the dish machine log, dated January 2026, revealed staff did not document dish machine temperatures or chemical sanitization concentration on 01/26/26 during the breakfast dish washing cycle. D. On 01/26/26 at 1:15 PM, during an interview, the dietary director stated the following: 1. Staff were expected to check refrigerator and freezer temperatures as soon as they arrived in the morning and in the evening. 2. She confirmed staff did not document refrigerator or freezer temperatures on the evening of 01/25/26 or in the morning on 01/26/26. 3. Staff were expected to check dish washer temperatures and chemical sanitization concentration when washing dishes after each meal. 4. She confirmed staff did not document the temperature or chemical sanitization concentration during the breakfast dish washing cycle on 01/26/26.

Based on observations and interview, the facility failed to treat residents with respect and dignity for 6 (R #24, R #38, R #44, R #111, R #141, and R #142) of 6 (R #24, R #38, R #44, R #111, R #141, and R #142) randomly observed residents, when staff failed to knock on resident's doors before entering their room. This deficient practice could likely cause residents to feel anxious or depressed and like they are not valued. The findings are: A. On 01/27/26 at 11:57 AM, during an observation of the 500 unit, it was observed that the Nurse Practitioner (NP) entered R #24's, R #38's, R #44's, and R #111's rooms without knocking. R #24's, R #38's, R #44's, R #111's doors were closed and the NP opened the doors and walked into the rooms without knocking. B. On 01/27/26 at 12:01 PM, during an observation of the 700 unit, it was observed that the NP entered R #141's and R #142's rooms without knocking. R #141's and R #142's door was open C. On 01/27/26 at 11:43 am, during an interview, the NP stated it is polite to knock before entering a resident's room. The NP stated he was in a hurry and was rushed, that was why he did not knock before entering. D. On 01/27/26 at 12:16 pm, during an interview, the Administrator confirmed her expectation is that staff knock before entering residents' rooms.

Based on record review, observation, and interview, the facility failed to ensure care plan revision and care plan meeting requirements occurred for 5 (R #2, R #12, R #14, R #24, and R #33) of 5 (R #2, R #12, R #14, R #24, and R #33) residents when the staff failed to: 1. Revise the care plan with the most current resident information for R #24 and R #33. 2. Have the required IDT members participate in the care plan meeting for R #2, R #12, R #14, and R #33. These deficient practices could likely result in the care plan not being updated with the most current resident conditions and appropriate interventions, staff being unaware of changes in care provided, and residents not receiving the care related to changes in their health status or healthcare decisions. The findings are: R #2 A. Record review of R #2's face sheet, no date, revealed an admission date of 08/23/19. B. Record review of R #2's care plan meeting notes, dated 12/30/25, revealed the CNA with responsibility for the resident and the provider did not attend the care plan meeting or provide input. R #12 C. Record review of R #12's face sheet, no date, revealed an admission date of 03/19/25. D. Record review of R #12's care plan meeting notes, dated 12/23/25, revealed the individuals that were present at the meeting were R #12's family member (FM), the Unit Manager (UM), the Social Services Director (SSD), recreation staff, Dietician, and Scheduler. R #14 E. Record review of R #14's face sheet, no date, revealed an admission date of 04/10/25. F. Record review of R #14's care plan meeting notes, dated 12/18/25, revealed the individuals that were present at the meeting were the UM, the Social Services Assistant (SSA), recreation staff, Dietician, and Scheduler. G. On 01/30/26 at 1:05 PM, during an interview with SSD, the following was confirmed: 1. R #14's last care plan meeting on 12/18/25 did not include the Provider and CNA. 2. Individuals who are invited to care plan meetings include the residents, the resident's representative, UM, Dietician, recreation staff, transportation staff, SSA. 3. CNAs with responsibility for the residents were not invited to the care plan meeting. 4. Providers were not invited to the care plan meeting. R #24 H. On 01/28/26 at 9:11 AM, during an interview, R #24 stated that sometimes she only gets one shower a week. R #24 stated she refuses showers sometimes when it is too cold or when she doesn't feel well. I. On 01/29/26 at 10:01 AM, during an interview, CNA #8 stated R #24 had been refusing showers lately. CNA #8 stated when a resident refuses showers that they will let the nurse know and that she documents the refusal on the resident's shower sheet. J. On 01/29/26 at 10:10 AM, during an interview, CNA #9 stated R #24 does refuse showers when she doesn't feel well. K. Record review of R #24's care plan, dated 01/19/26, revealed there were no interventions or documentation of R #24's refusals of showers. L. On 01/29/26 at 12:45 PM, during an interview, Unit Manager (UM) #8 stated R #24 is not compliant with showering and that she refuses often. UM # 8 confirmed that R #24's refusals are not documented in her care plan. UM #8 stated that R #24's refusals should be documented in her care plan. R #33 M. Record review of R #33's admission record, no date, revealed an admission date of 01/26/24. N. Record review of R #33's care plan meeting notes, dated 12/16/25, revealed the CNA with responsibility for the resident and the provider did not attend the care plan meeting or provide input. O. On 02/05/26 at 12:10 PM, during an interview, the SSD confirmed the CNA's and provider did not attend the care plan meeting for R #2 and R #33. P. On 01/27/26 at 2:25 PM, during an interview and observation, revealed R #33's toenails were overgrown, yellow, thick and cracked. R #33 stated is toenails had not been cut in a long time. Q. On 01/29/26 at 2:18 PM, during an observation and interview, the DON confirmed R #33's toenails were overgrown and not cut. R. Record review of a progress note, dated 10/28/25, revealed R #33 had painful mycotic (fungal infection) toenails. The progress note stated to remove all affected mycotic nail tissue to the exposed nail beds as R #33 can tolerate and a follow up appointment in two (2) months for routine foot care. S. Record review of R #33's care plan, dated 01/26/26, revealed staff did not document R #33's interventions for toenail care. T. On 01/29/2026 at 2:18 PM, during an interview, the DON stated that resident care should be documented on the care plan.

Based on record review, observation, and interview, the facility failed to meet professional standards of practice for 4 (R #2, R #3, R #33, and R #127) of 8 (R #2, R #3, R #7, R #8, R #33, R #77, R #106, and R #127) residents reviewed for medical care, when staff failed to: 1. Update an order for R #2's fluid restriction. 2. Monitor R #3's blood sugar levels and signs and symptoms of high blood sugar or low blood sugar. 3. Schedule a follow-up appointment for R #33's nail care. 4. Update an order for R #127's wound care. These deficient practices could likely lead to the residents not receiving the care needed to attain their highest practicable wellbeing. The findings are R #2 A. Record review of R #2's face sheet, no date revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. A diagnosis of end stage renal disease (the final, permanent stage of kidney failure). B. On 02/02/26 at 9:44 AM, during an interview, CNA #10 stated R #2 was not on a fluid restriction (limiting your daily liquid intake, including beverages and fluids in foods to prevent fluid buildup). C. Record review of R #2's physician's order, dated 12/23/24, revealed hemo-dialysis (a life-sustaining medical procedure that filters waste, toxins, and excess fluid from the blood using a machine and a specialized filter) on Tuesday, Thursday, and Saturday. D. Record review of a Hemodialysis Communication Record, dated 01/29/26, revealed an order for a fluid restriction of 1500 ml (milliliter). E. Record review of R #2's medical record, no date, revealed staff did not document the order for fluid restriction. F. On 02/02/26 at 11:49 AM, during an interview, the DON confirmed that there was an order to restrict R #2's fluid on 01/29/26. The DON confirmed the order was not entered into R #2's medical record. He confirmed R #2's fluids were not restricted as ordered. The DON stated the order should have been entered when it was received. R #3 G. Record review of R #3's face sheet, no date, revealed the following: 1. R #3 was admitted to the facility on [DATE]. 2. R #3 had a diagnosis of diabetes mellitus (DM). H. Record review of R #3's convalescent care orders (physician-signed, temporary, medically necessary orders to admit a patient to a skilled nursing facility, typically for rehabilitation after a qualifying 3-day hospital stay, with a duration often not to exceed 30 days), dated 10/15/25, revealed an order to check R #3's blood sugar level before meals and at bedtime. I. Record review of R #3's physician's orders, multiple dates, revealed the following: 1. An order dated 10/15/25 and discontinued on 10/17/25, for Humulin R (Regular Insulin (a vital hormone produced by the pancreas that regulates blood sugar), per sliding scale (a reactive method of diabetes management where the dosage of rapid- or short-acting insulin is adjusted based on a patient's blood sugar levels) before meals. 2. An order dated 10/15/25 and discontinued on 10/17/25, for Humulin R per sliding scale at bedtime. 3. An order dated 10/16/25, for Insulin Glargine (a long-acting, synthetic (man-made) human insulin used to manage blood sugar levels), inject 20 units twice a day for DM. J. Record review of R #3's care plan, revised 10/21/25, revealed the following: 1. R #3's goal was to be free from signs and symptoms of high blood sugar and low blood sugar, including symptoms such as sweating, trembling, thirst, fatigue, weakness, and blurred vision. 2. R #3 occasionally refused blood sugar checks and insulin. 3. Staff would monitor R #3's blood glucose levels as ordered. 4. Staff would monitor R #3 for signs and symptoms of high blood sugar and low blood sugar and report abnormal findings to the provider. K. Record review of R #3's nursing progress note, dated 10/17/25, revealed the following: 1. R #3 had refused insulin, blood sugar check, and blood work. 2. Staff notified the provider about R #3's refusal. 3. The provider ordered for staff to discontinue R #3's order for Humulin R before meals and at bedtime. 4. Staff were to continue to monitor R #3 and report any changes to the provider. L. Record review of R #3's administration record (a formal, legal document used by healthcare professionals and caregivers to track, record, and verify the medications and treatments administered to a patient), dated October 2025, revealed the following: 1. Staff did not document R #3's blood sugar levels or refusal to have blood sugar checked between 10/18/25 and 10/31/25. 2. Staff did not document whether R #3 had symptoms of high blood sugar or low blood sugar. M. Record review of R #3's administration record, dated November 2025, revealed the following: 1. Staff did not document R #3's blood sugar levels or refusal to have blood sugar checked. 2. Staff did not document whether R #3 had symptoms of high blood sugar or low blood sugar. N. Record review of R #3's administration record, dated December 2025, revealed the following: 1. Staff did not document R #3's blood sugar levels or refusal to have blood sugar checked. 2. Staff did not document whether R #3 had symptoms of high blood sugar or low blood sugar. O. Record review of R #3's administration record, dated January 2026, revealed the following: 1. Staff did not document R #3's blood sugar levels or refusal to have blood sugar checked. 2. Staff did not document whether R #3 had symptoms of high blood sugar or low blood sugar. P. Record review of R #3's administration record, dated February 2026, revealed the following: 1. Staff did not document R #3's blood sugar levels or refusal to have blood sugar checked. 2. Staff did not document whether R #3 had symptoms of high blood sugar or low blood sugar. Q. Record review of R #3's vital signs, dated 10/15/25 to 02/03/26, revealed the following blood sugar levels: 1. 10/15/25- 114 milligrams per deciliter (mg/dl, unit of measurement for blood sugar) 2. 10/16/25- 284 mg/dl 3. 10/17/25- 136 mg/dl 4. 11/20/25- 124 mg/dl 5. 11/24/25- 192 mg/dl 6. 12/18/25- 89 mg/dl 7. 12/22/25- 74 mg/dl 8. 12/25/25- 249 mg/dl 9. 12/26/25- 165 mg/dl 10. 02/03/26- 93 mg/dl R. Record review of R #3's progress notes, dated 10/16/25 to 02/02/26, revealed staff did not document monitoring R #3 for signs or symptoms of high or low blood sugars. S. On 02/05/26 at 9:35 AM, during an interview, LPN #16 stated the following: 1. R #3 did not have an order in the medical record to monitor R #3's blood sugar levels. 2. When staff discontinued R #3's order for Humulin R on 10/17/25, the order for monitoring R #3's blood sugar was inadvertently (without intention; accidentally) discontinued. 3. R #3 did not have an order to monitor for signs and symptoms of high or low blood sugar. 4. He confirmed R #3's care plan indicated that staff were expected to monitor R #3 for signs and symptoms of high and low blood sugar. 5. He stated he does not routinely monitor residents with DM for signs and symptoms of high or low blood sugar. T. On 02/05/26 at 9:41 AM, during an interview, the DON confirmed the following: 1. R #3 had a diagnosis of DM. 2. Staff did not document monitoring R #3 for signs and symptoms of high or low blood sugar. 3. Staff were expected to monitor all diabetic residents for signs and symptoms of diabetes. U. On 02/04/26 at 3:03 PM, during an interview, the Doctor stated the following: 1. R #3 had extremely uncontrolled diabetes (occurs when blood sugar levels remain consistently high, causing severe, often irreversible damage to organs). 2. He was contacted on 10/17/25 regarding R #3 refusing to have her blood sugar checked and refusing to take insulin. 3. He confirmed he ordered for staff to discontinue R #3's order for Humulin R before meals and after bedtime. 4. He stated he did not intend for staff to stop monitoring R #3's blood sugar levels. 5. Staff should have monitored R #3's blood sugar levels at least daily since she had diabetes and received insulin. V. On 02/05/26 at 9:00 AM, during an interview, the medical director confirmed the following: 1. Staff were expected to monitor R #3's blood sugar levels before meals and at bedtime. 2. If residents refuse blood sugar checks, staff were expected to document the refusal and notify the provider. R #33 W. On 01/27/26 at 2:25 PM, during an interview and observation revealed R #33's toenails were overgrown, yellow, thick and cracked. R #33 stated his toenails had not been cut in a long time. X. On 01/29/26 at 2:18 PM, during an interview, the DON confirmed R #33's toenails were overgrown and had not been cut. Y. Record review of R #33's progress note, dated 10/28/25, revealed R #33 had painful mycotic (fungal infection) toenails, follow up appointment in two (2) months for routine foot care. Z. Record review of R #33's medical record, no date, revealed staff did not document a follow up appointment for R #33. AA. On 01/30/26 at 9:13 AM, during an interview, the DON confirmed the progress notes for the medical appointment on 10/28/25 documented that a 2 month follow up appointment for routine foot care was ordered. The DON confirmed a follow up appointment for R #33 was not scheduled. The DON stated a follow-up appointment should have been scheduled. R #127 BB. Record review of R #127's face sheet, no date, revealed R #127 was admitted to the facility on [DATE]. CC. Record review of R #127's skin check assessment, dated 1/25/26, revealed R #127 had a pressure wound on her sacrococcygeal (lowest portion of the back) area. DD. Record review of R #127's skin issue list, no date, revealed R #127's pressure wound on her sacrococcygeal area started on 10/17/25. EE. Record review of R #127's physician's order, dated 01/14/26, revealed an order to cleanse the sacrococcygeal wound with normal saline (a sterile, crystalloid solution of 9 grams of sodium chloride per liter of water that is used to cleans wound) or wound cleanser, pat dry, apply calcium alginate (highly absorbent, sterile, non-woven wound dressings derived from brown seaweed) to the wound bed (the exposed tissue surface within a wound), and cover with optifoam (absorbent, breathable foam dressings used to manage moderate to heavily draining wounds) every Monday, Wednesday, and Friday. FF. Record review of R #127's hospice documents, dated 01/28/26, revealed the following orders: 1. Discontinue previous sacrococcygeal wound care orders. 2. Cleanse the sacrococcygeal wound with wound cleanser. 3. Apply calcium alginate to the wound. 4. Apply crushed Flagyl (an antibiotic and antiprotozoal (medication used to treat infections caused by protozoa, single-celled parasites) medication used to treat a variety of bacterial and parasitic infections) to the wound. 5. Cover with carboflex (a 5-layer, sterile, non-adhesive dressing designed to manage odor in shallow or deep, chronic and acute malodorous wounds) then optifoam. 6. Wound care to be completed daily and as needed. GG. Record review of R #127's medical record, no date, revealed staff did not document the wound care order from hospice dated 01/28/26. HH. Record review of R #127's Treatment Administration Record (a legal document used in healthcare settings to track non-medication treatments, procedures, and interventions provided to a patient), dated January 2026, revealed staff did not document performing wound care treatment on 01/29/26. II. On 01/30/26 at 10:17 AM, during an interview with Wound Care Nurse #1, the following was revealed: 1. Staff did not enter R #127's hospice order for wound care dated 01/28/26 into R #127's medical record. 2. He confirmed the order in R #127's medical record was the order dated 01/14/26. 3. He stated that staff were expected to notify the facility provider about any changes to the hospice orders. 4. He stated if the facility provider agreed with the new orders from hospice, they were expected to enter the new orders in the medical record. 5. He confirmed that staff did not document in R #127's medical record that they notified the provider about hospice giving new wound care orders for R #127. JJ. On 01/30/26 at 11:23 AM, during an interview, the DON confirmed the following: 1. When hospice staff give orders to the facility nurse, the facility nurse was expected to verify the order with the facility provider and enter the orders in the medical record. 2. He confirmed that on 01/28/26, hospice provided new wound care orders for R #127 to receive wound care daily. 3. He confirmed staff did not document if the provider was contacted regarding new wound care orders for R #127. 4. He confirmed R #127's medical record still had the order from 01/14/26. 5. He confirmed R #127 did not receive wound care on 01/29/26

Based on observation, record review, and interview, the facility failed to properly store and secure medications for all 20 residents on the 400 hall (residents were identified by the resident matrix provided by the Administrator on 01/26/26), when staff failed to ensure: 1. The medication cart was secured. 2. Medications were not expired in treatment cart for R #21, R #43, R #86, and R #134. This deficient practice could likely result in residents obtaining medications not prescribed to residents, and that are no longer effective, resulting in adverse side effects. The findings are: Medication Cart A. On 01/30/26 at 10:28 AM, an observation of the 400 hall revealed the medication cart was near the nurse's station was unlocked, and staff were not present. B. On 01/30/26 at 10:28 AM, during an interview, LPN #28 confirmed the medication cart was unlocked. It should always be locked. Expired Medications C. Record review of R #43's face sheet, no date, revealed an admission date of 08/08/23. D. On 01/30/26 at 9:13 AM, during an observation of the treatment cart on 400 hall revealed a medication prescribed to R #43 of Breyna inhaler (is used for the long-term treatment of asthma and chronic obstructive pulmonary disease (COPD), 160-4.5 mcg (microgram) expired in December 2025. E. Record review of R #86 face sheet, no date, revealed an admission date for 06/24/10. F. On 01/30/26 at 9:13 AM, during an observation of the treatment cart on 400 hall revealed a medication prescribed for R #86 of ipratropium bromide and albuterol Sulfate inhalation solution 0.5 mg/3 mg per 3ml (is a combination inhalation solution used to treat and prevent breathing difficulties in chronic lung diseases), expired on 06/20/25. G. Record review of R #134 Face sheet, no date, revealed an admission date for 02/03/23. H. On 01/30/26 at 9:13 AM, during an observation of the medication cart on 400 hall revealed a medication prescribed to R #134 of IPAT-ALUBUT UD0 0.5-3 MG/3AMPUL-NEB (is used to help control the symptoms of lung diseases, such as asthma, chronic bronchitis, and emphysema), expired on 02/25. I. On 01/30/26 at 9:13 AM, during an interview with LPN #28 stated that nurses are to check daily and make sure the medications are not expired. When medications are expired or residents have discharged the nurses take the medication to east medication room for disposal. The nurse is to make sure the resident has enough of the medication, and order medication for the resident if needed. When a resident expires, the nurses take medication to east hall medication room so the pharmacy can collect it. J. On 01/21/25 at 3:35 PM, during an interview with the DON, she confirmed expired medications should not be in the medication carts. Nurses should check for expired medications in the medication carts each shift.

Based on observation, interview and record review the facility failed to ensure residents obtained dental services for 2 (R #9 and R #11) of 2 (R #9 and R #11) residents sampled for dental services, when staff failed to ensure residents receive routine and/or 24-hour emergency dental care. Dental services include an annual inspection of the mouth for signs of disease, dental cleaning, fillings, or minor partial or full denture adjustments, treatment of acute pain in teeth, gums, or palate; broken, or otherwise damaged teeth, or any other problem of the oral cavity. This deficient practice is likely to cause the resident unnecessary pain, embarrassment over the condition/appearance of teeth, potential dental or oral complications, and overall health complications. The findings are: R #9 A. Record review of R #9's Face Sheet revealed an admission date of 12/06/24. B. On 01/27/26 at 11:35 PM, during an observation of R #9, revealed she had dark discolored and missing teeth. C. Record review of R #9's provider progress notes revealed the following: 1. Note dated 01/14/25, Diagnosis, assessment and plan: Dental infection needs urgent dental referral, obtain x-rays of lower mandible (lower jaw), start chlorhexidine (germicidal mouth wash used to decrease the bacteria in the mouth) swish and spit twice daily patient to be supervised. Start Augmentin (combination antibiotic that is more effective against a wider range of infections) double strength one every twelve hours as well as metronidazole (antibiotic used to treat a wide range of infections) 500 mg three times daily. 2. Note dated 02/23/25, Diagnosis, assessment and plan: Gingivitis (a common and mild form of gum disease which causes irritation, redness, swelling and bleeding of the gum around the base of teeth and can lead to a much more serious gum disease and tooth loss), continue chlorhexidine twice a day. D. Record review of R #9's nursing progress notes revealed the following: 1. Note dated 01/24/25 staff documented: provider contacted regarding missed dose of metronidazole, per provider do not give remaining doses, continue with Peridex (Trade name for chlorhexidine mouthwash) and refer resident for dental appointment. 2. Note dated 03/02/25, does resident have: a. Obvious or likely cavity or broken natural teeth? Staff documented yes. b. Inflamed or bleeding gums or loose natural teeth? Staff documented yes. c. Mouth or facial pain, discomfort or difficulty with chewing: Staff documented yes. 3. Note date 03/28/25 staff documented: Resident does not let staff assess mouth, resident does have rotting and tooth decay. Resident is taking antibiotic therapy prior to dental work. 4. Note date 04/07/25 staff documented: Resident complains of dental pain. Resident is going to have dental extractions due to poor dental health. 5. Note dated 04/29/25, does resident have: a. Obvious or likely cavity or broken natural teeth? Staff documented yes. 6. Note date 04/30/25 staff documented: Resident has dental decay. E. Record review of R #9's dental notes revealed the following: 1. R #9 was seen by the dentist on 03/24/25 was started on antibiotics and was to have a dental extraction pending insurance authorization. 2. R #9's dentist appointment for 04/08/25 was rescheduled. 3. R #9's dentist appointment for 04/14/25 was canceled due to R #9 not wanting to go to appointment. 4. R #9 was a no show for her dentist appointment on 05/27/25. 5. R #9 was a no show for her dentist appointment on 06/18/25. F. Record review of R #9's medical record revealed no further documentation regarding dental appointment, gingivitis or status of pending dental extraction. R #11 G. Record review of R #11's face sheet, no date, revealed an admission date of 02/21/24. H. On 01/27/26 at 2:09 PM, during an interview, R #11 stated she hasn't been to the dentist and would like to go. R #11 stated that her teeth hurt, and she had a denture and doesn't know where it is. I. Record review of R #11's physician's orders dated 02/22/24 revealed the following 1. An order dated 02/22/24 for dental, obtain consultation as needed/indicated and treatment for patient health and comfort. 2. A discontinued clarification order to schedule R #11 for dental evaluation with no directions specified for the order was discontinued on 09/07/25. J. Record review of R #11's physician's orders dated 01/20/26 revealed R #11 was prescribed Amoxicillin-CLAV 1 tab 875-125 mg every 12 hours for dental pain for 7 days. K. Record review of R #11's progress notes revealed no notes for dental pain or that the provider was contacted for R #11's dental pain. No referral for a dental appointment was made for dental pain. L. Record review of R #11's quarterly MDS dated [DATE] revealed the dental section was not marked to indicate R #11 had any issues for the following: 1. Broken or loosely fitting full or partial denture (chipped, cracked, uncleanable, or loose) 2. Mouth or facial pain, discomfort or difficulty with chewing. M. Record review of R #11's care plan, revised dated 11/14/25 revealed R #11 had a suspected/actual dental infection. N. Record review of the facility's Dental Policy dated 09/15/25 revealed that routine dental services means-an annual inspection of oral cavity for signs of diseases and conditions of tooth decay, gum disease, oral cancer and other issues affecting the mouth and throat. To ensure that patients obtain needed dental services, including routine dental care. When necessary or requested the center staff will assist the patient in making dental appointments and arranging transportation to and from the dental service location. O. On 01/30/26 at 1:22 PM, during an interview with the SSD, she stated the social service assistant completes a whole house quarterly audit for dental, vision, and hearing to see if residents need an appointment. A referral is sent to the scheduler to schedule appointments. SSD stated that the facility is having a hard time working on getting an in-house dentist for residents. SSD confirmed the facility does not do routine dental appointments for residents. P. On 02/04/26 at 12:19 PM, during an interview, the scheduler stated there was no referral for R #11 to schedule a dental appointment. The Scheduler stated there are no previous or future appointments for R #11 regarding dental appointments. Q. On 02/04/26 at 12:27 PM, during an interview with the DON stated his expectation is that all residents receive an annual exam for dental treatment and that staff follow the orders.

Based on observation, record review, and interview, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 2 (R #10 and R #77) of 3 (R #10, R #77, and R #127) residents reviewed for pressure wounds and respiratory care when staff failed to: 1. Follow enhanced barrier precautions (EBP, an infection control intervention) for R #127. 2. Change R #10's nasal cannula (a lightweight, flexible, medical-grade tube used to deliver supplemental oxygen (0.5-6 liters per minute) directly into the nostrils for respiratory support, allowing for mobility, eating, and speaking) as ordered. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illness. The findings are: Enhanced Barrier Precautions R #127 A. Record Review of the [Name of Federal Agency] Enhanced Barrier Precautions in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs), dated 03/20/24, revealed the following: 1. MDRO transmission is common in long term care (LTC) facilities. 2. EBP refers to an infection control intervention designed to reduce transmission of MDRO that employs targeted gown and glove use during high contact resident care activities. a. Examples of high-contact care activities include: i. Dressing ii. Bathing/showering iii. Transferring iv. Changing linens v. Providing hygiene vi. Changing briefs or assisting with toileting vii. Device care or use: Central line, urinary catheter, feeding tube, or tracheostomy viii. Wound Care: any skin opening requiring a dressing 3. EBP are indicated for residents with wounds or indwelling medical devices, even if the resident is not known to be infected or colonized with a MDRO. B. Record review of R #77's face sheet, no date, revealed R #77 was admitted to the facility on [DATE]. C. Record review of R #77's physician's orders, multiple dates, revealed the following: 1. An order dated 10/27/25 for wound care to R #77's right shin every two days or as needed. 2. An order dated 10/30/25 for wound care for a stage two (2) pressure ulcer (a partial-thickness skin loss presenting as a shallow, open ulcer with a red-pink wound bed or an intact/ruptured serum-filled blister) every day and as needed. D. On 01/30/26 at 1:26 PM, during an observation of R #77's wound care, revealed the following: 1. There was a sign on R #77's door indicating staff were to use EBP when performing high contact care activities. 2. There was PPE available in a bin next to R #77's door. 3. Wound care nurse (WCN) #16 did not put on a gown when performing wound care for R #77. 4. CNA #17 did not put on a gown when assisting WCN #16 with positioning R #77 for wound care. 5. CNA #17 was observed to roll R #77 on her side. R #77's front of her body was against CNA #16's body. E. On 01/30/26 at 1:35 PM, during an interview, WCN #16 confirmed the following: 1. He did not wear a gown when completing wound care for R #77. 2. CNA #17 did not wear a gown when assisting with wound care for R #77. F. On 01/30/26 at 1:40 PM, during an interview, CNA #17 confirmed she did not wear a gown when assisting with wound care for R #77. G. On 01/30/26 at 1:47 PM, during an interview, the DON confirmed all staff are expected to follow EBP when performing any high contact resident care, including performing wound care and assisting with wound care. Nasal Cannula R#10H. Record review of R #10's face sheet, no date, revealed the following: 1. R #10 was admitted to the facility on [DATE]. 2. R #10 had a diagnosis of chronic obstructive pulmonary disease (COPD, a progressive, incurable lung disease-primarily caused by smoking-that causes airflow obstruction, breathing difficulty, and chronic cough). I. Record review of physician's orders, multiple dates, revealed the following: 1. An order dated 01/10/25, for oxygen at two (2) liters per minute (LPM, flow rate of oxygen) by nasal cannula. 2. An order dated 06/29/25, to change oxygen tubing weekly and label each component with date and initials. J. On 01/27/26 at 11:06 AM, during an observation and interview with R #10, the following was revealed: 1. R #10 was wearing a nasal cannula. 2. R #10's nasal cannula did not have a date indicating the date it was changed. 3. R #10 stated she did not know when her nasal cannula was changed or how frequently staff change it. K. On 01/27/26 at 11:07 AM, during an interview, CNA #16 confirmed the following: 1. R #10's nasal cannula did not have a date indicating when it was changed. 2. She was unable to determine when R #10's nasal cannula was last changed. 3. Staff are expected to write the date they change the nasal cannula on the tubing of the nasal cannula. L. On 02/04/26 at 11:55 AM, during an interview, the DON confirmed the following: 1. Staff are expected to change oxygen tubing every 7 days. 2. Staff are expected to label the tubing with the date they changed it.

Based on record review and interview, the facility failed to ensure the consultant pharmacist's recommendations were reviewed and implemented by the physician and/or the physician provided documentation of a rationale (a set of reasons or a logical basis for a course of action or a particular belief) for not following the consultant pharmacist's recommendation in the resident's medical record for 1 (R #2) of 5 (R #2, R #3, R #7, R #8, and R #106) residents reviewed for unnecessary medications. This deficient practice could likely result in residents receiving medications that are no longer necessary and may cause unnecessary drug interactions (changes to medication action caused by being combined with other foods, beverages, or drugs) or adverse side effects (unwanted, undesirable effects from medication). The findings are: A. Record review of R #2's face sheet, no date, revealed the following: 1. R #2 was admitted to the facility on [DATE]. 2. R #2 had the following diagnoses: a. Essential (primary) hypertension (high blood pressure without a single, identifiable cause). b. End stage renal disease (is the final, permanent stage of kidney failure where kidney function is less than 15%, necessitating dialysis (a life-sustaining treatment for kidney failure (ESRD) that filters waste, toxins, and excess fluid from the blood when kidneys can no longer function) or a transplant for survival). B. Record review of R #2's physician's orders, multiple dates, revealed the following: 1. An order dated 05/17/25 for amlodipine (medication used to treat high blood pressure) 5 mg daily for hypertension. 2. An order dated 05/15/25 for clonidine (medication primarily used to treat high blood pressure) 0.2 mg twice a day for hypertension. 3. An order dated 05/15/25 for carvedilol (medication used to treat high blood pressure) 25 mg twice a day for hypertension. 4. An order dated 08/21/25 for midodrine (medication primarily used to treat orthostatic hypotension (low blood pressure when standing up) 5 mg once a day on Tuesday, Thursday, and Saturday for cramping related to dialysis. C. Record review of R # 2's New admission Review (form provided to the facility with pharmacist recommendation for people who were newly admitted or returned from the hospital) dated 11/18/25, revealed the following: 1. R #2 was sent to the hospital on [DATE] and returned to the facility on [DATE]. 2. R #2 was taking clonidine 0.2 mg twice a day for hypertension, amlodipine 5 mg every day for hypertension, and carvedilol 25 mg twice a day for hypertension. 3. R #2 was taking midodrine 5 mg once a day on Tuesday, Thursday, and Saturday. 4. The pharmacist recommended evaluation of the use of medications for both hypertension and hypotension and recommended possibly holding morning dose of antihypertensives (medications used to treat high blood pressure) on dialysis days. 5. The form was signed by the unit manager on 11/21/25. 6. The form did not have a provider signature. D. Record review of R #2's medical record, no date, revealed the provider did not document a rationale for why the pharmacist recommendation was not followed. E. On 02/02/26 at 10:24, during an interview, Unit Manager (UM) #16 the following was revealed: 1. She confirmed the pharmacist recommended for the physician to review R #2's orders for both hypertension medications and hypotension medications. The pharmacists recommended not giving the medications for hypertension prior to R #2 receiving dialysis. 2. She confirmed the New admission Review form was not signed by the provider. 3. She confirmed R #2's medication orders for antihypertensives or midodrine had not been changed since the pharmacist's recommendation on 11/18/25. 4. She was unable to determine if the provider had reviewed the pharmacist's recommendation. F. On 02/02/26 at 10:48 AM, during an interview, the DON confirmed the following: 1. The provider was expected to review all pharmacist recommendations and sign the pharmacist recommendation forms. 2. If the provider did not agree with the pharmacist's recommendation, the provider was expected to document a clinical rationale for why they did not want to follow the recommendation.

Based on observation, record review, and interview, the facility failed to provide foot care for 1 (R #33) of 4 (R #2, R #22, R #24, and R #33) resident reviewed for foot care when staff failed to provide nail care for R #33's toenails. This deficient practice could likely cause podiatric complications (foot and toenail health issues such as ingrown toenails, fungal infections, and trauma-related injuries). The findings are: A. Record review of R #33's facesheet, no date, R #33 was admitted to the facility on [DATE]. B. On 01/27/26 at 2:25 PM, during an observation of R #33's foot, and an interview, revealed R #33's toenails were overgrown, yellow, thick and cracked. R #33 stated his toenails had not been cut in a long time. C. Record review of R #33's, annual MDS, dated [DATE], revealed R #33 is totally dependent on staff to complete ADL care. D. Record review of R #33's progress note dated 10/28/25, revealed R #33 had painful mycotic (fungal infection) toenails. The progress note stated to remove all affected mycotic nail tissue to the exposed nail beds as R #33 can tolerate. E. Record review of R #33's medical record, no date, revealed staff did not document providing toenail care for R #33. F. On 01/29/26 at 2:18 PM, during an observation of R #33's foot, and interview, the DON confirmed R #33's fingernails were overgrown and had not been cut. G. On 01/30/26 at 9:13 AM, during an interview, the DON confirmed staff did not document that R #33's toenails were being cared for. The DON confirmed R #33's toenails were overgrown and in need of medical care and that toenail care should be provided to R #33.

Based on record review the facility failed to ensure residents received quality treatment and care for 1 (R #106) of 6 (R #2, R #24, R #40, R #47. R #56 and R #106) residents reviewed for accidents when staff failed to ensure resident received follow-up treatment. This deficient practice could likely lead to resident's needs not being met and/or a worsening of their medical condition and prognosis. The findings are: A. Record review of emergency room (ER) visit notes dated 09/18/25 revealed the following: 1. R #106 was seen in the ER. 2. R #106 was diagnosed with olecranon (bony tip of the elbow) fracture. 3. R #106 was placed in a longarm splint (used for injuries requiring immobilization of the elbow) and was to follow up with orthopedic surgeon (medical doctor who specializes in diagnosing, treating, and preventing disorders of the musculoskeletal system, including bones, joints, muscles, ligaments, tendons, and nerves). B. Record review of R #106 provider progress note dated 09/23/25 revealed the following: 1. Diagnosis, assessment and plan: Olecranon fracture followed by orthopedic surgeon, no interventions performed. Please schedule with orthopedic surgeon for follow up. Continue soft casts for at least 6 weeks. C. Record review of R #106 provider progress note dated 12/03/25 revealed diagnosis, assessment and plan: Olecranon fracture followed by orthopedic surgeon, no interventions performed. We can repeat the X-ray now and then remove the soft cast. D. Record review of R #106's medical record revealed she did not have a follow up visit with the orthopedic surgeon as recommended by the ER or the facility provider.

Based on record review, observation, and interview, the facility failed to provide activities of daily living (ADL) assistance for 1 (R #33) of 4 (R #10, R #24, R #33, and R #77) residents reviewed for ADL care when staff failed to provide R #33 nail care. This deficient practice is likely to affect the dignity and health of the residents. The findings are: A. Record review of R #33's admission record, no date, R #33 was admitted to the facility on [DATE]. B. On 01/27/26 at 2:25 PM, during an interview and observation, revealed R #33's fingernails were overgrown, yellow, thick and cracked. R #33 stated his fingernails had not been cut in a long time. C. On 01/29/26 at 2:18 PM, during an interview, the DON confirmed R #33's fingernails were overgrown and had not been cut. D. Record review of R #33's, annual MDS, dated [DATE], revealed R #33 is totally dependent on staff to complete ADL care. E. Record review of R #33's medical record, no date, revealed staff did not document providing fingernail care for R #33. F. On 01/29/26 at 2:24 PM, during an interview, the Unit Manager (UM) confirmed that R #33's fingernails were overgrown and thick. The UM stated that R #33's fingernail condition would require him to be referred to an outside provider. G. On 01/30/26 at 9:13 AM, during an interview, the DON confirmed that staff did not document that R #33's fingernails were being cared for. The DON confirmed that R #33 is totally dependent and that a helper does all of the effort to complete ADL care. The DON confirmed that R #33's fingernails were overgrown and in need of medical care and that ADL care should be provided for R #33.

Based on record review and interview, the facility failed to provide the required transfer information for 1 (R #136) of 2 (R #6 and R #136) residents sampled for hospitalizations when staff failed to: 1. Notify the resident and resident representative(s) of the resident's transfer to the hospital in writing and in a language and manner they understand. 2. Send a written copy of the Transfer Notice to the Ombudsman (an advocate for residents in nursing homes and assisted living facilities). 3. Ensure the resident and their representative received a written notice of the bed hold policy which indicated the duration the bed would be held. These deficient practices could likely result in the residents and/or their representatives not knowing the reason for the transfer, the location of the transfer or discharge, their rights to advocate and make informed decisions regarding the resident's healthcare. The findings are: A. Record review of R #136's face sheet, no date, revealed R #136 was admitted to the facility on [DATE]. B. Record review of R #136's nurses progress note, dated 11/12/25, revealed she was sent to the hospital due to blood in her vomit. C. Record review of R #136's medical record, no date, revealed staff did not document a transfer notice and a bed hold notification for R #136's transfer to the hospital on [DATE]. D. On 01/30/26 at 8:53 AM, during an interview, the Social Services Director confirmed the following: 1. Staff did not complete a written Transfer Notice for R #136's transfer to the hospital on [DATE]. 2. Staff did not complete a written Bed Hold Notification for R #136's transfer to the hospital on [DATE]. 3. Staff did not send a written copy of a Transfer Notice for R #136's transfer to the hospital on [DATE] to the Ombudsman. 4. Staff were expected to complete a written Transfer Notice and Bed Hold Notification when residents were transferred to the hospital. 5. Staff were expected to send a copy of the written Transfer Notice to the Ombudsman.

Based on record review and interview, the facility failed to ensure residents did not receive psychotropic medications (group of drugs that affect behavior, mood, thoughts, or perception) unless the medication was medically necessary for 1 (R #7) of 5 (R #2, R #3, R #7, R #8, and R #106) residents reviewed for unnecessary medications, when staff failed to ensure PRN psychotropic medications were not prescribed for longer than 14 days without a written rationale from the provider. This deficient practice could likely result in residents receiving medications longer than needed without a rationale from the provider causing a higher risk of adverse side effects (unwanted, harmful, or abnormal result). The findings are: A. Record review of R #7's Face sheet, no date, revealed the following: 1. An admission date of 10/20/25. 2. R # 7 had a diagnosis of anxiety disorder (is a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). B. Record review of R #7's physician's orders revealed an order dated 12/05/25 for hydroxyzine (medication that can be used to treat anxiety) 25 mg give 1 tablet by mouth every 12 hours as needed for anxious behaviors. Physician did not document an end date. C. Record review of R #7's MAR, dated January 2026, revealed the following: 1. On 01/02/26, R #7 received hydroxyzine 25 mg at 3:05 PM. 2. On 01/03/26, R #7 received hydroxyzine 25 mg at 1:33 PM. 3. On 01/04/26, R #7 received hydroxyzine 25 mg at 5:46 PM. 4. On 01/06/26, R #7 received hydroxyzine 25 mg at 4:33 PM. 5. On 01/10/26, R #7 received hydroxyzine 25 mg at 5:48 AM. 6. On 01/12/26, R #7 received hydroxyzine 25 mg at 2:36 PM. 7. On 01/15/26, R #7 received hydroxyzine 25 mg at 9:16 AM. 8. On 01/20/26, R #7 received hydroxyzine 25 mg at 5:00 PM. 9. On 01/23/26, R #7 received hydroxyzine 25 mg at 3:05 PM. 10. On 01/24/26, R #7 received hydroxyzine 25 mg at 6:30 AM. 11. On 01/24/26, R #7 received hydroxyzine 25 mg at 8:02 PM. 12. On 01/25/26, R #7 received hydroxyzine 25 mg at 12:36 PM. 13. On 01/27/26, R #7 received hydroxyzine 25 mg at 12:07 PM. 14. On 01/28/26, R #7 received hydroxyzine 25 mg at 12:00 PM. 15. On 01/29/26, R #7 received hydroxyzine 25 mg at 12:11 PM. 16. On 01/30/26, R #7 received hydroxyzine 25 mg at 11:35 AM. D. On 02/05/26 at 1:10 PM, during an interview with the Unit Manager (UM) the following was revealed: 1. R #7 has been on PRN hydroxyzine since 10/20/25. 2. UM confirmed the provider did not document a rationale in R #7's medical record for the long-term use of PRN hydroxyzine with an end date. E. On 02/05/26 at 1:25 PM, during an interview the DON confirmed the following: 1. Hydroxyzine PRN was ordered indefinitely for R #7. 2. The provider did not document a rationale in R #7's medical record. 3. His expectation is that the provider documents a clinical rationale for a PRN hydroxyzine order with an end date greater than 14 days.

Based on record review and interview, the facility failed to ensure pharmaceutical services (the direct, responsible provision of medication-related care) were met when staff failed to keep controlled drug records (mandatory documentation required by the Drug Enforcement Agency (DEA))to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) for controlled medication (drugs or chemicals that the government regulates because they can be easily abused and lead to addiction.) for 4 (R #17, R #24, R #25 and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed for misappropriation of property. This deficient practice could likely lead to a delay in the incident investigation process and lead to potential drug misuse or diversion (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use). The findings are: R #17 A. Record review of R #17’s admission documents, no date, revealed R #17 was admitted to the facility on [DATE]. B. Record review of R #17’s physician orders, multiple dates, revealed the following: 1. An order dated 03/12/25, for hydrocodone-acetaminophen (prescription medication used for the relief of moderate to moderately severe pain. It combines an opioid pain reliever (hydrocodone) and a non-opioid pain reliever (acetaminophen)) 5-325 mg one tablet every four (4) hours as needed for severe pain (an intense, often sudden or long-lasting sensation that acts as a warning sign for injury or disease, or it can be a symptom of chronic pain, which is a disease itself) 7-10 on pain scale (typically refers to a level on a pain scale, where a higher number indicates more intense pain) for 30 days. 2. An order dated 04/14/25, for hydrocodone-acetaminophen 5-325 mg one tablet every six (6) hours as needed for moderate to severe pain 6-10 on pain scale for 30 days. 3. An order dated 05/19/25, for hydrocodone-acetaminophen 5-325 mg one tablet every six (6) hours as needed for moderate to severe pain for 12 days. 4. An order dated 05/31/25 for hydrocodone-acetaminophen 5-325 mg one tablet every six (6) hours as needed for pain for 14 days. 5. An order dated 06/16/25, for hydrocodone-acetaminophen 5-325 mg one tablet every six (6) hours as needed for moderate to severe pain (no end date). C. Record review of R #17’s controlled drug records for hydrocodone-acetaminophen 5-325 mg, dated 03/13/25 through 08/13/25, revealed the following: 1. A controlled drug record with documentation for R #17’s medication uses for dates and times between 03/13/25 at 2:26 PM and 05/19/25 at 2:00 PM. 2. A controlled drug record with documentation for R #17’s medication uses for dates and times between 06/12/25 at 11:40 PM and 07/03/25 at 6:00 AM. 3. A controlled drug record with documentation for R #17’s medication uses for dates and times between 07/24/25 at 9:00 AM through 08/13/25 at 10:14 AM. 4. There were no controlled drug records for 05/19/25 at 2:00 PM through 06/12/25 at 11:40 PM. 5. There were no controlled drug records for 07/03/25 at 6:00 AM through 07/24/25 at 9:00 AM. D. Record review of R #17’s MAR, dated May 2025, revealed R #17 had hydrocodone-acetaminophen 5-325 mg documented as administered 14 times between 05/19/25 at 2:00 PM and 05/31/25. E. Record review of R #17’s MAR, dated June 2025, revealed R #17 had had hydrocodone-acetaminophen 5-325 mg documented as administered 17 times between 06/01/25 and 06/12/25 at 11:40 PM. F. Record review of R #17’s MAR, dated July 2025, revealed R #17 had had hydrocodone-acetaminophen 5-325 mg documented as administered 48 times between 07/03/25 at 6:00 AM and 07/24/25 at 9:00 AM. R #24 G. Record review of R #24’s admission Record, no date revealed R #24 was admitted to the facility on [DATE]. H. Record review of R #24’s physician orders revealed an order dated 11/22/24, for Oxycodone-Acetaminophen 5-325mg (a combination pain-relief medication prescribed to treat acute moderate-to-severe pain), give 1 tablet by mouth every 4 hours as needed for pain. I. Record review of the Controlled Drug Record revealed R #24’s record for Oxycodone-Acetaminophen 5-325 dated 06/12/25 through 07/15/25 revealed missing pages from the record. J. On 08/20/25 at 9:24 AM, during an interview, the DON confirmed the following: 1. Narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications are controlled drugs. 2. Every order for a controlled medication for a resident has a controlled drug record to account for the narcotic medication. 3. Staff were expected to document on the controlled drug record and the MAR each time a controlled medication was used. 4. Staff were expected to place completed controlled drug records in a box for the medical records staff to scan into the resident’s medical record. 5. The facility was expected to keep the controlled drug records for all narcotic medications received at the facility. 6. The controlled drug record for R #17’s hydrocodone-acetaminophen 5-325 mg was missing between 05/19/25 and 06/12/25. 7. The controlled drug record for R #17’s hydrocodone-acetaminophen 5-325 mg was missing between 07/03/25 and 07/24/25. 8. The controlled drug record for R #24’s oxycodone-acetaminophen 5-325 mg was missing between 06/10/25 and 07/15/25. 9. He was not aware that the controlled drug records were missing for R #17 and R #24 until the surveyors requested documentation. 10. He stated he couldn’t find the Controlled Drug Record to reconcile the medications with the MAR’s. R #25 K. Record review of R #25’s admission Record, no date revealed R #25 was admitted to the facility on [DATE]. L. Record review of R #25’s physician orders revealed an order dated 06/30/25, for Oxycodone HCl Tablet 5 MG (is a prescription medicine used to treat moderate to severe pain), give 1 tablet by mouth every 6 hours as needed for moderate to severe pain. M. Record review of the Controlled Drug Record revealed R #25’s Oxycodone HCl Tablet 5 MG dated 05/6/25 to 07/1/25 revealed missing pages of the record. N. On 08/21/25 at 2:24 PM, during an interview with the DON, he stated there was missing Controlled Drug Record sheets for R #25’s Oxycodone dated 05/06/25-07/01/25. R #27 O. Record review of R #27’s admission Record, no date revealed R #27 was admitted to the facility on [DATE]. P. Record review of R #27’s physician orders revealed the following: 1. Order dated 07/09/25, for Oxycodone HCI 5mg (is a prescription medicine used to treat moderate to severe pain), give 1 tablet by mouth every 6 hours as needed for pain. 2. Order dated 07/30/25, for Oxycodone HCI 5mg (is a prescription medicine used to treat moderate to severe pain), give 1 tablet by mouth every 4 hours as needed for pain. Q. Record review of R #27’s MAR dated July 2025 revealed staff documented R #27 was administered the following: 1. Oxycodone every 6 hours; a. On 07/21/25 at 3:50 AM. b. On 07/27/25 at 2:00 PM. 2. Oxycodone every 4 hours; a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM. R. Record review of R #27’s Controlled Drug Record for Oxycodone HCI 5mg dated July 2025 revealed staff did not document the following: 1. Oxycodone every 6 hours; a. On 07/21/25 at 3:50 AM. b. On 07/27/25 at 2:00 PM. 2. Oxycodone every 4 hours; a. On 08/01/25 at 7:03 AM. b. On 08/02/25 at 1:15 PM. S. On 08/21/25 at 2:24 PM, during an interview with the DON, he stated there was missing documentation on R #27’s Controlled Drug Record sheets for Oxycodone.

Based on record review and interview, the facility failed to meet professional standards of practice for 4 (R #16, R #17, R #18, and R #24) of 4 (R #16, R #17, R #18, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Ensure narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications were not administered earlier than ordered for R #16 and R #17. 2. Ensure staff notified the provider when R #16 and R #17 required pain medications more frequently than ordered. 3. Ensure R #16 and R #24 did not receive narcotic medications at a higher dose than ordered. 4. Ensure staff document the narcotic medication administration on the MAR for R #16, R #17, R #18, and R #24. 5. Reassess R #16, R #17, R #18, and R #24. These deficient practices could likely lead to the resident having worsening of their medical conditions, adverse (unwanted, harmful, or abnormal result) side effects, or could lead to an overdose (happens when a toxic amount of a drug, or combination of drugs overwhelms the body) of narcotic medication. The findings are: R #16 A. Record review of R #16’s admission record, no date, revealed R #16 was admitted to the facility on [DATE]. B. Record review of R #16’s admission MDS assessment dated [DATE], revealed the following: 1. R #16 had a BIMS of 15. 2. R #16 had pain that was being treated with PRN pain medication. 3. R #16 was receiving opioid (sometimes called narcotics, are a type of drug. They include strong prescription pain relievers such as oxycodone, hydrocodone, fentanyl, and tramadol) pain medication. C. Record review of R #16’s physician’s orders, dated 05/28/25, revealed an order for hydrocodone-acetaminophen (prescription medication used for the relief of moderate to moderately severe pain. It combines an opioid pain reliever (hydrocodone) and a non-opioid pain reliever (acetaminophen)) 7.5-325 mg, one tablet every four (4) hours as needed for moderate to severe pain (typically refers to a level on a pain scale that ranges from roughly 4 to 10 on a 0-10 scale, where a higher number indicates more intense pain). D. Record review of R #16’s Controlled Drug Record (mandatory documentation required by the Drug Enforcement Agency (DEA) to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) for hydrocodone-acetaminophen 7.5-325 mg, dated 05/28/25 through 06/06/25, revealed the following administration dates and times: 1. 05/28/25 at 9:00 PM 2. 05/29/25 at 10:31 AM 3. 05/29/25 at 9:00 PM 4. 05/30/25 at 10:20 AM 5. 05/30/25 at 6:27 PM 6. 05/31/25 at 12:31 AM 7. 05/31/25 at 3:06 AM (less than 4 hours from previous administration as ordered). 8. 05/31/25 at 8:00 AM 9. 05/31/25 at 5:00 PM 10. 05/31/25 at 9:00 PM 11. 06/01/25 at 1:15 AM 12. 06/01/25 at 12:35 PM 13. 06/01/25 at 8:50 PM 14. 06/02/25 at 1:45 AM 15. 06/02/25 at 11:03 AM 16. 06/02/25 at 8:05 PM 17. 06/03/25 at 2:35 AM 18. 06/03/25 at 4:17 PM 19. 06/03/25 at 8:40 PM 20. 06/04/25 at 2:00 AM 21. 06/04/25 at 10:15 AM 22. 06/04/25 at 8:00 PM 23. 06/05/25 at 10:54 AM 24. 06/05/25 at 6:00 PM 25. 06/06/25 at 1:20 PM E. Record review of R #16’s MAR, dated May 2025, revealed the following administration times for hydrocodone-acetaminophen 7.5-325 mg and effectiveness (successful in producing a desired or intended result) of medication: 1. 05/29/25 at 10:31 AM, Effective (E) 2. 05/30/25 at 10:26 AM, (E) 3. 05/30/25 at 6:27 PM, (E) 4. 05/31/25 at 3:03 AM, (E) 5. 05/31/25 at 10:43 AM, (E) F. Record review of R #16’s Controlled Drug Record for hydrocodone-acetaminophen 7.5-325 mg, dated 06/06/25 through 06/28/25, revealed the following administration dates and times: 1. 06/06/25 at 10:00 PM 2. 06/07/25 at 8:25 AM 3. 06/07/25 at 6:30 PM 4. 06/07/25 at 10:15 PM (less than 4 hours from previous administration as ordered) 5. 06/08/25 at 9:52 AM 6. 06/08/25 at 9:00 PM 7. 06/09/25 at 6:50 AM 8. 06/09/25 at 7:40 PM 9. 06/10/25 at 7:21 AM 10. 6/10/25 at 8:00 PM 11. 06/11/25 at 11:10 AM 12. 06/12/25 at 10:16 AM 13. 06/12/25 at 7:00 PM 14. 06/12/25 at 11:00 PM 15. 06/13/25 at 06:30 AM 16. 06/13/25 at 6:45 PM 17. 06/13/25 at 11:15 PM 18. 06:14/25 at 3:30 AM 19. 06/14/25 at 10:34 AM 20. 06/14/25 at 8:00 PM 21. 06/15/25 at 12:15 AM 22. 06/15/25 at 3:00 AM (less than 4 hours from previous administration as ordered) 23. 06/15/25 at 10:16 AM 24. 06/15/25 at 4:14 PM 25. 06/16/25 at 7:15 AM 26. 06/16/25 at 8:00 PM 27. 06/17/25 at 4:14 PM 28. 06/17/25 at 12:00 AM (Incorrectly documented, should have been 06/18/25) 29. 06/18/25 at 12:00 AM (duplicate entry, indicating 2 pills taken at same time, order for 1 pill every four hours as needed) 30. 06/18/25 at 7:00 PM 31. 06/19/25 at 4:19 PM 32. 06/19/25 at 6:00 PM (less than 4 hours from previous administration as ordered) 33. 06/19/25 at 10:00 PM 34. 06/20/25 at 1:30 AM (less than 4 hours from previous administration as ordered) 35. 06/20/25 at 7:10 AM 36. 06/20/25 at 5:00 PM 37. 06/20/25 at 9:00 PM 38. 06/21/25 at 12:00 AM (less than 4 hours from previous administration as ordered) 39. 06/21/25 at 3:00 AM (less than 4 hours from previous administration as ordered) 40. 06/21/25 at 9:00 AM 41. 06/21/25 at 7:30 PM 42. 06/21/25 11:00 PM (less than 4 hours from previous administration as ordered) 43. 06/22/25 at 2:30 AM (less than 4 hours from previous administration as ordered) 44. 06/23/25 at 4:17 PM 45. 06/24/25 at 1:33 PM 46. 06/24/25 at 7:00 PM 47. 06/25/25 at 10:18 AM 48. 06/25/25 at 6:30 PM 49. 06/25/25 at 10:00 PM 50. 06/26/25 at 3:30 AM 51. 06/26/25 at 9:31 AM 52. 06/26/25 at 2:00 PM 53. 06/26/25 at 7:48 PM 54. 06/26/25 at 11:15 PM (less than 4 hours from previous administration as ordered) 55. 06/27/25 at 7:00 PM 56. 06/27/25 at 11:00 PM 57. 06/28/25 at 8:00 AM 58. 06/28/25 at 10:29 AM 59. 06/28/25 at 7:40 PM 60. 06/29/25 at 11:37 AM G. Record review of R #16’s MAR, dated June 2025, revealed the following administration times for hydrocodone-acetaminophen 7.5-325 mg and effectiveness of medication: 1. 06/01/25 at 1:14 AM, (E) 2. 06/01/25 at 12:34 PM, (E) 3. 06/01/25 at 8:50 PM, (E) 4. 06/02/25 at 1:45 AM, (E) 5. 06/02/25 at 11:03 AM, (E) 6. 06/02/25 at 8:05 PM, (E) 7. 06/03/25 at 2:36 AM, (E) 8. 06/03/25 at 4:17 PM, (E) 9. 06/03/25 at 8:37 PM, (E) 10. 06/04/25 at 1:59 AM, (E) 11. 06/05/25 at 10:54 AM, (E) 12. 06/06/25 at 1:16 PM, (E) 13. 06/07/25 at 8:25 AM, (E) 14. 06/07/25 at 10:15 PM, (E) 15. 06/08/25 at 9:56 AM, (E) 16. 06/08/25 at 9:10 PM, (E) 17. 06/09/25 at 7:41 PM, (E) 18. 06/10/25 at 7:31 AM, (E) 19. 06/11/25 at 11:06 AM, (E) 20. 06/12/25 at 10:15 AM, (E) 21. 06/12/25 at 11:01 PM, (E) 22. 06/13/25 at 6:45 PM, (E) 23. 06/13/25 at 11:16 PM, (E) 24. 06/14/25 at 10:34 AM, (E) 25. 06/14/25 at 8:00 PM, (E) 26. 06/15/25 at 3:00 AM, (E) 27. 06/15/25 at 10:16 AM, (E) 28. 06/15/25 at 4:14 PM, (E) 29. 06/16/25 at 7:14 AM, (E) 30. 06/17/25 at 4:13 PM, (E) 31. 06/18/25 at 12:00 AM, (E) 32. 06/18/25 at 7:16 PM, (E) 33. 06/19/25 at 4:19 PM, (E) 34. 06/20/25 at 1:30 AM, (E) 35. 06/20/25 at 7:21 AM, (E) 36. 06/21/25 at 3:00 AM, (E) 37. 06/21/25 at 7:05 PM, (E) 38. 06/21/25 at 11:00 PM, (E) 39. 06/23/25 at 4:17 PM, (E) 40. 06/24/25 at 1:33 PM, (E) 41. 06/25/25 at 10:18 AM, (E) 42. 06/25/25 at 6:36 PM, (E) 43. 06/26/25 at 3:29 AM, (E) 44. 06/26/25 at 11:15 PM, (E) 45. 06/28/25 at 2:00 AM, (E) 46. 06/28/25 at 10:29 AM, (E) 47. 06/28/25 at 7:40 PM, (E) 48. 06/29/25 at 11:37 AM, (E) H. Record review of R #16’s entire medical record, no date, revealed the following: 1. Staff did not document whether R #16’s pain was reassessed for effectiveness after medication administration for the administration times that were not documented on the May and June 2025 MAR’s. 2. Staff did not document whether the provider was notified that R #16 was having pain that required medication to be administered more frequently than ordered. R #17 I. Record review of R #17’s admission documents, no date, revealed R #17 was admitted to the facility on [DATE]. J. Record review of R #17’s quarterly MDS, dated [DATE], revealed the following: 1. R #17 had a BIMS of 15. 2. R #17 had pain that was being treated with PRN pain medication. 3. R #17 was receiving opioid pain medication. K. Record review of R #17’s physician order, dated 06/16/25, revealed an order for hydrocodone-acetaminophen 5-325 mg one tablet every six (6) hours as needed for moderate to severe pain (typically refers to a level on a pain scale that ranges from roughly 4 to 10 on a 0-10 scale, where a higher number indicates more intense pain). L. Record review of R #17’s Controlled Drug Record for hydrocodone-acetaminophen 5-325 mg, dated 07/03/25 through 07/13/25, revealed the following administration dates and times: 1. 07/03/25 at 9:27 AM 2. 07/03/25 at 5:41 PM 3. 07/03/25 at 10:49 PM (less than 6 hours from previous administration as ordered) 4. 07/04/25 at 3:00 AM (less than 6 hours from previous administration as ordered) 5. 07/04/25 at 8:30 AM (less than 6 hours from previous administration as ordered) 6. 07/04/25 at 4:32 PM 7. 07/04/25 at 9:30 PM (less than 6 hours from previous administration as ordered) 8. 07/05/25 at 2:30AM (less than 6 hours from previous administration as ordered) 9. 07/05/25 at 12:56 PM 10. 07/05/25 at 6:30 PM (less than 6 hours from previous administration as ordered) 11. 07/05/25 at 10:30 PM (less than 6 hours from previous administration as ordered) 12. 07/06/25 at 10:52 AM 13. 07/06/25 at 5:00 PM 14. 07/06/25 at 11:00 PM 15. 07/07/25 at 10:15 AM 16. 07/07/25 at 5:41 PM 17. 07/08/25 at 9:28 AM 18. 07/08/25 at 6:06 PM 19. 07/09/25 at 2:00 AM 20. 07/09/25 at 6:40 PM 21. 07/09/25 at 11:00 PM (less than 6 hours from previous administration as ordered) 22. 07/10/25 at 9:00 AM 23. 7/10/25 at 6:46 PM 24. 07/11/25 at 12:15 AM (less than 6 hours from previous administration as ordered) 25. 07/11/25 at 7:15 AM 26. 07/11/25 at 4:37 PM 27. 07/11/25 at 10:00 PM (less than 6 hours from previous administration as ordered) 28. 07/12/25 at 8:59 AM 29. 07/12/25 at 3:34 PM 30. 07/12/25 at 9:30 PM 31. 07/13/25 at 10:05 AM M. Record review of R #17’s MAR, dated July 2025, revealed the following administration times for hydrocodone-acetaminophen 5-325 mg and effectiveness of medication: 1. 07/03/25 at 9:27 AM, (E) 2. 07/03/25 at 5:41 PM, (E) 3. 07/03/25 at 10:44 PM, (E) 4. 07/04/25 at 8:33 AM, (E) 5. 07/04/25 at 4:31 PM, (E) 6. 07/04/25 at 9:23 PM, (E) 7. 07/05/25 at 2:38 AM, (E) 8. 07/05/25 at 12:56 PM, (E) 9. 07/05/25 at 6:31 PM, (E) 10. 07/06/25 at 2:29 AM, (E) 11. 07/06/25 at 10:52 AM, (E) 12. 07/06/25 at 5:03 PM, (E) 13. 07/07/25 at 10:15 AM, (E) 14. 07/07/25 at 5:41 PM, (E) 15. 07/08/25 at 9:28 AM, (E) 16. 07/08/25 at 6:16 PM, (E) 17. 07/09/25 at 6:41 PM, (E) 18. 07/09/25 at 11:00 PM, (E) 19. 07/10/25 at 9:35 AM, (E) 20. 07/10/25 at 6:43 PM, (E) 21. 07/11/25 at 12:14 AM, (E) 22. 07/11/25 at 7:15 AM, (E) 23. 07/11/25 at 4:37 PM, (E) 24. 07/11/25 at 10:50 PM, (E) 25. 07/12/25 at 8:59 AM, (E) 26. 07/12/25 at 3:34 PM, (E) 27. 07/13/25 at 10:05 AM, (E) N. Record review of R #17’s entire medical record, no date, revealed the following: 1. Staff did not document whether R #17’s pain was reassessed for effectiveness after medication administration for the administration times that were not documented on July 2025 MAR. 2. Staff did not document whether the provider was notified that R #17 was having pain that required medication to be administered more frequently than ordered. R #18 O. Record review of R #18’s admission documents, no date, revealed R #18 was admitted to the facility on [DATE]. P. Record review of R #18’s quarterly MDS, dated [DATE], revealed the following: 1. R #18 had a BIMS of 15. 2. R #18 had pain that required the use of PRN pain medication. 3. R #18 was receiving opioid pain medication. Q. Record review of R #18’s physician’s order, dated 06/14/25, revealed an order for oxycodone (a powerful opioid pain medication used to treat moderate to severe pain) 5 mg every four (4) hours as needed for pain level 6-10. R. Record review of R #18’s Controlled Drug Record for oxycodone 5 mg, dated 08/10/25 through 08/20/25, revealed the following administration dates and times: 1. 08/10/25 at 8:59 PM 2. 08/11/25 at 8:17 AM 3. 08/11/25 at 8:00 PM 4. 08/12/25 at 8:23 AM 5. 08/12/25 at 8:00 PM 6. 08/13/25 at 7:43 AM 7. 08/13/25 at 9:05 PM 8. 08/14/25 at 7:58 AM 9. 08/14/25 at 9:35 PM 10. 08/15/25 at 8:41 AM 11. 08/15/25 at 8:00 PM 12. 08/16/25 at 8:00 PM 13. 08/17/25 at 8:17 AM 14. 08/17/25 at 7:00 PM 15. 08/18/25 at 9:23 AM 16. 08/18/25 at 10:19 PM 17. 08/19/25 at 9:02 AM 18. 08/19/25 at 8:55 PM 19. 08/20/25 at 9:11 AM 20. 08/20/25 at 4:43 PM 21. 08/20/25 at 10:35 PM S. Record review of R #18’s MAR, dated August 2025, revealed the following administration times for oxycodone 5 mg and effectiveness of medication: 1. 08/10/25 at 9:53 PM, (E) 2. 08/11/25 at 8:17 AM, (E) 3. 08/12/25 at 8:23 AM, (E) 4. 08/12/25 at 8:00 PM, (E) 5. 08/13/25 at 7:43 AM, (E) 6. 08/13/25 at 9:07 PM, (E) 7. 08/14/25 at 7:58 AM, (E) 8. 08/14/25 at 9:32 PM, (E) 9. 08/15/25 at 8:41 AM, (E) 10. 08/16/25 at 8:00 PM, (E) 11. 08/17/25 at 8:00 PM, (E) 12. 08/18/25 at 9:16 AM, (E) 13. 08/19/25 at 9:03 AM, (E) 14. 08/20/25 at 9:11 AM, (E) 15. 08/20/25 at 4:43 PM, (E) 16. 08/20/25 at 10:36 PM, (E) T. Record review of R #18’s entire medical record, no date, revealed staff did not document whether R #17’s pain was reassessed for effectiveness after medication administration for the administration times that were not documented on the August 2025 MAR. R #24 U. Record review of R #24’s Administration Record, no date revealed R #24 was admitted to the facility on [DATE]. V. Record review of R #24’s physician orders revealed an order dated 11/22/24, for Oxycodone-Acetaminophen 5-325mg (a combination pain-relief medication prescribed to treat acute moderate-to-severe pain), give 1 tablet by mouth every 4 hours as needed for pain. W. Record review of R #24’s Controlled Drug Record for Oxycodone-Acetaminophen 5-325 dated 07/16/25 through 08/18/25 revealed staff documented administering R #24 Oxycodone-Acetaminophen earlier than ordered on the following dates and times: 1. On 07/16/25 at 7:30 PM Oxycodone-Acetaminophen was documented as given. 2. On 07/17/25 at 12:00 AM Oxycodone-Acetaminophen was documented as given (30 minutes earlier than ordered). 3. On 07/26/25 at 1:00 AM Oxycodone-Acetaminophen was documented as given twice. X. On 08/21/25 at 12:21 PM, during an interview, LPN #17 stated the following: 1. Narcotic medication that is ordered as needed should not be administered any earlier than the time frame ordered. 2. The provider should be contacted if the resident is requesting pain medication more frequently than ordered. 3. Resident must be reassessed for effectiveness after pain medication is administered. 4. The EMR notifies the nurse that a pain assessment is required to assess the resident for effectiveness of the medication after pain medication administration is documented in the EMR. 5. If someone did not document the pain medication administration in the EMR, the nurse would not be notified that a pain assessment was due for the resident. Y. On 08/21/25 at 12:24 PM, during an interview, CMA #17 stated the following: 1. All narcotic medications should be documented on the controlled drug sheet and the residents’ MAR. 2. Narcotic medication that is ordered as needed should not be administered any earlier than the ordered time frame. 3. He notifies the nurse if the resident is requesting pain medication more frequently than ordered. 4. He notifies the nurse when pain medications are administered so the nurse can reassess the resident for the effectiveness of the medication administration. Z. On 08/21/25 at 11:19 PM, during an interview, the DON confirmed the following: 1. He was unsure how early a narcotic pain medication that was ordered PRN could be administered, but he thought 30 minutes early would be ok. 2. He was not aware that staff had been administering R #16 and R #17’s narcotic medication earlier than ordered. 3. Staff were expected to document administration of all medication on the residents’ controlled drug record and the MAR. 4. Staff were expected to reassess residents for pain after administering pain medication to determine if the medication was effective. 5. Staff were expected to document the effectiveness of pain medication on the MAR. AA. On 08/21/25 at 3:09 PM, during an interview, NP #16 stated the following: 1. She looks at the MAR to determine the resident’s usage of pain medications. 2. She does not look at the controlled drug records. 3. If staff don’t document in the MAR, she would not know how frequently the resident used pain medication and would not be able to accurately assess the resident’s pain management. 4. If a resident requested their pain medication more frequently than ordered, that would indicate that the resident’s pain was not controlled, and she would refer the resident to pain management. 5. She had never been notified that R #16 received his pain medication more frequently than ordered. 6. Giving a resident their narcotic pain medication 30 minutes early would be considered early administration. 7. She would expect staff to notify her if a resident was requesting their pain medications early more frequently than once a week.

Based on record review and interview, the facility failed to thoroughly investigate an allegation of misappropriation of property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) of 7 (R #16, R #17, R #18, R #24, R #25, R #26, and R #27) residents reviewed when staff failed to: 1. Document interviews with residents for the investigation of allegation of misappropriation of resident's narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medication. 2. Document interviews with staff for the investigation of allegation of misappropriation of resident's narcotic medication. 3. Interview potential witnesses to the allegation of misappropriation of resident's narcotic medication. 4. Review medical records for all residents in the facility with the potential for misappropriation of narcotic medications and potential for missing documentation for narcotic medications. 5. Initiate corrective action to ensure residents' narcotic medications are not being taken by someone other than the resident for whom the medication was ordered. 6. Initiate corrective action to ensure the use of narcotic medication is documented in the residents' MAR. If the facility does not adequately investigate allegations of misappropriation of resident medication, then corrective action is not implemented to protect other residents from misappropriation of medications which could cause residents to run out of their pain medications and puts residents at risk of adverse outcomes. The findings are: A. On 08/19/25 at 12:18 PM, during an interview, DON stated the following: 1. On 07/30/25, UM #16 and CMA #16 talked to him about a concern regarding CMA #16 (staff member who is responsible for administering narcotic medication during the day shift) thinking that someone forged her signature on a controlled drug record (mandatory documentation required by the DEA to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) on 07/26/25 and that UM #16 had looked at R #16, R #17, and R #24 controlled drug records and noticed that a lot of the narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications during night shift were not documented in the EMR during the month of July 2025 by LPN #16 (staff member who was responsible to administer narcotic medications during the night shift). 2. CMA #16 and UM #16 had noticed a pattern of R #16, R #17, and R #24 receiving pain medications more at night during LPN #16's shifts and these residents don't usually take pain medications as frequently as what was documented. 3. LPN #16 was interviewed and denied forging CMA #16's signature. 4. LPN #16 denied taking any of the residents' medications. 5. LPN #16 admitted that she may have forgotten to document the medication administrations in the EMR. 6. They were unable to prove whether the narcotic medication was administered to the residents. 7. He still suspected that LPN #16 was diverting (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) controlled medication, but he couldn't prove it. 8. The only thing they were able to prove was that LPN #16 had not documented controlled medications on resident's MAR's. B. Record review of all of the facility's investigation documents, no date, revealed the following: 1. Staff did not document interviews with R #16, R #17, and R #24. 2. Staff did not document interviews with CMA #16, RN #16, and LPN #16. 3. Staff did not document dates and times of discrepancies found between controlled drug records and resident MAR's for R #16, R #17, and R #24. 4. Staff did not expand the investigation to determine if residents on other units were affected by discrepancies in narcotic medication documentation in the MAR. 5. Staff did not interview other staff who may have witnessed concerns regarding controlled medications or controlled drug records. C. On 08/20/25 at 9:24 AM, during an interview, UM #16 stated she asked R #16 and R #24 questions regarding controlled medication usage. She did not document these conversations. D. On 08/21/25 at 11:09 AM, during an interview, the administrator stated she had the DON, ADON, and UM #16 complete the investigation into alleged misappropriation of controlled medications because they are more familiar with processes related to controlled medications. E. On 08/21/25 at 11:22 AM, during a joint interview with the DON, ADON, Administrator, and Corporate Resource Clinician, the following was confirmed: 1. The DON spot checked (a random, unplanned inspection or examination of a few items in a group to look for problems or ensure quality) controlled drug records on other units for concerns. 2. The DON was unable to state which residents' controlled drug records were reviewed. 3. The DON was unable to state what he was included in the spot check. 4. The DON did not document the spot checks. 5. The DON and ADON interviewed CMA #16, RN #16, and LPN #16. 6. UM #16 interviewed R #16 and R #24. 7. There was no documentation regarding interviews with residents. 8. No additional residents besides R #16 and R #24 were interviewed regarding use of controlled medications. 9. No additional staff members besides CMA #16, RN #16, and LPN #16 were interviewed to determine if there were witnesses or other concerns related to controlled medications. 10. The Corporate Resource Clinician stated that staff had been trained on diversion and documentation after the concern regarding misappropriation of controlled medications was investigated. F. On 08/21/25 at 12:14 PM, during an interview, the Nurse Educator stated the following: 1. The diversion training that was given to the nurses and CMAs after the concern regarding misappropriation of controlled medications was a training that was sent to the staff via email that required them to answer questions regarding diversion. 2. Diversion training did not include reviewing controlled drug records for patterns of controlled medication administration that seemed different than resident typical patterns. 3. Staff did not receive education regarding documentation of controlled medications after the concern regarding misappropriation of controlled medications was investigated and identified documentation as an issue. G. See findings in F658, F755, and F842 related to controlled drug records and MAR's.

Based on record review the facility failed to report allegations of misappropriation of resident property (the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent) to the State Agency within 24 hours of allegation for 3 (R #16, R #17, and R #24) of 3 (R #16, R #17, and R #24) residents reviewed for misappropriation of property, when staff failed to: 1. Report an allegation of misappropriation (diversion of medication) for R #16 with in 24 hours of becoming aware of the allegation. 2. Report the allegations of misappropriation (diversion of medication) for R #17 and R #24 when staff became aware of the allegation. If the facility fails to report allegations of misappropriation of property to the state agency within 24 hours of the allegation, then corrective action may not be taken, and residents may suffer increased anxiety and worsening of their condition. The findings are: A. On 08/19/25 at 12:18 PM, during an interview, the DON stated the following: 1. On 07/30/25, UM #16 and CMA #16 talked to him about a concern regarding CMA #16 (staff member who is responsible for administering narcotic medication during the day shift) thinking that someone forged her signature on a controlled drug record (mandatory documentation required by the DEA to track the complete life cycle of controlled substances, including their acquisition, administration, dispensing, and disposal. The purpose is to prevent diversion and ensure accountability for potentially addictive and illicitly traded drugs) on 07/26/25 and that UM #16 had looked at R #16, R #17, and R #24 controlled drug records and noticed that a lot of the narcotic (a substance used to treat moderate to severe pain. Narcotics are like opiates such as morphine and codeine but are not made from opium) medications during night shift were not documented in the EMR during the month of July by LPN #16 (staff member who was responsible to administer narcotic medications during the night shift). 2. CMA #16 and UM #16 had noticed a pattern of R #16, R #17, and R #24 receiving narcotic pain medications more frequently at night during LPN #16's shifts and these residents don't usually take pain medications as frequently as what was documented. 3. LPN #16 was interviewed on 07/30/25 and denied forging CMA #16's signature on the controlled drug record. 4. LPN #16 denied taking any of the residents' medications. 5. LPN #16 admitted that she may have forgotten to document the medication administrations in the EMR. 6. The facility was unable to prove whether the narcotic medication was administered to the residents. 7. DON stated he still suspected LPN #16 was diverting (medical and legal concept involving the transfer of any legally prescribed controlled substance from the individual for whom it was prescribed to another person for any illicit use) controlled medication, but he couldn't prove it. 8. The only thing the facility was able to prove was that LPN #16 had not documented controlled medications on resident's MAR's. B. Record review of the facility's document titled [name of LNP #16]; agency nurse (document outlining concerns regarding LPN taking narcotic medications from residents), no date, revealed the following: 1. Timeline of Events: a. Date of discovery (did not specify what they discovered): 07/30/25 b. Date of investigation initiated: 07/30/25 c. Date of Urine Drug Screen (UDS, urine test to detect presence of drugs): 07/30/25 d. Date LPN #16 was placed on administrative leave: 07/30/25 e. Date of initial lab results (UDS): 08/01/25 f. Date of final lab [off site] results (UDS): 08/05/25 g. Date report (didn't specify what report) received (by Reporter): 08/07/25 2. On 07/30/25, CMA #16 reported to Unit Manager (UM) that she believed her signature had been forged on a controlled drug record. 3. A pattern was noted with LPN #16 signing out controlled medications for residents on the controlled drug record, but there were no corresponding MAR administration records found. 4. The investigation focused on three (3) residents with BIMS of 15 (names of residents were not included) who also had controlled medications ordered. 5. All three (3) residents investigated had controlled medications signed out routinely (did not specify frequency or dates that were reviewed) on nights LPN #16 worked, but not on nights LPN #16 did not work. 6. Each resident (did not specify which residents) was interviewed and denied requesting or receiving controlled medications that were signed out (on controlled drug record) multiple (did not specify quantity) times during the course of a shift (did not specify what dates). 7. LPN #16 did not document administering the controlled medications in the MAR (did not specify which specific medication, dates, or times). 8. On 07/30/25, LPN #16 was presented with the early findings of the investigation. 9. LPN #16 had no answer for not documenting controlled medications in the MAR. 10. LPN #16 said she might forget to document sometimes. 11. LPN #16 was placed on administrative leave at the end of the conversation, which included LPN #16, Human Resources, DON, and ADON. 12. LPN #16 was sent for a UDS. 13. The Market Leadership for the facility, state-agency, and sheriffs department were notified about the situation. 14. LPN #16's UDS indicated she had barbiturates (a class of depressant drugs derived from barbituric acid, used medically as anxiolytics, hypnotics, and anticonvulsants, though they carry significant risks of addiction, overdose, and other side effects) which was consistent with a medication prescribed for LPN #16. 15. Facility requested for LPN #16 to be added to a do not place list (list that ensures this agency staff member will not be hired by any other facilities in their corporation). 16. The document did not state whether the facility was able to determine if LPN #16 stole the narcotic medications. C. Record review of an email between the DON, administrator, and corporate staff, dated 07/30/25, revealed the following: 1. The subject was Diversion (the illegal redirection of a prescription drug from its intended medical purpose to illicit use) - LPN #16, dated 07/30/25. 2. CMA #16 believed her signature was forged on the controlled drug record for R #16. 3. LPN #16 had been administering hydrocodone-acetaminophen (prescription medication used for the relief of moderate to moderately severe pain. It combines an opioid pain reliever (hydrocodone) and a non-opioid pain reliever (acetaminophen)) 7.5-325 mg to R #16 and R #16 did not remember receiving the medication overnight/evenings. 4. R #17 had been given PRN medications at night without it being documented in the EMR (dates not provided). 5. R #24 received oxycodone acetaminophen (a prescription combination medication used to treat moderate to severe pain. It contains an opioid pain reliever (oxycodone) and a non-opioid pain and fever reducer (acetaminophen) 5-325 mg three times during night shift (dates not given). R #24 was interviewed by UM #16 and had verbalized that she doesn't usually ask for pain medication at night. 6. The pattern documented on the controlled drug record for R #16, R #17, and R #24 reflected the same pattern every time LPN #16 worked. 7. Any time other nurses worked on night shift, residents are not asking for PRN pain medications. 8. None of the medications documented on the controlled drug records by LPN #16 were documented in electronic medical record. 9. CMA #16's signatures were reviewed and appeared to be forged. 10. LPN #16 was called to go to the facility an hour before her shift on 07/30/25 to be interviewed, receive a drug test, and be placed on administrative leave pending the results of the investigation. D. Record review of the incident report submitted to the state agency, dated 08/01/25 (not within 24 hours of concern on 07/30/25), revealed the following: 1. Date of incident was 07/31/25 at 11:00 AM (discrepancy with concern of diversion on 07/30/25). 2. Resident identified was R #16. 3. CMA #16 had reported to UM #16 that she believed someone had forged her signature on a controlled drug record (an official, documented account of a controlled substance's handling, including its acquisition, storage, distribution, administration, and disposal, designed to meet the strict regulatory requirements of laws in the United States). 4. UM #16 reviewed the controlled drug records and noted additional concerns. 5. UM #16 asked residents with BIMS of 15 about taking their PRN medications and a total of three residents (names not provided) had reported that they had not asked for or been given their PRN medication. 6. LPN #16 was placed on administrative leave. 7. Pain assessments were completed on all three residents (resident's names not provided). 8. The local Sheriff department was called. E. Record review of the facility's follow-up report submitted to the state agency, dated 08/07/25, revealed the following: 1. On 07/31/25, UM #16 reported there was a discrepancy in documentation for narcotics and documentation was missing from PCC. 2. CMA #16's signature did not match her true signature. 3. LPN #16 was sent for drug testing. 4. Drug test was negative for opioid medication. 5. LPN #16 agency contract was cancelled due to failing to document narcotics. 6. CMA's and nurses were educated regarding drug diversion (the transfer of legally prescribed controlled substances from the individual they were prescribed for to another person for illicit use). 7. Follow-up report did not include the names of other residents identified as being affected by the allegation of misappropriation of narcotic medication. G. Record review of the incidents reported to the state agency, no date, revealed the facility did not report concerns regarding misappropriation of property for R #17 or R #24.

Based on record review and interview, the facility failed to keep residents free from accidents for 3 (R #1, R #2, and R #3) of 3 (R #1, R #2, and R #3) residents sampled for elopement when staff failed to do the following: 1. Recognize the elopement risk for R #1 and R #3. 2. Secure the exit doors and the exterior gates of the facility before and after R #1, R #2 and R #3 eloped on 04/20/25 and 04/22/25. These deficient practices resulted in multiple elopements/attempted elopements: 1. R #2 eloped on 04/20/25, 2. R #3 eloped on 04/22/25 with R #1, 3. R #1 eloped on 04/22/25 with R #3, attempted to elope on morning of 04/24/25, and eloped on afternoon of 04/24/25 which resulted in R #1 being missing for approximately 30 hours and being hospitalized for four days in the Intensive Care Unit for emergency dialysis, dehydration, and sunburn as a result of the elopement on 04/24/25 through 04/25/24. The findings are: R #2 elopement on 04/20/25 A. Record review of R #2's medical record revealed R #2 had the following diagnoses: 1. Dementia (impairment of at least two brain functions, such as memory loss and judgment), and 2. Muscle weakness. B. Record review of the facility's incident report dated 04/21/25, revealed that R #2 eloped from the facility on 04/20/25 at 11:30 AM. R #2 was found located outside the facility in the south parking lot area (on 04/20/25). The incident report stated that R #2 left through a dining room door. The lock on the dining room door was not functioning properly. C. Record review of R #2's elopement evaluation dated 04/09/25, revealed Score value of 1 or higher indicates a Risk of Elopement. R #2 scored the following on her elopement evaluation: 1. R #2 had a history of elopement or attempts to leave the facility. 2. R #2 verbally expressed the desire to go home. 3. R #2 wandering behavior was a pattern and goal directed (i.e. specific destination in mind, going home etc.). 4. R #2 wandering behavior is likely to affect the safety or well-being of self /others. 5. R #2 Resident's wandering behavior likely to affect the privacy of others. 6. Staff did not document focus, goals, or interventions check boxes. 7. Staff did not document Clinical suggestions check boxes. D. On 05/09/25 at 12:31 PM, during an interview, CNA #1 stated that R #2 always told him she wanted to go home. CNA #1 stated that R #2 would wait for the front door to open, and R #2 would try to get out. CNA #1 stated that R #2 would also follow people out of the front door if they weren't paying attention. CNA #1 stated that even the Administrator had to direct R #2 back into the facility after R #2 had walked out the door following someone. (CNA #1 was not specific about a date) E. On 05/09/25 at 12:35 PM, during an interview with LPN #1, she stated that staff knew R #2 was an elopement risk. LPN #1 stated that she would be sitting at the nurse's station, and she would see R #2 with her walker heading down the hall towards the door anytime it was opened. LPN #1 stated that they were always reminding people to look out for R #2 when leaving the facility. F. On 05/08/25 at 3:38 PM, during an interview, the Administrator stated that after R #2 was found in the south parking lot area, the Administrator told maintenance to check the doors and gates. The Administrator stated that after R #2 was found in the south parking area, she went out there and determined it to be unsafe for the residents to be out in that area and told staff to lock the gate leading out to that area. G. Record review of a text message dated 04/20/25, revealed the Administrator had sent a text message to the Maintenance Director (MD), telling him that the doors on the [NAME] side into the parking lot were not locking and the gate in the back courtyard was being left unsecured and open, and that it must be secured. H. On 05/08/25 at 3:06 PM, during an interview, MD stated that the south courtyard gate was never locked. MD #1 stated that there was a padlock on the gate, but it was never secured in the locked position. MD #1 stated he would unlock the gate in the morning, and secure the lock, in the locked position at night. MD stated that he secured the gate after instructed to do it by the Administrator. Findings related to elopement on 04/22/25: I. Record review of R #1's medical record revealed R #1 had the following diagnoses: 1. End stage renal failure (kidneys no longer work properly) requiring dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly), 2. Type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy), 3. Congestive heart failure (a serious condition in which the heart doesn't pump blood as efficiently as it should), and 4. Cognitive communication deficiency (attention and concentration difficulties). J. Record review of R #3's medical record revealed R #3 had the following diagnoses: 1. Dementia, 2. Mild cognitive impairment (condition in which people have more memory or thinking problems than other people their age), 3. Muscle weakness, 4. Post Traumatic Stress Disorder (a mental health condition that's caused by an extremely stressful or terrifying event), and 5. Schizophenia (a disorder that affects a person's ability to think, feel, and behave clearly). K. On 05/08/25 at 3:00 PM, during an interview, Maintenance Assistant (MA) #2 stated that on 04/22/25 at 6:30 PM, he found R #1 and R #3 in the facility's south parking lot area. MA #2 stated that he told Unit Manager (UM) #1 about R #1 and R #3. MA #2 stated that he checked all the doors and gates and that everything was locked except for the south courtyard gate after he found R #1 and R #3. L. On 05/08/25 at 3:12 PM, during an interview, CNA #2 stated that on 04/23/25, during morning report, staff were told that R #1 and R #3 were found on 04/22/25 in the facility's south parking lot. M. On 05/08/25 at 3:17 PM, during an interview, R #3 stated that he and R #1 went out of the back gate one day. R #3 stated that R #1 wanted him to leave with her. R #3 stated that staff came out and got them and took them back into the facility. N. On 05/12/25 at 10:30 AM, during an interview, MA #2 stated that R #1 and R #3 left through the south court yard entered the physical therapy area and out the door (this contradicts MA #2's previous statement Finding K). He found R #1 and R #3 in the south parking lot. O. Record review of R #1's medical record revealed staff did not document an updated elopement assessment after R #1 eloped on 04/22/25. P. Record review of R #1's elopement evaluations revealed Score value of 1 or higher indicates Risk of Elopement. R #1 scored the following on her elopement evaluations: 1. On 10/22/24, staff scored R #1 as resident expressed the desire to go home. 2. On 01/26/25, staff scored R #1 as resident has a history of elopement or attempt of leaving the facility. Q. Record review of R #3's elopement evaluation revealed Score value of 1 or higher indicates Risk of Elopement. R #3 scored the following on her elopement evaluation: 1. On 05/04/25, staff documented that R #3 was not an elopement risk. 2. On 05/09/25, staff documented that R #3 wanders. a. Staff did not document that R #3 had eloped on 04/22/25. R. On 05/08/25 at 3:38 PM, during an interview, the Administrator stated she was aware that R #1 and R #3 were found out by the dumpsters in the facility's south parking lot on 04/22/25. The Administrator stated that R #1 and R #3 got out through the back gate through the corridor. The Administrator stated that R #1 and R #3 were escorted back into the facility by staff. The Administrator stated she did not know if an elopement assessments were done for R #1 and R #3 after that incident. Findings related to elopement on 04/24/25: S. On 05/08/25 at 2:31 PM, during an interview, MA #1 stated that on 04/24/25, earlier in the morning, R #1 walked out of the facility's south courtyard gate that was unlocked. MA #1 stated that he escorted R #1 back into the gated area when he found her. MA #1 stated that he immediately told the staff on the east unit that R #1 had gone out of the gate. T. Record review of the facility's incident report dated 04/24/25, revealed R #1 eloped from the facility on 04/24/25 at 12:30 PM. R #1 was not found until 04/25/25 at 6:30 PM (The facility's incident report did not detail where R #1 was found or in what condition). U. On 05/07/25 at 11:06 during an interview, R #1 stated that on 04/24/25, she walked out the South courtyard back gate (that was unsecured) of the facility because she didn't want to be there anymore. R #1 stated that she was going back to the facility she was at before. R #1 couldn't remember the name of the facility. R #1 stated that she was out of the facility over night. R #1 stated that she didn't know where to go, so she stayed in the ditch until someone found her (R #1 did not indicate how she got in the ditch). R #1 confirmed that she was unable to get herself out of the ditch. V. On 05/07/25 at 11:26 PM, during an interview, CMA #3 stated that he noticed R #1 was missing when he did med pass at 12:00 PM. CMA #3 stated that when he could not find R #1, that he and staff walked around the facility (on 04/24/25, CMA #3 was not specific about the time). CMA #1 stated that after a search of the facility that everyone was alerted that R #1 was missing from the facility. W. On 05/07/205 at 11:31 AM, during an interview, CNA #1 stated that she had noticed during lunch that R #1 was not in the dining room (on 04/24/25. R #1 was not specific about the time). CNA #1 took R #1's meal to her room. CNA #1 stated that when she went to go pick up the tray, she noticed R #1 did not eat. CNA #1 stated that she went back to the nurses station to inform the nurse about R #1, she learned that no one had seen R #1. CNA #1 stated that is when she and other staff began to look for R #1. CNA #1 stated they searched the facility and the facility grounds. X. On 05/07/25 at 11:51 AM, during an interview, the Business Office Manager (BOM) stated the following: 1. R #1 went missing around 1:00 PM on 04/24/25. 2. The facility alerted all staff that R #1 was missing. 3. Staff began walking around the facility and the BOM and Administrator got in their cars and drove the surrounding area to search for R #1 (the BOM was not specific about the time). 4. Law enforcement (LE) was called around 1:30 PM. 5. LE searched with [NAME] and did not locate the resident on 04/24/25. 6. LE left for the evening. 7. On the morning of 04/25/25, LE came back to the facility and continued their investigation. 8. Search and Rescue was called to help search for R #1 at approximately 5:00 PM (on 04/25/25). 9. R #1 was found in a ditch at 6:00 PM (approximately 30 hours missing). 10. R #1 was transferred to the hospital. Y. On 05/08/25 at 3:38 PM, during an interview, the Administrator confirmed that R #1 had dialysis scheduled on Mondays, Wednesdays, and Fridays. R #1 had missed her dialysis treatment on Wednesday, 04/23/25 because R #1's transportation did not show up to take her that day. The Administrator also confirmed that because R #1 was still missing on Friday, 04/25/25 and R #1 had missed dialysis that day as well (a total of 2 days). Z. Record review of R #1's medical record, no date revealed R #1 was in the hospital from 04/24/25 through 04/29/25. R #1 was treated for emergency dialysis, dehydration, and sunburned as a result of the elopement. The above findings resulted in an Immediate Jeopardy. The Administrator was notified on 05/09/25 at 11:00 AM. The facility submitted a final plan of removal on 05/09/25 at 5:00 PM. Plan of Removal 5/9/2025 . Identification/Correction All residents have the potential to be affected by this alleged deficient practice . .- A house wide audit of current resident assessments for elopement, was conducted by the nursing team. The Facility IDT (Interdisciplinary team) Team reviewed and identified all residents at risk for elopement, their need for increased supervision as applicable, vigilance in observation for residents at risk making or attempting to elope (including sounding door alarms, and understanding to respond immediately to assess situation and complete a new development risk assessment when that occurs. Orders and care plans reviewed for accuracy to ensure the residents identified at risk have a plan for safety, and complete daily reviews of residents at risk during clinical meetings - House wide head to toe assessments completed 4/30/2025. Any CIC (change in condition) noted or observed a change in condition assessment was completed with provider notification and follow up. - The facility will monitor for CIC fs, all new residents and elopement attempts during clinical meetings to ensure all risks are assessed and appropriate action taken by the facility to ensure resident safety. Orders and care plans will be updated as appropriate. - Facility inspection of exterior doors and gates completed on 4/24/25 and daily thereafter to prevent unauthorized exit. All exterior doors and gates are inspected daily to ensure they remain secure, and gates around the perimeter of property are secured at all times. Magnetic locks were installed to secure all gates automatically once closed. Daily audits by maintenance staff of all doors and gates are being completed and documented as part of the ongoing regular daily maintenance and safety checks of the facility. - The NHA and Maintenance inspected the facility environment immediately, and identified additional areas of risk for elopement including smoking areas, and immediately moved the smoking area to a secure area. - Current residents picture updated and process will implemented to ensure all new admissions have a picture on admission - Market resource clinician re-educated Administrator / Incident commander on 5/9/2025 on the elopement process and procedure searching of grounds, notifying law enforcement and any state agencies, where applicable. Center may also, if appropriate, notify local hospitals, public transportation providers, etc. Provide law enforcement and other search party members a copy of elopement risk identification form. If indicated, center staff will expand search beyond the center and grounds into the extended community. Physical search will not stop until the center is notified or instructed by law enforcement or the resident is found. Systematic Measures - Nursing staff educated on elopement assessment and process: How to identify resident elopement risk upon admission and quarterly. - When and how often to complete and elopement assessment - How to identify level of elopement risk, then care plan elopement risk - What to do when a resident is exit seeking - Reporting to nursing management immediately when a resident is exit seeking for increased assessment and observation - Reporting to management immediately when a resident is missing, exit seeking. - Options for residents who are exit seeking - Educated staff on company Elopement Policy and Procedure - Documentation to be completed after the elopement . CIC . --New elopement assessment . update to care plan - All staff educated on monitoring exit doors upon leaving/entering and waiting 20 seconds at the door to ensure the alarm is rearmed. - All staff educated on all shifts on elopement policy and process as well as changes to be alerted to in residents such as mentation, grief, increased independence etc. - Elopement Binder updated with current residents identified at risk. Completed on 4/25/2025, and ongoing for all new residents or residents with CIC at risk. - Nurse Practice Educator/Designee began education on 4/25/2025 and continued until all staff were educated prior to their next shift. Any staff member on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. - Daily rounding by NHA/Designee to include locks in place and functional. - Daily change in condition audit to include review of progress notes, vitals and behaviors that put residents at risk during morning clinical meetings. Quality Assurance and Monitoring The Director of Nursing/designee will audit all new admissions and 5 current residents weekly to ensure that elopement assessments are accurate and care planned accordingly for 2 months. The NHA/designee will audit locks daily for 4 weeks and then monthly for 2 months or until ongoing compliance is achieved. QAPI (Quality Assurance and Performance Improvement) Committee Review monthly to verify ongoing compliance. DON and/or designee will bring results of audits to QAPI committee for further recommendations based on tracking and trending presented monthly for the next 2 months or until ongoing compliance is achieved. The QAPI committee is overseen by the Administrator . Implementation of the POR was verified onsite. The IJ was lifted on 05/12/25 at 4:44 PM by observations, interviews, and record review. Scope and Severity was reduced to Level 2, E. Implementation was verified through: Observations of the south court yard gates to ensure the gates were closed and secure with electronic locks. Record review of the monitoring of doors, exits, and gates to ensure the doors were secured from 04/24/25 through 05/12/25. Record review of the facility's elopement evaluations audits completed on 05/12/25 to ensure all resident had an accurate and up to date elopement evaluation. R #7 was identified as an elopement risk on 05/12/25. Record review of the residents' care plan and orders for all current residents at risk for elopement were in place. Record review of the house wide head to toe assessments for all residents with CIC dated 04/30/25. Record review of the facility daily clinical meeting notes for facility review of CIC, all new residents, and elopement attempts from 05/05/25 through 05/09/25. Record review of staff elopement training agenda and signature sheets for the education provided to the licensed staff, that included the following: -Elopement assessment and process -When and how often to complete and elopement assessment - How to identify level of elopement risk, then care plan elopement risk - What to do when a resident is exit seeking - Reporting to nursing management immediately when a resident is exit seeking for increased assessment and observation - Reporting to management immediately when a resident is missing, exit seeking. - Options for residents who are exit seeking - Educated staff on company Elopement Policy and Procedure - Documentation to be completed after the elopement . CIC . --New elopement assessment . update to care plan - All staff educated on monitoring exit doors upon leaving/entering and waiting 20 seconds at the door to ensure the alarm is rearmed. Interviews of five nurses (RN #8, RN #9, RN #10, LPN #8, and LPN #9) verified the in-service they received on 04/25/25 and 05/09/25 included the following: -Elopement assessment and process -When and how often to complete and elopement assessment - How to identify level of elopement risk, then care plan elopement risk - What to do when a resident is exit seeking - Reporting to nursing management immediately when a resident is exit seeking for increased assessment and observation - Reporting to management immediately when a resident is missing, exit seeking. - Options for residents who are exit seeking - Educated staff on company Elopement Policy and Procedure - Documentation to be completed after the elopement . CIC . --New elopement assessment . update to care plan - All staff educated on monitoring exit doors upon leaving/entering and waiting 20 seconds at the door to ensure the alarm is rearmed. Interview with the Unit Managers, Administrator and Nursing staff confirm that the the facility has updated the elopement risk binders that are kept on every unit nursing station with current residents identified as elopement risk on 05/12/25. Current Resident pictures were updated in the binders. Record review of the facility elopement risk binders for updated elopement risk residents with pictures.

Recite from 06/20/24 Based on observation, record review, and interview the facility failed to report alleged allegations of abuse to the State Agency for 4 (R #12, R #16, R #94 and R #117) of 5 (R #12, R #16, R #94, R #117 and R #133) residents sampled for abuse, when they failed to; 1. Report R #12's allegation of abuse within 2 hours. 2. Submit R #16's 5 day follow-up report to the state agency within 5 working days. 3. Report R #94's allegation of abuse within 2 hours 4. Report R #117's allegation of abuse within 2 hours If the facility fails to report allegations of abuse and the results of the investigations to the State Survey Agency, then corrective action may not be taken, and residents could likely suffer serious bodily injury. The facility's failure to report witnessed abuse of R #117 by RN #24 likely resulted in RN #24 being able to physically abuse R #94 a few hours later. The findings are: R #12 A. On 09/17/24 at 10:55 AM, during an interview with R #12, the following was stated: 1. About five weeks before the interview, she had fallen twice in the restroom. 2. She fell because CNA #16 told her she was lazy and could do more, so she went to the restroom by herself. 3. She does not want CNA #16 to help her. B. Record review of Abuse Questionnaire (questions the facility staff use to ask residents to determine if they have been abused), dated 08/09/24, revealed that R #12's sister told staff that CNA #16 speaks loudly not because resident is hard of hearing, but it's her tone, it's bossy, not right. C. Record review of Abuse Questionnaire, dated 08/09/24, revealed that R #66 (R #12's roommate) told staff that she does not like CNA #16 because she is mean and doesn't talk nice to R #12. D. Record review of Abuse Questionnaire, dated 08/09/24, revealed that R #5 told staff that CNA #16 was not helpful and bossed her around. E. On 09/25/24 at 3:32 PM, during an interview CNA #17, the following was stated: 1. R #12 is not supposed to transfer by herself. 2. R #12 is selective about which CNAs she will allow to help her. 3. R #12 does not like CNA #16 to help her. 4. R #12 has told him that CNA #16 had called her lazy (was unsure of date). 5. R #12 is more likely to get up without assistance when CNA #16 is working, because she doesn't want CNA #16's help. 6. Several residents have told him that CNA #16 is mean to them and they don't like her. 7. R #73 told him that CNA #16 had called her lazy (was unsure of date). 8. A couple of months prior (unsure of the date) to the interview he told RN #16 and another LPN who is no longer working at the facility about CNA #16 calling the residents lazy. 9. He was unsure what was done after he reported the allegations to the nurses. F. On 09/25/24 at 3:49 PM, during an interview with RN #16, the following was stated: 1. On 08/13/24, R #12 told her that CNA #16 had told her she was lazy and needed to do things for herself. 2. On 08/13/24, RN #16 reported to the DON or ADON what R #12 said of CNA #16 telling R #12 she was lazy. 3. Administration made sure that CNA #16 did not work with R #12 anymore. 4. She had not been notified about any other incidents of CNA #16 telling residents that they were lazy prior to the report by R #12 on 08/13/24 5. She was not aware of any other residents who have had issues with CNA #16. G. On 09/26/24 at 4:14 PM, during an interview with the DON, the following was confirmed: 1. Staff calling a resident lazy would be considered abuse. 2. She became aware of CNA #16 calling R #12 lazy after speaking with R #12's sister after R #12 fell on [DATE]. 3. Prior to speaking with R #12's sister on 08/13/24, she had not been made aware of CNA #16 being rude or calling resident's lazy 4. If she had been made aware of CNA #16 calling resident's lazy prior to 08/13/24, the facility would have reported it to the SA, CNA #16 would have been suspended until her or the administrator completed an investigation. 5. Staff were expected to report any allegations of abuse to their charge nurse, unit manager, DON, or Administrator. 6. The expectation was for any nurse or unit manager who received an allegation of abuse to report it to the DON or Administrator. H. On 09/30/24 at 10:57 AM, during an interview with the Administrator, the following was revealed: 1. She had completed the abuse questionnaires from R #12's sister, R #66, and R #5 on 08/09/24 due to allegation of abuse. 2. She became aware of CNA #16 calling R #12 lazy after R #12's sister called her to report it on 08/13/24. 3. Prior to the report by R #12's sister on 08/13/24, she had not been made aware of CNA #16 calling residents lazy R #16 I. On 09/18/24 at 11:44 AM, during an interview, R #16 stated approximately one month ago (unsure of exact date) his ex-roommate hit him with a cane. R #16 stated that staff intervened during the incident, and his roommate was moved to another room. J. Record review of R #16's progress note dated 09/07/24 at 2:32 PM revealed R #16 and roommate had a physical altercation at approximately 8:45 AM, R #16 was hit in the face and head by roommate On assessment, resident has small area of localized inflammation (swelling to a confined area) to right zygomatic arch (cheek bone) and temple, and small area of tenderness and redness to the bridge of his nose. No open injuries or breaks to the skin . K. Record review of the facility's incident report revealed that the altercation between R #16 and his roommate was reported to the State Survey Agency on 09/07/24 at 10:05 AM. L. Record review of the facility's 5 day follow-up report (no date) revealed that R #16's roommate was moved to another room on 09/07/24 after the incident. The 5 day follow-up report was not sent to the State Survey Agency until 09/18/24 at 1:55 PM. M. On 09/27/24 at 10:35 AM, during an interview with the DON, she confirmed that the 5 day follow-up report for R #16's incident on 09/07/24 was sent to the State Survey Agency on 09/18/24 and was not sent within 5 working days of the incident. R #117 N. Record review of R #117 admission record revealed the following: 1. R #117 was admitted to the facility on [DATE]. 2. R #117 was diagnosed with unspecified psychosis not due to a substance or known physiological condition and other specified disorders of brain. O. On 09/19/24 at 2:56 PM, during an interview with CNA #24 he stated the following: 1. On 09/11/24 at 10 PM, he was walking out the Dementia unit and noticed RN #24 yelling at R #117 in an aggressive tone being confrontational and disrespectful. 2. CNA #24 saw RN #24 drag R #117 off the dining room chair and yelled at her, told her You can't sleep here; you need to go to your room. 3. He reported the incident to the unit manager on 09/12/24. P. On 09/20/24 at 9:52 AM, during an interview with R #117, she stated the following: 1. On multiple occasions RN #24 has hit me on my face, body, and nobody said anything because of repercussions (an unintended consequence occurring some time after an event or action, especially an unwelcome one). 2. She feels that RN #24 has degraded her by telling her she had no value, and she was useless. R #117 did not provide detail of how many times this has happened. 3. She was asleep on the dining room chair and RN #24 pulled her up and told her You will not be falling asleep here and sat her back down. R #117 did not provide further information. Q. Record review of the facility's Abuse Questionnaire to the residents completed by facility staff on 09/24/24 revealed R #117 stated I have a threat from staff, she has not worked a shift with me, it's been addressed, this woman is dangerous [referring to RN #24]. R. On 09/24/24 at 8:34 AM, during an interview with the unit manager, she stated staff did not report the incident with R #117 and she did not know anything about the incident. S. On 09/24/24 at 2:38 PM, during an interview with CNA #24, he stated the following: 1. He reported the incident between R #117 and RN #24 to the unit manager during his shift on 09/12/24 at 2 PM. 2. He was told by the unit manager to complete a written statement, he completed the statement and turned it in to the unit manager on 09/12/24 around 2:30 PM. 3. On 09/12/24 during his 2 PM shift, R #117 told him Last night she (RN #24) dragged me off the chair. R #117 was having behaviors and would not allow staff to provide care telling them I don't trust you all on 09/12/24. R #94 T. Record review of R #94's admission record revealed the following: 1. R #94 was admitted to the facility on [DATE]. 2. R #94 was diagnosed with unspecified Dementia (diagnosis given a person has dementia but it can't be classified as a specific type) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. U. Record review of R #94's nursing progress notes revealed the following: 1. On 9/12/2024 at 6:36 AM, note written by RN #24 stated [Name of R #94] became very agitated while being changed, hitting, scratching, kicking, and trying to bite staff, very combative and yelling that we were trying to kill her. She had pulled off her nasal cannula and became more combative while staff put it back in place thrashing her head back and forth and screaming. She sustained skin tears to both hands and one on her left wrist. Skin tears cleaned and dressed with her resisting care and trying to tear the dressings back off. 2. According to nurse's progress note written by RN #24 revealed no other staff was present at time of the incident. 3. On 09/12/24 at 1:11 PM, note written by LPN #24 stated, during morning report, night nurse reported [Name of R #94] was being combative during brief change and [Name of R #94] had obtained skin tears to bilateral (both) hands and left wrist. [Name of R #94] was medicated with as needed medications for pain and anxiety by night nurse. [Name of R #94] slept through breakfast. CNA went to get [Name of R #94] up for lunch and noted large bruise to right side of face and reported to nurse. [Name of R #94] was assessed for further injuries and noted to bruises to right calf. Skin tears cleansed and wrapped and covered with gauze. Medicated [Name of R #94] with morphine as needed. Called Power of Attorney (POA) and notified of change in condition, called Hospice twice and no response. Notified physician about change in condition. 4. Staff did not document any other progress notes in the previous months of R #94 being combative with any staff except for RN #24 on 09/12/24 during brief change. V. On 09/19/24 at 12:42 PM, during an interview with R #94's Power of Attorney (POA) she stated the following: 1. Family Member (FM) was informed by LPN #24, that R #94 was hitting and biting. 2. R #94 obtained some small cuts on her hands. 3. R #94 obtained a small bruise on her cheek. W. On 09/19/24 at 12:51 PM, during an interview with R #94's FM, the following was stated: 1. POA notified FM (unknown date) R #94 was combative during brief change and asked him to check on R #94. 2. The bruise and the scratches were not small at all and looked big. 3. R #94 had a bruise to her face and to her neck. X. On 09/19/24 at 2:47 PM, during an observation of R #94 the following was revealed: 1. R #94's index finger and middle finger on her left hand had a two-inch cut and an abrasion (a superficial injury to the skin or other body tissue caused by rubbing or scraping). 2. R #94's right hand had a cut between the thumb and the index finger in a U shape. 3. R #94's right cheek and right side of her neck had a purplish and green bruise about two inches in width and five inches in length. Y. On 09/20/24 at 9:21 AM, during an interview with LPN #24, she stated the following: 1. On 09/12/24, LPN #24 came onto her shift from 6 AM to 2 PM. 2. During shift change meeting approximately between 6 AM and 6:30 AM, RN #24 informed her R #94 became combative during brief change. 3. R #94 obtained skin tears to both of her left and right hand (bilateral). 4. RN #24 medicated R #94 with morphine and lorazepam and dressed her wounds. 5. R #94 slept through breakfast and was checked on by a CNA. 6. The CNA saw the bruises and injuries on R #94, and she (LPN #24) assessed R #94 and reported the incident to the unit manager, the administrator and the DON on 09/12/24 at 12:15 PM. Z. On 09/20/24 at 10:42 AM, during an interview with CNA #25 she stated the following: 1. On 09/12/24 (between 5:00 am-6:00 am), CNA #25 was told by RN #24 hurry up and get in here in R #94 room. 2. CNA #25 walked into R #94's room and saw blood everywhere; bed sheets, shirt and floor and on RN #24 hands and upper arms. 3. CNA #25 asked RN #24 what happened and was told by RN #24 I have to do wound care on her and RN #24 did not provide more information. 4. RN #24 and herself CNA #25 worked the night shift when incident happened. 5. CNA #25 did not report what she observed to anyone. AA. On 09/24/24 at 8:34 AM, during an interview with the unit manager, she stated when LPN #24 reported the incident, she instructed LPN #24 to contact the administrator and start a report for R #94 [she did not elaborate on time frames or follow up]. BB. Record review of the facility's Abuse Questionnaire to the residents completed by facility staff on 09/24/24 revealed R #51 stated the tall nurse at night hurt my roommate (R #94), she caused the blue on her arms, she did that. I forgot to tell. The above findings resulted in an Immediate Jeopardy that was called on 09/24/24 at 5:48 PM The facility submitted a final plan of removal on 09/25/24 and implementation was verified onsite. Plan of Removal .The following identification/corrections will be completed by 09/25/24: -A full abuse investigation will occur within the facility with staff, residents and families of those who are unable to speak for themselves to ensure no other residents have witnessed abuse or been abused. Descriptors of abuse will be updated on the Facility Abuse Questionnaires to include simplified examples of abuse as needed, so that residents understand or are able to answer questions. -If any further potential abuse, neglect, exploitation, or mistreatment are brought forward the facility will immediately remove the resident from the situation, and ensure they are safe, and reportable filed with the state. If a staff member is identified as the alleged perpetrator, they will be suspended immediately, pending a thorough investigation. -A quiz will be given to all staff members after education to ensure the abuse process is retained. The quiz will include who the staff notifies upon alleged abuse identification (the abuse coordinator or DON), and when they notify (immediately). -Staff will be provided the corporate compliance telephone number to anonymously report allegations or suspected abuse if they are afraid to report to the abuse coordinator or DON. -An audit of current memory care residents' skin will occur to ensure that there are no unidentified signs of injury or abuse. If any concerns are noted, the change in condition process will be followed and notifications to the provider, family and abuse coordinator will occur to ensure monitoring occurs. A report to the state agency will occur as necessary . 49313 50497

Based on interview and record review, the facility failed to keep residents free from abuse for 3 (R #12, R #94, R #117) of 3 (R #12, R #94, and R #117) residents sampled for abuse when staff failed to: 1. Prevent staff from being verbally abusive to R #12. 2. Prevent R #94 from being physically abused, which caused injuries to R #94 face, neck, and hands. 3. Prevent R #117 from being fearful of staff who provide care. These deficient practices likely resulted in physical harm to the residents and psychosocial distress (unpleasant emotions associated with a highly stressful situation). The findings are: R #12 A. On 09/17/24 at 10:55 AM, during an interview with R #12, the following was stated: 1. About five weeks before the interview, she had fallen twice in the restroom. 2. R #12 fell because CNA #16 told her she was lazy and can do more, so R #12 went to the restroom by herself. 3. R #12 does not want CNA #16 to help her. B. Record review of Abuse Questionnaire (questions the facility staff use to ask residents to determine if they have been abused), dated 08/09/24, revealed R #12's sister told staff that [Name of CNA #16] speaks loudly not because resident is hard of hearing, but it's her tone, it's bossy, not right. C. Record review of Abuse Questionnaire, dated 08/09/24, revealed that R #66 (R #12's roommate) told staff that she does not like CNA #16 because she is mean and doesn't talk nice to R #12. D. Record review of the Complaint Narrative Investigation Follow-Up Report (5-day), dated 08/21/24, revealed the following: 1. The facility investigation determined that CNA #16 told R #12 that she was lazy because the resident stated she could not stand. 2. CNA #16 was attempting to encourage the resident to do as much for herself as possible. 3. CNA #16 has a direct, loud approach which seems bossy to the residents. 4. The facility substantiated that there was verbal abuse by CNA #16. E. On 09/25/24 at 3:32 PM, during an interview with CNA #17, the following was revealed: 1. R #12 is not supposed to transfer by herself. 2. R #12 is selective about which CNAs she will allow to help her. 3. R #12 does not like CNA #16 helping her. 4. R #12 has told him that CNA #16 had called her lazy (was unsure of date). 5. R #12 is more likely to get up without assistance when CNA #16 is working because she doesn't want CNA #16's help. 6. Several residents have told him that CNA #16 is mean to them and they don't like her. 7. A couple of months prior to the interview (he was unsure of the date) he told RN #16 and another LPN who no longer worked at the facility about CNA #16 calling the residents lazy 8. He was unsure what was done after he reported the allegations to the nurses. F. On 09/25/24 at 3:49 PM, during an interview with RN #16, the following was stated: 1. On 08/13/24, R #12 told her CNA #16 had told her she was lazy and needed to do things for herself. 2. On 08/13/24, RN #16 reported to the DON or ADON what R #12 said of CNA #16 telling R #12 she was lazy. 3. Administration made sure that CNA #16 does not work with R #12 anymore. 4. She had not been notified about any other incidents of CNA #16 telling residents that they were lazy prior to the report by R #12 on 08/13/24 5. She was not aware of any other residents who have had issues with CNA #16. G. On 09/26/24 at 1:24 PM, during an interview with R #66 (R #12's roommate), she stated CNA #16 is rude and she heard CNA #16 call R #12 lazy (resident was unsure of the dates). H. On 09/26/24 at 4:14 PM, during an interview with the DON, the following was confirmed: 1. Staff calling a resident lazy would be considered abuse. 2. She became aware of CNA #16 calling R #12 lazy after speaking with R #12's sister and after R #12 fell on [DATE]. 3. Prior to speaking with R #12's sister on 08/13/24, she had not been made aware of CNA #16 being rude or calling residents lazy 4. After the complaint from R #12's sister, she completed a training with CNA #16 on what verbal abuse looks like and being more approachable. I. On 09/30/24 at 10:57 AM, during an interview with the Administrator, the following was stated: 1. She completed the abuse questionnaires from R #12's sister. 2. She complete the abuse questionnaires from R #66 on 08/09/24 (prior to the complaint from R #12's sister on 08/13/24). 2. She became aware of CNA #16 calling R #12 lazy after R #12's sister called her to report it on 08/13/24. 3. She was not aware of any concerns about CNA #16 prior to the complaint made by R #12's sister on 08/13/24. R #117 J. Record review of R #117 admission record revealed the following: 1. R #117 was admitted to the facility on [DATE]. 2. R #117 was diagnosed with unspecified psychosis not due to a substance or known physiological condition and other specified disorders of brain. K. On 09/19/24 at 2:56 PM, during an interview with CNA #24, he stated the following: 1. On 09/11/24 at 10 PM, he was walking out the Dementia unit and noticed RN #24 yelling at R #117 in an aggressive tone being confrontational and disrespectful. 2. CNA #24 saw RN #24 dragged R #117 off the dining room chair and yelled at her, told her You can't sleep here; you need to go to your room. 3. He reported the incident to the unit manager on 09/12/24. L. On 09/20/24 at 9:52 AM, during an interview with R #117, she stated the following: 1. On multiple occasions RN #24 has hit me on my face, body, and nobody said anything because of repercussions (an unintended consequence occurring some time after an event or action, especially an unwelcome one). 2. She feels that RN #24 degraded her by telling her she had no value, and she was useless. R #117 did not provide detail of how many times this has happened. 3. She was asleep on the dining room chair and RN #24 pulled her up and told her You will not be falling asleep here and sat her back down. R #117 did not provide further information. M. Record review of the facility's Abuse Questionnaire to the residents completed by facility staff on 09/24/24 revealed R #117 stated I have a threat from staff, she has not worked a shift with me, it's been addressed, this woman is dangerous [referring to RN #24]. N. On 09/24/24 at 8:34 AM, during an interview with the unit manager, she stated staff did not report the incident with R #117 and she did not know anything about the incident. O. On 09/24/24 at 2:38 PM, during an interview with CNA #24, he stated the following: 1. He reported the incident between R #117 and RN #24 to the unit manager during his shift on 09/12/24 at 2 PM. 2. He was told by the unit manager to complete a written statement, he completed the statement, and turned it in to the unit manager on 09/12/24 around 2:30 PM. 3. On 09/12/24 during his 2 PM shift, R #117 told him Last night she (RN #24) dragged me off the chair. R #117 was having behaviors and would not allow staff to provide care telling them I don't trust you all on 09/12/24. R #94 P. Record review of R #94's admission record revealed the following: 1. R #94 was admitted to the facility on [DATE]. 2. R #94 was diagnosed with unspecified Dementia (diagnosis given a person has dementia but it can't be classified as a specific type) unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. Q. Record review of R #94's nursing progress notes revealed the following: 1. On 9/12/2024 at 6:36 AM, note written by RN #24 stated [Name of R #94] became very agitated while being changed, hitting, scratching, kicking, and trying to bite staff, very combative and yelling that we were trying to kill her. She had pulled off her nasal cannula and became more combative while staff put it back in place thrashing her head back and forth and screaming. She sustained skin tears to both hands and one on her left wrist. Skin tears cleaned and dressed with her resisting care and trying to tear the dressings back off. 2. According to nurse's progress note written by RN #24 revealed no other staff was present at time of the incident. 3. On 09/12/24 at 1:11 PM, note written by LPN #24 stated, during morning report, night nurse reported [Name of R #94] was being combative during brief change and [Name of R #94] had obtained skin tears to bilateral (both) hands and left wrist. [Name of R #94] was medicated with as needed medications for pain and anxiety by night nurse. [Name of R #94] slept through breakfast. CNA went to get [Name of R #94] up for lunch and noted large bruise to right side of face and reported to nurse. [Name of R #94] was assessed for further injuries and noted to bruises to right calf. Skin tears cleansed and wrapped and covered with gauze. Medicated [Name of R #94] with morphine as needed. Called Power of Attorney (POA) and notified of change in condition, called Hospice twice and no response. Notified physician about change in condition. 4. Staff did not document any other progress notes in the previous months of R #94 being combative with any staff except for RN #24 on 09/12/24 during brief change. R. On 09/19/24 at 12:42 PM, during an interview with R #94's Power of Attorney (POA) she stated the following: 1. Family Member (FM) was informed by LPN #24, that R #94 was hitting and biting. 2. R #94 obtained some small cuts on her hands. 3. R #94 obtained a small bruise on her cheek. S. On 09/19/24 at 12:51 PM, during an interview with R #94's FM, the following was stated: 1. POA notified FM (unknown date) R #94 was combative during brief change and asked him to check on R #94. 2. The bruise and the scratches were not small at all and looked big. 3. R #94 had a bruise to her face and to her neck. T. On 09/19/24 at 2:47 PM, during an observation of R #94 the following was revealed: 1. R #94's index finger and middle finger on her left hand had a two-inch cut and an abrasion (a superficial injury to the skin or other body tissue caused by rubbing or scraping). 2. R #94's right hand had a cut between the thumb and the index finger in a U shape. 3. R #94's right cheek and right side of her neck had a purplish and green bruise about two inches in width and five inches in length. U. On 09/20/24 at 9:21 AM, during an interview with LPN #24 she stated the following: 1. On 09/12/24 she came into her shift from 6 AM to 2 PM. 2. During shift change approximately between 6 AM and 6:30 AM, RN #24 informed her R #94 became combative during brief change. 3. R #94 obtained skin tears to both of her left and right hand (bilateral). 4. RN #24 medicated R #94 with morphine and lorazepam and dressed her wounds. 5. R #94 slept through breakfast and was checked on by a CNA. 6. The CNA saw the bruises and injuries on R #94, and she (LPN #24) assessed R #94 and reported the incident to the unit manager, the administrator and the DON on 09/12/24 at 12:15 PM. V. On 09/20/24 at 10:42 AM, during an interview with CNA #25 she stated the following: 1. On 09/12/24 (between 5:00 am-6:00 am), CNA #25 was told by RN #24 hurry up and get in here in R #94 room. 2. CNA #25 walked into R #94's room and saw blood everywhere; bed sheets, shirt and floor and on RN #24 hands and upper arms. 3. CNA #25 asked RN #24 what happened and was told by RN #24 I have to do wound care on her and RN #24 did not provide more information. 4. RN #24 and herself CNA #25 worked the night shift when incident happened. 5. CNA #25 did not report what she observed to anyone. W. On 09/24/24 at 8:34 AM, during an interview with the unit manager, she stated when LPN #24 reported the incident to the unit manager, she instructed LPN #24 to contact the administrator and start a report for R #94 [she did not elaborate on time frames or follow up]. X. Record review of the facility's Abuse Questionnaire to the residents completed by facility staff on 09/24/24 revealed R #51 stated the tall nurse at night hurt my roommate (R #94), she caused the blue on her arms, she did that. I forgot to tell. The above findings resulted in an Immediate Jeopardy that was called on 10/28/24 at 6:15 PM The facility submitted a final plan of removal on 10/28/24 at 6:39 PM which replicated effort previously made and verified for the F609 IJ on 09/25/24. Plan of Removal .The following identification/corrections will be completed by 09/25/24: -A full abuse investigation will occur within the facility with staff, residents and families of those who are unable to speak for themselves to ensure no other residents have witnessed abuse or been abused. Descriptors of abuse will be updated on the Facility Abuse Questionnaires to include simplified examples of abuse as needed, so that residents understand or are able to answer questions. -If any further potential abuse, neglect, exploitation, or mistreatment are brought forward the facility will immediately remove the resident from the situation, and ensure they are safe, and reportable filed with the state. If a staff member is identified as the alleged perpetrator, they will be suspended immediately, pending a thorough investigation. -A quiz will be given to all staff members after education to ensure the abuse process is retained. The quiz will include who the staff notifies upon alleged abuse identification (the abuse coordinator or DON), and when they notify (immediately). -Staff will be provided the corporate compliance telephone number to anonymously report allegations or suspected abuse if they are afraid to report to the abuse coordinator or DON. -An audit of current memory care residents' skin will occur to ensure that there are no unidentified signs of injury or abuse. If any concerns are noted, the change in condition process will be followed and notifications to the provider, family and abuse coordinator will occur to ensure monitoring occurs. A report to the state agency will occur as necessary. -The nurse in question was placed on Administrative leave at 10:30 am on September 12, 2024 and was not permitted back on site. She was terminated on September 16th after the investigation was complete . 50497

Based on observation, interview, and record review, the facility failed to keep residents free from accident hazards for 7 (R #6, R #30, R #70, R #80, R #109, R #136, and R #137) of 7 (R #6, R #30, R #70, R #80, R #109, R #136, and R #137) residents on the 700 unit who had poor safety awareness due to dementia or low cognition as measured by their Brief Interview for Mental Status (BIMS a test for cognition) score, when they failed to protect residents from unsafe water temperatures. This deficient practice could likely cause a third degree burns for all 7 residents who had access to this hot water. The findings are: A. Record review of a list of residents with a diagnosis of Dementia on the 700 Unit provided by the DON no date revealed R #30, R #70, R #80, and R #136 noted to have a diagnosis of Dementia. B. Record review of a list of residents with BIMS score (A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment) on the 700 Unit provided by the DON no date revealed the following: 1) R #6 BIMS 12 2) R #30 BIMS 06, 3) R #70 BIMS 04, 4) R #80 BIMS 00, 5) R #109 BIMS 06, 6) R #136 BIMS 06, and 7) R #137 BIMS 08. C. On 02/24/23 at 1:45 PM, during an interview LPN #18 revealed the following: 1. R #6 has poor safety awareness. 2. R #30, R #70, R #80, and R #136 are cognitively impaired and would not understand something that could cause them harm. D. On 02/24/23 at 11:31 AM, during an observation of the 700 unit revealed the following: 1. room [ROOM NUMBER] water from the sink was extremely hot to touch instantly 2. room [ROOM NUMBER] water from the sink was extremely hot to touch instantly 3. room [ROOM NUMBER] water from the sink was extremely hot to touch instantly E. On 2/24/23 at 12:04, during an observation of the 700 unit and interview with the Maintenance Director (MD) revealed the following: 1. room [ROOM NUMBER] water from the sink was 131.7* F. 2. room [ROOM NUMBER] water from the sink was 140* F. 3. Shower room on 700 unit 131.3* F. F. On 02/24/23 at 12:54 PM, during an observation of the 700 unit water heater and interview MD revealed water heater access doors are located outside of the building. The MD confirmed that the facility did not have a way to secure the access door to the water heater. The MD confirmed that they had no key for the access door. The hot water tank thermometer was reading 140* F. The MD stated We don't know who is turning it up. I would never turn it up that high. The MD confirmed that the facility had a problem with another water heater that someone was messing with. The MD confirmed that they had to put a padlock on that water heater access door but had not locked this water heater. The above findings resulted in an Immediate Jeopardy that was called on 02/24/23 at 2:17 PM. A final Plan of Removal was submitted and approved on 02/24/23 at 3:42 PM. Plan of Removal Water heater temperature was immediately adjusted, and temperature of rooms were immediately assessed. Hot water heater was drained, and lines flushed for entire 700 unit. Water was brought back up to temp . System Change: a. Hot water heater room has been secured by a new double lock system. b. Door is going to be checked daily for security and any deficient practice will be corrected immediately. c. Hot water heater room temperature checks will be conducted daily by maintenance person or designee to maintain at regulation of 110 degrees. d. Seven (7) resident rooms down each hall/unit and shower room will have water temperature checked and logged daily by maintenance person or designee. e. Doors on water heater rooms will be checked for security, daily by maintenance person or designee . The facility was verified to have fully implemented this approved plan of removal on 02/27/23 by: 1. Purging (empty) the hot water heater, 2. Securing the access door to the water heater for the 700 Unit with 2 locks, and 3. Monitoring hot water temperatures and access door being secured. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on 02/24/23 and scope and severity was lowered to E. 38148 47510

Based on observation, interview, and record review, the facility failed to ensure that a resident with Pressure Ulcers (an injury to the skin and underlying tissue, caused by prolonged pressure on the skin) received the necessary treatment and services, consistent with professional standards of practice for 1 (R #1) of 3 (R #1, R #2, and R #3) residents reviewed for Pressure Ulcers, when they failed to: 1) Initiate wound care order for R #1's pressure wound upon admission to the facility, 2) Start antibiotic treatment (treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 3) Provide documentation consistently in accordance with wound care orders for R #1's pressure wound , 4) Initiate a wound vac (vacuum-assisted closure of a wound, a type of therapy to help wound heal) for R #1's pressure wound per Physician request, 5) Obtain weekly wound assessment and measurements for R #1's pressure wound, and 6) Place the R #1 under contact precautions for [CONDITION(S)] ([CONDITION(S)] infection caused by bacteria that are resistant to commonly used antibiotics. Very infectious organism that requires contact precautions) . This deficient practice has likely caused R #1 wound to became infected and not healed and ultimately result in amputation (limb loss) at level between knee and ankle to the right lower leg. The findings are: Wound Orders A. Record review of R #1's Convalescent Order (orders from previous facility that R #1 came from) revealed: 1. 07/21/20 Wound care to right heel trauma. Soak 4x4's with Dakins's solution (use to prevent and treat skin and tissue infection) and let sit 15 minutes before placing new wound vac then cleanse with NS (normal saline), apply black foam, drape (cloth) and wound vac . B. Record review of R #1's medical record indicate the following: 1. R #1 was admitted to the facility on [DATE] as a transfer from sister facility. 2. R #1's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . C. Record review of Nursing Documentation V6 (nursing assessment) 08/03/20 revealed the reason for admission wound care to right heel pressure wound. D. Record review of R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 08/03/20 monitor wound site daily for status of surrounding tissue and wound pain (no wound care orders documented until 08/08/20). 2. 08/08/20 Dakins (1/4 strength) solution 0.125% (sodium Hypochlorite)( to prevent and treat skin and tissue infections), apply to R (right) foot wound(s) topically (to skin) every day and evening shift. (first wound care order). 3. 09/17/20 wound care to right plantar (long, thin ligament directly beneath the skin on the bottom of foot) heel/foot pressure wound 1 time a day every Monday, Wednesday, and Friday. Antibiotic Treatment/Isolation precaution E. Record review of physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 08/06/20 Wound culture (is a laboratory test in which microorganisms from a wound are grown in a special growth medium. It is done to find and identify the microorganism causing an infection in a wound or an abscess) of right heel wound . (prior to 1st wound care order). 2. 08/07/20 Wound Culture . completed. F. Record review of R #1's Lab Results Report dated 08/12/20 revealed: Heavy Growth of Pseudomonas aeruginosa (is a type of bacteria (germ) that is found commonly in the environment, like in soil and in water) isolated and Moderate Growth of [CONDITION(S)] isolated. G. Record review of R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. 08/13/20 [MEDICATION(S)] (type of antibiotics) Tablet 800-160 MG. Give one tab orally two times a day for Pseudomonas and [CONDITION(S)] in right plantar foot wound for 10 days. 2. 08/13/20 [MEDICATION(S)] Solution Reconstituted (type of antibiotics) . every 6 hours for pseudomonas and [CONDITION(S)] in right plantar foot wound for 10 Days . 3. Record review of R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . H. Record review of R #1's Medication Administration Records revealed: 1. 08/14/20 start date of antibiotic therapy [MEDICATION(S)] and [MEDICATION(S)] Solution . I. Record review of Infectious Disease Management policy dated 11/15/20 revealed: Patients who have evidence of an infectious disease will be treated according to physician/provider and current guidelines. All suspect or diagnosed cases will be reported to the infection preventionist or designee. Wound Care J. Record review of Treatment Administration Report (TAR) for month of August 2020 and September 2020 revealed : 08/08/20 Dakins (1/4 strength) solution 0.125% (sodium Hypochlorite), apply to R foot wound(s) topically (to skin) every day and evening shift. 1. Wound treatment was performed eight times during month of August on the following dates and times: 6 am-2 pm: 08/09/20, 08/10/20, 08/11/20, 08/12/20, and 08/22/20. 6 pm-6 am: 08/08/20, 08/11/20, and 08/12/20. 2. Wound treatment was performed thirteen times during month of September on the following dates and times: 6 am-2 pm: 09/10/20, 09/11/20, 09/13/20, 09/14/20,09/15/20, 09/16/20, and 09/17/20. 6 pm-6 am: 09/10/20, 09/11/20, 09/12/20, 09/14/20, 09/15/20, and 09/16/20. K. On 09/22/21 at 2:55 pm, during an interview with the DON, she confirmed that there was missing documentation for R #1's right heel pressure wound. Wound Measurement L. Record review of progress notes (wound measurement) revealed the following: 1. 08/04/20 wound measurement - right heel surgical site, 12 x 4 x 0.2 cm. 2. 08/12/20 wound measurement - right plantar heel/foot surgical site 11.5 x 5 x 0.2 cm. 3. 09/04/20 wound measurement - right plantar foot surgical site 9 x 5 x 0.2 cm. 4. No other documentation was found for wound measurements. M. Record review of Skin Integrity Management policy dated 12/20/19 revealed: 1. Perform skin inspection on admission/readmission and weekly. Document on treatment administration record (TAR) or in [name of electronic medical records]. 2. Perform wound observations and measurements and complete Skin Integrity Report upon initial identification of altered skin integrity, weekly and with anticipated decline of wound. Wound Vac N. Record review of R #1's Progress Notes revealed the following: 1. 08/12/20 Wound to right foot patient is going to continue with treatment and be followed closely by wound care nurse who is going to put wound VAC back on and change Monday, Wednesday, Friday patient is waiting to see [ name of doctor] before getting wrapped to help with fluid retention. 2. 08/17/20 first documentation of R #1 wound vac (before order in place). O. Record review of R #1's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (first order for wound vac) P. Record review of R #1's Care Plan date 08/04/20 revealed : DTI (Deep Tissue Injury: injury to the underlying tissue bellow the skin surface and not an open wound) pressure ulcer. Location: right heel. Care plan was not updated to show the on going status of the wound when it became open from DTI and the wound vac was not care planned. Q. Record review of R #1 Progress Notes revealed the following: 1. 10/06/20 R #1 sent to local hospital. 2. 10/21/20 R #1 returned from hospital with right lower leg amputation. R. On 09/22/21 at 2:55 pm, during an interview with the DON, she stated I was not here during that time, I did not look at the wound, but I believe if resident would start the antibiotic and wound vac sooner, she could benefit from that. The DON confirmed that the wound was not measured weekly per care plan and facility policy. The DON also confirmed facility should have placed R #1 under contact precautions per culture results of [CONDITION(S)] and they failed to to that. The DON also confirmed they failed to document wound care regularly per order. The DON continued to state It was a delay from the day of admission and start of the wound care, I cannot confirm if that could contribute to the amputation or not. S. On 09/23/21 at 9:44 am, during an interview with the Nurse Practitioner (NP), she was asked about R #1 pressure wounds and the care she received during her stay at this facility. The NP stated This resident came in very sick, she had multiple health issues. We were trying to focus on what to solve because it was so many different illnesses. I didn't start the antibiotics because I did not have the result of the culture. Resident admitted with wound care orders, her admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The NP was asked about R #1's wound vac, she stated I have no idea why it was such a long delay to place the wound vac since the day I recommended it . The NP continued to state R #1 had many diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] .I think a lot could be done better, I think a lot was missed, but not intentionally . T. On 10/06/21 at 8:18 am, during an interview with the DON, she confirmed R #1's wound to her right heel was a pressure ulcer. The DON stated she was unsure why some nurses documented R #1's right heel pressure ulcer as something other than a pressure wound. The DON also confirmed that if R #1's wound was draining it was no longer a DTI and it was an open pressure ulcer. This deficient practice was cited as past noncompliance: Review of onsite residents sampled for pressure wounds revealed the following: 1. Orders in place for wound care, 2. No concerns for antibiotic treatment, 3. Wound documentation was consistent wound care orders, 4. No concerns for wound vac, 5. No concerns for weekly wound assessment and measurements, 6. No concerns for contact precautions for [CONDITION(S)], and 7. New administration and new staff.

During an annual survey, the following deficient practice was found to be Immediate Jeopardy: 1) R #110 developed three facility acquired (developed in the facility) pressure ulcers. One on the coccyx (the bottom portion of the spine), one on the left heel, and one on the right heel. The left heel healed. The right heel was unstageable (not able to be staged). The pressure wound on the coccyx progressed to a Stage IV (reaching into muscle and bone). 2) Record review of R #110's care plan revealed weekly skin assessments to include measurements and description of wound status. Record review of R #110's wound tracking assessments revealed only one assessment in (MONTH) ([DATE]) and no assessments (MONTH) 2019 were found. 3) The staging from the Nurse Practitioner, the Physician's assistant, and the Physician reflect an initial stage of R #110's coccyx pressure wound as Stage II that worsened. On [DATE], the Nurse Practitioner staged R #110's coccyx wound as Stage III (extends into the tissue beneath the skin). On [DATE], the Nurse Practitioner staged R #110's coccyx wound as a Stage IV. On [DATE], the Physician's assistant staged the coccyx wound as a Stage IV. On [DATE] and [DATE], the Physician staged the coccyx wound as a Stage IV. The wound assessments completed by the facility staff stage the coccyx wound as a Stage II (skin breaks open expands to the deeper layer of the skin) until [DATE]. 4) Only one nurse in the facility had completed the wound treatment training. Also, only one nurse (a separate nurse) in the facility had completed pressure wound staging. 5) The nurse providing wound care for R #110 did not have any nursing competency for any nusing care. 6) Observations of wound care revealed improper infection control practices: a) hand hygiene, b) aseptic (clean) technique, c) and the return of contaminated wound care supplies to the common stock to be used for others, and 7) In (MONTH) 2019, the doctor ordered R #110 to have an air mattress for pressure relief. The air mattress was not implemented for R #110. This resulted in an Immediate Jeopardy that was called on [DATE] at 3:40 pm. A Plan of Removal was submitted on [DATE] at 9:20 am, and 11:20 pm were rejected. On [DATE] at 11:40 am the final Plan of Removal was approved. Plan of Removal This Abatement Plan is in response to the identification of Immediate Jeopardy communicated by the survey team on (MONTH) 23, 2019 at (name of the facility). The Immediate Jeopardy finding was identified in the following area(s). F-686 Pressure Ulcers The Facility respectfully submits this Abatement Plan pursuant to Federal and State regulatory requirements. Submission of this Letter of credible Allegations does not constitute an admission or agreement of the facts alleged or the conclusions set forth in the verbal and written notice of immediate jeopardy and/or any subsequent Statement of Deficiencies. Please accept this Abatement Plan as a credible allegation of compliance for Immediate Jeopardy initiated on (MONTH) 23, at 3:40 pm due to allegation that resident (R #110) received non-compliant care for Pressure Ulcers. 1. Corrective actions for resident(s) affected: On (MONTH) 23,2019 the Center Nurse Executive and the Assistant Director of Nursing completed the Basic Principles of Wound Management course and the NQI Pressure Ulcer Staging course through the Vital Learn education platform. By Noon, on (MONTH) 24, The Clinical Quality Specialist validated the Clinical Competency for Wound Dressing: aseptic of the Center nurse Executive and the Assistant Director of nursing Then, the Clinical Quality Specialist, the Center Nurse Executive and the Assistant Director of Nursing re-assessed and measured the Pressure Ulcers on (name of R #110) right heel and coccyx. The wounds were assessed, measured and documented on skin integrity report form. MD and family updated on resident wound assessment and current treatment plan. The coccyx wound was clean, pink, no signs of infection. The right heel wound was malodorous, with drainage, was moist, and no signs or symptoms of infection around the wound. (Name of R #110) mattress was changed to an Alternating Pressure Mattress on (MONTH) 21, 2019. (Name of R #110) Care Plan was updated to reflect Alternating Pressure Mattress, off-loading of heels, and turning and repositioning, pressure reducing cushion for W/C, boot to heel when out of bed. Current care plan interventions reviewed and in place for wound care and healing. (Name of R #110) continues to receive treatment at (Name of local Wound Care clinic). As of (MONTH) 22, 2019, both wounds are improving based on the assessment by the Wound Care Clinic. 2. Identification of residents with the potential to be affected: On (MONTH) 23, 2019, the Center Nurse Executive and or designees are performing a skin sweep of current residents to identify residents with any additional unidentified pressure wounds New pressure wounds identified, will be assessed, measured, documented, care planned and wound care orders obtained. This assessment will be made subsequent to the education and validation of the Center Nurse Execute in step one above. Additionally, preciously identified pressure wounds were measured and assessed and compared with preciously identified pressure wounds being tracked on the Skin Integrity Report. This skin sweep, and reconciliation of wounds to Skin Integrity Reports will be completed by 112:00 noon on (MONTH) 24, 2019. On (MONTH) 23, 2019, the Center Nurse Executive and or designee ran a physician order listing report to identify residents with orders for Alternating Pressure Mattresses. The four (4) residents with physician orders for alternating pressure mattresses were checked to ensure mattresses are present for resident use as ordered and the mattresses were in place and care planned as of (MONTH) 23, 2019. On (MONTH) 24, 2019, the Center Nurse Executive and/or designee ran a physician order listing report to identify residents with wound treatment orders. Orders were traced to the Treatment Administration Record to ensure that the orders were transcribed and implemented and were performed as ordered. This audit will be completed by 12:00 noon on (MONTH) 24, 2019. 3. Measures to prevent recurrence: Beginning on (MONTH) 23, 2019, Licensed Nurses will complete the ninety minute, basic Principles of Wound Management course through the Vital Learn education platform to include weekly wound evaluation and measurement, documentation, care plan update and following wound treatment pan as ordered. After completion of this course, the center Nurse Executive an or designee will validate their Clinical Competency for Wound dressing: Aseptic. As of 12:00 Noon, (MONTH) 24, 2019, Licensed Nurses will not be assigned to provide aseptic wound care until they have successfully completed the Basic Principles of Wound Management course and been validated as competent for aseptic dressing changes. Education and validation of Licensed Nurses will be completed by (MONTH) 30, 2019. Beginning on (MONTH) 24, 2019, Certified Nurse Aides will be re-educated on pressure ulcer prevention, skin management, off- loading and repositioning. CNA's were also re-educated on reporting skin irregularities identified while performing care and reporting refusals and or non-compliance with offloading and reposition. Staff members who are not re-educated by (MONTH) 24, 2019, will have re-education completed prior to working on their next scheduled shift. Beginning on (MONTH) 23, 2019, the Center Nurse Executive, Assistant Director of Nursing and the RN Unit Managers will complete the NQI pressure Ulcer Staging course through the Vital Learn education platform and will be their competence will be validated by the Clinical Quality Specialist using the Clinical Competency for Wound Dressing: Aseptic. This education and validation will be completed by Noon on (MONTH) 24, 2019, The RN Unit Manager currently on vacation will complete the education and be validated by the Clinical Quality Specialist, or the Center Nurse Executive, prior to returning to work. Beginning on (MONTH) 23, 2019, the Center Nurse Executive and or designee re-educated licensed nurses on transcribing physician orders for specialty mattress, updating resident care pans to reflect orders for specialty mattresses and communication with the Center Nurse Executive, Unit Managers and/or Central Supply Clerk to request and obtain required specialty mattress necessary to implement the physician order Licensed nurses were re-educated on communication of equipment needs shift to shift to ensure timely implementation of physician orders for specialty mattresses. Staff members who are not re-educated by (MONTH) 24, 2019, will have re-education completed prior to working on their next scheduled shift. Beginning on (MONTH) 23, 2019, the Center Nurse Executive and or designee re-educated licensed nurses on transcribing new physician orders for wound care treatments, assigned the order to the Treatment Administration Record, and updating of care plans with the new wound care interventions. Staff members who are not re-educated by (MONTH) 24, 2019, will have re-education completed prior to working on their next scheduled shift . Upon implementation of the Plan of Removal and surveyor verification, the Immediate Jeopardy was lifted on [DATE] at 2:45 pm. This resulted in the scope and severity reduced from a K to an H. Based observation, interview, and record review, the facility failed to provide services to residents to prevent the development and promote healing of pressure ulcers for 1 (R #110) of 2 (R #80 and R #110) sampled for pressure ulcers, when the facilty failed to 1) prevent R #110 from developing 3 pressure ulcers (one on her coccyx area that progressed to a Stage IV, one on the left heel that healed, and one on the right heal that became unstageable), 2) follow R #110's care plan to assess, measure, describe the R #110's wounds weekly, 3) ensure nurses had education for wound treatment and staging, 4) had differing staging of R #110 coccyx wound between the nurse staging the wound and the Physician/Physician Assistant/Nurse Practitioner, 5) provide wound care appropriately and congruent with infection control practices, and 6) follow physician's orders for an air mattress on [DATE] that was not implemented. This deficient practice resulted in R #110's Stage 4 coccyx and unstageable right heel pressure ulcers. The findings are: History A. Record review of the admission assessment dated [DATE] revealed no documentation of pressure wounds. B. On [DATE] at 10:13 am, during an interview, the DON confirmed that R #110 had 3 pressure wounds, all in-house acquired. On her left heel, R #110 had a DTI (Deep Tissue Injury) that healed. On her right heel, R #110 had DTI that had to be debrided (remove damaged tissue) and was at the time of the survey, unstageable. The third was on R #110's coccyx, a Stage III. (The DON got this information reviewing the Skin Integrity Reports for R #110. The DON was not aware of the physician's documentation of the wound staging for R #110 coccyx wound (see findings H. & I.)). C. On [DATE] at 10:35 am, during an interview LPN #1 stated that she had been doing wound care regularly for R #110 because she worked days and was assigned to her hallway. LPN #1 explained that she wound do wound care and the unit managers wound do the skin assessments that included staging. LPN #1 explained that R #110 had fallen and fractured her hip at the end of (MONTH) (YEAR) the doctor ordered an abduction pillow (devise used to separate the resident's legs) after the surgery to keep her knees from touching. In LPN #1's opinion, this is what help contribute to the pressure wounds due to R #110's lack of mobility and limited ways to reposition her. D. Record review of R #110 Physician's Orders dated [DATE] revealed Weight bearing: continue with Abduction pillow for 6 weeks, out of bed for limb ROM. This would have expired on [DATE]. E. On [DATE] at 12:37 pm, during an interview, the DON explained that R #110 had been on hospice from (MONTH) - (MONTH) (YEAR). The DON continued She would have gotten better after October. The DON confirmed that R #110 fell in (MONTH) (YEAR) and the pressure wounds began on [DATE]. The DON was asked about interventions for R #110 and if an air mattress was considered. She stated that R #110 goes to the wound care clinic. I think she can be healed; we stay on top of it. I don't believe it was considered, all of the mattress are pressure reliving (the air mattress orders were discovered after the interview (see findings K. - P.)). The DON was asked if R #110's pressure wounds were unavoidable, she stated, I think they were unavoidable. Just the way she came back she was so confused, the abduction pillow, just trying to get her in the position we needed her (was difficult). She would go back (to the position she was in). The DON was asked if there was any documentation for R #110 difficulty for repositioning. She stated The nurses should have documented the issues with repositioning. The DON was asked if she found any documentation to support this to provide it to the survey team; no documentation was provided. F. Record review of the Nursing Notes for January, February, March, April, and (MONTH) 2019 did not reveal any documentation of R #110 having been difficult/non-cooperative with repositioning. Care Plan/Skin Assessment G. Record review of R #110's Care Plan dated [DATE] revealed: 1) (Name of R #110) has actual skin breakdown related to: .(R) (Right) HEEL DTI (NOW ONE) CO[NAME]YX STAGE II AS OF [DATE] . o Apply barrier cream with each cleansing o Offer/encourage fluids of choice o skin check per policy o Utilize positioning devices as appropriate to prevent pressure over boney prominences o Weekly wound assessment to include measurements and description of wound Status 2) (Name of R #110) is at risk for skin breakdown; as evidenced by history of pressure ulcer, limited mobility, shear/friction risks o Apply barrier cream with each cleansing o Encourage (name of R #110) in repositioning frequently throughout day and night. o Observe skin condition with ADL care daily and report abnormalities o Weekly skin assessment by license nurse H. Record review of the Skin Integrity Reports for R #110's left heel, right heel, and coccyx revealed the following: 1) Pressure wounds on R #110's left heel, right heel, and coccyx started on [DATE]. 2) Coccyx wound documentation revealed [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage II, [DATE] Stage III, and [DATE] Stage III. 3) Left Heel wound documentation revealed [DATE] no stage, [DATE] no stage, and [DATE] no stage. 4) Right heel wound documentation revealed [DATE] stage DTI, [DATE] DTI, [DATE] DTI, [DATE] DTI, [DATE] DTI, [DATE] no stage, [DATE] DTI, [DATE] DTI. I. Reocord review of the Physician's Progress Notes revealed the following: 1) On [DATE], the Nurse Practitioner stages R #110's coccyx wound as Stage III. 2) On [DATE], the Nurse Practitioner stages R #110's coccyx wound as a Stage IV. 3) On [DATE], the Physician's assistant stages the coccyx as a Stage IV. 4) On [DATE] and [DATE], the Physician stages the coccyx as a Stage IV. J. On [DATE] at 9:50 am, during an interview, the DON confirmed the missing skin assessments in (MONTH) and (MONTH) 2019. I don't have documentation. I would say no we did not (do the skin assessments). The DON had a concern that the Nurse Practitioner, the Physican's Assistant, and the Physican did not look at the wounds because the unit manager who had staged R #110's coccyx wound was so different. The DON confirmed that the Unit Manager who did the staging was out of the facility and was unavailable through the duration of the survey. Air Mattress K. Record review of the electronic Physician Orders revealed the following: [DATE]- [DATE] install air mattress for 30 days. Entered into the electronic orders by LPN #1. L. On [DATE] at 1:02 pm, during an observation of R #110's room revealed no air mattress. M. Record review of the Physician Order (paper) revealed dated [DATE] revealed .Need low air mattress . need to be turned every 2 hr (hours) . noted to have been taken by LPN #1 and signed by R #110's Physician. N. On [DATE] at 1:52 pm, during an interview, LPN #1 stated No, I do not recall an air mattress (for R #110). During a simultaneous interview, LPN #5 also confirmed that R #110 did not currently have an air mattress. O. On [DATE] at 3:56 pm, during an interview, the DON confirmed R #110's order for a low air mattress was ordered in [DATE]. It looks like she wrote in 30 days (for the air mattress). I am not sure why she would put that. The DON also confirmed that R #110 did not have an air mattress (at that time or anyother time) and that it should have been implemented. P. On [DATE] at 3:43 pm, during an interview, R #110's Physician confirmed that he had staged R #110's coccyx pressure wound as a Stage IV. The Physician also confirmed that R #110's left heel DTI had healed. The Physician was asked if R #110's pressure wounds were unavoidable, he stated, If you are going to put this on me, than I am going to say they were unavoidable. We knew it was going to happen due her comorbidities (diabetes and dementia) and the difficulty repositioning her. The doctor was asked if he was aware the air mattress he ordered was not in place, he answered, No. Wound Care Observation Q. On [DATE] at 8:02 am, during observation of wound care, LPN #1 placed a handful of gauze sponges on top of R #110's bedside table (not a aseptic surface). She placed a piece of paper towel on the table and placed a medication cup of [MEDICATION NAME] (a type of medication used to treat wounds), and a medication cup of zinc (a type of medication used to treat wounds), and a small, plastic drinking cup with Dakin's Solution (a solution containing sodium hypochlorite-bleach- that was developed to treat infected wounds) on the towel. LPN #1 uncapped a bottle saline (a salt and water solution) that was about ,[DATE] full. LPN #1 cleansed the wound on the coccyx (tail bone) by wiping the same area back and forth with the sponge she had picked up off the table top and had wetted with the saline. LPN #1 opened a package of cotton swabs and used a swab to apply zinc around the wound. She opened a package and freely handled the puracol (a collagen dressing used to aid in healing) dressing with her gloved fingers, then folded dressing and pushed it into the coccyx wound with her fingers. LPN #1 then used scissors to cut a gauze wrap dressing off R #110's right heel. The dressing had an area of about 10 cm (centimeters-a metric unit of measure) at the heel that was wet with serosanguinous (blood and clear fluid drainage that had soaked through the dressing. The dressing itself was malodorous (smelled bad) as was the wound itself when the dressing was removed. An area of approximately 4 cm x 3 cm was an open wound, the edges and some of the wound were black, and there was a moderate amount of slough (a fibrous, yellow substance of nonviable (dead) tissue) was visible. LPN #1 attempted to pour the Dakin's solution from the cup over the wound, the heel wound was in a dependent position (heel down) and LPN #1 sloshed the liquid up to try and contact the wound. She held a bulky dressing pad under the wound to catch the solution. Some solution fell on the pad, some solution that had touched the wound ran into the blanket on the bed leaving several wet patches on the blanket. LPN #1 took the bulky dressing pad that had been used to catch the run off and rubbed it back and forth over the wound before and then applied the dressing. LPN #1 opened supplies, applying the xeroform dressing with the dressing falling onto the blanket and touching the prop (the foam boot) to support the leg. LPN #1 repeatedly provided wound care and then, with the same gloves, touched items on the bedside table, including unopened supplies. LPN #1 took the used scissors and placed them on an unopened package of xeroform, gauze, ,[DATE] of a roll of gauze used for wrapping wound and placed them on top of the treatment cart. She wiped the scissors with an alcohol wipe, and replaced the xeroform gauze packing and the partially used role of gauze back into the supplies of the treatment cart. R. On [DATE] at 9:57 am, during an interview, LPN #1 said she was not aware the solution used to clean the heel leaked onto blanket, and was aware supplies should be prepared on clean field an opened prior to performing wound care. LPN #1, said it was difficult to pour Dakin's solution from a cup to clean the heel. She said, We put supplies back (in the treatment cart for use for others) if they are unopened or there are usable pieces left. When asked if they supplies have been contaminated being handled when she is handling the resident's wound with same gloves, LPN #1 stated, Yes, I could see that. LPN #1 stated that she had cleaned the bedside table earlier than morning with the Bleach Wipes but was not familiar with the contact or dwell time needed to actually disinfect that table. She said she had laid a piece of paper towel on the table for a field but had supplies all over the table. S. On [DATE] at 10:17 am, during an interview, the DON stated, If they (staff) use supplies for the resident, the supplies should be left in that resident's room for the next dressing change. The nurse should have cleaned the heel wound with the Dakin's solution in a syringe so she could direct the solution. The nurse should not have taken the dressing she used to collect the drips from the wound to clean the wound, it should have been new gauze sponges to blot or clean. The nurse should have set up a field before starting to care for the wounds. The packages that had been handle with the same gloves when touching the wound for doing care would have made those packages contaminated. I have to find out what documentation we have of the nurses receiving wound care training. We use a computer education program to provide training to the staff. The outcome to the residents could be that wounds could become infected and take much longer to heal. T. Record review of the facility nursing procedure Wound Dressing: Aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms), revised [DATE] revealed: 5. Place clean barrier on the over bed table and place supplies on the barrier. 13. If a break in aseptic technique occurs, stop the procedure, remove gloves, cleanse hands, and apply clean gloves. 14. Open dressings without contaminating. Keep the dressing/gauze within the open packet and place it directly on top of the barrier. 15. Prepare medication/ointment, if indicated, by placing the dressing gauze within the open packet and place it directly on top of the barrier. 16.1 If applicable, place bed protector under or adjacent to wound site and remove the soiled dressing. 28. Unused supplies are discarded according to infection control procedure or remain dedicated to the patient and stored appropriately. Wound Treatment/Staging Training and Competencies U. Record review of LPN #5's employee record revealed no competencies for nursing services to include wound care. V. Record review and simultaneous interview with the DON on [DATE] at 1:00 pm comfirmed there is no competency for wound care for LPN #1. W. Record review of LPN #5's electronic training record revealed no training for wound care or wound staging. X. On [DATE] at 8:17 am, during an interview, the DON confirmed that the facility had Only 2 nurses with the training. Only one nurse had wound treatment training and another nurse had the wound staging training. Neither was working with R #110.

During an annual survey the following was discovered: 1) R (resident) #67 experienced a significant weight loss of 14.39% during a three month period within the facility, from 01/18/18 to 04/13/18. 2) The Registered Dietitian failed to conduct a nutrition assessment for a two month period and R #67 continued to lose excessive amounts of weight during that period of time. 3) The Registered dietitian failed to monitor R #67's progress despite documenting a nutrition concern and significant weight loss on 01/28/18 and R #67 continued to lose excessive amounts of weight during that time. 4) The facility failed to ensure that the physician was evaluating R #67's nutritional status and implementing necessary interventions. 5) The attending physician had recorded R #67's weight loss monthly, but did not implement any interventions. 6) The facility failed to update and revise the Care plan according to effectiveness for R #67's weight loss and nutrition status despite his change of condition. This resulted in an Immediate Jeopardy that was called on 04/19/18 at 3:45 pm. A Plan of Removal was submitted on 04/20/18 at 8:50 am, 11:00 am, and 1:30 pm and were rejected. A final Plan of Removal was approved on 04/20/18 at 2:45 pm. Corrective Action : On (MONTH) 19, (YEAR), the Director of Dining Services and the Registered Dietitian met with Resident # 67 and identified his meal preferences. The Registered Dietitian verified, through interviewing Resident #67, he has been receiving the MD (medical doctor) ordered Health/House Supplement shake as ordered daily between 11:00 am and noon. This is supported by review of the Medication Administration Record. Resident #67 had not been consistently receiving or consuming the fortified shakes with his Lunch and Dinner. Resident #67 stated that he does not enjoy the Fortified Shakes and prefers the Health/House supplement shakes in chocolate flavor. Licensed Nurse called MD and notified of weight loss and received an MD order for the Health/House Supplement shakes, in chocolate flavor, per resident preferences, three times a day on (MONTH) 19, (YEAR). The resident's care plan was updated by the Center Nurse Executive on (MONTH) 29, (YEAR), to reflect current nutritional interventions. Registered Dietitian assessment was completed on (MONTH) 20, (YEAR). On (MONTH) 19, (YEAR), Director of dining Services and Registered Dietitian obtained a list of preferred meals from Resident #67 The Director of dining Services will provide Resident #67 with both a copy of the three-week cycle menu per current diet order and a list of frozen main course meals on hand so that Resident #67 can Request his lunches and dinners based upon his appetite and preferences from the list. Resident #67 also has the ability to request snacks as desired based upon his appetite. The Director of Dining Services will meet with Residents #67 weekly to discuss his preferences, the center's menus and his meal satisfaction and intake until his weight loss issue has resolved per Registered Dietitian's and Resident's weight goal. Resident plan of care will be updated as needed. Resident #67 will be weighed weekly and the center Nurse Executive and the Registered Dietitian will review his weight changes, discuss current interventions identify needed updates to his plan of care to include continuation of weekly weights and notify MD and carry out orders if any. On (MONTH) 19, (YEAR), Center Nurse Executive conducted an audit to ensure that residents, who had significant weight loss for the month of (MONTH) (YEAR) have been addressed with appropriate MD notifications. Audit also include a review of current dietary interventions and MD ordered interventions for weight loss to ensure that these interventions are in place and are being followed. Corrective actions were implemented for deficient areas identified. Center Nurse Executive and Registered Dietitian will review the weekly weights obtained during the beginning of the week of (MONTH) 16, (YEAR), and the monthly weights obtained during the week of (MONTH) 2, (YEAR), for weight changes and notify residents' physicians as indicated. The Center Nurse Executive and/or the Registered Dietitian will review weight changes, Registered Dietitian's Assessments with the Inter Disciplinary Team for identification of appropriate interventions and care plan updates as needed. Licensed Nurses will notify physicians as needed on Registered Dietitian or Inter Disciplinary Team's recommendations. Center Nurse Executive and Registered Dietitian will audit the list of recommendations at the end of each week for follow up, care plans and MD orders for implementation of interventions. Should a primary physician not respond to reports of significant weight loss, Center Nurse executive will notify Medical Director for follow up with resident's physician regarding weight loss interventions. Center Nurse executive and Registered Dietitian will review residents for weekly weights and residents who need updated Assessments. Licensed nurses will check weekly weights and monthly weights for accuracy against previous weights and observe re-weights as needed. Licensed nurses will enter the weights into Point Click care (helps to manage workflow, remotely track patient compliance, check progress for practitioner and improve the quality of patient care), review weight section in the electronic medical record and note any exceptions listed. Licensed nurse will assess patient, identify potential causes and potential interventions and notify resident's physicians of the noted significant weight loss. Licensed nurse will update care plan with new interventions. Registered Dietitian will meet weekly with the Director of dining Services to review care plans, meal intakes, and interventions for fortified foods, portions and other non-MD ordered interventions. Director of Dining Services will maintain a list of residents with interventions for use in tracking proper meal service of the care pan interventions. Director of Dining Services will audit the log twice a week, for two weeks and then weekly for one month to ensure accuracy of meal service. On (MONTH) 20, (YEAR), Center Nurse Executive and or designee will re-educated licensed nurses on the importance of obtaining and documenting accurate weights, what constitutes significant weight loss (5% in 30 days and 10% in 180 days), the potential clinical significance of weight loss, the nursing process (assessment, identification and career planning of potential interventions, implementation, and evaluation of effectiveness of interventions), the importance of documenting notifications of weight loss to the Registered Dietitian and to the residents physicians. Re-education will also include how to check weights for accuracy against previous weights, how to observe re-weights when needed. On (MONTH) 20, (YEAR) Center Nurse Executive and or designee will re-educate Certified Nurse's Aides on verifying accuracy of meals served against the tray card to ensure that the care planned interventions are properly served by the dining staff. On (MONTH) 20, (YEAR) Center Nurse Executive will re-educate the Inter Disciplinary Team, to include Social Worker, Director of Dining Services, Activities Director, Alzheimer's ( a disease characterized by progressive mental deterioration) Unit Program Director, RN Unit Managers, and center Executive Director on the systemic correction addressing weight loss identification, MD notification and intervention implementation identified above. On (MONTH) 20, (YEAR), center Nurse Executive and/or Director of Dining Services will re-educate Residents #67's direct care staff on his identified meal preferences and his ability to request alternative main courses from the list of prepared and frozen meals on hand. Staff members who are no re-educated by (MONTH) 20, (YEAR) will have re-education completed prior to working their next scheduled shift. A QAPI (Quality Assurance and Performance Improvement) meeting was held (MONTH) 20, (YEAR) with the Center Nurse Executive, center Executive Director, and Inter Disciplinary Team to discuss the implementation and acceptance of the above plan. Center Executive Director/Center Nurse Executive will report finding of audits in the monthly QAPI meeting for 3 Months or until Substantial compliance is determined by the Committee. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on Friday, 04/20/18 at 2:45 pm This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review, the facility failed to revise the plan of care when resident's needs changed when they 1) failed to revise for significant weight loss and change of nutritional status for 1 (R #67) of 1 (R #67) resident sampled for nutrition, 2) failed to revise for refusal of care for 1 (R #32) of 1 (R #32) resident sampled for ADLs (Activities of Daily Living), and 3) failed to revise for uncontrolled pain for 1 (R #69) of 1 (R #69) sampled for pain management This deficient practice of not revising the care plan contributed to R #67's significant weight loss and nutritional decline, and resident's not receiving care to reflect their current condition. The findings are: R #67 A. On 04/17/18 at 8:50 am, during an interview with R #67, he stated, I have lost some weight, my appetite isn't there anymore. I went from the 150's (pounds) down to 120 (pounds) and I think the last time I weighed I was at 121 (pounds), so I gained a pound. When asked how quickly he lost that weight he said, I don't know, I don't really keep track but maybe a couple months or so. They have me on shakes once a day, but those aren't doing anything. They said they were going to talk to the doctor about getting something to help my appetite but I keep forgetting to remind them. It's my fault, they can't know unless I tell them. The food sucks and there's this suggestion box to help with it, but that's not going to change anything. I don't like to eat it, it's not good but even if it was I don't have an appetite. B. On 04/17/18 at 9:01 am, during an interview with LPN #1, she stated, He has lost weight and he is on nutritional supplements, I believe three times a day. His appetite isn't so great. He works with (Name of MD #1), but she always comes in after hours. I've never even met her. I just leave messages for her if I need something. As far as I know, she has not done anything new or ordered an appetite stimulant or anything like that for him. C. Record review of R #67's recorded weights and vitals in electronic chart revealed R #67 was hospitalized in (MONTH) and on 01/18/18, after his return from the hospital, his weight was 140.0 lbs. It decreased to 120.0 lbs. on 04/13/18, a calculated weight loss percentage of 14.29% in three months. On 01/18/18, he weighed 140 lbs. On 02/01/18, he weighed 130 lbs. On 02/20/18, he weighed 128 lbs. On 03/01/18, he weighed 128 lbs. On 04/13/18, he weighed 120.5 lbs. D. Record Review of R #67's Nutrition Progress notes dated 12/08/17 at 4:15 pm, revealed R #67 weighed 153 lbs. On 01/04/18 it states, (Name of resident) has had a significant weight loss of -5.8% in > (greater than) 1 month. Current weight is 144 lb. (Name of resident) has had a decreased appetite and is encouraged to try to eat as much of meals as possible. E. Record review of R #67's paper chart dietary orders revealed R #67 is on an 1800 (calorie) diabetic diet (healthy eating plan that's naturally rich in nutrients and low in fat and calories.) 3 meals and 3 snacks effective (MONTH) 18, (YEAR) (sic) and no documentation was found that it had been updated or reviewed for effectiveness since it was ordered. F. Record review of nutrition assessment dated [DATE] revealed, (Name of resident) has a [MEDICAL CONDITION] ( a surgical operation in which a piece of the colon is diverted to an artificial opening the abdomen wall) and ostomy (an artifical opening in an organ of the body). Diet order is Regular/Liberalized Recorded PO intake per ADL's 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has tremors in hands and is spilling more food. He would like to be assessed for built up utensils. Significant weight loss of -8.4% in >30 days. G. Record review of R #67's nutritional assessment in the electronic chart dated 01/28/18 revealed Diet order is Regular/Liberalized Recorded PO (by mouth) intake per ADL's (Activities of daily living) 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has distension (enlarged or swollen from internal pressure) of abdomen and Heart Burn (sic). (Name of resident) has a new [DIAGNOSES REDACTED]. Current weight is 140 lbs. with BMI (body mass index) of 23.2 which is a healthy weight. (Name of resident) has history of low BMI and history of significant weight gains at this facility. Now with significant weight loss of -8.4 % in > 30 days. (Name of resident) has tremors in hands and is spilling more food. (Name of resident) would like to be assessed for built up utensils. H. Record review of R #67's progress notes, dated 02/14/18 at 3:23 pm, revealed, (Name of resident) has had significant weight loss of -15.8% in >90 days and -11.4% in >30 days. PO (by mouth) intakes 0-100% of 2 meals. (Name of resident) is receiving health shake QD (once a day). RD (Registered dietitian) spoke with (name of resident) about weight loss and poor appetite. (Name of resident) reports appetite is slowly improving and agrees to try to eat more. (Name of resident) agrees to have Fortified Shake with the meals. 02/16/18 RD informed unit manager of Care plan changes including supplements as ordered and fortified foods. I. Review of R #67's progress notes dated 04/13/18 revealed, (Name of resident) is has (sic) had significant weight loss of -20.9% (-32.5 lbs.) in >180 days and -15.2% in > 90 days and reports a very poor appetite. (Name of resident) receives a house supplements QD and Fortified shakes BID (twice per day). PO intake varies from 0-75% and many meals are not eaten. (Name of resident) has voiced a concern and wonders if an appetite stimulant may help. J. Record review of R #67's paper and electronic chart revealed that no progress notes were documented for a period of 56 days/8 weeks (from 2/16/18 to 4/13/18). No nutritional assessments were completed after 01/28/18 until 03/21/18. K. Record review of Nutrition progress notes, dated 01/24/18 at 10:44 am, revealed that a nutrition concern was identified at this time, stating, A Nutrition Assessment was completed today. The resident's Nutrition Concerns Category Score is: Nutrition Problems. There are nutrition problems. Nutritional [DIAGNOSES REDACTED]. Progress notes were entered on 02/14/18 at 3:23 pm, 02/16/18 at 13:54 pm, and 04/13/18 at 14:33 pm, however, another nutritional assessment was not completed until 03/21/18. L. Record review of R #67's care plan start date 11/29/17 and target date 02/27/18 revealed, (Name of resident) is at nutritional risk r/t (related to) hx (history) diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract), GI (gastrointestinal) surgery, [MEDICAL CONDITIONS], ([MEDICAL CONDITION]) T2DM (type 2 diabetes mellitus), Tremors in hands, and history of fluctuating weights now with significant weight loss. (Name of resident) will consume 50-100 % of at least 3 meals q (every) day x (for) 90 days. (Name of resident) will maintain a stabilized weight with < (less than) 5% wt (weight) change x 30 days and <10% wt change x 180 days. Honor food preferences within meal plan. Encourage 100% consumption of all fluids provided. (Name of resident) chooses to eat in room R/T (related to) anxiety/agitation and reports not wanting to wait in dining room for food. Weigh per protocol and alert dietitian and physician to any significant loss or gain. Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. Provide diet as ordered. Offer snacks 2/5/2018 (DM initials). Provide supplement as ordered and Fortified Foods BID. 2/5/2018 (DM initials). No changes or updates have been made to the care plan since 02/05/18. M. On 04/18/18 at 10:20 am, during an interview with RD, when asked what has been implemented for R #67 as far as nutrition she stated, He is receiving shakes to supplement his diet twice a day, I believe. He was admitted to the hospital with [REDACTED]. He doesn't eat a lot of his meals, and he has had concerns and tells me,'I'm not doing any better' and even expressed to me that he would maybe like to try an appetite stimulant. When asked was the physician notified of R #67 significant weight loss and if any new orders or interventions being implemented, she stated, We monitor his intake and weight and the effectiveness of the supplements he is on. N. On 04/19/18 at 10:03 am, during an interview with RD, when asked again if MD #1 had been notified of R #67's weight loss, she stated, It's nursing's responsibility to let the physician know if there is an issue like this. As far as I know, no one has let (name of MD #) know. O. On 04/19/18 at 10:09 am, during an interview, the RD stated, I just wanted to let you know that I actually did let (name of MD #1) know and she is going to work on the issue. We increased his shakes to TID (three times per day) and I suggested an appetite stimulant which she agrees to. I just called her this morning. When asked why MD #1 wasn't aware that the resident had lost so much weight before today, she stated, The only thing that I can think is it's on the nursing end. I usually only let the doctor know if I feel like it's a really important issue. P. Record Review of R #67's Nutrition Progress note, dated 04/19/18 at 10:04 am revealed, RD spoke with (name of physician) about (Name of resident) significant weight loss. RD recommended diet liberalization which Physician (sic) agreed to. RD recommended that [MEDICATION NAME] ( a medication used to stimulate the appetite) be considered for Depression which may increase the appetite. RD reported to physician that (name of resident) is receiving Nutritional supplements TID. Nutritional supplements include Health shake QD and Fortified Shakes with meals BID. (Name of resident) reports enjoying Health shakes and Fortified shakes. (Name of resident) reports disliking many meals at this facility and does not want to talk with the Kitchen Manager about this today. Current weight is 120.5 lbs. with BMI of 20.1 and significant weight loss of -20.5% in >60 days. (Name of resident) reports a poor appetite and has refused or not eaten 19 meals in the last 18 days. When meals are eaten PO intakes varies from 25-100% and is only occasionally 100%. (Name of resident) usually does not eat breakfast and eats usually eats (sic) lunch and dinner. Food preferences are honored. RD will continue to monitor PO intakes, weight, and encourage (name of resident) to eat more and take nutritional supplements. Q. On 04/19/18 at 12:20 pm, during an interview with R #67, when asked if he feels like he needs more help doing the daily activities that he used to do without help, R #67 stated, I do feel like I can't do as much, I'm a lot weaker probably over the last few months and can't really leave my room much. I have tremors and pain, too; so, that doesn't help. I'm also feeling more depressed, I just don't feel good. When asked if he feels like his significant weight loss might be contributing he said, Yeah, it's a lot of weight and I feel so weak, but I don't like the food here either. (Name of dietitian) came in this morning, though, and said she talked to the doctor and they're going to put me on an appetite stimulant. When asked if he is okay with that, he stated, I wouldn't say I'm happy about it, but I don't have an appetite and I think that will give me one. But, the food is still not good so I'll have an appetite but still won't want to eat the food. I've taken one before and it did give me an appetite, so I asked for it again. When asked if they are giving him his supplemental shakes everyday he stated, They forget to send them a lot. Yesterday I didn't get one and sometimes it will be days and days when I don't get them, but sometimes I do. R. On 04/19/18 at 12:37 pm, during and interview, LPN #1 stated, I've only worked here for two months. So in the time I've known him, I feel like he is weaker than he was when I first came. He's (R #67) struggling with more depression and doesn't eat much or come out of his room too often. And he is not an early riser; definitely a little higher functioning after noon. When asked if the nursing staff gives him his shakes, she stated, It should be in the MAR (medication administration record) when he gets them, but yes I know he has them ordered. S. Record review of R #67's MAR (medication administration record) for the months of February, March, and (MONTH) (YEAR) revealed, House Supplement one time a day for Supplement-Start Date-02/02/2018 1100 qd (once a day) no end date. According to the MAR, R #67 has received a supplemental shake daily at 11:00 am since the order was implemented T. On 04/19/18 at 12:45 pm, during an interview, the UM (unit manager) #1 stated, I had been really worried about him, actually I feel like he (R #67) has improved over the last month or so. He has gone from a wheelchair to a walker and does really well when (Name of nurse) is here. When asked in comparison to R #67's baseline or normal level of functioning, did she feel like his ADL's have declined, she stated, He did decline a lot for the two months after he came back from the hospital in January, he got really depressed. He was using a walker at first and actually ended up in a wheelchair during those two months. But like I said, he's back to a walker again. When asked if R #67's care plan had been updated or revised according to effectiveness of the interventions that were in there she stated, It doesn't look like anything new is in there except for what RD entered in February. U. On 04/19/18 at 01:40 pm, during an interview with the DON, when asked if she feels like R #67 has declined the she stated, I think probably, and a lot of it has to do with his depression. I know the Unit Manager over there has been concerned that he has declined. When asked if she feels like his ADL's have declined she stated, He was hospitalized in (MONTH) and since he got back here he just hasn't been the same, I don't really know if it's physical and he feels weak or if it's more because of the depression that he's not functioning like he was. But yes I would say there has been a little bit of a decline there. V. On 04/19/18 at 03:24 pm, during an interview, the MD #1 stated, I was informed of his weight loss this morning, no one notified me before that to let me know he had lost that much weight. But it's not really their fault. I go out once a month and am supposed to get their vitals and weight and I don't always get them. I have 5 facilities that I go to and maybe 40 residents at each one, I'm not going to get all of their weights; it's too hard to do that. So they called me this morning and said they were worried about his weight loss, but they have him on an 1800 calorie diabetic diet and he won't eat his meals, but he eats his snacks. I told them they need to increase his caloric intake. When surveyor informed MD #1 that R #67 stated that he feels weak and less inclined to participate in anything throughout the day and doesn't have an appetite she stated, Yes, they said they felt like he needed to be put on [MEDICATION NAME] (an appetite stimulant), but I don't think it's a good idea to just put him on a medication that increases his appetite, I think they need to change his diet and increase his calories. He's losing weight, but the man has [MEDICAL CONDITION], I mean what are you going to do? W. Record review of Physician notes, date of service 03/23/18, revealed that MD #1 had obtained R #67 weights each month on 12/22/17-153.0 lbs, 01/24/18-144.0 lbs., 02/18/18-127.5 lbs, and 03/23/18-125.2 lbs. Documented significant weight loss by PCP: (Name of physician). No new orders were implemented by MD #1 for documented weight loss. X. Review of Weights and Heights Policies and Procedures, revised date 05/15/17 revealed, Significant weight change management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1. Significant weight change is defined as: 5% in one month, 10% in six months. 2.2 The licensed nurse will: 2.2.1. Notify the physician/APN (advanced practice nurse) /PA (physician's assistant) and Dietitian of significant weight changes. Y. Record review of Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing at https://www.ncbi.nlm.nih.gov/pubmed/ 338 dated 07/04/03 revealed, Clinically significant involuntary weight loss (IWL) is defined as a loss of 4.5 kg or > 5% of the usual body weight over a period of 6 - 12 months, especially when progressive. Weight loss of > 10% of normal body weight is considered to represent protein-energy malnutrition (PEM). Z. Review of Food and Nutrition Services Policies and Procedures Nutrition Care Process, revised date of 11/28/16 revealed, 2. Nutrition assessment is completed by the Dietitian or the non-dietitian designee upon admission and with changes in nutritional status. Generally, a nutrition assessment is completed in conjunction with a MDS 3.0 OBRA (Omnibus Budget Reconciliation Act) assessment. 2.1 The Dietician completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. 2.2 Patient/Resident is notified of any changes to his/her care plan in advance. 3. Patients/Residents with a nutrition [DIAGNOSES REDACTED]. R #32 AA. Record review of Medication Review Report dated 04/22/18, revealed the [DIAGNOSES REDACTED]. BB. On 04/16/18 at 11:18 am, during observation of R #32, it was observed all her fingernails were dirty with thick brown matter under her nails, the resident has food (both wet and dry) on her shirt in several places, and has several long whiskers on her chin (approximately 1 inch long, and heavy, dark mustache). CC. On 04/16/18 at 1:50 pm during observation, the resident was sleeping, now in a clean shirt. Her nails and facial hair were unchanged. DD. On 04/18/18 at 1:01 pm, during observation, R #32 is in bed and talking with surveyor. Her fingernails are dirty with brown/black matter underneath the nails. Resident # 32 has many long whiskers on her chin and a dark mustache. When asked if she would let staff shave her R #32 replies, I know I am so ugly but I guess they (staff) would do what they want and they don't want to and don't want me. R #32 was confused, and some of her responses are inappropriate. EE. On 04/18/18 at 01:23 pm, during an interview with CNA #4, when asked about the care she provides to the resident, states, She (R #2) is total care (requires full assistance). I have to clean her, dress her, give her oral care, help wash her face, and brush her hair. She is (scheduled for) an evening shower. Sometimes she will hit or tell us no. It depends her mood and how she is approached. I go in real calm. She (R #32) always says don't yell, don't yell. I talk softly to her and get better results. She refuses care few times a week. She does not reposition herself, I turn her every 2 hours. When CNA #4 was asked if she had a care plan to help her know what the resident needs and how to deal with refusals , CNA #4 replied, Nothing written, just what we hear in report. She may refuse her care. If she refuses I tell the nurse and the nurse will talk to her. We give time to calm down and try again. She is usually OK the 2nd time (I ask) . I document in ADL book. For most part she does let us shave her, we shave her just when we notice it (facial hair). I think she feels better about herself when we do that. FF. On 04/18/18 at 1:44 pm, during an interview with the NS (Nursing Supervisor) she stated, She (R #32) fights us to shave her. She often refuses care. The NS showed the surveyor the ADL book (a notebook where the CNAs chart about the assistance they give the residents with their ADLs. The NS stated, Her (R #32) last bath was 1 week ago, and then 1 week before that. She refuses in between. GG. Record review of the MDS (Minimum Data Set) dated 01/16/18 for R #32 revealed: Personal hygiene - how resident maintains personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (excludes baths and showers) indicated R #32 was totally dependent on staff and required a 2 person (staff) physical assist. Bathing -indicated R #32 was totally dependent on staff and required a 2 person (staff) physical assist. HH. Record review of the plan of care for R #32, revised on 02/06/18 revealed: Focus: (Name of R #32) requires extensive to total assistance (sic) with 1 staff for ADL care in bathing, grooming, dressing, bed mobility, transfer, toileting due to cognitive loss/dementia, compromising functional ability Goal: ADL care needs will be anticipated and met in order to maintain the highest practicable level of functioning and physical well-being x (for) 90 days. Target date 03/07/18) Interventions: Needs extensive to total assistance with her bed mobility, transfers, dressing, grooming and showering. Showers per schedule and PRN (as needed) .at times will refuse showers (There were no interventions listed for refusals). II. On 04/19/18 at 10:45 am, during an interview with the DON (Director of Nursing), she said that R #32 should have been care planned for refusals including interventions for the refusals for the resident's ADLs. R #69 JJ. On 04/16/18 at 11:33 am, during an observation, R #69 was breathing strenuously and wincing when pushing himself in his wheelchair. He stopped pushing every two to three feet and would close his eyes and moan. Staff was observed walking around him and no one stopped and offered him assistance. KK. On 04/16/18 at 11:35 am, during an interview with R #69, surveyor asked him where he was heading and he stated, I'm working on going to my room, but I'm in some pain, it's taking me a while. When asked why he is in so much pain he stated, I'm always in pain, but it's been bad for the last few days. They (the nurses) gave me a Tylenol this morning, but I usually take pain meds (medications) and they (the nurses) said my prescription hasn't come in yet. I ran out of it on Saturday and I'm hurting. When asked what his pain level is he stated I'm at a 10. When asked if that is normal for him he stated, Yes, here lately. When asked what pain level he would be satisfied with he stated, A 5 or a 6 would be good. LL. On 04/16/18 at 11:47 am, during an interview with LPN #3, when asked when the last time R #69 had received his pain medication, she stated He ran out on Saturday evening. When asked why his prescription hadn't been refilled she stated, We have a hard time getting (TRUNCATED)

During an annual survey the following was discovered: 1) R (resident) #67 experienced a significant weight loss of 14.39% during a three month period within the facility, from 01/18/18 to 04/13/18. 2) The Registered Dietitian failed to conduct a nutrition assessment for a two month period and R #67 continued to lose excessive amounts of weight during that period of time. 3) The Registered dietitian failed to monitor R #67's progress despite documenting a nutrition concern and significant weight loss on 01/28/18 and R #67 continued to lose excessive amounts of weight during that time. 4) The facility failed to ensure that the physician was evaluating R #67's nutritional status and implementing necessary interventions. 5) The attending physician had recorded R #67's weight loss monthly, but did not implement any interventions. 6) The facility failed to update and revise the Care plan according to effectiveness for R #67's weight loss and nutrition status despite his change of condition. This resulted in an Immediate Jeopardy that was called on 04/19/18 at 3:45 pm. A Plan of Removal was submitted on 04/20/18 at 8:50 am, 11:00 am, and 1:30 pm and were rejected. A final Plan of Removal was approved on 04/20/18 at 3:45 pm. Corrective Action: On (MONTH) 19, (YEAR), the Director of Dining Services and the Registered Dietitian met with Resident # 67 and identified his meal preferences. The Registered Dietitian verified, through interviewing Resident #67, he has been receiving the MD ordered Health/House Supplement shake as ordered daily between 11:00 am and noon. This is supported by review of the Medication Administration Record. Resident #67 had not been consistently receiving or consuming the fortified shakes with his Lunch and Dinner. Resident #67 stated that he does not enjoy the Fortified Shakes and prefers the Health/House supplement shakes in chocolate flavor. Licensed Nurse called MD and notified of weight loss and received an MD order for the Health/House Supplement shakes, in chocolate flavor, per resident preferences, three times a day on (MONTH) 19, (YEAR). The resident's care plan was updated by the Center Nurse Executive on (MONTH) 29, (YEAR), to reflect current nutritional interventions. Registered Dietitian assessment was completed on (MONTH) 20, (YEAR). On (MONTH) 19, (YEAR), Director of dining Services and Registered Dietitian obtained a list of preferred meals from Resident #67 The Director of dining Services will provide Resident #67 with both a copy of the three-week cycle menu per current diet order and a list frozen main course meals on hand so that Resident #67 can Request his lunches and dinners based upon his appetite and preferences from the list. Resident #67 also has the ability to request snacks as desired based upon his appetite. The Director of Dining Services will meet with Residents #67 weekly to discuss his preferences, the center's menus and his meal satisfaction and intake until his weight loss issue has resolved per Registered Dietitian's and Resident's weight goal. Resident plan of care will be updated as needed. Resident #67 will be weighed weekly and the center Nurse Executive and the Registered Dietitian will review his weight changes, discuss current interventions identify needed updates to his plan of care to include continuation of weekly weights and notify MD and carry out orders if any. On (MONTH) 19, (YEAR), Center Nurse Executive conducted an audit to ensure that residents, who had significant weight loss for the month of (MONTH) (YEAR) have been addressed with appropriate MD notifications. Audit also include a review of current dietary interventions and MD ordered interventions for weight loss to ensure that these interventions are in place and are being followed. Corrective actions were implemented for deficient areas identified. Center Nurse Executive and Registered Dietitian will review the weekly weights obtained during the beginning of the week of (MONTH) 16, (YEAR), and the monthly weights obtained during the week of (MONTH) 2, (YEAR), for weight changes and notify residents' physicians as indicated. The Center Nurse Executive and/or the Registered Dietitian will review weight changes, Registered Dietitian's Assessments with the Inter Disciplinary Team for identification of appropriate interventions and care plan updates as needed. Licensed Nurses will notify physicians as needed on Registered Dietitian or Inter Disciplinary Team's recommendations. Center Nurse Executive and Registered Dietitian will audit the list of recommendations at the end of each week for follow up, care plans and MD orders for implementation of interventions. Should a primary physician not respond to reports of significant weight loss, Center Nurse executive will notify Medical Director for follow up with resident's physician regarding weight loss interventions. Center Nurse executive and Registered Dietitian will review residents for weekly weights and residents who need updated Assessments. Licensed nurses will check weekly weights and monthly weights for accuracy against previous weights and observe re-weights as needed. Licensed nurses will enter the weights into Point Click care, review weight section in the electronic medical record and note any exceptions listed. Licensed nurse will assess patient, identify potential causes and potential interventions and notify resident's physicians of the noted significant weight loss. Licensed nurse will update care plan with new interventions. Registered Dietitian will meet weekly with the Director of dining Services to review care plans, meal intakes, and interventions for fortified foods, portions and other non-MD ordered interventions. Director of Dining Services will maintain a list of residents with interventions for use in tracking proper meal service of the care pan interventions. Director of Dining Services will audit the log twice a week, for two weeks and then weekly for one month to ensure accuracy of meal service. On (MONTH) 20, (YEAR), Center Nurse Executive and or designee will re-educated licensed nurses on the importance of obtaining and documenting accurate weights, what constitutes significant weight loss (5% in 30 days and 10% in 180 days), the potential clinical significance of weight loss, the nursing process (assessment, identification and career planning of potential interventions, implementation, and evaluation of effectiveness of interventions), the importance of documenting notifications of weight loss to the Registered Dietitian and to the residents physicians. Re-education will also include how to check weights for accuracy against previous weights, how to observe re-weights when needed. On (MONTH) 20, (YEAR) Center Nurse Executive and or designee will re-educate Certified Nurse's Aides on verifying accuracy of meals served against the tray card to ensure that the care planned interventions are properly served by the dining staff. On (MONTH) 20, (YEAR) Center Nurse Executive will re-educate the Inter Disciplinary Team, to include Social Worker, Director of Dining Services, Activities Director, Alzheimer's Unit Program Director, RN Unit Managers, and center Executive Director on the systemic correction addressing weight loss identification, MD notification and intervention implementation identified above. On (MONTH) 20, (YEAR), center Nurse Executive and/or Director of Dining Services will re-educate Residents #67's direct care staff on his identified meal preferences and his ability to request alternative main courses from the list of prepared and frozen meals on hand. Staff members who are no re-educated by (MONTH) 20, (YEAR) will have re-education completed prior to working their next scheduled shift. A QAPI meeting was held (MONTH) 20, (YEAR) with the Center Nurse Executive, center Executive Director, and Inter Disciplinary Team to discuss the implementation and acceptance of the above plan. Center Executive Director/Center Nurse Executive will report finding of audits in the monthly QAPI meeting for 3 Months or until Substantial compliance is determined by the Committee. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on Friday, 04/20/18 at 2:45 pm This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review the facility failed to provide nutrition status maintenance for 1 (R #67) of 1 (R #67) residents sampled for nutrition by: 1) Failing to conduct a nutrition assessment after 01/24/18 and before 03/21/18, an 8 week/56 day period; 2) Failing to monitor R #67's progress despite documented nutrition concern and significant weight loss on 01/28/18; 3) failing to ensure that the physician was evaluating R #67's nutritional status and implementing necessary interventions. 4) Failing to implement new orders or interventions despite record of monthly weight loss; and 6) Failing to update and revise the Care plan according to effectiveness for R #67's weight loss and nutrition status despite his change of condition. This deficient practice lead to the resident's significant involuntary weight loss. The findings are: A. On 04/17/18 at 8:50 am, during an interview with R #67, he stated, I have lost some weight, my appetite isn't there anymore. I went from the 150's (pounds) down to 120 (pounds) and I think the last time I weighed I was at 121 (pounds), so I gained a pound. When asked how quickly he lost that weight he said, I don't know, I don't really keep track but maybe a couple months or so. They have me on shakes once a day, but those aren't doing anything. They said they were going to talk to the doctor about getting something to help my appetite but I keep forgetting to remind them. It's my fault, they can't know unless I tell them. The food sucks and there's this suggestion box to help with it, but that's not going to change anything. I don't like to eat it, it's not good but even if it was I don't have an appetite. B. On 04/17/18 at 9:01 am, during an interview with LPN #1, she stated, He has lost weight and he is on nutritional supplements, I believe three times a day. His appetite isn't so great. He works with (Name of MD #1), but she always comes in after hours. I've never even met her. I just leave messages for her if I need something. As far as I know, she has not done anything new or ordered an appetite stimulant or anything like that for him. C. Record review of R #67's recorded weights and vitals in electronic chart revealed R #67 was hospitalized in (MONTH) and on 01/18/18, after his return from the hospital, his weight was 140.0 lbs. It decreased to 120.0 lbs. on 04/13/18, a calculated weight loss percentage of 14.29% in three months. On 01/18/18, he weighed 140 lbs. On 02/01/18, he weighed 130 lbs. On 02/20/18, he weighed 128 lbs. On 03/01/18, he weighed 128 lbs. On 04/13/18, he weighed 120.5 lbs. D. Record Review of R #67's Nutrition Progress notes dated 12/08/17 at 4:15 pm, revealed R #67 weighed 153 lbs. On 01/04/18 it states, (Name of resident) has had a significant weight loss of -5.8% in > (greater than) 1 month. Current weight is 144 lb. (Name of resident) has had a decreased appetite and is encouraged to try to eat as much of meals as possible. E. Record review of R #67's paper chart dietary orders revealed R #67 is on an 1800 (calorie) diabetic diet (healthy eating plan that's naturally rich in nutrients and low in fat and calories.) 3 meals and 3 snacks effective (MONTH) 18, (YEAR) (sic) and no documentation was found that it had been updated or reviewed for effectiveness since it was ordered. F. Record review of nutrition assessment dated [DATE] revealed, (Name of resident) has a [MEDICAL CONDITION] ( a surgical operation in which a piece of the colon is diverted to an artificial opening the abdomen wall) and ostomy (an artifical opening in an organ of the body). Diet order is Regular/Liberalized Recorded PO intake per ADL's 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has tremors in hands and is spilling more food. He would like to be assessed for built up utensils. Significant weight loss of -8.4% in >30 days. G. Record review of R #67's nutritional assessment in the electronic chart dated 01/28/18 revealed Diet order is Regular/Liberalized Recorded PO (by mouth) intake per ADL's (Activities of daily living) 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has distension (enlarged or swollen from internal pressure) of abdomen and Heart Burn (sic). (Name of resident) has a new [DIAGNOSES REDACTED]. Current weight is 140 lbs. with BMI (body mass index) of 23.2 which is a healthy weight. (Name of resident) has history of low BMI and history of significant weight gains at this facility. Now with significant weight loss of -8.4 % in > 30 days. (Name of resident) has tremors in hands and is spilling more food. (Name of resident) would like to be assessed for built up utensils. H. Record review of R #67's progress notes, dated 02/14/18 at 3:23 pm, revealed, (Name of resident) has had significant weight loss of -15.8% in >90 days and -11.4% in >30 days. PO (by mouth) intakes 0-100% of 2 meals. (Name of resident) is receiving health shake QD (once a day). RD (Registered dietitian) spoke with (name of resident) about weight loss and poor appetite. (Name of resident) reports appetite is slowly improving and agrees to try to eat more. (Name of resident) agrees to have Fortified Shake with the meals. 02/16/18 RD informed unit manager of Care plan changes including supplements as ordered and fortified foods. I. Review of R #67's progress notes dated 04/13/18 revealed, (Name of resident) is has (sic) had significant weight loss of -20.9% (-32.5 lbs.) in >180 days and -15.2% in > 90 days and reports a very poor appetite. (Name of resident) receives a house supplements QD and Fortified shakes BID (twice per day). PO intake varies from 0-75% and many meals are not eaten. (Name of resident) has voiced a concern and wonders if an appetite stimulant may help. J. Record review of R #67's paper and electronic chart revealed that no progress notes were documented for a period of 56 days/8 weeks (from 2/16/18 to 4/13/18). No nutritional assessments were completed after 01/28/18 until 03/21/18. K. Record review of Nutrition progress notes, dated 01/24/18 at 10:44 am, revealed that a nutrition concern was identified at this time, stating, A Nutrition Assessment was completed today. The resident's Nutrition Concerns Category Score is: Nutrition Problems. There are nutrition problems. Nutritional [DIAGNOSES REDACTED]. Progress notes were entered on 02/14/18 at 3:23 pm, 02/16/18 at 13:54 pm, and 04/13/18 at 14:33 pm, however, another nutritional assessment was not completed until 03/21/18. L. Record review of R #67's care plan start date 11/29/17 and target date 02/27/18 revealed, (Name of resident) is at nutritional risk r/t (related to) hx (history) diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract), GI (gastrointestinal) surgery, [MEDICAL CONDITIONS], ([MEDICAL CONDITION]) T2DM (type 2 diabetes mellitus), Tremors in hands, and history of fluctuating weights now with significant weight loss. (Name of resident) will consume 50-100 % of at least 3 meals q (every) day x (for) 90 days. (Name of resident) will maintain a stabilized weight with < (less than) 5% wt (weight) change x 30 days and <10% wt change x 180 days. Honor food preferences within meal plan. Encourage 100% consumption of all fluids provided. (Name of resident) chooses to eat in room R/T (related to) anxiety/agitation and reports not wanting to wait in dining room for food. Weigh per protocol and alert dietitian and physician to any significant loss or gain. Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. Provide diet as ordered. Offer snacks 2/5/2018 (DM initials). Provide supplement as ordered and Fortified Foods BID. 2/5/2018 (DM initials). No changes or updates have been made to the care plan since 02/05/18. M. On 04/18/18 at 10:20 am, during an interview with RD, when asked what has been implemented for R #67 as far as nutrition she stated, He is receiving shakes to supplement his diet twice a day, I believe. He was admitted to the hospital with [REDACTED]. He doesn't eat a lot of his meals, and he has had concerns and tells me,'I'm not doing any better' and even expressed to me that he would maybe like to try an appetite stimulant. When asked was the physician notified of R #67 significant weight loss and if any new orders or interventions being implemented, she stated, We monitor his intake and weight and the effectiveness of the supplements he is on. N. On 04/19/18 at 10:03 am, during an interview with RD, when asked again if MD #1 had been notified of R #67's weight loss, she stated, It's nursing's responsibility to let the physician know if there is an issue like this. As far as I know, no one has let (name of MD #) know. O. On 04/19/18 at 10:09 am, during an interview, the RD stated, I just wanted to let you know that I actually did let (name of MD #1) know and she is going to work on the issue. We increased his shakes to TID (three times per day) and I suggested an appetite stimulant which she agrees to. I just called her this morning. When asked why MD #1 wasn't aware that the resident had lost so much weight before today, she stated, The only thing that I can think is it's on the nursing end. I usually only let the doctor know if I feel like it's a really important issue. P. Record Review of R #67's Nutrition Progress note, dated 04/19/18 at 10:04 am revealed, RD spoke with (name of physician) about (Name of resident) significant weight loss. RD recommended diet liberalization which Physician (sic) agreed to. RD recommended that [MEDICATION NAME] ( a medication used to stimulate the appetite) be considered for Depression which may increase the appetite. RD reported to physician that (name of resident) is receiving Nutritional supplements TID. Nutritional supplements include Health shake QD and Fortified Shakes with meals BID. (Name of resident) reports enjoying Health shakes and Fortified shakes. (Name of resident) reports disliking many meals at this facility and does not want to talk with the Kitchen Manager about this today. Current weight is 120.5 lbs. with BMI of 20.1 and significant weight loss of -20.5% in >60 days. (Name of resident) reports a poor appetite and has refused or not eaten 19 meals in the last 18 days. When meals are eaten PO intakes varies from 25-100% and is only occasionally 100%. (Name of resident) usually does not eat breakfast and eats usually eats (sic) lunch and dinner. Food preferences are honored. RD will continue to monitor PO intakes, weight, and encourage (name of resident) to eat more and take nutritional supplements. Q. On 04/19/18 at 12:20 pm, during an interview with R #67, when asked if he feels like he needs more help doing the daily activities that he used to do without help, R #67 stated, I do feel like I can't do as much, I'm a lot weaker probably over the last few months and can't really leave my room much. I have tremors and pain, too; so, that doesn't help. I'm also feeling more depressed, I just don't feel good. When asked if he feels like his significant weight loss might be contributing he said, Yeah, it's a lot of weight and I feel so weak, but I don't like the food here either. (Name of dietitian) came in this morning, though, and said she talked to the doctor and they're going to put me on an appetite stimulant. When asked if he is okay with that, he stated, I wouldn't say I'm happy about it, but I don't have an appetite and I think that will give me one. But, the food is still not good so I'll have an appetite but still won't want to eat the food. I've taken one before and it did give me an appetite, so I asked for it again. When asked if they are giving him his supplemental shakes everyday he stated, They forget to send them a lot. Yesterday I didn't get one and sometimes it will be days and days when I don't get them, but sometimes I do. R. On 04/19/18 at 12:37 pm, during and interview, LPN #1 stated, I've only worked here for two months. So in the time I've known him, I feel like he is weaker than he was when I first came. He's (R #67) struggling with more depression and doesn't eat much or come out of his room too often. And he is not an early riser; definitely a little higher functioning after noon. When asked if the nursing staff gives him his shakes, she stated, It should be in the MAR (medication administration record) when he gets them, but yes I know he has them ordered. S. Record review of R #67's MAR (medication administration record) for the months of February, March, and (MONTH) (YEAR) revealed, House Supplement one time a day for Supplement-Start Date-02/02/2018 1100 qd (once a day) no end date. According to the MAR, R #67 has received a supplemental shake daily at 11:00 am since the order was implemented T. On 04/19/18 at 12:45 pm, during an interview, the UM (unit manager) #1 stated, I had been really worried about him, actually I feel like he (R #67) has improved over the last month or so. He has gone from a wheelchair to a walker and does really well when (Name of nurse) is here. When asked in comparison to R #67's baseline or normal level of functioning, did she feel like his ADL's have declined, she stated, He did decline a lot for the two months after he came back from the hospital in January, he got really depressed. He was using a walker at first and actually ended up in a wheelchair during those two months. But like I said, he's back to a walker again. When asked if R #67's care plan had been updated or revised according to effectiveness of the interventions that were in there she stated, It doesn't look like anything new is in there except for what RD entered in February. U. On 04/19/18 at 01:40 pm, during an interview with the DON, when asked if she feels like R #67 has declined the she stated, I think probably, and a lot of it has to do with his depression. I know the Unit Manager over there has been concerned that he has declined. When asked if she feels like his ADL's have declined she stated, He was hospitalized in (MONTH) and since he got back here he just hasn't been the same, I don't really know if it's physical and he feels weak or if it's more because of the depression that he's not functioning like he was. But yes I would say there has been a little bit of a decline there. V. On 04/19/18 at 03:24 pm, during an interview, the MD #1 stated, I was informed of his weight loss this morning, no one notified me before that to let me know he had lost that much weight. But it's not really their fault. I go out once a month and am supposed to get their vitals and weight and I don't always get them. I have 5 facilities that I go to and maybe 40 residents at each one, I'm not going to get all of their weights; it's too hard to do that. So they called me this morning and said they were worried about his weight loss, but they have him on an 1800 calorie diabetic diet and he won't eat his meals, but he eats his snacks. I told them they need to increase his caloric intake. When surveyor informed MD #1 that R #67 stated that he feels weak and less inclined to participate in anything throughout the day and doesn't have an appetite she stated, Yes, they said they felt like he needed to be put on [MEDICATION NAME] (an appetite stimulant), but I don't think it's a good idea to just put him on a medication that increases his appetite, I think they need to change his diet and increase his calories. He's losing weight, but the man has [MEDICAL CONDITION], I mean what are you going to do? W. Record review of Physician notes, date of service 03/23/18, revealed that MD #1 had obtained R #67 weights each month on 12/22/17-153.0 lbs, 01/24/18-144.0 lbs., 02/18/18-127.5 lbs, and 03/23/18-125.2 lbs. Documented significant weight loss by PCP: (Name of physician). No new orders were implemented by MD #1 for documented weight loss. X. Review of Weights and Heights Policies and Procedures, revised date 05/15/17 revealed, Significant weight change management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1. Significant weight change is defined as: 5% in one month, 10% in six months. 2.2 The licensed nurse will: 2.2.1. Notify the physician/APN (advanced practice nurse) /PA (physician's assistant) and Dietitian of significant weight changes. Y. Record review of Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing at https://www.ncbi.nlm.nih.gov/pubmed/ 338 dated 07/04/03 revealed, Clinically significant involuntary weight loss (IWL) is defined as a loss of 4.5 kg or > 5% of the usual body weight over a period of 6 - 12 months, especially when progressive. Weight loss of > 10% of normal body weight is considered to represent protein-energy malnutrition (PEM). Z. Review of Food and Nutrition Services Policies and Procedures Nutrition Care Process, revised date of 11/28/16 revealed, 2. Nutrition assessment is completed by the Dietitian or the non-dietitian designee upon admission and with changes in nutritional status. Generally, a nutrition assessment is completed in conjunction with a MDS 3.0 OBRA (Omnibus Budget Reconciliation Act) assessment. 2.1 The Dietician completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. 2.2 Patient/Resident is notified of any changes to his/her care plan in advance. 3. Patients/Residents with a nutrition [DIAGNOSES REDACTED].

During an annual survey the following was discovered: 1) R (resident) #67 experienced a significant weight loss of 14.39% during a three month period within the facility, from 01/18/18 to 04/13/18. 2) The Registered Dietitian failed to conduct a nutrition assessment for a two month period and R #67 continued to lose excessive amounts of weight during that period of time. 3) The Registered dietitian failed to monitor R #67's progress despite documenting a nutrition concern and significant weight loss on 01/28/18 and R #67 continued to lose excessive amounts of weight during that time. 4) The facility failed to ensure that the physician was evaluating R #67's nutritional status and implementing necessary interventions. 5) The attending physician had recorded R #67's weight loss monthly, but did not implement any interventions. 6) The facility failed to update and revise the Care plan according to effectiveness for R #67's weight loss and nutrition status despite his change of condition. This resulted in an Immediate Jeopardy that was called on 04/19/18 at 3:45 pm. A Plan of Removal was submitted on 04/20/18 at 8:50 am, 11:00 am, and 1:30 pm and were rejected. A final Plan of Removal was approved on 04/20/18 at 2:45 pm. Corrective Action: On (MONTH) 19, (YEAR), the Director of Dining Services and the Registered Dietitian met with Resident # 67 and identified his meal preferences. The Registered Dietitian verified, through interviewing Resident #67, he has been receiving the MD ordered Health/House Supplement shake as ordered daily between 11:00 am and noon. This is supported by review of the Medication Administration Record. Resident #67 had not been consistently receiving or consuming the fortified shakes with his Lunch and Dinner. Resident #67 stated that he does not enjoy the Fortified Shakes and prefers the Health/House supplement shakes in chocolate flavor. Licensed Nurse called MD and notified of weight loss and received an MD order for the Health/House Supplement shakes, in chocolate flavor, per resident preferences, three times a day on (MONTH) 19, (YEAR). The resident's care plan was updated by the Center Nurse Executive on (MONTH) 29, (YEAR), to reflect current nutritional interventions. Registered Dietitian assessment was completed on (MONTH) 20, (YEAR). On (MONTH) 19, (YEAR), Director of dining Services and Registered Dietitian obtained a list of preferred meals from Resident #67 The Director of dining Services will provide Resident #67 with both a copy of the three-week cycle menu per current diet order and a list frozen main course meals on hand so that Resident #67 can Request his lunches and dinners based upon his appetite and preferences from the list. Resident #67 also has the ability to request snacks as desired based upon his appetite. The Director of Dining Services will meet with Residents #67 weekly to discuss his preferences, the center's menus and his meal satisfaction and intake until his weight loss issue has resolved per Registered Dietitian's and Resident's weight goal. Resident plan of care will be updated as needed. Resident #67 will be weighed weekly and the center Nurse Executive and the Registered Dietitian will review his weight changes, discuss current interventions identify needed updates to his plan of care to include continuation of weekly weights and notify MD and carry out orders if any. On (MONTH) 19, (YEAR), Center Nurse Executive conducted an audit to ensure that residents, who had significant weight loss for the month of (MONTH) (YEAR) have been addressed with appropriate MD notifications. Audit also include a review of current dietary interventions and MD ordered interventions for weight loss to ensure that these interventions are in place and are being followed. Corrective actions were implemented for deficient areas identified. Center Nurse Executive and Registered Dietitian will review the weekly weights obtained during the beginning of the week of (MONTH) 16, (YEAR), and the monthly weights obtained during the week of (MONTH) 2, (YEAR), for weight changes and notify residents' physicians as indicated. The Center Nurse Executive and/or the Registered Dietitian will review weight changes, Registered Dietitian's Assessments with the Inter Disciplinary Team for identification of appropriate interventions and care plan updates as needed. Licensed Nurses will notify physicians as needed on Registered Dietitian or Inter Disciplinary Team's recommendations. Center Nurse Executive and Registered Dietitian will audit the list of recommendations at the end of each week for follow up, care plans and MD orders for implementation of interventions. Should a primary physician not respond to reports of significant weight loss, Center Nurse executive will notify Medical Director for follow up with resident's physician regarding weight loss interventions. Center Nurse executive and Registered Dietitian will review residents for weekly weights and residents who need updated Assessments. Licensed nurses will check weekly weights and monthly weights for accuracy against previous weights and observe re-weights as needed. Licensed nurses will enter the weights into Point Click care, review weight section in the electronic medical record and note any exceptions listed. Licensed nurse will assess patient, identify potential causes and potential interventions and notify resident's physicians of the noted significant weight loss. Licensed nurse will update care plan with new interventions. Registered Dietitian will meet weekly with the Director of dining Services to review care plans, meal intakes, and interventions for fortified foods, portions and other non-MD ordered interventions. Director of Dining Services will maintain a list of residents with interventions for use in tracking proper meal service of the care pan interventions. Director of Dining Services will audit the log twice a week, for two weeks and then weekly for one month to ensure accuracy of meal service. On (MONTH) 20, (YEAR), Center Nurse Executive and or designee will re-educated licensed nurses on the importance of obtaining and documenting accurate weights, what constitutes significant weight loss (5% in 30 days and 10% in 180 days), the potential clinical significance of weight loss, the nursing process (assessment, identification and career planning of potential interventions, implementation, and evaluation of effectiveness of interventions), the importance of documenting notifications of weight loss to the Registered Dietitian and to the residents physicians. Re-education will also include how to check weights for accuracy against previous weights, how to observe re-weights when needed. On (MONTH) 20, (YEAR) Center Nurse Executive and or designee will re-educate Certified Nurse's Aides on verifying accuracy of meals served against the tray card to ensure that the care planned interventions are properly served by the dining staff. On (MONTH) 20, (YEAR) Center Nurse Executive will re-educate the Inter Disciplinary Team, to include Social Worker, Director of Dining Services, Activities Director, Alzheimer's Unit Program Director, RN Unit Managers, and center Executive Director on the systemic correction addressing weight loss identification, MD notification and intervention implementation identified above. On (MONTH) 20, (YEAR), center Nurse Executive and/or Director of Dining Services will re-educate Residents #67's direct care staff on his identified meal preferences and his ability to request alternative main courses from the list of prepared and frozen meals on hand. Staff members who are no re-educated by (MONTH) 20, (YEAR) will have re-education completed prior to working their next scheduled shift. A QAPI meeting was held (MONTH) 20, (YEAR) with the Center Nurse Executive, center Executive Director, and Inter Disciplinary Team to discuss the implementation and acceptance of the above plan. Center Executive Director/Center Nurse Executive will report finding of audits in the monthly QAPI meeting for 3 Months or until Substantial compliance is determined by the Committee. Upon implementation of the Plan of Removal the Immediate Jeopardy was lifted on Friday, 04/20/18 at 2:45 pm This resulted in the scope and severity being reduced from a K to an E. Based on observation, interview, and record review the facility failed to ensure that a physician was supervising the resident's care for 1 (R #67) of 1 (R #67) residents sampled for nutrition by failing to ensure that the physician was evaluating R #67's nutritional status and implementing necessary interventions despite record of monthly weight loss. This deficient practice lead to the resident's significant involuntary weight loss. The findings are: A. On 04/17/18 at 8:50 am, during an interview with R #67, he stated, I have lost some weight, my appetite isn't there anymore. I went from the 150's (pounds) down to 120 (pounds) and I think the last time I weighed I was at 121 (pounds), so I gained a pound. When asked how quickly he lost that weight he said, I don't know, I don't really keep track but maybe a couple months or so. They have me on shakes once a day, but those aren't doing anything. They said they were going to talk to the doctor about getting something to help my appetite but I keep forgetting to remind them. It's my fault, they can't know unless I tell them. The food sucks and there's this suggestion box to help with it, but that's not going to change anything. I don't like to eat it, it's not good but even if it was I don't have an appetite. B. On 04/17/18 at 9:01 am, during an interview with LPN #1, she stated, He has lost weight and he is on nutritional supplements, I believe three times a day. His appetite isn't so great. He works with (Name of MD #1), but she always comes in after hours. I've never even met her. I just leave messages for her if I need something. As far as I know, she has not done anything new or ordered an appetite stimulant or anything like that for him. C. Record review of R #67's recorded weights and vitals in electronic chart revealed R #67 was hospitalized in (MONTH) and on 01/18/18, after his return from the hospital, his weight was 140.0 lbs. It decreased to 120.0 lbs. on 04/13/18, a calculated weight loss percentage of 14.29% in three months. On 01/18/18, he weighed 140 lbs. On 02/01/18, he weighed 130 lbs. On 02/20/18, he weighed 128 lbs. On 03/01/18, he weighed 128 lbs. On 04/13/18, he weighed 120.5 lbs. D. Record Review of R #67's Nutrition Progress notes dated 12/08/17 at 4:15 pm, revealed R #67 weighed 153 lbs. On 01/04/18 it states, (Name of resident) has had a significant weight loss of -5.8% in > (greater than) 1 month. Current weight is 144 lb. (Name of resident) has had a decreased appetite and is encouraged to try to eat as much of meals as possible. E. Record review of R #67's paper chart dietary orders revealed R #67 is on an 1800 (calorie) diabetic diet (healthy eating plan that's naturally rich in nutrients and low in fat and calories.) 3 meals and 3 snacks effective (MONTH) 18, (YEAR) (sic) and no documentation was found that it had been updated or reviewed for effectiveness since it was ordered. F. Record review of nutrition assessment dated [DATE] revealed, (Name of resident) has a [MEDICAL CONDITION] ( a surgical operation in which a piece of the colon is diverted to an artificial opening the abdomen wall) and ostomy (an artifical opening in an organ of the body). Diet order is Regular/Liberalized Recorded PO intake per ADL's 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has tremors in hands and is spilling more food. He would like to be assessed for built up utensils. Significant weight loss of -8.4% in >30 days. G. Record review of R #67's nutritional assessment in the electronic chart dated 01/28/18 revealed Diet order is Regular/Liberalized Recorded PO (by mouth) intake per ADL's (Activities of daily living) 25-75% for 2 meals since readmission post hospital stay. (Name of resident) has not been eating breakfast and reports poor appetite. (Name of resident) has distension (enlarged or swollen from internal pressure) of abdomen and Heart Burn (sic). (Name of resident) has a new [DIAGNOSES REDACTED]. Current weight is 140 lbs. with BMI (body mass index) of 23.2 which is a healthy weight. (Name of resident) has history of low BMI and history of significant weight gains at this facility. Now with significant weight loss of -8.4 % in > 30 days. (Name of resident) has tremors in hands and is spilling more food. (Name of resident) would like to be assessed for built up utensils. H. Record review of R #67's progress notes, dated 02/14/18 at 3:23 pm, revealed, (Name of resident) has had significant weight loss of -15.8% in >90 days and -11.4% in >30 days. PO (by mouth) intakes 0-100% of 2 meals. (Name of resident) is receiving health shake QD (once a day). RD (Registered dietitian) spoke with (name of resident) about weight loss and poor appetite. (Name of resident) reports appetite is slowly improving and agrees to try to eat more. (Name of resident) agrees to have Fortified Shake with the meals. 02/16/18 RD informed unit manager of Care plan changes including supplements as ordered and fortified foods. I. Review of R #67's progress notes dated 04/13/18 revealed, (Name of resident) is has (sic) had significant weight loss of -20.9% (-32.5 lbs.) in >180 days and -15.2% in > 90 days and reports a very poor appetite. (Name of resident) receives a house supplements QD and Fortified shakes BID (twice per day). PO intake varies from 0-75% and many meals are not eaten. (Name of resident) has voiced a concern and wonders if an appetite stimulant may help. J. Record review of R #67's paper and electronic chart revealed that no progress notes were documented for a period of 56 days/8 weeks (from 2/16/18 to 4/13/18). No nutritional assessments were completed after 01/28/18 until 03/21/18. K. Record review of Nutrition progress notes, dated 01/24/18 at 10:44 am, revealed that a nutrition concern was identified at this time, stating, A Nutrition Assessment was completed today. The resident's Nutrition Concerns Category Score is: Nutrition Problems. There are nutrition problems. Nutritional [DIAGNOSES REDACTED]. Progress notes were entered on 02/14/18 at 3:23 pm, 02/16/18 at 13:54 pm, and 04/13/18 at 14:33 pm, however, another nutritional assessment was not completed until 03/21/18. L. Record review of R #67's care plan start date 11/29/17 and target date 02/27/18 revealed, (Name of resident) is at nutritional risk r/t (related to) hx (history) diverticulitis (an inflammation or infection in one or more small pouches in the digestive tract), GI (gastrointestinal) surgery, [MEDICAL CONDITIONS], ([MEDICAL CONDITION]) T2DM (type 2 diabetes mellitus), Tremors in hands, and history of fluctuating weights now with significant weight loss. (Name of resident) will consume 50-100 % of at least 3 meals q (every) day x (for) 90 days. (Name of resident) will maintain a stabilized weight with < (less than) 5% wt (weight) change x 30 days and <10% wt change x 180 days. Honor food preferences within meal plan. Encourage 100% consumption of all fluids provided. (Name of resident) chooses to eat in room R/T (related to) anxiety/agitation and reports not wanting to wait in dining room for food. Weigh per protocol and alert dietitian and physician to any significant loss or gain. Monitor intake at all meals, offer alternate choices as needed, alert dietitian and physician to any decline in intake. Provide diet as ordered. Offer snacks 2/5/2018 (DM initials). Provide supplement as ordered and Fortified Foods BID. 2/5/2018 (DM initials). No changes or updates have been made to the care plan since 02/05/18. M. On 04/18/18 at 10:20 am, during an interview with RD, when asked what has been implemented for R #67 as far as nutrition she stated, He is receiving shakes to supplement his diet twice a day, I believe. He was admitted to the hospital with [REDACTED]. He doesn't eat a lot of his meals, and he has had concerns and tells me,'I'm not doing any better' and even expressed to me that he would maybe like to try an appetite stimulant. When asked was the physician notified of R #67 significant weight loss and if any new orders or interventions being implemented, she stated, We monitor his intake and weight and the effectiveness of the supplements he is on. N. On 04/19/18 at 10:03 am, during an interview with RD, when asked again if MD #1 had been notified of R #67's weight loss, she stated, It's nursing's responsibility to let the physician know if there is an issue like this. As far as I know, no one has let (name of MD #) know. O. On 04/19/18 at 10:09 am, during an interview, the RD stated, I just wanted to let you know that I actually did let (name of MD #1) know and she is going to work on the issue. We increased his shakes to TID (three times per day) and I suggested an appetite stimulant which she agrees to. I just called her this morning. When asked why MD #1 wasn't aware that the resident had lost so much weight before today, she stated, The only thing that I can think is it's on the nursing end. I usually only let the doctor know if I feel like it's a really important issue. P. Record Review of R #67's Nutrition Progress note, dated 04/19/18 at 10:04 am revealed, RD spoke with (name of physician) about (Name of resident) significant weight loss. RD recommended diet liberalization which Physician (sic) agreed to. RD recommended that [MEDICATION NAME] ( a medication used to stimulate the appetite) be considered for Depression which may increase the appetite. RD reported to physician that (name of resident) is receiving Nutritional supplements TID. Nutritional supplements include Health shake QD and Fortified Shakes with meals BID. (Name of resident) reports enjoying Health shakes and Fortified shakes. (Name of resident) reports disliking many meals at this facility and does not want to talk with the Kitchen Manager about this today. Current weight is 120.5 lbs. with BMI of 20.1 and significant weight loss of -20.5% in >60 days. (Name of resident) reports a poor appetite and has refused or not eaten 19 meals in the last 18 days. When meals are eaten PO intakes varies from 25-100% and is only occasionally 100%. (Name of resident) usually does not eat breakfast and eats usually eats (sic) lunch and dinner. Food preferences are honored. RD will continue to monitor PO intakes, weight, and encourage (name of resident) to eat more and take nutritional supplements. Q. On 04/19/18 at 12:20 pm, during an interview with R #67, when asked if he feels like he needs more help doing the daily activities that he used to do without help, R #67 stated, I do feel like I can't do as much, I'm a lot weaker probably over the last few months and can't really leave my room much. I have tremors and pain, too; so, that doesn't help. I'm also feeling more depressed, I just don't feel good. When asked if he feels like his significant weight loss might be contributing he said, Yeah, it's a lot of weight and I feel so weak, but I don't like the food here either. (Name of dietitian) came in this morning, though, and said she talked to the doctor and they're going to put me on an appetite stimulant. When asked if he is okay with that, he stated, I wouldn't say I'm happy about it, but I don't have an appetite and I think that will give me one. But, the food is still not good so I'll have an appetite but still won't want to eat the food. I've taken one before and it did give me an appetite, so I asked for it again. When asked if they are giving him his supplemental shakes everyday he stated, They forget to send them a lot. Yesterday I didn't get one and sometimes it will be days and days when I don't get them, but sometimes I do. R. On 04/19/18 at 12:37 pm, during and interview, LPN #1 stated, I've only worked here for two months. So in the time I've known him, I feel like he is weaker than he was when I first came. He's (R #67) struggling with more depression and doesn't eat much or come out of his room too often. And he is not an early riser; definitely a little higher functioning after noon. When asked if the nursing staff gives him his shakes, she stated, It should be in the MAR (medication administration record) when he gets them, but yes I know he has them ordered. S. Record review of R #67's MAR (medication administration record) for the months of February, March, and (MONTH) (YEAR) revealed, House Supplement one time a day for Supplement-Start Date-02/02/2018 1100 qd (once a day) no end date. According to the MAR, R #67 has received a supplemental shake daily at 11:00 am since the order was implemented T. On 04/19/18 at 12:45 pm, during an interview, the UM (unit manager) #1 stated, I had been really worried about him, actually I feel like he (R #67) has improved over the last month or so. He has gone from a wheelchair to a walker and does really well when (Name of nurse) is here. When asked in comparison to R #67's baseline or normal level of functioning, did she feel like his ADL's have declined, she stated, He did decline a lot for the two months after he came back from the hospital in January, he got really depressed. He was using a walker at first and actually ended up in a wheelchair during those two months. But like I said, he's back to a walker again. When asked if R #67's care plan had been updated or revised according to effectiveness of the interventions that were in there she stated, It doesn't look like anything new is in there except for what RD entered in February. U. On 04/19/18 at 01:40 pm, during an interview with the DON, when asked if she feels like R #67 has declined the she stated, I think probably, and a lot of it has to do with his depression. I know the Unit Manager over there has been concerned that he has declined. When asked if she feels like his ADL's have declined she stated, He was hospitalized in (MONTH) and since he got back here he just hasn't been the same, I don't really know if it's physical and he feels weak or if it's more because of the depression that he's not functioning like he was. But yes I would say there has been a little bit of a decline there. V. On 04/19/18 at 03:24 pm, during an interview, the MD #1 stated, I was informed of his weight loss this morning, no one notified me before that to let me know he had lost that much weight. But it's not really their fault. I go out once a month and am supposed to get their vitals and weight and I don't always get them. I have 5 facilities that I go to and maybe 40 residents at each one, I'm not going to get all of their weights; it's too hard to do that. So they called me this morning and said they were worried about his weight loss, but they have him on an 1800 calorie diabetic diet and he won't eat his meals, but he eats his snacks. I told them they need to increase his caloric intake. When surveyor informed MD #1 that R #67 stated that he feels weak and less inclined to participate in anything throughout the day and doesn't have an appetite she stated, Yes, they said they felt like he needed to be put on [MEDICATION NAME] (an appetite stimulant), but I don't think it's a good idea to just put him on a medication that increases his appetite, I think they need to change his diet and increase his calories. He's losing weight, but the man has [MEDICAL CONDITION], I mean what are you going to do? W. Record review of Physician notes, date of service 03/23/18, revealed that MD #1 had obtained R #67 weights each month on 12/22/17-153.0 lbs, 01/24/18-144.0 lbs., 02/18/18-127.5 lbs, and 03/23/18-125.2 lbs. Documented significant weight loss by PCP: (Name of physician). No new orders were implemented by MD #1 for documented weight loss. X. Review of Weights and Heights Policies and Procedures, revised date 05/15/17 revealed, Significant weight change management: 2.1 Significant weight changes will be reviewed by the licensed nurse for assessment. 2.1. Significant weight change is defined as: 5% in one month, 10% in six months. 2.2 The licensed nurse will: 2.2.1. Notify the physician/APN (advanced practice nurse) /PA (physician's assistant) and Dietitian of significant weight changes. Y. Record review of Protein-energy malnutrition and involuntary weight loss: nutritional and pharmacological strategies to enhance wound healing at https://www.ncbi.nlm.nih.gov/pubmed/ 338 dated 07/04/03 revealed, Clinically significant involuntary weight loss (IWL) is defined as a loss of 4.5 kg or > 5% of the usual body weight over a period of 6 - 12 months, especially when progressive. Weight loss of > 10% of normal body weight is considered to represent protein-energy malnutrition (PEM). Z. Review of Food and Nutrition Services Policies and Procedures Nutrition Care Process, revised date of 11/28/16 revealed, 2. Nutrition assessment is completed by the Dietitian or the non-dietitian designee upon admission and with changes in nutritional status. Generally, a nutrition assessment is completed in conjunction with a MDS 3.0 OBRA (Omnibus Budget Reconciliation Act) assessment. 2.1 The Dietician completes a comprehensive or further assessment for any patients/residents determined to be of nutrition concern. 2.2 Patient/Resident is notified of any changes to his/her care plan in advance. 3. Patients/Residents with a nutrition [DIAGNOSES REDACTED].

Based on observation, interview, and record review the facility failed to provide pain management for 1 (R #69) of 1 (R #69) residents sampled for pain management by 1) failing to obtain a refill on R #69's pain medication prescription from physician for 2 days 04/14/18 and 04/15/18; and 2) failing to follow policy and inform the supervisor and medical director that R #69 was out of his pain medication. This deficient practice led to a prolonged period of significant pain at a level 10 (measures a patient's pain intensity with a level 0 being no pain and a level 10 being the most severe pain possible for the resident) as well as an inability to function at a level that was acceptable to the resident. The findings are: A. On 04/16/18 at 11:33 am, during an observation, R #69 was breathing strenuously and wincing when pushing himself in his wheelchair. He stopped pushing every two to three feet and would close his eyes and moan. Staff was observed walking around him and no one stopped and offered him assistance. B. On 04/16/18 at 11:35 am, during an interview with R #69, surveyor asked him where he was heading and he stated, I'm working on going to my room, but I'm in some pain, it's taking me a while. When asked why he is in so much pain he stated, I'm always in pain, but it's been bad for the last few days. They (the nurses) gave me a Tylenol this morning, but I usually take pain meds (medications) and they (the nurses) said my prescription hasn't come in yet. I ran out of it on Saturday and I'm hurting. When asked what his pain level is he stated I'm at a 10. When asked if that is normal for him he stated, Yes, here lately. When asked what pain level he would be satisfied with he stated, A 5 or a 6 would be good. C. On 04/16/18 at 11:47 am, during an interview with LPN #3, when asked when the last time R #69 had received his pain medication, she stated He ran out on Saturday evening. When asked why his prescription hadn't been refilled she stated, We have a hard time getting a hard order from (name of MD). She's really the only one we have trouble with. He takes 5-325 [MEDICATION NAME]-[MEDICATION NAME] (5 milligrams [MEDICATION NAME]- 325 milligrams [MEDICATION NAME], a medication used to assist with pain relief) twice a day normally. He did have a Tylenol this morning. The doctor just hasn't responded yet with the prescription for his pain meds. D. Record review of R #69's MAR (medication administration record) revealed that he had received his last [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet on Saturday evening (04/14/18) at 5:07 pm. E. On 04/17/18 at 09:43 am, during an interview with LPN #3, when asked if R #69 had received his pain medication she stated, Yes, we received the order last night and he got one this morning. After I spoke with you yesterday, I called her again and she sent the order. When asked what she would normally do in a situation where she can't get a hold of the physician and the resident needs something she stated, We just keep hounding her (MD #1). When asked if they would also normally contact (Name of MD #2) (medical director) when this happens she stated, No, (Name of MD #2) is the medical director and he doesn't like to override (Name of MD #1) because she's been [MEDICATION NAME] longer than he has, so we just hound (name of MD #1) until she answers us. If she is in her office and you can catch her there then we will get an order really quick. If you call her when she is out of the office it's hard to get what we need from her. F. On 04/17/18 at 9:56 am, during an interview with the DON, when asked what their protocol is when the facility physicians cannot be reached and a resident needs something, she stated, That doesn't really happen. I can usually get a hold of (name of MD #1) pretty easily, I'll just call her on her cell phone or at her office. But if for some reason we need it right away and can't get her, I'll send someone over to her office if I have to. When asked if they have a protocol for a situation where the attending physician can't be reached and a prescription is needed, she stated, If I can't reach her I will call (name of MD #2) and he writes me a temporary prescription so the residents will have what they need until their attending physician can be reached. When asked if she was aware that R #69 hadn't received his pain medications since Saturday evening she stated, No I didn't know, and it aggravates me a little bit that no one told me. I will get with the nurses and let them know that they need to be letting me know if there is an issue getting a hold of the doctor. G. Record review of prescription from MD #1 dated 04/16/18 revealed, [MEDICATION NAME] APAP (a medication used to relieve pain) 5-325 (5 milligrams [MEDICATION NAME]-325 milligrams [MEDICATION NAME]) #60 sixty (60 tablets) 1 po (take one by mouth) TID (three times a day) prn (as needed).' H. Record review of MAR (medication administration record) revealed that R #69 received one [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg tablet from his refilled prescription at 07:45 am on 04/17/18. I. On 04/20/18 at 1:00 pm, during an interview with LPN #3, when asked why R #69 did not receive the medication until the day after receiving the refilled prescription from the physician, she stated, We didn't receive the hard script until the morning of the 17th. We did call the pharmacy and they gave us the code for the Omnicell (medication supply cabinet system located within the facility) and got him one out of there the night of the 16th. J. Record review of Omnicell transaction dated 04/16/18 at 7:43 pm revealed, [MEDICATION NAME]-ACETAMIN 5-325 TAB 1EA had been removed for R #69. K. Record review of R #69's MAR indicated [REDACTED]. L. Record review of Pain assessment interview, dated 03/11/17 revealed, Pain Assessment Interview Results: The resident responded that in the last 5 days he/she experienced pain frequently. The resident stated the pain has made it hard to sleep at night. His/her pain has limited day-to-day activities. Pain intensity using the Numeric Rating Scale: 8 The pt.(patient) is not experiencing new pain or new signs/symptoms of pain, therefore a pain evaluation was not indicated. M. Record review of pain assessment interview, dated 04/25/17 revealed, Pain Assessment Interview Results: The resident responded that in the last 5 days he/she experienced pain occasionally. Pain intensity using the Numeric Rating Scale: 9. The pt. is not experiencing new pain or new signs/symptoms of pain, therefore a pain evaluation was not indicated. The resident is satisfied with his/her current level of pain. No further pain assessment interviews were completed or documented after 04/25/17. N. Record review of R #69's Care plan dated 11/17 effective date 02/13/17 revealed (Name of resident) exhibits or is at risk for alterations in comfort related to chronic pain to his knees. (Name of resident) will achieve acceptable level of pain control over next 90 days. Evaluate pain characteristics: quality, severity location, precipitating/relieving factors. Utilize pain scale. Medicate resident as ordered for pain and monitor for effectiveness and monitor for side effects, report to physician as indicated. Monitor for non-verbal signs/symptoms of pain and medicate as ordered. Monitor for change in mood or mental status. No updates or revisions were made since his initial care plan was implemented. O. On 04/23/18 at 10:05 am, during an interview with the UM (Unit Manager) #1, when asked what information she could provide regarding R #69's pain management she states, He (R #69) does say he has pain, but I just don't believe his pain is what he says it is. But how can you really know? When asked if he's been assessed for pain or if interventions in his careplan have been re-evaluated for effectiveness, she stated, Everything is still the same as it was when we did his initial careplan. There hasn't been anything updated in it for pain. P. Review of LTC Facility's Pharmacy Services and Procedure Manual, revised date of 01/01/13 revealed, 7. If Facility nurse is unable to obtain a response from the attending Physician/Prescriber in a timely manner, Facility nurse soul notify the nursing supervisor and contact Facility's Medical Director for orders/direction, making sure to explain the circumstances of the medication shortage.

Based on record review and interview, the facility failed to ensure that residents are free from sexual abuse for 2 (R #48, 120) of 4 (R #36, 48, 116, 120) residents reviewed regarding resident-to-resident abuse by R #39. This deficient practice likely resulted in R #48 and R #120 having experienced fear and anxiety as a result of R #39 exhibiting sexually aggressive behaviors towards them during resident smoke breaks. The findings are: A. On 02/18/14 at 9:51 am, during interview with R#120, when asked if anyone at the facility has abused you, she responded, "There is a man who is on his way out. When I go out to smoke, he's actually grabbed my breast before. I freaked out. I've told every person in the world, and they say- 'I know, he's bad.'" When asked if she has informed staff, she responded, "They tell me to watch out for him, but why I should I have to watch out for him." When asked if she has seen any residents being abused, she responded "I've heard him with other residents too, saying sexual comments. Staff has been present but they don't do anything." B. On 02/19/14 at 4:48 pm during interview with Social Services Director (SSD), when asked if R #120 has made any complaints, she responded, "She had one incident with another resident where she felt that she was groped. I visited with her about the incident and told her I would follow up about it. When I spoke to the nurse, I was told by the nurse that (name of R #39) has a difficult time moving around. Since she's the one that is able to move more easily, we told her to give him a wide girth. Since then, we told her that if he was blocking the door for her, to ask staff to redirect him out of the way. Since it happens a lot outside activities, the activities staff is aware. Staff is aware of assisting her in getting past him. Unfortunately it's up to her to keep the distance. I have asked (name of R#120) at least 3 times if it's happened more than one time and she has denied it. She stays clear of him and asks for help from staff. She has the mobility and he doesn't. He can only push back with his chair." C. On 02/20/14 at 2:30 pm during interview with R #120, when asked to name the resident that grabbed her, she identified R #39. When asked how many times, she responded, "He has grabbed me several times but he is always trying to grab at me. Especially during smoking time, he blocks the door so it is hard to avoid him. Just last night I went outside to smoke and the nurse brought him out. I was scared to death of him. Then I left and he was so verbal, saying things like 'Come here baby, let me touch you.'" When asked if she informed any staff about what happened last night, she responded "yes" but was unable to provide names of staff that she told. When asked if he has touched anyone else, she responded, "Yes, (name of R #48) and (name of R #36). They don't like it either." D. On 02/21/14 at 9:55 am during interview with R #48, when asked if she knew of any problems between residents, she responded "(R #39) groped (R #120). I saw it and (name of R #36) saw it too. She told him to leave her alone. The nurse saw it, too, on east. I don't remember who. We put her in the middle, like a train so he doesn't touch her. He's tried to touch me too, he tries to grope for the breasts and (female genitalia). He reaches for all of us when we go smoke. They told us to stay away from him, but why should we give up our rights. I told everybody, and they say 'stay away.' Like right now that's where I am going and I'm scared. He just grabs for your boobs and (female genitalia). He says 'Oh, Baby, Oh Baby. I love you.' When we pass, I try to stay away from him. He tried to grab at (name of R #116) too. I don't think we should have to be afraid. Why should we have to accommodate him? Then in activities he blocks the door." E. On 02/21/14 at 10:18 am during interview with R #120, when asked if she has had any recent contact with R #39, she responded, "Just last night he was towards the smoking area. I told him to back up. He stopped right there and he refused to move. I grabbed one of the workers and asked them to move him and he started arguing with them. When I came back in, I had to go behind him. He said, 'I'll let you pass this time, but I'll get you yet.' Where he sits in the dining area it's hard for me. It's emotionally exhausting and it's not a good thing for me. The MS ([MEDICAL CONDITION]) already puts me on edge. I'm losing some of my hair, but I don't know it's from the stress of this place or what." When asked about staff 's response, she responded, "It depends on who it is. A lot of the staff just don't know how bad it is. They don't get what I'm dealing with. I look ok but they don't have a clue on how it affects me. They listen to me but haven't been very effective in dealing with it. My anxiety is increasing. I feel afraid and anxious. It's making me sad. There are problems that aren't being dealt with and they are still there." F. Record review of Interdisciplinary notes for R #120 revealed the following information: 1. 01/15/14- "SSD contacted rsd (resident) re (regarding): statement made that she had been groped by another resident. Rsd confirmed incident. SSD to f/u (follow up) w/ (with) nursing. In mean time- resident was asked to avoid interaction. Rsd stated she already was. ADON (Assistant Director of Nursing) was contacted. ADON reported other resident was dependent on staff for mobility so long as (name of R #120) avoids him, there will not be any further incidents. Staff is aware and will monitor as needed." 2. 02/06/14- "SSD visited Rsd regarding issue she was having with another rsd and a groping incident. Rsd stated there has not been any further incident." G. Record review of Interdisciplinary Progress Notes for R #39 revealed the following information dated: 1. 01/19/14- "Resident was attempting to touch female residents prior to being talked to by ADON. Stated he would behave better." 2. 01/21/14- "(Care Team) Also showing signs of sexual behavior." 3. 01/24/14- "some sexual behaviors, redirected with good response. will cont to monitor" 4. 01/28/14- "rsd displaying sexual behaviors to another rsd. Redirected rsd and then it was good." 5. 02/01/14- "Also reaches out to female residents. Redirected on person space and residents rights to be free from any resident contact, stated he understands. will continue to monitor behaviors." H. Record review of Care Plan for R #39 revised on 01/22/14 revealed "(name of R #39) has hx (history) of inappropriate sexual behavior related to: will expose self & inappropriate touching/sexual remarks to staff. Interventions: Document a summary of each episode, Redirect and set limits for acceptable behavior, remove (name of R #39) from public area when behavior is disruptive/unacceptable." I. On 02/19/14 at 3:09 pm during interview with Licensed Practical Nurse (LPN) #1, when asked about (name of R #39) level of functioning, she responded "Cognitively, he's a bit delayed. His sense of reasoning is a bit impaired. He can move himself but is slow. No behavioral issues with him. His cognitive and judgment are impaired. He acts like a teenage boy, but I haven't seen any strong bad behavior. With him, someone said he tried to grab her but I never witnessed that. I told her that I would monitor him but I've never seen it." When asked if the complainant was R #120, she responded, "No, not her. Someone else but I don't remember." J. On 02/19/14 at 3:14 pm during interview with LPN #2 when asked about complaints against (name of R #39) she responded, "Yes, (name of R#120) said that he tried grabbing her breasts. I try and separate them. I've never seen it and it's hard to image because one of his arms, his right arm, doesn't have a lot of function. When I asked him about it, he denies touching her but he says that she wears low blouses, so maybe he said something to her. It comes to the point that if she's outside, I have him wait before he goes out. He is not able to go out on his own. No one else has ever complained. I deal with him a lot. He's like a kid, he doesn't understand. He likes to argue though but I really watch him." K. On 02/19/14 at 4:48 pm during interview with SSD when asked if R #39 is responsive to redirection, SSD responded, "I think he does understand, but he'll deny it and say, 'I didn't. I actually talked with him about his inappropriate actions and that it wasn't ok to touch other people without their permission." L. On 02/21/14 at 10:15 am during interview with R #116 when asked if there had been any issues with R #39, she responded, "He likes to touch. He tries but I stay away and tell him to behave. They say he's been touching other women but I haven't seen him. He says, 'I love the women' and touch them. He's never had any verbal language to me." When asked if it makes her feel uncomfortable, she responded "Yes, but I just walk away." When asked if she told anyone, she responded "Everybody knows. The staff knows." M. On 02/21/14 at 10:58 am during interview with Director of Nursing (DON) when asked about R #39 behaviors, she responded, "He goes up and down. Sometimes he's wonderful and we can talk to him if he is having behaviors and he's good for a bit. He says some off-color things sometimes, 'They call me Mr. Love Bug' and depends on the situation and where he is at. If he's with other residents, we tell him not to say things. Sometimes he's more inappropriate with the female residents. Some residents know how to egg him on. 95% of the time we can talk to him about his behaviors and he can turn it off and say 'I know.' He has some cognition issues and he's not always responsible. He's good with redirections. He grabbed at one of the residents one of the time, (name of R #120). He grabbed at her breast and it was immediately broke up and redirected. It should be documented in her IDP (Interdisciplinary progress) notes and his. Mainly, it's just saying things but I don't put it all on him because sometimes he's egged on. Regarding (name of R #48), I instructed her to stay away from him and get another staff member. I explained to her that she should take responsibility because she's alert and oriented. She asked me to take her to smoke. We are still working with (name of R #120) but she eggs it. Sometimes she says things to him instead of going around it. She says, 'Get out of my way, stay away from me.' That just eggs him; he talks ugly to her, cursing at her- not sexual. It should all be documented; his behaviors and theirs in the IDP notes. Sometimes he gets a little racy with the aides, but I remind them not to take it personally. In the immediate, he responds well to redirection. At the moment, he responds well. If there was an injury, we would do an RMS (Risk Management System). If it gets to the point, we would report it to DOH (Department of Health) and state." N. Record review of Center Operations Policies and Procedures dated 07/01/13 revealed: 1. "Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." 2. "Process - '4. Actions to prevent abuse: 4.2 Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property are more likely to occur. 5. Staff will observe for signs that may constitute abuse such as suspicious bruising of patients, occurrences, patterns, and trends including patient-to-patient abuse. 7. If suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. 7.1 The family and physician will be notified and any follow-up recommended will be completed (e.g., psychiatric evaluation). 7.3 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. '"

Based on record review and interview, the facility failed to implement their policy and procedures for 2 (R #48, 120) of 4 (R #36, 48, 116, 120) residents reviewed regarding resident-to-resident abuse from R #39, by not identifying sexual abuse and preventing further incidences of abuse from occurring. This deficient practice likely resulted in R #48 and R #120 having experienced fear and anxiety as a result of R #39 exhibiting sexually aggressive behaviors towards them during resident smoke breaks. The findings are: A. Record review of Center Operations Policies and Procedures dated 07/01/13 revealed: 1. "Sexual Abuse includes but is not limited to, sexual harassment, sexual coercion, or sexual assault." 2. "Process '"4. Actions to prevent abuse: 4.2 Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property are more likely to occur. "5. Staff will observe for signs that may constitute abuse such as suspicious bruising of patients, occurrences, patterns, and trends including patient-to-patient abuse. "7. If suspected abuse is patient-to-patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation. 7.1 The family and physician will be notified and any follow-up recommended will be completed (e.g., psychiatric evaluation). 7.3 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted.'" B. On 02/18/14 at 9:51 am, during interview with R#120, when asked if anyone at the facility has abused you, she responded, "There is a man who is on his way out. When I go out to smoke, he's actually grabbed my breast before. I freaked out. I've told every person in the world, and they say- 'I know, he's bad.'" When asked if she has informed staff, she responded, "They tell me to watch out for him, but why I should I have to watch out for him." When asked if she has seen any residents being abused, she responded "I've heard him with other residents too, saying sexual comments. Staff has been present but they don't do anything." C. On 02/19/14 at 4:48 pm during interview with Social Services Director (SSD), when asked if R #120 has made any complaints, she responded, "She had one incident with another resident where she felt that she was groped. I visited with her about the incident and told her I would follow up about it. When I spoke to the nurse, I was told by the nurse that (name of R #39) has a difficult time moving around. Since she's the one that is able to move more easily, we told her to give him a wide girth. Since then, we told her that if he was blocking the door for her, to ask staff to redirect him out of the way. Since it happens a lot outside activities, the activities staff is aware. Staff is aware of assisting her in getting past him. Unfortunately it's up to her to keep the distance. I have asked (name of R#120) at least 3 times if it's happened more than one time and she has denied it. She stays clear of him and asks for help from staff. She has the mobility and he doesn't. He can only push back with his chair." D. On 02/20/14 at 2:30 pm during interview with R #120, when asked to name the resident that grabbed her, she identified R #39. When asked how many times, she responded, "He has grabbed me several times but he is always trying to grab at me. Especially during smoking time, he blocks the door so it is hard to avoid him. Just last night I went outside to smoke and the nurse brought him out. I was scared to death of him. Then I left and he was so verbal, saying things like 'Come here baby, let me touch you.'" When asked if she informed any staff about what happened last night, she responded "yes" but was unable to provide names of staff that she told. When asked if he has touched anyone else, she responded, "Yes, (name of R #48) and (name of R #36). They don't like it either." E. On 02/21/14 at 9:55 am during interview with R #48, when asked if she knew of any problems between residents, she responded "(R #39) groped (R #120). I saw it and (name of R #36) saw it too. She told him to leave her alone. The nurse saw it, too, on east. I don't remember who. We put her in the middle, like a train so he doesn't touch her. He's tried to touch me too, he tries to grope for the breasts and (female genitalia). He reaches for all of us when we go smoke. They told us to stay away from him, but why should we give up our rights. I told everybody, and they say 'stay away.' Like right now that's where I am going and I'm scared. He just grabs for your boobs and (female genitalia). He says 'Oh, Baby, Oh Baby. I love you.' When we pass, I try to stay away from him. He tried to grab at (name of R #116) too. I don't think we should have to be afraid. Why should we have to accommodate him? Then in activities he blocks the door." F. On 02/21/14 at 10:18 am during interview with R #120, when asked if she has had any recent contact with R #39, she responded, "Just last night he was towards the smoking area. I told him to back up. He stopped right there and he refused to move. I grabbed one of the workers and asked them to move him and he started arguing with them. When I came back in, I had to go behind him. He said, 'I'll let you pass this time, but I'll get you yet.' Where he sits in the dining area it's hard for me. It's emotionally exhausting and it's not a good thing for me. The MS ([MEDICAL CONDITION]) already puts me on edge. I'm losing some of my hair, but I don't know it's from the stress of this place or what." When asked about staff 's response, she responded, "It depends on who it is. A lot of the staff just don't know how bad it is. They don't get what I'm dealing with. I look ok but they don't have a clue on how it affects me. They listen to me but haven't been very effective in dealing with it. My anxiety is increasing. I feel afraid and anxious. It's making me sad. There are problems that aren't being dealt with and they are still there." G. Record review of Interdisciplinary notes for R #120 revealed the following information: 1. 01/15/14- "SSD contacted rsd (resident) re (regarding): statement made that she had been groped by another resident. Rsd confirmed incident. SSD to f/u (follow up) w/ (with) nursing. In mean time- resident was asked to avoid interaction. Rsd stated she already was. ADON (Assistant Director of Nursing) was contacted. ADON reported other resident was dependent on staff for mobility so long as (name of R #120) avoids him, there will not be any further incidents. Staff is aware and will monitor as needed." 2. 02/06/14- "SSD visited Rsd regarding issue she was having with another rsd and a groping incident. Rsd stated there has not been any further incident." H. Record review of Interdisciplinary Progress Notes for R #39 revealed the following information dated: 1. 01/19/14- "Resident was attempting to touch female residents prior to being talked to by ADON. Stated he would behave better." 2. 01/21/14- "(Care Team) Also showing signs of sexual behavior." 3. 01/24/14- "some sexual behaviors, redirected with good response. will cont to monitor" 4. 01/28/14- "rsd displaying sexual behaviors to another rsd. Redirected rsd and then it was good." 5. 02/01/14- "Also reaches out to female residents. Redirected on person space and residents rights to be free from any resident contact, stated he understands. will continue to monitor behaviors." I. Record review of Care Plan for R #39 revised on 01/22/14 revealed "(name of R #39) has hx (history) of inappropriate sexual behavior related to: will expose self & inappropriate touching/sexual remarks to staff. Interventions: Document a summary of each episode, Redirect and set limits for acceptable behavior, remove (name of R #39) from public area when behavior is disruptive/unacceptable." J. On 02/19/14 at 3:09 pm during interview with Licensed Practical Nurse (LPN) #1 when asked about Resident #39's level of functioning, she responded "With him, someone said he tried to grab her, but I never witnessed that. I told her that I would monitor him but I've never seen it." When asked if the complainant was R #120, she responded, "No, not her. Someone else but I don't remember." K. On 02/19/14 at 3:14 pm during interview with LPN #2, when asked about complaints against (name of R #39) she responded, "Yes, (name of R#120) said that he tried grabbing her breasts. I try and separate them. I've never seen it and it's hard to image because one of his arms, his right arm doesn't have a lot of function. When I asked him about it, he denies touching her but he says that she wears low blouses, so maybe he said something to her. It comes to the point that if she's outside, I have him wait before he goes out. He is not able to go out on his own. No one else has ever complained. I deal with him a lot. He's like a kid, he doesn't understand. He likes to argue though but I really watch him." L. On 02/19/14 at 4:48 pm during interview with SSD and Social Services Assistant Director (SSAD), when asked if R #39 is responsive to redirection, SSD responded, "I think he does understand, but he'll deny it and say, 'I didn't. I actually talked with him about his inappropriate actions and that it wasn't ok to touch other people without their permission. '" When asked if there were any other complaints about R #39, she responded "Not that I know of." When asked what is the procedure when you receive a complaint, she responded, "I complete a grievance form and then the nursing staff addresses it. We encourage all complaints to be reported and tracked through the grievances." When asked what would be the procedure if the behavior continued, SSAD responded, "We would want to check if he's taking his medication. Get a psych eval (psychological evaluation) and talk to his doctor. Even with one-time events, it's being taken seriously." When asked if R #39 has had a psych eval before, she responded, "No, he hasn't and I am not sure why. He came from (other local facility) with those behaviors." M. On 02/21/14 at 10:15 am during interview with R #116 when asked if there had been any issues with R #39, she responded, "He likes to touch. He tries but I stay away and tell him to behave. They say he's been touching other women but I haven't seen him. He says, 'I love the women' and touch them. He's never had any verbal language to me." When asked if it makes her feel uncomfortable, she responded "Yes, but I just walk away." When asked if she told anyone, she responded "Everybody knows. The staff knows." N. On 02/21/14 at 10:58 am during interview with Director of Nursing (DON) when asked about R #39 behaviors, she responded, "He goes up and down. Sometimes he's wonderful and we can talk to him if he is having behaviors and he's good for a bit. He says some off-color things sometimes, 'They call me Mr. Love Bug' and depends on the situation and where he is at. If he's with other residents, we tell him not to say things. Sometimes he's more inappropriate with the female residents. 95% of the time we can talk to him about his behaviors and he can turn it off and say 'I know.' He has some cognition issues and he's not always responsible. He's good with redirections. He grabbed at one of the residents one of the time, (name of R #120). He grabbed at her breast and it was immediately broke up and redirected. It should be documented in her IDP (Interdisciplinary progress) notes and his. Mainly, it's just saying things but I don't put it all on him because sometimes he's egged on. Regarding (name of R #48), I instructed her to stay away from him and get another staff member. I explained to her that she should take responsibility because she's alert and oriented. She asked me to take her to smoke. We are still working with (name of R #120) but she eggs it. Sometimes she says things to him instead of going around it. She says, 'Get out of my way, stay away from me.' That just eggs him; he talks ugly to her, cursing at her- not sexual. It should all be documented; his behaviors and theirs in the IDP notes. Sometimes he gets a little racy with the aides, but I remind them not to take it personally. In the immediate, he responds well to redirection. At the moment, he responds well. If there was an injury, we would do an RMS (Risk Management System). If it gets to the point, we would report it to DOH (Department of Health) and state."