Every finding on record at Clovis Healthcare and Rehabilitation Center

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following:1. Facility name.2. The current date.3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:-Registered nurses.-Licensed practical nurses.-Certified nurse aides.-Resident census. This deficient practice has the potential to affect all 59 residents as identified by the census provided by the Director of Nursing on 05/15/26 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 05/15/26 at 9:35 am, an observation and interview revealed the following:1. The nurse staffing data form was dated 05/14/26.2. The Director of Nursing (DON) stated the nurse staffing data form should be posted daily and stated it was not.

Based on observation, record review, and interview, the facility failed to maintain an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) for 2 (R #1 and R #2) of 3 (R #1, R #2, and R #3) residents reviewed by not ensuring Enhanced Barrier Precaution (EBP; an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and glove use during high contact resident care activities) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection) readily available. If the facility fails to maintain an effective infection control program, then infections could spread to residents throughout the facility, resulting in illnesses. The findings are:A. On 05/15/26 at 9:35 am, a random observation of the facility revealed no signage regarding enhanced barrier precautions EBP or PPE was seen outside of rooms for R #1 and R #2.B. Record review of R #1's medical orders revealed an order for R #1 to utilize an indwelling catheter (a thin, sterile tube inserted into the bladder to drain urine) due to a diagnosis of neurogenic bladder (the bladder does not empty properly due to a neurological condition).C. Record review of R #2's medical orders revealed an order for R #2 to utilize an indwelling catheter for a diagnosis of urinary retention (a condition that occurs when a person is unable to empty their bladder, either partially or completely).D. On 05/15/26 at 10:46 am, during an interview with the Director of Nursing (DON), she stated R #1 and R #2 should be on EBP due to their use of indwelling catheters. The DON stated she expected all residents that utilize indwelling catheters to be on EBP and stated R #1 and R #2 are not.

Based on observation and interviews, the facility failed to safeguard residents' Private Health Information (PHI) for 1 (R #3) of 3 (R #1, R #2, and R #3) residents reviewed for privacy and confidentiality of records when staff left clinical information on the medication cart where unauthorized people had ability to access it. If the resident's clinical information is not sufficiently safeguarded, resident's PHI is likely to be viewed by unauthorized residents, visitors, and staff. The findings are:A. On 05/15/26 at 9:43 am, during a random observation of the facility, a prescription label for one of R #3's medications was left face up on the medication cart.B. On 05/15/26 at 10:46 am, during an interview with the Director of Nursing (DON) she stated prescription labels should be destroyed after the medication is gone because of the PHI they contain. The DON stated prescription labels should never be left in view of unauthorized people.

Based on observation and interview, the facility failed to ensure safe medication storage practices by not ensuring the following:1. The medication carts were locked while unattended,2. The medical supply storage rooms were kept free of expired medications,3. Personal drinking cups were not kept stored in the medication cart.These deficient practices have the potential to affect all 62 residents as identified by the census provided by the Administrator on 12/01/25. If the facility does not ensure safe storage practices, then residents are at risk for unauthorized persons to have access to medications and adverse effects due to improper storage. The findings are:Medication Carts:A. On 12/02/25 at 8:39 am, during an observation of the facility, the medication cart located near the nurse's station was found unlocked and unattended.B. On 12/02/25 at 8:39 am, during an interview with Licensed Practical Nurse (LPN) #1, she confirmed that the medication cart near nursing station was not locked and should be.Medication Storage:C. On 12/04/25 at 9:20 am, during a medical storage observation revealed the following:1. The nurse had her personal drinking cup located in the bottom right-hand drawer of the 100-hall medication cart.2. The East/West Medication Storage room vaccine refrigerator revealed one opened box of five prefilled syringes of Hepatitis B Vaccine (a vaccine given to help prevent against getting Hepatitis B virus) with the expiration date of 05/19/25.D. On 12/04/25 at 9:30 am, during an interview with the DON, she confirmed the vaccines were expired and should be properly disposed of. The DON confirmed there should not be any personal drinks/items on the medication carts due to infection control concerns.

Based on observation and interview, the facility failed to ensure that residents have a safe and functional environment for all 62 residents reviewed. This deficient practice could likely result in residents being injured and living in an environment in poor repair, which would put the residents at risk of unwanted items, including insects and dust particles to come into their living space. The findings are:A. On 12/01/25 at 11:04 am during observation of the facility, there were several holes on the floor near the wall approximately 1.5 inches by 8 inches long. There were no screens or vent covers covering the holes in the floor.B. On 12/01/25 at 11:25 am during an observation of the facility, the handrails throughout the facility were scuffed and scratched.C. On 12/01/25 at 11:58 am during observation and interview with the Maintenance Director (MD) and the Administrator, they confirmed that there were no vent covers in the hallways. They confirmed that the vents were missing while they were replacing the laminate flooring and the scuffed and scratched handrails.

Based on observation and interview, the facility failed to post nurse staffing data on a daily basis at the beginning of the shift that included the following: 1. Facility name. 2. The current date. 3. The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: 1. Registered nurses. 2. Licensed practical nurses. 3. Certified nurse aides. 4. Resident census. This deficient practice has the potential to affect all 62 residents as identified by the census provided by the Administrator on 12/01/25 and could likely result in residents and visitors not having the staffing information readily available. The findings are:A. On 12/01/25 at 11:04 AM, during observation of the main entrance, the nurse staffing data was dated 11/30/25 and was not posted for the current day. B. On 12/01/25 at 11:10 AM, during an interview with the Administrator, he confirmed the nursing staff data should be posted daily and was not.

Based on observation, record review, and interview, the facility failed to implement an ongoing infection prevention and control program (a program that is used to prevent, recognize, and control the onset and spread of infections) by not ensuring Enhanced Barrier (EBP) signs are posted outside of rooms with Personal Protective equipment (PPE; protective clothing, face masks, goggles, or other garments or equipment designed to protect the wearer's body from injury or infection). This failed practice has the potential to affect all 62 residents living in the facility as identified by the census provided by the Administrator 12/01/25. These deficiencies place residents at risk of contracting infections, hospitalization, and death. The findings are:A. On 12/01/25 at 10:22 am, during a random observation of the facility, PPE was hanging on the doors outside rooms 100, 205, 306, 307, and 311. Enhanced barrier precaution signs for Rooms 205, 306 and 307 were not posted.B. Record review of the facility's Infection control policies and procedures dated 07/15/25 indicated to refer to Centers for Disease Control and Prevention (CDC).C. Record review of CDC guidelines from CDC website Enhanced Barrier Precautions (EBP) in Nursing Homes. Centers for Disease Control. https://www.cdc.gov/infection-control /Webinar-EBPinNH-Nov2022-Slides-508.pdf on Slide number 28 Communication, revealed the use appropriate and legible signs for precautions, the CDC recommends that EBP signs be displayed outside the door of the room where EBP is required. The sign should indicate the type of precaution and PPE to be used during high-contact resident care activities.D. On 12/05/25 at 11:35 am during an interview with Administrator, she stated signs should be in a place for residents with enhanced precautions.

Based on observation and interview, the facility failed to ensure food was prepared and served under sanitary conditions when staff failed to:1. Properly store dishes in sanitary conditions.2. Properly label food items in the refrigerator.3. Properly wear hair nets while in the kitchen.These deficient practices are likely to affect all 62 residents listed on the resident census list provided by the Administrator on 12/01/25 and are likely to lead to foodborne illnesses in residents if safe food handling practices are not adhered to and food stored properly. The findings are: A. On 12/01/25 at 11:05 am, an observation of the kitchen revealed Dietary Aid (DA) #1 not wearing a hairnet.B. On 12/01/25 at 11:06 am, during an interview with DA #1, she stated she was brand new employee and was unaware that she always needed a hairnet.C. On 12/01/25 at 11:08 am during an interview with Dietary Manager (DM) #1, she confirmed that DA #1 was not properly wearing the hairnet. She stated her expectation is for all staff to properly wear hairnets while in the kitchen or serving foodD. On 12/01/25 at 11:15 am, an observation of the kitchen revealed what appeared to be dry parmesan cheese and lettuce in the main refrigerator and did not have a label indicating the contents or date it was prepared.E. On 12/01/25 at 11:16 am, during an interview with the Kitchen Director (KD) #1, he confirmed the items in the fridge were not labeled and dated. He stated his expectations are for all items in the fridge to properly be labeled, dated, and stored.F. On 12/01/25 at 11:20 am, an observation of dishes being stored under the kitchen warmers appeared to be stored on top of other dirty containers.G. On 12/01/25 at 11:21 am, during an interview with KD #1, he confirmed the dishes were not stored under sanitary conditions. He stated his expectations would be for all dishes and kitchen equipment to be stored under sanitary conditions.

Based on record review and interview, the facility failed to ensure the medical records contained documentation that each resident received, or was offered the COVID-19 (an acute respiratory disease in humans characterized mainly by fever and cough and capable of progressing to severe symptoms and in some cases death, especially in older people and those with underlying health conditions) vaccinations (treatment with a vaccine to produce immunity to a particular infections disease or pathogen) for 2 (R #4 and R #5) of 5 (R #3, R #4, R #5, R #8, and R #40) residents reviewed for immunizations. This deficient practice could likely result in residents not having the knowledge or opportunity to get needed vaccinations. The findings are:R #4A. Record review of R #4's admission record revealed R #4 was admitted to the facility on [DATE]. B. Record review of R #4's Electronic Health Record (EHR) revealed R #4 did not receive or was offer the COVID vaccination. R #5C. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE]. D. Record review of R #5's Electronic Health Record (EHR) revealed R #5 did not receive or was offer the COVID vaccination E. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed:1. R #4 did not have record of receiving or being offered the COVID vaccination.2. R #5 did not have record of receiving or being offered the COVID vaccination.

Based on observation, record review, and interview, the facility failed to obtain physician orders and informed consent prior to installation of bed rails for 2 (R # 3 and R #5) of 5 (R #3, R #5, R #9, R #27 and R #60) resident reviewed for accidents. This deficient practice could result in the physician and the resident not knowing the needs, risks and benefit of bed rails. The findings are:R #3A. Record review of R #3 admission Record revealed R #3 was admitted to the facility on [DATE], with the following diagnoses:1. Spondylolysis (a stress fracture in a small bone), cervical region (neck area of the spine),2. Osteoarthritis (degenerative joint disease where the protective cartilage cushioning your bones wears down over time),3. Reduced Mobility (movement is limited), 4. Muscle weakness,5. Paraplegia (paralysis affecting the lower half of the body).B. Record review of R #3's bed rail assessment dated [DATE] revealed a recommendation for quarter size bed rails on the left and right upper sides of the bed.C. Record review of R #3's Electronic Health Record (EHR) revealed the following:1. There was no physician order for bed rails.2. There was no informed consent.D. On 12/02/25 at 12:10pm during a random observation of R #3's room, revealed quarter size bed rails on the right and left upper sides of R #3's bed.E. On 12/02/25 at 12:14pm during an interview with R #3, he confirmed he uses the bed rails for repositioning.R #5F. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses:1. Sciatica (pain, numbness, or weakness radiating along your lower back down through your buttock and leg), left side,2. Muscle Weakness,3. Abnormalities of Gait and Mobility (a significant deviation from normal walking or movement), 4. Lack of Coordination.G. Record review of R #5's bed rail assessment dated [DATE] revealed a recommendation for quarter size bed rails on the left and right upper sides of the bed.H. Record review of R #5's Electronic Health Record (EHR) revealed the following:1. A physician order for quarter size bed rails as an enabler for turning and repositioning dated 07/10/25.2. There was no informed consent.I. On 12/01/25 at 11:53am during a random observation of R #5's room, revealed quarter size bed rails on the right and left upper sides of the R #5's bed.J. On 12/01/25 at 11:53 pm during an interview with R #5, she confirmed she uses the bed rails for repositioning.K. On 12/05/25 at 1:22 pm during an interview with the Director of Nursing (DON), she confirmed the following:1. R #3 uses quarter size bed rails on the right and left upper sides of his bed.2. R #3 does not have a physician order for bed rails and should.3. R #3 does not have an informed consent and should.4. R #5 uses quarter size bed rails on the right and left upper sides of her bed.5. R #5 does not have an informed consent and should.

Based on record review and interview, the facility failed to ensure residents and/or their representatives were informed in advance of what medications they received and understood the reasons, risks, and benefits of the medications for 1 (R #3) of 5 (R #1, R #3, R #5, R #9 and R #27) residents reviewed for unnecessary medications. If the residents or their representatives are not informed of the risks and benefits of the medication or treatment alternatives, they are not able to make informed decisions regarding residents' care. The findings are:A. Record review of R #3's physician's orders revealed the following: 1. An order for Lorazepam tablet (anti-anxiety medication), 0.5 milligrams (mg). Give one tablet by mouth two times a day for anxiety. Start date: 09/09/25,2. An order for Hydroxyzine HCL tablet (antihistamine; medications used to treat anxiety, allergic reactions and as a sedative before and after surgery) 25 milligrams. Give one tablet by mouth two times a day for anxiety. Start date: 10/22/25.B. Record review of R #3's medical record revealed there were no consents for the use of Lorazepam and Hydroxyzine. C. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed staff did not obtain the consent form for the use of Lorazepam and Hydroxyzine for R #3 prior to the use of medication. The DON confirmed that staff are expected to complete the psychotropic medication (psychotropic medication; any drug that affects brain activities associated with mental processes and behavior) consent form prior to the resident starting psychotropic medications and did not.

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 3 (R #3, R #9 and R #60) of 5 (R #1, R #3, R #5, R #9, and R #60) residents reviewed for unnecessary medications, when staff failed to ensure psychotropic medications were necessary to treat a specific condition as diagnosed and documented in the clinical record. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are:R#3A. Record review of R #3 admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:2. Gastroenteritis and colitis (Gastroenteritis; inflammation of the stomach and intestines; Colitis; inflammation specifically of the large intestine)3. Hypotension (low blood pressure)4. Chronic pain5. Constipation6. Paraplegia (paralysis affecting the lower half of the body)7. Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significance impairment in daily life.) B. Record review of R #3's physician orders revealed the following:1. An order for Melatonin Oral Tablet (hypnotic; drugs whose primary function is to induce sleep) 3 milligrams (MG). Give 1 tablet by mouth at bedtime for insomnia. Start date 07/08/25. 2. An order for Tetrabenazine Oral Tablet 12.5 milligrams (MG). Give 1 tablet by mouth three times a day for Tardive Dyskinesia. Start date 07/13/25. R #9C. Record review of R #9's admission record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses: 1. Depression (a mood disorder that causes persistent feeling of sadness and loss of interest), 2. Insomnia (sleep disorder making it hard to fall or stay asleep)3. Cerebral infarction (ischemic stroke; happens when a blood clot blocks an artery in the brain, cutting off oxygen and causing brain cells to die)4. Hyperlipidemia (high levels of fat in your blood) D. Record review of R #9's physician order revealed an order for Hydroxyzine HCl Tablet (antihistamine; medications used to treat anxiety, allergic reactions and as a sedative before and after surgery) 50 milligrams (MG). Give 1 tablet by mouth two times a day for anxiety/agitation Start date 12/02/25. R #60E. Record review of R #60's admission record revealed R #60 was admitted to the facility on [DATE] with the following diagnoses. 1. Respiratory Failure (low blood oxygen)2. Anxiety Disorder (mental disorder characterized by intense, excessive, and persistent worry or fear that interferes with daily life,)3. History Of Ischemic Attack (ischemic stroke; happens when a blood clot blocks an artery in the brain, cutting off oxygen and causing brain cells to die)4. Dissociative Identity Disorder (a complex mental health condition, where a person's identity fragments into two or more distinct personalities)5. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs)6. Major Depressive Disorder (a mental heal disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.) F. Record review of R #60's physician order revealed an order for Depakote (anticonvulsant medication) Oral Capsule 125 MG. Give 1 capsule by mouth three times a day for Dementia with behavioral disturbance. Start date 07/22/25 G. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON) she confirmed the following:1. R #3 does not have a diagnosis for insomnia,2. R #3's indicated use of Melatonin is for insomnia, 3. R #3 does not have a diagnosis listed for Tardive Dyskinesia,4. R #3's indicated use of Tetrabenazine is for Tardive Dyskinesia, 5. R #9 does not have a diagnosis for anxiety, 6. R #9's indicated use of Hydroxyzine is for anxiety, 7. R #60 does not have a diagnosis for dementia, 8. R #60's indicated use of Depakote is for dementia. The DON confirmed medications should be documented to treat specific conditions as diagnosed and were not.

Based on observation, record review, and interview, the facility failed to ensure staff revised the care plan for 6 (R #3, R #4, R #7, R #24, R #27 and R #48) of 9 (R #1, R #3, R #4, R #5, R #7, R #9, R #24, R #27 and R #48) residents reviewed when staff failed to:1. Revise R #3's care plan to include use of psychotropic drugs (drugs that affect a person's mental state),2. Update R#4's care plan to remove the use of Voltaren (medication used for pain),3. Revise R#7's care plan to include appropriate interventions for falls.4. Revise R #24's discharge goals in the care plan to include current discharge goals. 5. Revise R #27's care plan to include the current size of bed rails.6. Revise R#48's care plan to remove the use of a wander guard (wearable device that tracks movement.)These deficient practices are likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are:R#3A. Record review of R #3's admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:1. Anxiety (feelings of fear or apprehension),2. Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),3. Hypotension (low blood pressure),4. Chronic pain,5. Constipation,6. Paraplegia (paralysis affecting the lower half of the body),7. Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significance impairment in daily life).B. Record review of R #3's physician order revealed an order for Melatonin Oral Tablet (hypnotic; drugs whose primary function is to induce sleep) 3 milligrams (MG). Give 1 tablet by mouth at bedtime for insomnia. Start date 07/09/25,C. Record review of R #3's care plan revised on 12/01/25 revealed the following:1. R #3 is at risk for complications related to the use of psychotropic drugs medications Mirtazapine (antidepressant), Sertraline (antidepressant), Buspirone (antianxiety), Lorazepam (antianxiety), Hydroxyzine (antihistamine used to treat anxiety) and Tetrabenazine (antipsychotic).2. The care plan does not contain the use of Melatonin.R #4D. Record review of R #4's admission record revealed R #4 was admitted into the facility on [DATE] with the following diagnoses:1. Chronic pain syndrome (long-lasting pain that significantly impacts life), 2. Chronic obstructive pulmonary disease, unspecified (ongoing lung condition caused by damage to the lungs),3. Essential (primary) hypertension (common form of high blood pressure),4. Depression, unspecified,5. Atherosclerotic heart disease of native coronary artery without angina pectoris (progressive condition characterized by the accumulation of lipids, inflammatory cells, and fibrous elements within the arterial walls).E. Record review of R #4's physician orders revealed a discontinued order for Voltaren Gel 1% with a discontinued date (DC) of 09/19/25.F. Record review of R #4's care plan revised 11/25/25 revealed an intervention for Voltaren gel to apply as ordered with initiated date of 08/22/25.R #7G. Record review of R #7's admission record revealed R #7 was admitted into the facility on [DATE] with the following diagnoses:1. History of falling,2. Lack of coordination (inability to make smooth, controlled movements), 3. Unspecified cirrhosis of liver (chronic liver disease characterized by the replacement of healthy liver tissue with scar tissue, leading to liver failure),4. Muscle weakness (generalized),5. Periorbital cellulitis (bacterial infection that causes swelling in the skin around your eye).H. Record review of R #7's quarterly Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 11/22/25, revealed the following:1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 05, severe cognitive impairment.2. R #7 has had falls since being admitted to the facility.I. Record review of R #7's care plan initiated on 02/14/25 revealed the following:1. R #7 is at risk for falls.2. R #7's care plan was revised to include falls for 09/18/25, 10/5/25, 10/10/25, 10/21/25, 11/1/25, 11/6/25, 11/18/25 however, R #7's care plan does not include interventions revised to ensure the safety of R #7 after potential risks related to falls.R #24J. Record review of R #24's admission record revealed R #24 was admitted to the facility on [DATE] with the following diagnoses:1. Stable burst fracture of unspecified lumbar vertebra (a serious spinal injury where the vertebral body is compressed and then fractures into multiple pieces),2. Type 2 diabetes mellitus (DM2, a condition that results from insufficient production of insulin, causing high blood sugar),3. Depression,4. Parkinsonism (an umbrella term that refers to a group of conditions characterized by slowed movement, rigidity, and tremors).K. Record review of R #24's care plan revised on 04/15/25 revealed the following Focus areas:1. R #24 is a long-term resident with no plans for discharge.2. R #24's goal is to increase ADL (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating) status and return home with family. R #27L. Record review of R #27's admission record revealed R #27 was admitted to the facility on [DATE] with the following diagnosis1. Hemiplegia (complete paralysis) and Hemiparesis (weakness) following Cerebral Infarction (stroke) affecting Left non-dominant sideM. Record review of R #27's most recent bed rail assessment dated [DATE] revealed bed rail recommendation of quarter size rails on left and right upper sides of beds.N. Record review of R #27's physician order revealed an order dated 09/23/24 for half size bed rails as an enable for turning and repositioning in bed.O. Record review of R #27's care plan revised on 11/19/25 revealed R #27 uses half-sized bed rails on each upper side of the bed for mobility.P. On 12/02/25 at 9:20 am during a random observation of R #27 room revealed quarter size bed rails on the left and right upper side of the bed.Q. On 12/02/25 at 9:45 am during an interview with R #27, she stated she uses the bed rails to help her reposition herself while lying in bed.R. On 12/4/25 at 9:16am during an interview with Registered Nurse (RN) 2, she confirmed the rails on R #27's bed are quarter size rails.R #48S. Record review of R #48's admission record revealed R #48 was admitted into the facility on [DATE] with the following diagnoses:1. Unspecified severe protein-calorie malnutrition (occurs when an individual does not consume enough protein and calories, leading to significant muscle and fat loss, and impaired bodily functions).2. Acute and chronic respiratory failure with hypoxia (respiratory failure when you don't have enough oxygen in your blood).3. Cachexia (condition that causes significant weight loss and muscle loss).4. Chronic diastolic (congestive) heart failure.T. Record review of R #48's physician record revealed a discontinued order for wander guard with a discontinued date (DC) of 10/07/25.U. Record review of R #48's care plan revised on 11/12/25 revealed an intervention for wander guard in place with initiated date of 08/12/25.V. On 12/05/25 at 1:22pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. The care plan for R #3 should have been revised to include use of melatonin as a psychotropic drug and was not.2. R #4 does not have an active order for Voltaren Gel. R#4's care plan should have been revised to remove the use of Voltaren gel and was not.3. Fall interventions that are in place for R #7 are not appropriate interventions and do not meet her expectations.4. R #24's care plan was not revised to include her current discharge goals.5. R #27 uses quarter size bed rails on each side of her bed. The care plan for R #27 should have been revised to include the use of current size bed rails and was not.6. R #48 does not have an active order for a wander guard. R#48's care plan should have been revised and was not.

Based on record review and interview, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by ensuring medications have an adequate indication of use and ensuring indication of use is based off of the residents' current diagnosis for 5 (R #1, R #3, R #5, R #9, and R #60) of 7 (R #1, R #3, R #5, R #9, R #11, R #40 and R #60) residents reviewed for unnecessary medications. This deficient practice could likely lead to adverse drug effects and poor patient outcomes. The findings are:R #1A. Record review of R #1's admission Record revealed R #1 was admitted to the facility on [DATE] with the following diagnoses:1. Chronic obstructive pulmonary disease (COPD; progressive lung disease that makes it difficult to breathe, irreversible damage to the lungs and airways).2. Hypertension (high blood pressure)3. Hyperlipidemia (high cholesterol)B. Record review of R #1's physician records revealed an order for Aspirin oral tablet 81 milligrams (MG). Give 1 tablet by mouth one time a day for preventative (does not identify use or need of medication). Start date 11/19/25.C. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed R #1 has an order for aspirin. The order for aspirin does not indicate what the medication is used for and should. She confirmed preventative is not an appropriate indication of use for medication and does not meet her expectations.R #3A. Record review of R #3 admission Record revealed R #3 was admitted to the facility on [DATE] with the following diagnoses:2. Gastroenteritis and colitis (Gastroenteritis; inflammation of the stomach and intestines; Colitis; inflammation specifically of the large intestine),3. Hypotension (low blood pressure),4. Chronic pain.5. Constipation.6. Paraplegia (paralysis affecting the lower half of the body).7. Major depressive disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significance impairment in daily life).E. Record review of R #3's physician orders revealed the following:1. Acidophilus Probiotic (dietary supplement) oral tablet. Give 2 capsules by mouth two times a day for probiotic. Start Date 07/09/25.2. The order does not contain the dosage of the medication.F. On 12/05/25 at 1:22 pm, during an interview with the DON, she confirmed1. R #3 has an order for Acidophilus Probiotic. 2. The order for Acidophilus Probiotic does not indicate what the medication is used for and should. She confirmed probiotic is not an appropriate indication of use for medication.3. The order should contain the dosage of medication4. The order and instructions should have the same form of medication (capsule vs tablet) being delivered.The DON stated the order for R #3's Acidophilus Probiotic does not meet her expectations.R #5G. Record review of R #5's admission record revealed R #5 was admitted to the facility on [DATE] with the following diagnoses:1. Emphysema (a chronic lung disease where tiny air sacs (alveoli) in the lungs become damaged and lose elasticity),2. Anemia (a common blood disorder where your body lacks enough healthy red blood cells to carry sufficient oxygen to tissues),3. Bell's Palsy (temporary condition causing weakness or paralysis on one side of the face due to inflammation of the facial nerve),4. Cerebral ischemic attack (a temporary blockage of blood flow to the brain),H. Record review of R #5's physician orders revealed the following:1. Potassium Chloride Extended Release (ER) Oral Tablet 8 milliequivalent (MEQ). Give 1 tablet by mouth two times a day for hypokalemia. Start Date 11/18/25.2. Atorvastatin Calcium Tablet 40 milligrams (MG). Give 1 tablet by mouth at bedtime for hyperlipidemia. Start Date 07/09/25.3. Colace Capsule 100 milligrams (MG). Give 1 capsule by mouth two times a day for Constipation. Start date 07/09/25.4. Aspirin Tablet 81 milligrams (MG). Give 1 tablet by mouth one time a day for prophylactic (does not identify use or need of medication). Start Date 07/10/25.5. Naloxone hydrochloride (HCl) Liquid 4 milligrams (MG)/0.1milliters (ML). Give 1 spray alternating nostrils every two minutes as needed for sign of opioid overdose. May be repeated every two to three minutes for unresponsiveness or difficulty breathing, until individual is breathing rate is greater than ten. Initiate emergency medical response protocol (e.g., call 911) and transfer to the hospital. Start Date 10/29/25.6. R #5 does not have current orders for opioid medications.I. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. R #5 does not have a diagnosis of hypokalemia, hyperlipidemia, and constipation.2. R #5's medications should be indicated to use as it relates to her diagnosis and does not.3. R #5 has an order for aspirin. The order for aspirin does not indicate what the medication is used for and should. She confirmed prophylactic is not an appropriate indication of use for medication does not meet her expectations.4. R #5 is not currently taking opioids and should not have an order for Naloxone. R #9J. Record review of R #9's admission record revealed R #9 was admitted to the facility on [DATE] with the following diagnoses:1. Depression (a mood disorder that causes persistent feeling of sadness and loss of interest),2. Insomnia (sleep disorder making it hard to fall or stay asleep),3. Cerebral infarction (ischemic stroke; happens when a blood clot blocks an artery in the brain, cutting off oxygen and causing brain cells to die),4. Hyperlipidemia (high levels of fat in your blood).K. Record review of R #9's physician orders revealed the following: 1. Cetirizine HCl Oral (allergy medication) Tablet 10 milligrams (MG). Give 1 tablet by mouth one time a day for allergies. Start Date 10/22/25.2. Cephalexin Oral Capsule (antibiotic medication) 500 milligrams (MG). Give 1 capsule by mouth three times a day for urinary track infection (UTI) for 7 Days. Start date 11/28/25.3. Aspirin Oral Tablet Chewable 81 MG. Give 1 tablet by mouth one time a day for preventative. Start Date 10/22/25.L. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed the following:1. R #9 does not have a diagnosis listed of allergies and UTI.2. R #9's medications should be indicated to use as it relates to her diagnosis and does not.3. R #9 has an order for aspirin. The order for aspirin does not indicate what the medication is used for and should. She confirmed preventative is not an appropriate indication of use for medication and does not meet her expectations.R #60M. Record review of R #60's admission record revealed R #60 was admitted to the facility on [DATE] with the following diagnoses.1. Respiratory Failure (low blood oxygen)2. Anxiety Disorder (mental disorder characterized by intense, excessive, and persistent worry or fear that interferes with daily life,)3. History Of Ischemic Attack (ischemic stroke; happens when a blood clot blocks an artery in the brain, cutting off oxygen and causing brain cells to die)4. Dissociative Identity Disorder (a complex mental health condition, where a person's identity fragments into two or more distinct personalities)5. Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs)6. Major Depressive Disorder (a mental heal disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life.)N. Record review of R #60's physician orders revealed the following:1. Furosemide Tablet (Diuretic; to treat fluid retention) 40 milligrams (MG). Give 1 tablet by mouth one time a day for bilateral lower edema. Start Date 11/18/252. Aspirin Tablet Chewable 81 milligrams (MG). Give 1 tablet by mouth one time a day for prophylactic. Start Date 04/08/25,O. On 12/05/25 at 1:22 pm, during an interview with the Director of Nursing (DON), she confirmed the flowing:1. R #60 does not have a diagnosis of edema.2. R #60's medications should be indicated to use as it relates to her diagnoses and does not.3. R #60 has an order for aspirin. The order for aspirin does not indicate what the medication is used for and should. She confirmed prophylactic is not an appropriate indication of use for medication and does not meet her expectations.

Based on record review and interview, the facility failed to provide a Facility Initiated Report (mandatory self-initiated facility report of an incident) and a five day follow up report to the State Survey Agency (SSA) for 1(R#7) of 1 (R #7) resident reviewed for incidents when staff failed to report the following incidents:1) Unwitnessed fall with injury for R #7.2) Injury of left hand for R #7 within two hours of becoming aware of the injuries.This deficient practice is likely to result in the State Survey Agency (SSA) not being aware of facility incidents and being unable to assure residents safety. The findings are:A. Record review of R #7's nursing documentation, dated 09/16/25 at 6:13 am, revealed R #7 reported falling into wheelchair. Noted swelling, mild deformity (a minor physical abnormality in the shape, size, or alignment of a body part), bruising, pain rated 6/10 (pain scale; a rating zero to ten where zero is no pain and ten is the worst pain possible) to left hand.B. Record review of the facility's complaint intake report dated 10/10/25 revealed R #7 had an unwitnessed fall on 09/16/25 resulting in a broken finger. C. Record review of the State Survey Agency's (SSA) Intake Report indicated no facility report was received on 09/16/25 for an unwitnessed fall with injury to R #7's left hand. D. Record review of the State Survey Agency's (SSA) Follow up Report dated 12/04/25 revealed the facility follow up report was completed 79 days after R #7 had an unwitnessed fall on 09/16/25. E. On 12/04/25 at 10:15 am during an interview with the Director of Nursing (DON), she stated any fall with significant injury should have been reported right away and it was not. DON stated they should have done an in-house report to the state when it was brought to their attention of the unwitnessed fall on 09/16/25 within two hours.

Based on observation, record review, and interview, the facility failed to develop and implement an accurate, comprehensive care plan for 1 (R #8) of 3 (R #8, R #12, and R #25) residents reviewed for care plans when staff failed to include R #8's use of an external catheter (external catheter (a non-invasive medical device used to collect urine from outside the body) and interventions needed to care for R #8 and the external catheter. This deficient practice could likely result in an increase in infections and other health concerns. The findings are: A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff to pump enough blood to meet the body's needs),3. Need for assistance with personal care. B. On 12/01/25 at 11:53 am during a random observation of R #8's room revealed a canister with what appeared to be urine. C. On 12/01/25 at 12:15 pm, during an interview with R #8, she confirmed the canister was connected to an external catheter that she utilizes. R #8 stated that she has used the external catheter since before she was admitted to the facility. D. Record review of R #8's electronic health record revealed no care plan or intervention in place for R #8's use of an external catheter. E. On 12/05/25 at 1:13 pm during an interview with the Director of Nursing (DON), she confirmed R #8 does utilize an external catheter. The DON confirmed the facility failed to develop and implement a care plan that includes R #8's external catheter use. The DON stated that she expects every resident that utilizes a catheter whether it's external or not to have a care plan that includes needed interventions.

Based on record review and interview, the facility failed to provide activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, transfers, toileting, and eating) assistance for transfers (assisting a resident from one place such as a bed to another place such as a wheelchair) for 1 (R #50) of 3 (R #27, R #50, and R #60) residents reviewed for ADL care. This deficient practice is likely to affect the dignity and health of the residents. The findings are:A. Record review of R #50's admission record revealed R #50 was admitted to the facility on [DATE] with the following diagnoses:1. Acute respiratory failure with hypoxia (a medical condition where a sudden decrease in oxygen levels in the blood is due to the lungs' inability to exchange gases), 2. Morbid (severe) obesity, 3. Chronic obstructive pulmonary disease (COPD; lung disease). B. Record review of R #50's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) dated 10/08/25, revealed the following: 1. A Brief Interview for Mental Status (BIMS; a screening for cognitive impairment) score of 15; Cognitively Intact. 2. R #50 is dependent (staff does all of the effort) on staff for toileting hygiene, showering or bathing, and all transfers from bed to wheelchair. C. On 12/02/25 at 8:52 am during an interview with R #50, she stated she cannot get out of bed when the facility is short staffed. R #50 stated this last occurred on 11/24/25, she was able to remember the date because she documented a note on her phone. R #50 stated the Director of Nursing (DON) told her on that date that the facility was short staffed so if R #50 would need to stay in bed or stay in her wheelchair until 9:00 pm or 10:00 pm that night because that is when staff would be able to transfer her again. R #50 said it hurts to stay in her wheelchair for that long, so she had to stay in bed. D. On 12/05/25 at 1:05 pm during an interview with the Director of Nursing (DON), she stated that she does not remember having that conversation with R #50 but confirmed that it does take extra people to get R #50 out of and into her bed because she uses a mechanical lift (a device designed to help staff move a resident from one place to another within a room or from one position to another) for all transfers.

Based on observation, record review and interview, the facility failed to ensure a resident with an external catheter (a non-invasive device worn over the genitals) had an order that demonstrated that a catheter was necessary, what type of catheter was needed, and how to care for the catheter for 1 (R #8) of 1 (R #8) resident reviewed for catheter use. This deficient practice could likely result in an increased and unnecessary risk of infections for residents. The findings are: A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff to pump enough blood to meet the body's needs),3. Need for assistance with personal care.B. On 12/01/25 at 11:53 am during a random observation of R #8's room revealed a canister with what appeared to be urine. C. On 12/01/25 at 12:15 pm, during an interview with R #8, she confirmed the canister was connected to an external catheter that she utilizes. R #8 stated that she has used the external catheter since before she was admitted to the facility. D. Record review of R #8's current medical orders revealed no order for the use of a catheter, the type of catheter that is needed, or the care that the catheter requires.E. Record review of R #8's electronic health record revealed no care plan or intervention in place for R #8's use of an external catheter.F. Record review of R #8's MDS assessment dated [DATE], section H revealed R #8 does not use an external catheter.G. On 12/05/25 at 1:13 pm during an interview with the Director of Nursing (DON), she confirmed R #8 does utilize an external catheter and should have an order and care plan with interventions in place.

Based on record review, observation, and interview, the facility failed to complete an accurate Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessment for 1 (R #8) of 1 (R #8) resident reviewed for assessments. This deficient practice could likely result in the residents' preferences and care needs not being met. The findings are:A. Record review of R #8's admission Record revealed R #8 was admitted to the facility on [DATE] with the following diagnoses:1. Adult failure to thrive (a syndrome that describes a decline characterized by weight loss, decreased appetite, poor nutrition, inactivity and often accompanied by dehydration, depressive symptoms, and impaired immune function, among others.),2. Chronic heart failure (a long-term condition where the heart muscle becomes too weak or stiff to pump enough blood to meet the body's needs),3. Need for assistance with personal care. B. Record review of R #8's MDS assessment dated [DATE], section H revealed R #8 does not use an external catheter (a non-invasive medical device used to collect urine from outside the body). C. On 12/01/25 at 11:53 am during a random observation of R #8's room revealed a canister with what appeared to be urine collecting. D. On 12/01/25 at 12:15 pm, during an interview with R #8, she confirmed the canister was connected to an external catheter that she utilizes. R #8 stated that she has used the external catheter since before she was admitted to the facility. E. On 12/05/25 at 1:13 pm during an interview with the Director of Nursing (DON), she confirmed that R #8 does utilize an external catheter. The DON confirmed that the external catheter was not included in R #8's MDS assessment and stated it should be included in the MDS assessment.

Based on record review and interview, the facility failed to create a baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) within 48 hours of admission for 1 (R #67) of 1 (R #67) resident reviewed for baseline care plans. This deficient practice could likely result in residents not receiving the appropriate care and may place residents at risk of an adverse event (undesirable experience, preventable or non-preventable, that caused harm to a resident because of medical care or lack of medical care) or worsening of current condition after admission. The findings are: A. Record review of R #67's admission Record revealed R #67 was admitted to the facility on [DATE] with the following diagnoses:1. Partial intestinal obstruction (a person's intestines are impacted with stool), 2. Essential hypertension (HTN; high blood pressure),3. Colostomy [a surgical procedure in which the colon is connected to the abdominal wall and anopening (stoma) is created in the abdominal wall created to allow waste to leave the body] status,4. Encounter for surgical aftercare following surgery on the digestive system (need for assistance after abdominal surgery). B. Record review of R #67's Electronic Health Record revealed there was no baseline care plan. C. On 12/05/25 at 12:50 PM during an interview with the Director of Nursing (DON), she confirmed the baseline care plan was not completed and should have been.

Based on record review and interview, the facility failed to complete and document a thorough investigation, implement measures to prevent further abuse, and implement corrective actions regarding allegations of neglect (failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness) and abuse (knowingly causing physical or mental harm or failing to provide goods and services necessary to avoid physical or mental harm) for 3 (R #s 4, 8 and 9) of 7 (R #s 4, 5, 6, 7, 8, 9 and 10) residents reviewed for abuse/neglect allegations when staff failed to: 1. Complete and document a thorough investigation, remove staff identified while the investigation was conducted, and implement corrective actions for R #4, R #8 and R #9. 2. Provide a follow-up report within five working days from the date of the incident to the State Survey Agency (SSA) for R #4. If the facility fails to implement preventive and corrective actions necessary to prevent and correct the incident from happening again and fails to send the report to the SSA, then it is likely residents will feel frustrated, unsafe, and not enjoy living to their highest practicable well-being. The findings are: R #8 A. Record review of R #8 face sheet revealed she was admitted into the facility 12/27/23. B. Record review of an Abuse Questionnaire form (a facility-initiated form which asked residents about abuse, neglect and exploitation by staff in the facility), dated 04/23/24, revealed the following: - R #8 stated Certified Nurse Aide (CNA) #3 was rude to her and made her feel bad for needing anything. - R #8 stated she knew how to report abuse, neglect, or exploitation. - The abuse coordinator was the Administrator (ADM). - The staff aware of the questionnaire form were the DON, ADM, and Licensed Practical Nurse (LPN) #2. C. Record review of the facility's records revealed staff did not investigate R #8's abuse allegations. D. On 05/06/24 at 4:45 pm during an interview with the DON, she stated staff did not report R #8's allegations to the SSA or complete an investigation. R #9 E. Record review of R #9 face sheet revealed she was admitted into the facility 11/22/23. F. Record review of an Abuse Questionnaire, dated 04/23/24 revealed the following: - R #9 stated CNA # 3 was very rude and made her feel bad for pushing the call button. - R #9 stated knew she how to report abuse, neglect, or exploitation. - The abuse coordinator was the ADM. - The staff aware of the questionnaire form were the DON, ADM, and Licensed Practical Nurse (LPN) #2. G. Record review of the facility's records revealed staff did not investigate R #9's abuse allegations. H. On 05/06/24 at 4:28 pm during an interview with Human Resources (HR), she stated staff should have conducted a thorough investigation of the allegations by R #8 and R #9. HR stated staff did not report R #8's and R #9's abuse allegations to the SSA, and the facility did not investigate the allegations. I. On 05/09/24 at 10:00 am during an interview with the ADM, she stated she assumed the DON documented and completed an initial incident report and a five-day follow-up report to the SSA for the allegations by R #8 and R #9. The ADM confirmed there was not any documentation regarding a thorough investigation of the residents' allegations. J. Record review of staffing schedule for CNA #3 revealed CNA #3 was removed from the schedule following the allegations on 04/23/24. R #4 K. Cross reference to findings for R #4 identified in F600. L. Record review of the facility's incident report, dated 04/23/24, revealed the following: - R #4 had injuries of unknown origin. - The SSA received the incident report from the facility on 04/25/24. - The facility did not submit a five-day follow-up report to the SSA. M. Record review of staffing schedule for LPN #4, LPN #5, and CNA #2, revealed each staff member continued to be placed on schedule to work. LPN #5 was terminated on 05/03/24, LPN #4 was suspended 05/14/24, and CNA #2 did not have a lapse in employment. N. Record review of R #4 medical record revealed staff did not conduct an investigation related to R #4's abuse allegation. O. Repeated requests for the facility investigation of the incident for R #4 were made to the Administrator, but the facility did not provide an investigation. Based upon observations, record reviews, and interviews, Immediate Jeopardy was identified on 05/15/24 at 2:24 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 05/15/24 at 4:43 pm. Implementation of the POR was onsite on 05/16/24 by conducting observations, record reviews, and staff interviews. The scope and severity was lowered to E. Plan of removal: A full abuse investigation will occur within the facility to ensure no other residents have witnessed abuse, or been abused, completed on 5/13/2024. If any further abuse allegations are brought forward, the facility will remove any resident from the abuse situation, and proper monitoring and interventions will be initiated immediately upon notification. There were no new allegations brought forth at that time. If any staff are identified in an allegation of abuse, they will be placed on administrative leave until the investigation is complete. On 5/15/2024 surveyor's identified an LPN [LPN #2/Unit Manager] of concern, this LPN was placed on administrative leave at that time on 5/15/2024, pending an investigation. This LPN last day worked was 5/9/2024. The Administrator resigned on 5/10/2024. The Director of Nursing was placed on administrative leave on 5/9/2024. The Interim Director of Nursing/designee re-educated current staff regarding abuse policy. The education includes the policy, with emphasis on the following: If abuse or behavioral issues are occurring (combative/physical behavior, threatening behavior, or anything that could be harmful to oneself or any other person), the victim should be separated from the aggressor immediately. The aggressor should be placed on 1:1 supervision immediately, and remain on this type of monitoring until they have been sent to the ER, a behavioral unit, or the provider has cleared them of all potential to harm themselves or others. Documentation needs to occur to reflect this monitoring, and clear discontinuation of the 1:1, and reasoning by a provider. If a staff member is accused of abuse, they should be replaced on their shift and removed from the building until police arrive (if necessary), removed from the schedule, and not put back on the schedule until an investigation is completed, and they have been cleared by the Administrator or DON to return. The provider, nurse manager and family has to be notified immediately. The eInteract change in condition assessment needs to be completed filled out with all the details of what happened. Monitoring and interventions need to continue to happen and be documented if the resident remains in the building, until we know they have stabilized per the provider, or have left the center. The Interim Director of Nursing/designee will begin education 05/15/24 and continue until all staff have been educated prior to their next shift, any licensed staff member on leave of absence (FMLA), vacation, or PRN staff will be re-educated prior to returning to duty. New hires/agency staff are educated on the abuse policy and process during orientation 49827 48960

Based on record review and interview, the facility failed to ensure nursing staff demonstrated appropriate competency and skills when: 1) LPN #2/Unit Manager failed to administer accurate medication dosages to a resident; 2) LPN #2 failed to follow facility process for receiving emergency medications; 3) LPN #2 inaccurately documented on the medication administration record to intentionally deceive; 4) LPN #1 began working without completing an application, having a background clearance, training and demonstration of competency prior to providing care to residents. This deficient practice likely resulted in: 1) R #1 receiving too much medication, which resulted in her being admitted to the hospital on 11/06/23 for difficulty breathing and altered mental status, and 2) A non-employee nurse working, including providing direct care and administering medication to residents, for three shifts without a background clearance, TB testing, or training. The findings are: Medication Error A. Record review of facility's Management of Controlled Drugs policy, dated 08/01/05 revised 04/01/22, revealed staff to utilize the Automated Medication Dispensing Systems (AMDS) which may have an emergency supply of controlled substances. Nurses must follow federal and state regulations to access emergency supplies of controlled substances. B. Record review of facility's Medication Error policy, dated 01/01/04 revised 06/01/21, revealed staff to investigate medication errors and implement appropriate interventions. Staff will report, log, and trend medication errors. A medication error was defined as a discrepancy between what the physician/advanced practice provider ordered and what the resident/patient received. Types of errors include: medication omission; wrong patient, dose, route (oral or injected), rate, or time; incorrect preparation; and/or incorrect administration technique. C. Cross reference F760 D. Record review of the facility's documents revealed the following: - Staff did not report the overdose to the hospital; - Staff did not report the overdose to the State Agency; - The Administration did not investigate the incident; - Staff did not document the medication error. - Staff inaccurately documented that the medication had spilled. E. On 05/09/24 at 3:03 pm during an interview, the Administrator (ADM) stated the DON and LPN #2/Unit Manager did not report the medication error to her. She stated she was not aware they reported the incident to the NP or that staff documented the morphine as spilled. Not conducting background check, provide training and verify competency prior to working F. Record review of the facility's Hiring Policy, dated 07/01/22 , revealed offers of employment were contingent upon successful completion of hiring requirements, including verifying credentials, licenses, and/or other documents required, completing a criminal background check, substance abuse screening, and employee health screening. G. On 05/07/2024 at 4:28 pm, during an interview with Payroll/Scheduler (PS), she stated she came into work on 05/06/24 and found a written time sheet on her desk, which was signed by LPN #2/Unit Manager and LPN #1. She stated LPN #1 was not a hired employee and did not have an application on file. The PS stated that according to the time sheet, LPN #1 worked in the facility from 05/03/24 thru 05/05/24. She stated LPN #2 told LPN #1 to work over the weekend in place of LPN #5, and LPN #1 used LPN #2's credentials to log into the system [electronic medication record] over the entire weekend. The PS stated she notified the Administrator on 05/06/24 and was told to just get her hired. The PS stated she also notified the Corporate Human Resources (CHR) as was told to just hurry and get LPN #1 hired. H. Review of the nursing schedule, dated May 2024, revealed the schedule did not include LPN #1. Further review revealed LPN #5 was scheduled to work 05/03/24 through 05/05/24. I. Review of the written time sheet revealed LPN #1 worked 05/03/24 through 05/05/24, and she signed the time sheet. Further review revealed the time sheet was also signed by LPN #2, the Unit Manager. J. Record review of LPN #1's application revealed it was submitted on 05/06/24. The records did not contain documentation prior to 05/06/24 that LPN #1 received background clearance, training and demonstration of competency. K. On 05/09/24 at 4:00 pm during and interview with ADM, she stated she told PS to hire LPN #1 on 05/01/24 and the PS forwarded on to the corporate human resource person. The ADM stated she did not know LPN #1 worked in the building 05/03/24 through 05/05/24. She stated the PS told her about LPN #1 on 05/06/24. Based upon record review and interviews, Immediate Jeopardy was identified on 05/09/24 at 1:08 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 05/10/24 at 2:02 pm. Implementation of the POR was onsite on 05/16/24 by conducting observations, record reviews, and staff interviews. Plan of removal: Effective immediately May 9, 2024, a full audit of all current staff working in the center will occur by the end of the day on May 14, 2024, to ensure the proper hiring process was completed, including screening and training, with emphasis on: background checks, finger prints, Electronic Health Record (EHR) access. Anyone identified as not meeting these requirements will immediately be removed from the schedule until requirements are met. A full audit of current direct care staff will occur by the end of the day on May 14, 2024, to ensure all direct care staff have their own EHR access. Market Human Resources/designee will re-educate current management staff on hiring process, including required screening and training prior (background checks, finger prints and EHR access) to beginning work within the center. Nurse manager/designee will provide education to all staff that they are never to use another staff member's sign-in for any application. If they are unable to use their own sign-in, they will contact IT and/or management immediately until their access issues have been resolved. Education will begin 05/09/24 and continue until all identified staff have been educated prior to their next shift. Any management staff member on leave of any type, or PRN (as needed) staff will be re-educated prior to returning to duty. New hires will be educated on this process upon hire. The Administrator/designee will review new hires daily to ensure the process for new hires is being followed. The Director of Nursing/designee will begin education 5/9/2024. As of the end of the day, 5/10/24, 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule as of 5/10/2024, is on leave of any type, or PRN staff will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation. 49827

Based on record review and interview, the facility failed to ensure residents were free of significant medication errors for 1 (R #1) of 1 (R #1) residents reviewed for neglect, when nursing staff administered the wrong dose of medication to R #1. This deficient practice likely resulted in the overdosing of R #1 which resulted in an immediate increased in heart rate, decrease in blood pressure, inability to respond and fatigue requiring admission to the hospital. The findings are: A. Record review of R #1's Face Sheet revealed an initial admitted [DATE] and a discharge date of [DATE]. B. Record review of R #1's Physician's Progress notes, dated 11/06/23, revealed the physician saw the resident for altered mental status (change in normal mental function), tachycardia (faster than normal heart rate), low blood pressure, and hypoxia (low levels of oxygen in blood). A Certified Nursing Assistant (CNA) called the writer to the shower room around 10:30 am, because resident was acting differently. The writer took the resident to the nursing station and obtained the resident's vital signs (the basic functions of your body). The vital signs were as follows: oxygen 82 percent (%) room air (without the use of supplemental oxygen) , heart rate 154 beats per minute (bpm; normal heart rate for a female whose age is [AGE] years old is between 71 and 73 bpm), blood pressure unable to obtain. The resident did not appear to respond to the writer's voice, as the resident's baseline (normal state of being) was eye tracking (following with your eyes) with some verbal statements. The writer called the Registered Nurse (RN) and the Unit Manager to assist with the resident. The nursing staff reported the resident did not eat any breakfast and had loose stools throughout the weekend. The writer noted the resident had cracked, dry lips and dry oral membranes. Staff placed the resident in her room with intravenous (IV) started, normal saline infused, 500 milliliters (ml) bolus (single large dose of medication), and supplemental oxygen in place at 6 liters (L) via simple mask (a device that covers the nose and mouth and delivers oxygen to patients). Verbal order: 2 mg morphine oral concentrate one time, now. At 10:45 am, the writer attempted to call the resident's emergency contact. The daughter agreed with current interventions and agreed for resident to be transferred to the hospital for all life-saving interventions, if necessary. At 11:25 am, the resident's vitals were as follows: blood sugar 134 (normal range is 80-180), blood pressure 101/63 (normal range for an [AGE] year old female is 139/68 ), heart rate 117 bpm, and oxygen 98% on 6 L. The writer noted the resident's mentation (mental activity) was still altered from baseline. At 11:36 am, the resident was transferred to hospital via Emergency Medical Services (EMS). C. Record review of R #1's Physician's Order, dated 11/06/23, revealed an order for morphine sulfate concentrate (medication used to treat pain), oral solution, 20 milligram/milliliter (mg/mL). Give 2 mg orally immediately (STAT) for pain. [This was a one time order during an emergent situation.] D. Record review of Narcotic Tracking sheet for R #2 [morphine was borrowed from this resident to administer to R #1] revealed that on 11/06/23 there was a line through four doses of the morphine. Further review revealed staff documented the medication as spilled, and the Director of Nursing (DON) and LPN #2/Unit Manager signed the sheet. E. On 05/07/24 at 5:31 pm and 05/09/24 at 11:55 am during interviews, RN #1 stated that on 11/06/23, LPN #2/Unit Manager approached RN #1's medication cart and stated she was looking for morphine for an emergency situation. She stated that R #1 was having difficulty breathing. RN #2 stated the medical provider was in the building, and she assessed R #1. She stated the provider ordered 2 milligrams of morphine for R #1 to help the resident relax and to help her breathing. RN #1 stated LPN #2 told her the NP ordered morphine for R #1, but R #1 did not have a prescription for morphine. RN #1 stated LPN #2 retrieved a bottle of morphine belonging to R #2 from RN #1's medication cart. She stated LPN #2 was shaking, so RN #1 held the bottle of morphine while LPN #2 withdrew the medication with a syringe and administered the medication to R #1. She stated she was not aware of the NP's order, because the NP gave it directly to LPN #2. RN #1 stated LPN #2 kept saying, Do you know if it was 2 milligrams or 2 milliliters? RN #1 stated that after LPN #2 administered the morphine to the resident, R #1 became less responsive, and staff called the Emergency Medical Service (EMS) to take R #1 to the hospital. RN #2 stated after the resident left, staff informed her (RN #2) that LPN #2 made a mistake and administered 40 milligrams [2 ml] of morphine to R #1 instead of 2 milligrams. She stated she immediately told the DON that amount could just shut down a person's system (cause them to become unresponsive). She stated the DON told her not to worry about it, and she (DON) would call the emergency room (ER) to report the error. RN #1 stated she noticed later it was documented on R #2's narcotic medication tracking sheet, dated 11/6/23, that 40 milligrams of morphine was spilled. RN #1 stated she did not see R #2's morphine spilled. She stated that it would have been difficult to spill the morphine due to the type of bottle the medication was in. RN #1 stated that particular bottle came with a rubber stopper (small rubber-like device that provides a secure seal and protects medication from being contaminated or spilled), and she had to hold the bottle upside down while LPN #2 withdrew the medication. RN #1 also stated the morphine orders come with specific syringes that are designed to administer a specific dosage, but LPN #2 did not use the syringe that was specific to that particular prescription. RN #1 stated LPN #2 retrieved a different syringe from the medication room. RN #1 stated the normal process for retrieving emergency medications was for staff to get the order, contact the pharmacy, and then retrieve the ordered medication from the Omnicell (automated medication dispensing cabinet) or from the E-kit (Emergency kit). RN #1 stated LPN #2 asked her if she (RN #1) wanted to sign for or administer the morphine to R #1, and she told LPN #2 no. RN #1 stated she did not receive the order and borrowing medication from another resident was not right. She stated there were different concentrations for morphine, and she did not know if the order for R #1 was the same concentration as the medication borrowed from the other resident. She stated it was important to always check if its the right medication, right dose, right patient, and right route. F. On 05/08/24 at 10:00 am during an interview, Nurse Practitioner (NP) stated she ordered 2 mg of morphine to be administered to R #1 on 11/06/23. She stated LPN #2/Unit Manager and the DON reported to her that LPN #2 administered 40 mg [2 mL] of morphine to R #1. The NP stated she immediately told LPN #2 and the DON to call the hospital emergency room and report this medication error. G. On 05/08/24 at 2:07 pm during an interview, RN #2 stated R #1 came out of the shower room on 11/06/23, and she was not feeling well. RN #2 stated the resident's oxygen level was low, she was breathing heavily, her blood pressure was low, and her heart rate was high. She stated the resident had difficulty breathing. RN #2 stated the medical provider was in the building, and she assessed R #1. She stated the provider ordered 2 milligrams of morphine for R #1 to help the resident relax and to help her breathing. She stated that after LPN #2 administered the morphine to the resident, R #1 became less responsive, and staff called the Emergency Medical Service (EMS) to take R #1 to the hospital. RN #2 stated after the resident left, staff informed her (RN #2) that LPN #2 made a mistake and administered 40 milligrams [2 ml] of morphine to R #1 instead of 2 milligrams. She stated she immediately told the DON that amount could just shut down a person's system (cause them to become unresponsive). She stated the DON told her not to worry about it, and she (DON) would call the emergency room (ER) to report the error. H. Record review of R #1's Medication Administration Record (MAR), dated November 1, 2023 through November 30, 2023, revealed staff did not document morphine was administered to R #1 on 11/06/23. I. Record review of R #1's Nursing Progress Notes revealed staff documented the following: - On 11/06/23 at 11:21 am, received a new order from the Nurse Practitioner (NP) to send resident to the emergency room (ER) for evaluation and treatment, as indicated. - On 11/06/23 at 12:56 pm, the EMT's arrived to transport resident to the ER. The resident received morphine sulfate (MSO4; pain medication) per NP orders. The resident's blood pressure fluctuated as well as heart rate. The resident departed to facility at approximately 11:05 am. - On 11/07/23 at 1:18 pm, the nurse called the hospital at 12:24 pm. The patient's account was password protected. At 12:45 pm [Name of] Power of Attorney (POA - person responsible for making decisions on behalf of another person) returned call and verbalized the resident had abnormal heart rate, dehydrated, UTI (Urinary tract infection - infection in any part of the urinary system), bladder infection, oxygen saturation up and down, as well as a fracture to right collarbone which appeared to either be unhealed or refractured. - On 11/08/23 at 3:46 pm, the facility nurse spoke to the Registered Nurse (RN) at the hospital's Intensive Care Unit (ICU). The resident's admitting diagnoses were sepsis due to UTI; pneumonia: Hypoxic (low level of oxygen in blood) due to pneumonia; bladder infection; acute renal failure (when your kidneys become unable to filter waste products from your blood); Atrial fibrillation (AFib; irregular heartbeat) with RVR (very rapid heart rhythm). J. Record review of R #1's hospital records revealed the following: - Admission record, dated 11/06/23, the resident was admitted with the chief complaints of mental status and shortness of breath. The resident had a medical history of high blood pressure, arthritis (swelling and tenderness of joints), chronic obstructive pulmonary disease (COPD; lung disease), asthma (narrowing of the airways), and anxiety (mental disorder that causes persistent worry and fear). The patient lived at a retirement home, and staff noted the resident had more trouble breathing. Staff called EMS, who arrived and found the resident's blood pressure was 90/50. Staff reported the resident did not have any trauma to the body. Patient arrived in the emergency department (ED) initially alert but unresponsive to verbal commands. History of Present Illness: Altered Mental Status - This was a new problem. The current episode started 6 to 12 hours ago. The problem has not changed since onset. Associated symptoms include confusion, somnolence (drowsiness), unresponsiveness and weakness. Review of Systems: Positive for activity change and fatigue (extreme tiredness), shortness of breath, weakness, confusion, and tachycardia (faster than normal heart rate). - Discharge summary, dated 11/14/24, the resident passed away. Discharge diagnosis and principal cause of death was aspiration pneumonia (lung infection caused by inhaling substances like food, liquid, or vomit.) K. Record review of R #1's medical record revealed the records did not contain evidence the facility staff notified the hospital ER that staff administered 40 mg of morphine to R #1. Based upon observations and interviews, Immediate Jeopardy was identified on 05/09/24 at 5:15 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 05/10/24 at 2:02 pm. Implementation of the POR was verified onsite on 05/16/24 by conducting observations, record reviews, and staff interviews. Scope and severity was lowered from J to D. Plan of removal: Effective immediately May 9, 2024, an audit will be completed of every resident with a narcotic order, to ensure that all narcotics ordered are on the medication carts. If medications are missing, then the medication availability process will be followed and pulled from the Omnicell/Ekit. Effective immediately May 9, 2024, all nursing staff will be re-educated on the six rights of medication administration with an emphasis on right patient/resident and right dosage. Nurse manager/designee will provide education to all nursing staff on medication availability process. A unit manager will begin education on 05/09/24 and continue until all licensed nursing staff have been educated prior to their next shift. New hires/agency staff will be educated during orientation. A unit manager will begin education on 05/09/24. As of the end of each shift on 05/10/24, 100% of currently scheduled staff will be educated on this information. Any staff member that is not on the current schedule as of 05/10/24 will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation. The Director of Nursing/designee will begin education on 05/10/24. As of the end of the day, 5/11/24, 100% of currently scheduled staff will have been educated on this information. Any staff member that is not on the current schedule as of 5/11/24 will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.

Based on record review, observation, and interview, the facility failed to:1. Ensure staff properly stored narcotic medications in a locked container. 2. Properly dispose of unused and expired medications. This deficient practice had the potential to affect all 52 residents identified on the facility census list provided by the Director of Nursing (DON) on 05/06/24. Improperly stored medications could result in a resident, staff member, or visitors taking the medications not prescribed to them. The findings are: A. On 05/06/24 at 12:42 pm, observation of the Director of Nursing's (DON) office revealed the office was unlocked, the door was open, and the office was accessible to residents, staff, and visitors. Further observation revealed various prescription bottles on the DON's desk and in an open box on the floor next to the desk. Observation also revealed piles of various bubble packs (a disposable package consisting of a clear plastic overlay affixed to a cardboard backing for protecting and displaying a product) and boxes of narcotic medications were undated and not labeled as to which resident the medications were prescribed. Medications in the DON's office included but were not limited to morphine (medication used to treat pain), fentanyl (medication used to treat pain), and various antibiotics (medications used to treat infections) B. Record review of the facility's Management of Controlled Drugs policy, dated 04/01/22 revealed the following:- Controlled substances shall not be accessible to other than licensed nursing staff, pharmacy, and medical staff (i.e., physicians, advanced practice providers) designated to the by the Center. - All controlled substances stored under double lock, separate from other medications. - Access to keys for controlled substances double locked box/cabinet for each medication cart limited to the licensed nursing staff. - Discrepancies noted at any step of the process will be reported to appropriate persons. - If a discrepancy is noted, the nursing supervisor will be notified and will immediately initiate investigation. - The Administrator (ADM) and the DON are responsible for notification of the appropriate enforcement agencies, according to state and federal regulations, of any controlled substance discrepancy which cannot be clarified satisfactorily. C. On 05/06/24 at 2:00 pm during an interview, the DON stated the process for disposing of medications was for the facility to hold all medications for months, until there was enough to destroy with the pharmacist. She stated the pharmacist asked her monthly if there were any medications to be destroyed, but she frequently told the pharmacist there were not enough to destroy yet. She stated it could be months and months before there were enough medications stocked up to be destroyed. The DON stated staff should log and account for all medications before destruction. She stated all narcotics should be locked in a locked container and logged immediately by two nursing staff. The DON stated she did not log any of the narcotics in her office, because they were very busy and did not have time. The DON confirmed medications should not be on her desk and in boxes in her office. She stated all narcotics should be stored in a safe place D. On 05/08/24 at 2:07 pm during an interview, Registered Nurse (RN) #2 stated she observed random narcotics from past residents in the DON's unlocked desk drawer on 02/13/24. RN #2 stated she reported her concerns to the ADM and to the Corporate Human Resources (CHR) Director, and nothing was ever done. E. On 05/08/24 at 4:28 pm during an interview, the Payroll/Scheduler (PS) stated she recently needed some paperwork from the DON's office. She stated when she went into the DON's office she observed narcotics in the desk drawers that should have been disposed. The PS stated she felt this was concerning. She stated she took pictures of the unlocked drawers with narcotics and sent them to CHR. The PS stated nothing was done about it. F. On 05/09/24 at 12:27 pm, an observation of the Infection Control Storage room revealed several unlabeled medium- to large-sized cardboard boxes and several unlabeled plastic bins contained various medications, some dating back to 2022, to include expired or discontinued medications and medications for residents that have been discharged from the facility. Further observation revealed there were not any medication destruction logs available for the stored medications. Medications identified in the Infection Control Storage room included but were not limited to antibiotics, antipsychotics, and hypertension medications. G. Record review of the facility's medication reconciliation logs revealed the records did not contain documentation for reconciling what medications were present in the Infection Control Storage room and what medications should be there. H. On 05/09/24 at 12:32 pm during an interview, the ADM stated she was not aware there were medications stored in the Infection Control office. She further stated no one was allowed to go into that office, and only Unit Manager/Licensed Professional Nurse (LPN) #2 and the DON had the key. I. On 05/09/24 at 2:02 pm during an interview, LPN #6 stated she shared the office with the DON while she was employed at the facility. LPN #6 stated during that time she constantly observed the DON's desk drawers unlocked and full of narcotics. She stated the facility's process for handling narcotic medications was for staff to keep them in the lock box in the nurses' medication carts, which also locked. LPN #6 stated if a resident was discharged or expired then the nurses would give the resident's narcotics and the Narcotic Count Sheet to the Unit Managers. She stated the Unit Managers would give these items to the DON. She stated she and the DON had keys to the lock box on the wall behind the DON's desk, where they kept controlled medications that were to be destroyed. She stated the lock box required two keys (LPN #6's and the DON's) to unlock the box. LPN #6 stated initially the DON would let her know when they needed to get into the lock box, but the DON stopped asking her to unlock the box after a few months. LPN #6 stated the floor nurses reported to her that they consistently observed the DON's desk drawer to be full of narcotics. She also stated the DON would tell the Pharmacist there were not any medications to be destroyed when the Pharmacist came in for medication destruction. LPN #6 stated she reported these concerns to the ADM, to HR, and to Corporate RN (CRN) #8. She stated the facility had a pharmacy inspection coming up so they were trying to get things in order. She stated there were a lot of medications that should have been destroyed months prior, there were medications in unlocked drawers, and the medication room cabinets were overflowing with medication to be destroyed. She stated there were four or five huge boxes of medications that needed to be destroyed, and the DON told her that she (the DON) hid the medications in her personal vehicle while the inspection occurred. J. On 05/09/24 at 2:48 pm during an interview, the Pharmacist stated she comes to the facility on ce a month, and her last visit was on 04/18/24. She stated she completed a non-controlled medication destruction, because the narcotics were not ready. She stated the normal process for medication destruction was staff popped the medication out of the bubble packs and into a tote. She stated the tote was then taken to the Department of Justice's office. She stated the medications that were prepared for destruction were several months worth of medications. She further stated the DON told her for several months that there were not any controlled drugs that needed to be destroyed during her (the Pharmacist's) monthly facility visits, that included medication destruction,. K. On 05/14/24 at 3:49 pm, an observation and interview revealed the East/West Medication Storage room contained various medications, in boxes and bubble packs, with no organization. Further observation revealed some medications were from 2018, and there were not any logs available to track the medications in the storage room. RN #1 stated the medications were discontinued, expired, or belonged to residents who were no longer at the facility. RN #1 also stated management had not yet reviewed or logged the medications for destruction, to the best of her knowledge. L. On 05/14/24 at 3:54 pm, an observation and interview revealed the North Hall Medication Storage room contained various medications, there were not any logs available to track the medications. LPN #3 stated these medications were discontinued, expired, were to be destroyed, or were to be returned to the pharmacy. LPN #3 stated management had not yet reviewed or logged the medications for destruction, to the best of her knowledge. M. On 05/14/24 at 4:05 pm, an observation of the narcotic medication lock box in the DON's office revealed RN #9 held both keys and unlocked the lock box. Observation revealed there was one bottle of unopened morphine with a medication count log secured to it with a rubber band. During an interview, RN #9 stated she knew this was not the correct way to do things, because one of the keys should be held by another staff. RN #9 stated the facility called her to come in and help during the survey and gave her both keys to the lock box. Based upon observations and interviews, Immediate Jeopardy was identified on 05/10/24 at 12:56 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR) on 05/10/24 at 3:18 pm. Implementation of the POR was onsite on 05/16/24 by conducting observations, record reviews, and staff interviews. Plan of Removal: Effective immediately, May 10, 2024, a full audit of current medications for destruction was performed on and completed by 05/11/24, to ensure all medication was accounted for, logged, secured, and locked in a medication storage area or lock box until pick-up was completed or pharmacy destruction was initiated. Effective immediately, May 10, 2024, all nursing staff was re-educated on Medication Storage Policy. The Director of Nursing/designee began education on 05/10/24. As of the end of the day, 05/11/24, 100% of currently scheduled staff have been educated on this information (Medication Storage). Any staff member that is not on the current schedule as of 05/11/24 will be educated prior to returning to their next shift. New hires/agency staff will be educated during orientation.

Based on record review and interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1(R #3) of 2 (R #3 and #5) residents when they failed to follow through with physician's orders to place a peripherally inserted central catheter (PICC; a long thin tube that is inserted through a vein in your arm and passed through to the larger veins near your heart) line to administer intravenous (IV) antibiotic treatment and to order and apply a wound vacuum [a medical device that uses negative pressure (suction) to help bring the edges of your wound together. It also removes fluid and dead tissue from the wound area and aids in healing] for R #3. This deficient practice likely resulted in the resident experiencing medical complications or a worsened condition. The findings are: A. Record review of R #3's face sheet revealed an initial admitted [DATE] with the following diagnoses: - Acute osteomyelitis (infection in the bone) left ankle and foot, - Cellulitis (a serious bacterial infection of the skin which usually affects the leg, and the skin appears as swollen and red and painful), - Acute kidney failure. B. Record review of R #3's nursing progress note, dated 06/13/23, revealed she was admitted to the facility for wound care infection and had wound dressings to left buttock, anterior (front side) thigh, and bilateral (both) lower extremities (legs). C. Record review of R #3's Wound Care Clinic progress report, dated 09/08/23, revealed R #3 received treatment for the following wounds: - Ischemic ulcer (wound that develops when the arteries do not deliver enough blood flow to specific area) to the left calcaneal (largest bone in the foot) region, which measured 6.5 x 4.5 x 1 centimeters (cm). - Venous ulceration (wounds that are caused by poor blood circulation) to the left medial (middle) lower extremity, which measured 4.7 x 3.5 x 0.3 cm. - Venous ulceration to the left anterior lower extremity, which measured 0.6 x 0.4 x 0.3 cm. - Ischemic ulcer to the right calcaneal region, which measured 3.2 x 3.6 x 1.3 cm. - Venous ulceration to the right anterior ankle, which measured 0.3 x 1 x 0.2 cm. - Non-healing wound to the right lower abdomen, which measured 0.5 x 1 x 0.2 cm. - Resident was placed on oral antibiotics pending wound culture results. D. Record review of R #3's Physician's Orders revealed the following: - An order, dated 09/29/23, for a wound vacuum per physician. Call for specific orders. - An order, dated 09/29/23, for a PICC line to be placed per physician. Start date: 09/29/23. End date: 10/10/23. E. Record review of R #3's Wound Care Clinic progress report, dated 09/29/23, revealed the following: - Physician called and spoke with the Director of Nursing (DON) at the care facility. The DON stated she ordered a PICC line for R #3, but the local hospital would not do the PICC line due to R #3 could not transfer herself and would not stay still for an hour. - Facility to order and administer the following medications: - Ciprofloxacin (medication used to treat infections), 500 milligrams (mg) orally twice a day for 14 days. Start 9/29/23, End 10/13/23; - Linezolid (medication used to treat infections), 600 mg orally, twice a day for 14 days. Start 9/29/23, End 10/13/23. - Facility to insert PICC line and administer intravenous (IV; a medical procedure that delivers fluids, medications, and nutrients directly into a person's vein) antibiotics (ABX; drugs that treat bacterial infections) as previously discussed with physician. - A wound vacuum will need to be ordered by facility. Send the machine and dressing changes with patient to next appointment. F. Record review of R #3's nursing note, dated 09/29/23, revealed staff documented the following: - At 1:30 pm: Received call from physician. Wants PICC line set up and placed. Will send culture (cx; a lab test to determine if infection is present in blood, skin tissue, or other substances found in or on the body). Wants physician or Nurse Practitioner (NP) to prescribe intravenous antibiotics (IV ABT). - At 2:00 pm: Wound Clinic unable to place PICC line. Called and spoke with charge nurse. Must go through Infusion Center. - At 2:25 pm: Returned call to physician to inform of complications. Office closed. - At 5:30 pm: Received culture from provider. Placed in NP box for review. G. Record review of a handwritten note, located in the DON's office, dated 09/29/23 and written by the DON, revealed staff received a call from the wound clinic physician with orders for a PICC line insertion for R #3. H. Record review of R #3's Physician's Orders revealed the following: - An order, dated 10/03/23, for a complete blood count (CBC; blood test that measures our blood cells in the blood stream), comprehensive metabolic panel (CMP; comprehensive metabolic panel blood test that measures specific elements found in the blood stream), prothrombin time test/ international normalized ratio [PT/INR; a blood test used to monitor warfarin (blood thinner) treatment and measures how long it takes for a clot to form in your blood] to be drawn for PICC line placement. One time only. Start date: 10/03/23. End date: 10/05/23. - An order, dated 10/04/23, for wound vacuum. Apply cutercin (type of wound dressing) then wound vacuum with setting at medium and/or 125 pressure to each heel. Send wound vacuum supplies with patient to wound care appointment on 10/06/23. Wound vacuum initial change will be completed by wound care specialist. Start date: 10/04/23. I. Record review of R #3's Wound Care Clinic progress report, dated 10/06/23, revealed R #3 had a significant wound culture with multidrug resistance (MDRO, a germ that is resistant to many antibiotics). Resident required IV antibiotics, which were ordered two weeks ago. Resident still cannot get a PICC line. Concerned R #3 may have progressed to a deeper space infection without initiation of IV antibiotics. Will send to hospital emergency department for admission. J. Record review of R #3's Physician Progress notes revealed the writer documented the following: - On 10/03/23 at 11:00 pm, spoke with daughter at resident's bedside about her concerns regarding wound care management of bilateral lower extremities. Daughter inquired about wound care specialist recommendation of PICC line placement and IV antibiotic, along with wound vacuum application. The writer called physician's office at 12:30 pm and spoke with a Registered Nurse (RN). The RN reported that patient needed PICC line for diagnosis of osteomyelitis and antibiotic therapy (ABT). Patient currently on two oral antibiotics, because patient did not have an established PICC line at this time. RN okay with linezolid by mouth (PO) and Cipro (an antibiotic) PO, that was previously ordered by physician. Per conversation with RN, she would like facility to place wound vacuum today to bilateral heels and to send wound care supplies to upcoming appointment on Friday. The physician's office will perform initial change. Discussed conversation with patient's daughter, nursing staff, and DON regarding plan of care. - On 10/06/23, the patient was sent to emergency room (ER). Facility to order and administer the following medications: - Ciprofloxacin, 500 mg, PO twice a day (BID) for 14 days. Start 09/29/23. End 10/13/23; and - Linezolid, 600 mg, PO BID for 14 days. Start 09/29/23. End 10/13/23. - Facility to insert PICC line and administer IV antibiotics as previously discussed with physician. - Again, a wound vacuum will need to be ordered by facility. Please send the machine and dressing changes with patient to next appointment. K. Record review of R #3's Nursing Notes, dated 10/2023, revealed staff documented the following: - On 10/02/23, Called infusion center. Able to schedule. Must have labs, order for antibiotic therapy of choice. Culture in NP box for review. Request order for labs and prescription (Rx) from NP. Patient scheduled for appointment with physician. Rescheduled for 10/03/23 per daughter. - On 10/03/23, staff documented the following: - Transportation aid contacted at appointment. Spoke to physician. Facility unable to get PICC. Sent back on oral antibiotics (PO ABT). - NP called physician's office. Continue PO at this time. - Stopped PICC line process. - Appointment with physician. Wound vacuum sent. - On 10/06/23, resident had an appointment with physician. Resident sent to ER and admitted . The daughter rescheduled appointment on 10/09/23, because she did not want R #3 riding with anyone in van. L. Record review of R #3's hospital records, dated 10/6/23 through 10/14/23, revealed the following: - Diagnoses: decreased circulation, ischemic ulcer of left heel with necrosis (the death of cells in body tissue) of muscle, high blood pressure, ischemic ulcer of right heel with necrosis of muscle, cellulitis of both lower extremities. - Infections: Methicillin-resistant staphylococcus aureus (MRSA; a type of drug-resistant staph infection and can cause infections in the skin, lungs, or other organs.) Onset 09/09/23. - Next Wound Care appointment for 10/20/23. - Discharge instructions: Start the following: - Metronidazole (Flagyl; antibiotic), 500 mg total, one tablet PO three times a day. - Vancomycin (antibiotic), infuse 1000 mg into a venous catheter one time each day at the same time. - Water for injection solution 20 ml with ceftriaxone (antibiotic) 2 gram. Infuse 2 g into venous catheter one time each day at the same time. M. Record review of R #3's Physician's Orders revealed the following: - An order, dated 10/14/23, for central vascular access service (CVAD; device inserted into the body through a vein to enable the administration of fluids, blood products, medications and other therapies into the bloodstream). IV medications for wound infection. - An order, dated 10/14/23, for ciprofloxacin HCI oral tablet, 500 mg. Give 500 mg PO twice a day. Start date 10/14/23. End date: 10/16/23. - An order, dated 10/14/23, for vancomycin HCI (antibiotic medication) IV solution, 1000 mg/200 ml. Use 1000 mg intravenously. Start date: 10/14/23. End date: 10/19/23. - An order, dated 10/17/23, for ciprofloxacin HCI oral tablet, 500 mg. Give 500 mg by mouth. Start date: 10/17/23. End date: 10/21/23. - An order, dated 10/19/23, for vancomycin HCI intravenous solution, 1000 mg/200 ml. Use 500 mg intravenously. Start date: 10/19/23. End date: 10/21/23. - An order, dated 10/19/23: If resident begins to decline, to include but not limited to abnormal vs. worsening mentation (term used to describe the process of thinking or reasoning), abnormal labs (kidney function specifically) call provider agency's on-call physician or physician as soon as possible. High-risk patient. Every day and every night shift. Start date: 10/19/23. End date: 10/21/23. N. Record review of R #3's Wound Care Clinic progress report, dated 10/20/23, revealed the following: - R #3 was admitted to the hospital from 10/6/23 until 10/14/23. She was treated for osteomyelitis to bilateral heels. She was discharged on IV Rocephin (medication used to treat infections), IV vancomycin; oral Flagyl (medication used to treat infections), and oral ciprofloxacin. - R #3 had new neurologic concerns. She was somnolent (sleepy, drowsy), had decreased responsiveness and slurred speech. - R #3 sent to hospital emergency room . - A wound vacuum will need to be ordered by facility. Please send the machine placed on patient for next appointment. - Run wound vacuum continuously at 150 mmHg (measurement of amount of pressure applied.) O. Record review of R #3's Physician Progress note, dated 10/20/23, revealed the writer documented the facility was to manage IV antibiotics. Patient may follow up with infectious disease physician. Again, a wound vacuum will need to be ordered by facility. Please send the machine placed on patient for next appointment. P. Record review of R #3's nursing notes revealed staff documented the following: - On 10/14/23, the resident returned to the facility and midline (a long thin, flexible tube that is inserted into a vein in the upper arm and is shorter in length then a PICC line) was placed. - On 10/20/23, the resident went to wound care appointment on 10/20/23 and was sent to the ER. Q. Record review of R #3's discharge Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 10/20/23, revealed the resident discharged to the hospital. R. Record review of NP email communication with facility, dated 11/22/23, revealed the following: - The NP became aware of new documents uploaded to R #3's profile. - The NP felt a document uploaded on 11/07/23 was alarming. It was a handwritten 'timeline of events'. The problem: The NP was mentioned multiple times as being notified or results placed in NP box between 09/29/23 and 10/02/23. - The NP disputed the following documentation: - On 09/29/23 at 1:30 pm, staff documented the physician wanted the NP to prescribe antibiotics based on the R #3's culture results, but the NP stated she was not made aware. The NP stated R #3 was already being treated with PO antibiotics by physician when she saw the resident. The NP stated the document also contradicted the note made by nursing staff on 09/29/23, which stated the staff attempted to contact the physician at 7:00 pm for IV antibiotic clarity, but the office was closed. Staff made the DON aware that orders were vague. The NP stated the staff statement did not state the NP or the physician was to manage IV antibiotics, and this was consistent with her earlier emails about the DON's poor communication. - On 09/29/23 at 5:30 pm, staff documented they obtained cultures from (name of facility) and deposited in the NP's box for evaluation. The NP stated that was incorrect. She stated the Unit Manager/LPN #2 supplied the sole document she received regarding cultures or labs on 10/03/23. The NP stated the results showed findings that were specifically sent to the DON on 09/15/23 and were not included in R #3's profile or placed in the NP's box. - On 10/02/23, staff documented a request for labs, antibiotics of choice, and culture in NP box for review was communicated to NP, but the NP stated that was incorrect. She stated she received the culture results via email on 10/03/23 and saw the patient on 10/04/23. - On 10/03/23, staff documented they stopped the PICC line process, but the NP stated that was incorrect, and the resident still required a PICC line. The NP stated RN #2 booked a PICC line placement after the NP requested that she look into PICC line insertion at [name of facility]. The NP stated staff documented a wound vacuum was provided on 10/03/23, which was also untrue. The NP stated she had the nursing staff and Minimum Data Set Coordinator (MDSC) try to get a second wound vacuum as soon as possible, because the facility only had one wound vacuum in the house. The NP stated R #3 required two wound vacuums for her upcoming appointment on 10/06/23 per the discussion with the Wound Care Clinic. The NP stated R #3 had yet to attend the Wound Care Clinic appointments with the requested supplies per the wound care nurse. The NP also stated it was worth noting that R #3's daughter did not reschedule the patient's appointment for 10/05/23 because she did not want anyone riding in the van with the resident. She stated it was a scheduling conflict. She stated the daughter did not want R #3 sitting in the city from early morning for an afternoon appointment, because the resident would miss lunch and no one would be available to assist with incontinence, or patient needs, etc. - The NP requested the document be corrected to reflect factual events. S. On 11/7/23 at 11:30 am during an interview, R #3's daughter stated R #3 did not have the PICC line or the wound vacuum in place for over a month. The daughter stated she felt the facility failed to properly carry out the orders from the wound care physician. T. On 05/08/24 at 2:07 pm during an interview, RN #2 stated R #3 had an order for a PICC line for antibiotics, but that was not done. RN #2 stated the DON told her that R #3 was supposed to have a PICC line for IV antibiotics. She said the DON stated, What do we do? RN #2 stated she contacted the hospital to see if they could get R #3 in for an appointment to get a PICC line done. She stated the hospital told her the resident had to get certain labs done prior to getting the PICC line put in. RN #2 stated she relayed the information to the DON, but it was not done. RN #2 stated R #3 ended up being sent from the wound clinic to the hospital. U. On 05/09/24 at 2:02 pm during an interview, Licensed Practical Nurse (LPN) #6 stated she worked on the floor when R #3 was a resident. LPN #6 stated the resident had wounds on her lower extremities and went to the Wound Care Center. LPN #6 stated, after one appointment at the wound clinic, the transportation driver came in late with R #3, and he gave her (LPN #6) papers for the DON. LPN #6 stated she told the transportation driver that she was not the nurse on the resident's side of the facility, but she would give the papers to RN #1, who was R #3's nurse. LPN #6 stated the transportation driver said, Ok, but [name of DON] told me not to give them to anyone except her (DON). LPN #6 stated she told him the DON was already gone, and her office door was shut. LPN #6 stated the transportation driver responded, I know but [name of DON] told me to just give them to her. LPN #6 stated she looked at the papers from the wound clinic, and there were orders for IV antibiotics and wound vacuums for R #3. LPN #6 stated she called the DON and told her about the new orders to have an IV placed, for IV antibiotics, for a wound vacuum, and for the wound vacuum to be sent with R #3 to her next appointment at the wound clinic. LPN #6 stated she was in the office about a month later, and the DON said, I totally forgot that [name of physician] wanted an IV put in for R #3 for IV antibiotics for her legs. LPN #6 stated the DON asked her if maybe RN #2 could get one of her friends at the hospital to get R #3 in right away to get a central line (a long, flexible tube inserted into a vein that leads to your heart) put in. LPN #6 stated RN #2 called the hospital and tried to get R #3 in for an appointment at 3:00 pm or 4:00 pm on a Friday afternoon, but the hospital could not get R #3 in. LPN #6 stated that about two to three weeks after the transportation driver gave her the orders from the wound clinic, R #3 went back to the wound care doctor for a follow-up. LPN #6 stated the wound clinic ordered again for the IV to be placed for R #3 to receive IV antibiotics. LPN #6 stated R #3 ended up being admitted to the hospital, and the resident passed away. LPN #6 stated the DON said she (LPN #6) never called her (the DON) about the order, and the DON said the order did not exist. LPN #6 stated she reported to RN #8 the order existed, and she (LPN #6) spoke the DON and gave her the information. LPN #6 stated R #3's family member called and asked about the order. She stated she told the the family member she saw the order and gave it to the DON. LPN #6 stated the orders were never uploaded into R #3's medical record, and the paper copy of the order disappeared. V. On 05/09/24 at 10:00 am and 4:00 pm during interviews, the Administrator stated she was not aware the DON withheld orders or medication for R #3. W. On 05/09/24 at 7:09 pm during an interview, RN #1 stated R #3 had wounds to both feet, and the resident was sent out multiple times due to the wounds being infected. RN #1 stated the resident went to a follow-up appointment with her wound care physician and was admitted to the hospital due to the infections. She stated two to three weeks prior to R #3 being hospitalized , the facility received an order for a PICC line, but it was never done. She stated the DON was responsible for R #3's orders, and the resident's medical record contained documentation of multiple requests for the PICC line. X. On 05/14/24 at 11:32 am during an interview, the Anonymous Staff (AS) stated the DON never communicated wound care orders to the other healthcare providers in the facility. She stated R #3's electronic health record did not contain any notes regarding the DON's conversation with the wound care physician, and the hand written note was not available for other healthcare providers to read. Y. On 05/22/24 at 1:41 pm during an interview with the Medical Doctor (MD) from the Wound Care Clinic that provided care for R #3, he stated he believed R #3's wounds became worse because they were not treated according to his orders. He stated the PICC line and IV antibiotics were never started at the time he placed the order, and those could have likely have prevented the infection from becoming worse. He stated the failure to start those may have likely also affected R #3's wounds ability to improve. The MD stated R #3 had necrotic tissue, bone exposure, and an infection which was confirmed by lab samples of wound tissue and bone scan of the affected areas. 34439

Based on interview, observation, and record review, the facility failed to keep residents free from abuse for 1 (R #4) of 4 (R #1, R #2, R #3, and R #4) residents reviewed. This deficient practice likely resulted in staff to resident abuse in which R #4 had bruising to her neck and wrists. The findings are: R #4 A. Record review of R #4's face sheet revealed she was admitted to the facility on [DATE] and was dependent on care for activities of daily living (ADLs: any of the routine tasks an individual must be capable of performing in order to function independently, as dressing, eating, moving around, and maintaining personal hygiene) Her diagnoses included but were not limited to: - Reduced mobility (severe chronic illness that requires immobilization in bed), - Need for assistance with personal care, - Acute respiratory failure, - Cellulitis (infection of skin and surrounding tissue) of right lower limb, - Acute kidney failure, - Sepsis (life threatening condition that arises when the body's response to infection causes injury to its own tissues and organs). - Metabolic encephalopathy (a condition in which brain function is disturbed either temporarily or permanently due to different diseases or toxins in the body). B. Record review of R #4's Admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated [DATE], revealed a Brief Interview for Mental Status (BIMS; tool to screen and identify the cognitive condition of long-term care residents 0 being the lowest and 15 being the highest) score of 12, moderate cognitive impairment. C. Record review of R #4's MDS, dated [DATE], revealed a BIMS score was a 3, severe impairment, with behaviors directed towards others, verbal behaviors directed toward others, other behaviors not directed toward others (self-inflicted.) D. Record review of R #4's discharge summary, dated [DATE], revealed NP #1 indicated ecchymosis (a discoloration of the skin resulting from bleeding underneath, typically caused by bruising) noted to the front of the resident's upper chest. E. On [DATE] at 2:32 pm during an interview, Family Member (FM) #1 stated she visited R #4 on the night of [DATE]. She stated R #4 told her there were things going on at the facility, and they should investigate if she (R #4) died there. FM #1 stated she visited R #4 on [DATE] from approximately 4:30 pm to approximately 9:00 pm, and she did not see any bruises on R #4. She stated she remembered this because R #4 kept saying she did not want to stay there. FM #1 stated R #4 held her hand so tight that she took a photo and sent it to her daughters. She stated on the same night, at approximately 11:00 pm, she received a phone call from the facility advising her that R #4 was very agitated and inconsolable. She stated she offered several times during the phone call to go to the facility, but the caller insisted to her it was not necessary for her to come. FM #1 state the caller told her the facility contacted R #4's Hospice Nurse (HRN). FM #1 stated she received a phone call on [DATE] from HRN #5, who was R #4's primary hospice nurse. FM #1 stated HRN #5 reported she (HRN #5) saw R #4 and noted bruising around the resident's neck, on her arms, and on her hands. FM #1 stated she went to the facility, and HRN #5, a Hospice Supervisor (HS), and nurses from an outside sexual assault advocacy company were there to complete a Sexual Assault Nurse Exam (SANE) on R #4. She stated, after the exam, law enforcement was called, and the police began their investigation. FM #1 stated she had the resident transferred to another facility on [DATE], and resident passed away on [DATE]. She stated the bruising was still so bad R #4 had to have a shirt placed on backwards during funeral to hide the bruising that was still visible. F. On [DATE] at 10:04 am during an interview with HRN #5, she stated she went to the facility to do her daily rounds on [DATE]. She stated she entered R #4's room to perform an assessment and noted bruising around R #4's neck, arms, and hands. HRN #5 stated she questioned R #4 about the bruising, and R #4 replied tight hands. HRN #5 stated she spoke with the DON, but the DON was not forthcoming with information about the nurses who worked the night shift. She stated she also spoke with RN #3, the day nurse on [DATE], and he told her the information he received in report from LPN #5. HRN #5 stated RN #3 reported that LPN #5 told him R #4 scratched herself while pulling at her gown and oxygen tubing. HRN #5 stated she notified the Hospice Supervisor (HSRN) #6 and R #4's daughter/Power of Attorney (POA; a legal document giving power or the authority to act for another person in specified or all legal or financial matter) about the incident. HRN #5 stated HSRN #6 came to the facility, and they decided to call Sexual Assault Services to do an exam of the resident. HRN #5 stated R #4's daughter/POA, consented to the exam. HRN #5 stated once SANE RN #7 (the nurse from the outside agency who conducted the exam), and DON were present at the facility, the exam was performed. HRN #5 stated the DON brought LPN #4 (the nurse that assisted LPN #5 with R #4 during the night because LPN #5 couldn't calm R #4 down) back into the facility to discuss what occurred with R #4 the night before and how R #4 may have gotten the bruises. HRN #5 stated while LPN #4 was in the room she was loud and stated she hoped R #4 would have died last night. HRN #5 stated LPN #4 kept repeating herself loudly, and R #4 gave LPN #4 not a very pleasant look. HRN #5 stated HSRN #6 told LPN #4 to leave due to her inappropriate behavior and comments. G. On [DATE] at 12:04 pm during an interview with HSRN #6, she stated HRN #5 notified her of the bruising noted on R #4 during the routine exam on [DATE]. HSRN #6 stated she went to the facility for an assessment of R #4. She stated there was bruising inside R #4's mouth and petechiae (pinpoint, round spots that form on the skin. They are caused by bleeding, which makes the spots look red, brown or purple in eye area) around her eyes. She stated there was not any bruising or marks to the back of R #4's neck, only to the front and sides of her neck. HSRN #6 stated R #4 complained of a sore throat and difficulty swallowing. She stated during their assessment and interview with R #4, the resident said she had been very angry and had thrown things. HSRN #6 stated the resident also said they had tight hands, tight hands, and they yelled at R #4 to stop yelling. HSRN #6 stated she informed the DON and LPN #2, the Unit Manager, that they would be filing a complaint with the SA. HSRN #6 stated the DON and LPN #2 told her they already filed a complaint with the SA. HSRN #6 stated she contacted R #4's daughter/POA and advised her the hospice agency would file an incident report with the SA. She stated R #4's daughter/POA stated she wanted to report the incident to law enforcement and have a SANE conducted. HSRN #6 stated while SANE RN # 7 completed the assault exam, LPN #4 came back to facility at the request of the DON. HSRN #6 stated they entered R #4's room, and LPN #4 was pretty animated describing how R #4 was yelled, spit, and grabbed at her the previous night. HSRN #6 stated R #4 became increasingly agitated by LPN #4's explanation. HSRN #6 stated LPN #4 said she prayed R #4 would die overnight. HSRN #6 stated she asked LPN #4 to leave the room, because her comments were inappropriate. H. On [DATE] at 1:04 pm and 3:04 pm, during an interview, SANE RN #7 stated the family of R #4 and the hospice staff requested a forensic exam due to the injuries R #4 sustained, and she performed the exam on [DATE]. She stated she found bruising around the resident's neck and chest area, bruising inside of her mouth, and petechiae in the area around the eyes. She stated her training taught her these findings are a result of strangulation. She stated she observed bruising on R #4's hands and wrists, and she observed some abrasions on the resident's left arm. She stated, in her professional opinion, with the length of the resident's nails, she would have expected to find abrasions and injuries of that sort had the resident injured herself. She stated she would have expected there to be some differing injuries. SANE RN #7 stated if R #4 had caused the bruising to herself then the bruising would have looked different. I. On [DATE] at 1:10 pm during an interview with RN #3, he stated when he arrived for his shift on the morning of [DATE] (6:00 am to 6:00 pm), he noted R #4's door was open. He stated R #4's gown and blankets were on the floor leaving the resident nude and uncovered. RN #3 stated he entered the resident's room and covered her. RN #3 stated he noticed redness on and around the resident's neck area. He stated the resident still appeared agitated. RN #3 stated R #4 had an order for ABH gel (a topical gel made from a combination of Ativan, Benadryl, and Haloperidol) and he applied this on her to help calm her down while he was getting report. RN #3 stated he had not spoken to the night nurse yet or received a hand-off report (when the nurse from the previous shift will tell the on-coming nurse about changes in resident, their care, or medications prior to the on-coming nurse assuming care of a resident) from LPN #5. RN #3 stated LPN #5 told him that R #4 was agitated during the evening, and R #4 pulled at her gown, threw things, and pulled at her oxygen tubing, which caused the resident's bruising. RN #3 stated LPN #5 said she required help from LPN #4 to calm down R #4. R #3 stated that when he had tried to put her oxygen tubing back on her which she pulled it off easily and without contacting her neck. J. On [DATE] at 4:47 pm during an interview with LPN #5, she stated she did not remember much from that night, except that R #4 was very agitated and she could not calm her down. She stated R #4 had been agitated before, but this time it went on and on. LPN #5 stated R #4 kept her gown off most of the time. K. On [DATE] at 5:28 pm during an interview, LPN #4 stated R #4 was so loud on the evening of [DATE] that she could hear the resident yelling from another part of the facility. LPN #4 stated she could hear R #4 call for staff to get her out of bed to see the babies. She stated she went to assist LPN #5 in calming the resident. LPN #4 stated when she went into R #4's room, R #4 was very agitated, had thrown off every blanket and pillow from her bed, dumped numerous cups of water onto the floor; and complained that she was very hot. LPN #4 stated she tried to plug in a fan, but R #4 immediately threw the fan across the room. LPN #4 stated R #4 pulled her gown on the right side which left a bruise on that side of the resident's neck. LPN #4 stated she tried to take the gown from R #4's hands. She stated she told R #4, You know what? Look. Can we just take this gown off? She stated R #4 decided she would just grab hold of her own skin and continually pull at it. LPN #4 stated R #4's gown was tied in the back, and the resident pulled on it with both of hands. LPN #4 stated the resident was kind of spinning the gown around, turning it all the way from left side to the right side. LPN #4 stated they asked her if they could take the gown off, and R #4 let them take it off. LPN #4 stated they tried to put a sheet over the resident, but R #4 did not allow it. LPN #4 stated they pulled the privacy curtain closed for dignity. LPN #4 stated she sat in the resident's room with Certified Nurse Aide (CNA) #2. She stated one of the bruises visible at that time looked like a start of a bruise from the gown on her neck, because the resident pulled on it so hard. LPN #4 stated the resident was very agitated and started grabbing hold of her skin with her bare hands. LPN #4 stated they gave R #4 a pillow to hold, but that did not help. LPN #4 stated R #4 wanted to get on the floor and just be out of bed. She stated R #4 pushed off everything from the tray table, she threw things and hit everything in the room with her left hand. LPN #4 stated the resident's left hand was very puffy, but it was not bruised that she could remember. She stated that while CNA #2 was in R #4's room with her, they called Hospice and the hospice nurse arrived (HRN #4). She stated HRN #4 stayed for awhile. LPN #4 stated the resident became calm while HRN #4 was with her. LPN #4 stated R #4 started screaming again as soon as HRN #4 left. LPN #4 stated she called R #4's daughter/POA that night ([DATE]) to inform FM #1 that R #4 was having a very rough evening. LPN #4 stated R #4 said she would like to die that night. LPN #4 stated she (LPN #4) did make the statement that she wished R #4 would just die, and the hospice person was in the room when she said it. L. On [DATE] at 9:34 am during an interview with HRN #4, he stated he received a call from the night shift staff on the evening of [DATE], and they stated R #4 was experiencing agitation. HRN #4 stated the staff reported they were unable to calm the resident down. HRN #4 stated he could hear yelling in the background during the phone call. HRN #4 stated he arrived at the facility on [DATE] and went to R #4's room. He stated he cared for the resident in the past, and she seemed to recognize him. HRN #4 stated R #4 appeared to become less agitated. RN #4 stated he observed fresh bruising around R #4's neck, chest area, and hands. RN #4 stated he reported the bruising to HRN #5 the next morning, because HRN #5 was the resident's primary hospice nurse. He stated during his visit R #4 remained calm and was no longer agitated. M. Record review of R #4's progress note, dated [DATE] at 1:32 am and written by LPN # 5, revealed the hospice nurse left and the resident became upset, crying out for her father again. N. Record review of R #4's physician orders, dated [DATE], revealed the following orders: - Alprazolam (medication used to treat anxiety and panic disorders), every 8 hours for restlessness or anxiety, - Haloperidol lactate oral concentrate (an antipsychotic medication used to treat certain mental and mood disorders), every 6 hours as needed for agitation, nausea, and vomiting. - Benadryl (medication to treat cold or allergy symptoms, motion sickness, and insomnia), 25 mg every 6 hours as needed for insomnia. - An order dated [DATE], for ABH gel every 4 hours as needed for anxiety. O. Record review of R #4's Medication Administration Record (MAR), dated [DATE] and [DATE] for the evening shift, revealed staff did not administer medications for anxiety, restlessness, or agitation to R #4 until after midnight when they gave her alprazolam. P. Record review of staffing schedule for LPN #4, LPN #5, and CNA #2, revealed each staff member continued to be placed on schedule to work. LPN #5 was terminated on [DATE], LPN #4 was suspended [DATE], and CNA #2 did not have a lapse in employment. Q. Repeated request for the facility's investigation of the incident were made to the Administrator, but the facility did not provide their investigation.

Based on record review and interview, the facility failed to provide the necessary care to effectively manage pain for 1 (R # 47) of 1 (R #47) resident reviewed for pain. This deficient practice likely resulted in R #47 experiencing significant (long) periods of pain without sufficient relief. The findings are: A. Record review of face sheet revealed R #47 was admitted into the facility on [DATE] with the following diagnoses: 1. Spastic hemiplegia affecting left non-dominant side. (Brain injury limiting mobility on the right side) 2. Hereditary and idiopathic neuropathy unspecified (sensory and motor nerves of the peripheral nervous system are affected) 3. Muscle weakness. B. Record review of R #47 physician orders dated 05/19/23 revealed order for: Gabapentin (to prevent and control seizures. It is also used to relieve nerve pain) 800 mg tablet, three times daily. C. Record review of R #47 physician orders dated 05/22/23 revealed order for: Acetaminophen (Tylenol a medication used to treat mild to moderate pain) Tablet 325 mg (milligram) PRN (as needed). D. Record review of R #47 physician orders dated 07/12/23 revealed order for: Cyclobenzaprine HCl Oral Tablet (used short-term to treat muscle spasms) 5 mg PRN. E. Record review of R #47 July 2023 MAR (Medication Administration Record) revealed that resident was receiving Hydrocodone-Acetaminophen (used to help relieve severe ongoing pain) 5-325 mg tablet (for pain management) that was started on 07/24/23 and was discontinued on 07/31/23. F. On 08/17/23 at 4:25 PM during an interview with R #47, he stated he typically rates his pain at an 8-9 on a numerical pain scale from 0-10 (0 is no pain, 10 extreme pain). R #47 stated he was unable to get out of bed all day due to muscle spasms (involuntary tensing of muscle). R #47 further stated that he believed the current medication regimen he is on to control pain is insufficient in managing his pain. He stated that some days he is unable to complete daily tasks due to level of pain. R #47 was observed grimacing and appeared to be in pain. He further stated he has let staff know that pain medication was not effective. G. Record review of R #47's vitals/pain assessment dated [DATE] revealed the following: 1. 08/17/23 at 12:03 AM pain was rated at 7 out of 10. 2. 08/17/23 at 7:27 AM pain was rated at 8 out of 10. 3. 08/17/23 at 11:32 PM pain was rated at 7 out of 10. H. Record review of R #47's MAR dated August 2023 revealed R #47 was not administered any PRN pain medication on 08/17/23. I. On 08/17/23 at 9:10 AM during an interview with LPN #1, she stated R #47's provider has been discussing pain management with R #47. She also stated that the provider identified R #47 was over-dependent on opioids (pain medication) and R #47 was discontinued from Hydrocodone Acetaminophen Oral Tablet for that reason. J. On 08/17/23 at 9:16 AM during an interview with CNE, stated it was her expectation that resident's pain is managed appropriately. She further stated that it was her professional opinion that R #47's current drug regimen is not adequately managing his pain levels and that R #47 was receiving PRN Hydrocodone-Acetaminophen Oral Tablet but was discontinued at the end of July due incident where Hydrocodone-Acetaminophen went missing was later found in R #47's room. She stated the provider was concerned of R #47 overdosing and the facility is currently working on getting R #47 into a pain specialist, but that appointment has not been made.

Based on record review and interview the facility failed to ensure a resident was free from neglect by not providing ongoing assessment for a change in condition, for 1 (R#1) of 6 (R #1, #2, #3, #4, #5 and #6) residents reviewed for neglect. This failure to provide on-going assessment potentially caused R #1's closed, non-operatively repairable left femur (bone of the thigh) fracture (broken bone) becoming an open (coming through the skin) fracture and subsequently requiring the left leg to be amputated (removed surgically) above the knee. The findings are: A. Record review of facility face sheet revealed R #1 was admitted to on 04/18/18. Admission [DIAGNOSES REDACTED]. R #1 was discharged from the facility on 05/24/18. B. Record review of Progress Notes dated 04/19/18 at 3:04 am revealed, Skilled Services: Skilled Nursing; . Nursing Observation: Skilled nursing and observation: Skilled nursing: Immobilizer management, Pain management, Assistance with ADL's (activities of daily living) and bed mobility. Observations: Resident alert, oriented (times 3) x 3 with intermittent confusion noted, she is able to make needs known .Immobilizer in place to left leg from ankle to upper thigh. Toes are warm, cap (capillary) refill is brisk, sensation intact. Resident complains of pain often to bilateral legs .R #1 requires two-person Hoyer (a mechanical device for lifting and moving patients) lift for transfers. Denies further needs or concerns at this time, will continue to monitor. Action/nursing interventions: Monitored immobilizer to left leg . C. Record review of Progress Note dated 05/16/18 at 1:15 pm revealed Resident has increased discomfort noted and bony prominence more apparent at the knee PRN (as necessary) Tylenol and [MEDICATION NAME] (medications for pain) given per order at resident request. Staff to ensure flexion restricted at all times immobilizer in place at all times. Will continue to monitor. D. Record review of Progress Notes date 05/22/18 at 3:47 pm revealed, Note: R #1 had large bowel movement this afternoon soiling her immobilizer- immobilizer sent to be cleaned - replaced with another immobilizer- this nurse was called to residents' room to assess, noted small open area to right knee that appears as if fractured un-repaired bone pierced skin, area noted to be draining copious (large in quantity) amount of purulent (containing pus) drainage, (name of facility medical director) notified with new order received for treatment to area. This nurse called (name of orthopedic surgeon) office and left message for (office) nurse to return call - awaiting return call at this time. E. Record review of Surgical Physician Documentation from (name of out of state hospital) dated 05/25/18 revealed .INDICATIONS: The patient is an [AGE] year-old female, demented (suffering from dementia), non-ambulatory, that had previously had a left distal third, cv(part of the femur below the knee) more of a supracondylar oblique femoral shaft fracture (Supracondylar femoral fracture (also called a distal fracture) is when the thigh bone, or femur, is broken at the knee), which was originally treated non-operatively in a knee immobilizer. Due to her lack of mobilization and ability to verbalize her discomfort, the distal spike converted the fracture to open which was opened yesterday. After a long discussion with the patient's family who was trying to determine whether non-operative in hospice care versus operative above the knee amputation, it was elected to proceed with amputation . F. Record review of Progress Notes dated 05/16/18 to 05/22/18 there is no evidence that the bony prominence more apparent at the knee was monitored or assessed during these six (6) days. G. On 08/29/18 at 2:40 pm during a phone interview the Director of Nursing (DON), Administrator (ADM) and Assistant Director of Nursing (ADON), the ADON stated On the prominent boney part (progress note 05/16/18),it was only prominent if you moved it for cleaning it. DON stated During the period 05/16/18 thru 05/22/18 several different nurses during several shifts provided care, no changes were noticed and no progress notes were made. The DON further stated that the facility had given us all documentation, nursing and physician progress notes [REDACTED].

Based on observation, record review, and interview, the facility failed to provide supervision for one (#111) of 3 (#111, 74 and 75) residents which resulted in Resident #111 attempt to elope from the facility and was stopped by another resident and her family from doing so, when there was no staff present. This resulted in an immediate jeopardy at a scope and severity of level K. 1. Review of the Care Plan revealed no interventions to address elopement issues other than a wanderguard which was operational for only the front door and not the other exits of the building and patio areas. 2. Both patio areas to the 300 Unit and 100-200 Unit of the building have chain link fencing and a gate that has a latch at the top that could be opened and closed by staff members and family entering or exiting the patios with no locking mechanism in place. Staff members were not observed ensuring the gate was properly latched to prevent resident elopements. 3. Staff members reported being aware of Resident #111's continued exit seeking behaviors and failed to report the behavior, document the behavior or address the behavior in any manner other than the wanderguard. 4. Staff member interviews revealed a continued behavior from admission on 02/21/11 until the elopement on 03/15/11 involving exit seeking behaviors of Resident #111. This elopement had the potential to cause injury or death to Resident #111 if the resident had wandered into the street. This deficient practice had the potential to present the risk of harm for two other residents (#74 and #75) who were identified by the facility as elopement risk. An immediate jeopardy was called on 03/15/11 at 5:45 pm. At that time, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) Coordinator were informed. A Plan of Removal was accepted by the survey team at 6:54 pm and included the following interventions: 1. Resident #111 was transferred to another facility with a locked unit. From the time of the incident until her transfer, she was placed on 1:1 supervision. A teleconference with her physician, family and the facility took place and it was agreed upon to send her to a secured unit for her safety. 2. The other two residents identified as elopement risks were placed on 1:1 supervision until locks were put in place on the three gates. 3. A staff member was placed on the north unit to maintain visual contact with the patio gate to make sure it was closed until the lock was in place. 4. A combination lock was placed at the west and north hall exit gates and a sign placed notifying staff and visitors to use only the front entrance to enter and leave the facility. 5. Staff received in-service training on utilizing the front door for entrance and exit, and on the combination to the locks in case of emergency events. 6. Equipment was ordered for the installation of wanderguard alarms for both the west and north hall. 7. The door in the rear of the building was noted to have a dead battery and was replaced immediately. 8. The other two residents identified as elopement risks had their wanderguards checked to make sure they were functioning properly. Acceptance of the Plan of Removal lowered the scope and severity to a level E. Based on observation, record review and interview, the facility failed to provide supervision for one (#111) of 3 residents (#111, 74 and 75) which resulted in Resident #111 attempt to elope from the facility. The resident was stopped by another resident and her family from eloping as there were no staff members present. There were no interventions on the care plan to address elopement issues other than a wanderguard which was operational for only the front door and not the other exits to the building and patio areas. Both patio areas to the 300 Unit and 100-200 Unit of the building have chain link fencing and a gate that has a latch at the top that could be opened and closed by staff and family entering or exiting the patios with no locking mechanism in place nor any one staff responsible for ensuring the gate was properly latched to prevent elopements. The exit seeking behavior was present from Resident #111's admission on 02/21/11 until the elopement on 03/15/11. This elopement had the potential to cause injury or death to Resident #111 if the resident had wandered into the street. This deficient practice had the potential to present a risk of harm for two other residents (#75 and #74) identified by the facility as elopement risks and who required monitoring of their behaviors. The findings are: A. During observations on 03/14/11 between 1:30 and 5:00 pm, Resident #111 was noted on the 300 Unit wandering in her wheelchair. Her room was located on the opposite end of the building. B. During observations on 03/15/11 between 8:20 am and 9:00 am, Resident #111 was noted in the lobby area of the 300 Unit. C. During observations on 03/15/11 at 3:00 pm, Licensed Practical Nurse (LPN) #1 gave Resident #111 a glass of water while on the 100-200 Unit near the Nurse's station. At 3:10 pm, Resident #111 was observed in the main hallway past the dining room wheeling herself toward the 300 Unit. D. During observations on 03/15/11 at 3:30 pm, Family Member #1 visiting Resident #120, reported a woman (Resident #111 was trying to leave the facility. On the patio, the surveyor observed Family Member #2, a child, also visiting Resident #120, holding on to the back of Resident #111's wheelchair. Resident #111 was at the exit of the gate leading to a parking lot that was 35-40 yards from a busy four-lane roadway with a posted speed limit of 45 miles per hour. The gate leading to the parking lot was wide open. No alarm was sounding and no staff were visible. By the time Nursing Assistant (NA) #6 had arrived, Family Member #2 had wheeled Resident #111 back into the facility. NA #6 asked Resident #111 what she was doing and commented, "You almost got out" to which Resident #111 replied, "Yeah, almost out." E. Review of the Admission Record revealed Resident #111 had [DIAGNOSES REDACTED]. 1. Review of Convalescent Care Orders dated 02/21/11 revealed a check-mark for "No" for, "Resident has decisional capacity." 2. Review of a Nursing Admission and assessment dated [DATE] revealed Resident #11 was oriented, had limitations in both upper and lower extremities, gait/balance limitations, weakness, was unsteady and used a wheelchair with impaired vision and hearing. 3. Review of an Elopement Risk assessment dated [DATE] revealed no areas of concern identified. An additional comment was added on 02/22/11. The handwritten entry revealed, "Many attempts to leave facility-wanting to go outside-q (every) 15 min (minute) visual checks-wanderguard placed on resident-care planned." 4. Review of physician's orders [REDACTED]. a. On 02/23/11, "poor safety awareness and recent fall; wanderguard d/t (due to) elopement risk." b. On 02/25/11, "Ativan 0.25 mg (milligrams) po (orally) Q (every) 4 hours PRN (as needed) for anxiety... restlessness Seroquel 25 mg Q day for psychosis... increased paranoia and audio hallucinations" 5. On 03/15/11 after the elopement incident, "D/c (discharge) to (name of another facility) r/t (related to) need for locked unit." 6. Review of Interdisciplinary Team Notes revealed the following: a. On 02/23/11, "has dx (diagnosis) of psychosis and depression. After fall stated she was trying to go outside. Will continue to monitor." b. On 02/25/11, "resident was fof (found on floor) next to bed d/t attempting self transfer...stood up from w/c (wheel chair) in beauty shop and fell to knees...that evening res (resident) sitting at nurses station in w/c slid out of w/c to knees...spoke c/ (with) physician who ordered ativan prn (as needed) and Seroquel. Spoke with POA (power of attorney) who explained that resident has psychosis and 'hears' voices that tell her to harm herself and others." c. On 03/8/11, "will obtain order for labs to be drawn and consult c/ (name of physician) re: (regarding) medications due to residents noted increase in restlessness and agitation." d. On 03/16/11, "elopement attempt on 03/15/11 at 1550 (3:50 pm). Resident went out north hall exit door other resident's family member kept resident from getting off patio and detained her from exiting thru chain linked fence gate (sic). Resident returned to nurses station immediately. Resident wanting to go home. Transferring resident to secured unit." 7. Review of the Patient Care Plan revealed the following areas of concern identified: a. "02/11, cognitive loss/dementia: short term and long term memory loss, dx: psychosis." b. "02/11, mood state: psychosis c/ ho (history of) hallucinations and paranoia, dx anxiety c/ ho restlessness." c. "02/11, depression: dx depression and hx (history) of depression." d. "02/11, behavioral symptoms: related dx psychosis...hallucinations and paranoia anxiety ho restlessness." e. "02/23/11, Elopement Care Plan....wanders, leaves unit, verbalized intent of going home, wants to go outside." No staff approaches were marked except a handwritten entry for "2-23-11 Wanderguard, check once q week for battery." 8. Review of Licensed Notes revealed the following entries: a. On 02/22/11 at 6:00 am, "Wanders hallways-wants to go outside-outside x 3 c/ supervision." b. On 02/22/11 at 6:00 pm, "Up in w/c most of shift, propels self in w/c. Desired to sit in w/c by back door most of night." c. On 03/09/11 at 6:00 am, "...propels self around facility." d. On 03/12/11 at 6:00 am, "Up and about in w/c outside x 1 (one time), alarm in place." e. On 03/13/11, 6:00 pm to 6:00 am shift, "...resident attempts to leave through the back door x 3 (three times)." 8. Review of Post-Fall Assessments described Resident #111's cognition as follows: a. On 02/24/11 and 03/02/11, "alert confused." b. On 03/05/11, "confused." c. On 03/08/11, "confused agitated." d. On 03/12/11, "confused at times." 9. Review of Social Work Progress Notes revealed an entry on 03/14/11, "has wanderguard in place as she is attempting to go to door and go outside." 10. Review of Physical Therapy Notes revealed an entry on 03/14/11, "shown excellent progress c/ ambulation as she is amb (ambulating) increased distances c/ decreased assistance. Pt (patient) has also improved c/ standing balance... has increased LE (lower extremity) strength." F. During an interview on 03/15/11 at 3:50 pm, Resident #120, Family Member #1 and #2 reported that Resident #111 came out onto the patio, that the chain-link gate was not latched. Resident #111 removed a loosely wrapped chain from the gate and proceeded to attempt to leave the area from the now-open gate. Resident #120 reported she grabbed onto the back of Resident #111's wheelchair and Family Member #2 came to assist her in holding the back of Resident #111's wheelchair to prevent her from leaving the area. Resident #120, Family Member #1 and #2 confirmed there were not staff out on the patio at the time of the incident. G. During an interview on 03/15/11 at 3:46 pm, the DON was asked if she could discuss the elopement that had just occurred. She reported she had just been informed of the elopement and that she was aware Resident #111 was an elopement risk for the front door. When asked why only the front door, she reported that the wanderguard alarm only functioned for the front door. She confirmed there were other gates on the property similar to the one Resident #111 had attempted to elope from. H. During an interview on 03/15/10 at 4:24 pm, LPN #1 was asked where the behavior tracking forms for Resident #111's exit seeking behaviors were located. She stated, "We don't have any." When asked if there should be, she stated she did not know and that the DON should be asked. At 4:25 pm, the DON confirmed there should have been behavior monitoring sheets. The DON, the ADON and the MDS Coordinator were asked to review the current Care Plan for Resident #111 and asked if the only intervention for Resident #111 was the wanderguard. The ADON confirmed that was the only intervention in place for Resident #111's elopement risk. The ADON confirmed that the facility relied on the wanderguard to monitor Resident #111. All three staff confirmed that the gate off the patio to the 300 Unit was used by staff and visitors and that there was no monitoring of the gate or safeguard on the door out to the patio or the gate itself. I. During an interview on 03/15/11 at 4:50 pm, Certified Nursing Assistant (CNA) #4 was asked if Resident #111 had ever attempted to leave the facility before. She confirmed Resident #111 had attempted to leave before and reported the behaviors started the week she arrived at the facility. When asked if anyone was responsible to ensure the gates were properly latched, she reported there was no one to check them and no one in charge of ensuring they were locked. J. During an interview on 03/15/11 at 4:55 pm, CNA #5 and NA #6 reported that Resident #111 had attempted to get out the front door, the door at the end of the 200 hall and that Resident #111 had been over at the 300 unit (north hall) "a lot." When asked if they felt Resident #111 would be able to get back in to the building were she out in the parking lot, they both felt she might not know how to. K. During an interview on 03/15/11 at 5:00 pm, CNA #7 and #8 were asked if Resident #111 attempted to leave the building. Both confirmed that Resident #111 had tried to get out of all the doors except those at the end of the 100 hall and that this was a regular behavior of Resident #111. They reported that Resident #111 was sometimes confused. CNA #7 reported that Resident #111 was easily agitated and did not believe that Resident #111 would be able to get back to the building were she to get out. When asked if anyone was responsible to monitor the latch on the gates, they both reported that they had been told to make sure it was latched but there was no one to check the latch or watch the gates. L. During an interview on 03/15/11 at 5:15 pm, Registered Nurse (RN) #9 reported that the doors to the patio off the 300 Unit were the only doors without security. She confirmed there were families that did not latch the gate there after entering or exiting the building. When asked if anyone monitored or was responsible to check the gate off the 300 Unit, she replied, "I don't know anyone designated to do that." M. An observation of the gate on 03/15/11 at 5:18 pm revealed a sign that read, "Please latch gate." It was hung on both sides of the gate and was at eye level when standing facing the gate. N. During an interview on 03/15/11 at 5:20 pm, LPN #1 was asked if Resident #111 was frequently on the 300 Unit. She reported, "I know she watches television over there." When asked if Resident #111 would be able to stand if she removed the lap buddy from her wheelchair, LPN #1 stated she believed Resident #111 could. When asked what would happen if Resident #111 did elope to the parking lot, LPN #1 reported, "She would keep going. Go home." When asked if she had observed any exit-seeking behaviors, she reported only having seen Resident #111 try to get "off" the 200 hall. O. During an interview on 03/17/11 at 9:15 am, LPN #2 reported Resident #111 wandered "a lot up and down the halls. It was recently she started attempting to get out the door to the patio." P. During an interview on 03/17/11 at 10:20 am, LPN #3 reported that Resident #111 exhibited exit seeking behaviors the "last few weeks... wandered a lot and tried all of the exits. She repeatedly said she wanted to go and go home... especially after her mother would leave, she would want to leave too." Q. During an interview on 03/17/11 at 2:32 pm, Physical Therapist (PT) #10 was asked if Resident #111 could ambulate out of her wheelchair. She reported that Resident #111 could ambulate 80-90 feet with minimum assist and hand-held assist. R. During an interview on 03/17/11 at 3:03 pm, the ADON and DON were asked if staff should report or document exit seeking behaviors. They replied, "Both." The ADON reviewed the Nursing Notes and was asked to identify where staff had documented the exit seeking behaviors described in the interviews. She replied, "I knew in the beginning she was attempting (to exit) but I thought it had kind of lulled and that's why it wasn't a significant focus of mine. Had they told me, it would have been a different issue." When asked if Resident #111 should have had a personalized Care Plan to address the elopement, the DON replied, "Yes." Both were asked if there were usually staff that accompanied residents out to the patio or if it was a general area that was unsupervised for residents. The DON reported that there usually was someone supervising either on the patio or from the Nurse's station.

Based on observation, record review and interview, the facility failed to update an individualized care plan for one (#111) of 3 residents (#111, 74 and 75) who exhibited exit seeking behaviors. Resident #111 attempted to leave the facility and the only intervention in place in the Care Plan to protect the resident against elopement was a wanderguard system that was effective for only the front entrance. Resident #111 had exhibited exit seeking behaviors since the first week of admission on 02/21/11 and within the few weeks prior to the attempted elopement on 03/15/11. This elopement had the potential to cause injury or death to Resident #111 if the resident had wandered into the street. This deficient practice had the potential to present the risk of injury for two other residents (#74 and #75) identified by the facility as being at risk for elopement. This resulted in an Immediate Jeopardy. An immediate jeopardy was called on 03/15/11 at 5:45 pm. At that time, the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) and Minimum Data Set (MDS) Coordinator were informed. A Plan of Removal was accepted by the survey team on 03/15/11 at 6:54 pm and included the following interventions: 1. Resident #111 was transferred to another facility with a locked unit. From the time of the incident until her transfer, she was placed on 1:1 supervision. A teleconference with her physician, family and the facility took place and it was agreed upon to send her to a secured unit for her safety. 2. The other two residents identified as elopement risks were placed on 1:1 supervision until locks were put in place on the gates, three total. 3. A staff member was placed on the north unit to maintain visual contact with the patio gate to make sure it was closed until the lock was in place. 4. A combination lock was placed at the west and north hall exit gates and a sign placed notifying staff and visitors to use only the front entrance to enter and leave the facility. 5. Staff were in-serviced on utilizing the front door for entrance and exit and on the combination to the locks in case of emergency events. 6. Equipment was ordered for the installation of wander guard alarms for both the west and north hall. 7. Other exit doors were examined and the door in the rear of the building was noted to have a dead battery and was replaced immediately. 8. The other two residents identified as elopement risks had their wanderguards checked to make sure they were functioning properly. Acceptance of the Plan of Removal lowered the scope and severity to a level E. Based on observation, record review and interview, the facility failed to update an individualized care plan for one (#111) of 3 residents (#111, 74, 75) who exhibited exit seeking behaviors. Resident #111 attempted to leave the facility and the only intervention in place in the Care Plan to protect the resident against eloping was a wanderguard system that was effective for only the front entrance. Since the time of admission on 02/21/11, the resident exhibited exit seeking behaviors. This elopement had the potential to cause injury or death to Resident #111 if the resident had wandered into the street. This deficient practice had the potential to harm two other residents (#74 and #75) identified by the facility as elopement risks. The findings are: A. During observations on 03/15/11 at 3:30 pm, a Family Member #1 visiting Resident #120, reported a woman was trying to leave the facility and pointed towards the north patio. On the patio, Family Member #2, a child, also visiting Resident #120, was observed holding on to the back of Resident #111's wheelchair. Resident #111 was at the exit of the gate leading to a parking lot that was 35 - 40 yards from a busy four-lane roadway with a posted speed limit of 45 miles per hour. The gate leading to the parking lot was wide open. No alarm was sounding and no staff were visible. At that time, Family Member #2 had wheeled Resident #111 back into the facility. Nursing Assistant (NA) #6 asked Resident #111 what she was doing and commented, "You almost got out" to which Resident #111 replied, "Yeah, almost out." B. Review of the Admission Record revealed Resident #111 was admitted [DATE] with [DIAGNOSES REDACTED]. C. Review of Convalescent Care Orders dated 02/21/11 revealed a check-mark for "No" for, "Resident has decisional capacity." D. Review of an Elopement Risk assessment dated [DATE] revealed no areas of concern identified. An additional comment was added on 02/22/11. The handwritten entry revealed, "Many attempts to leave facility-wanting to go outside-q (every)15 min (minute) visual checks-wanderguard placed on resident-care planned." E. Review of the 02/23/11 physician's orders [REDACTED]." After the incident, Physician orders [REDACTED]." F. Review of Interdisciplinary Team Notes revealed the following information: 1. On 02/23/11, "has dx (diagnosis) of [MEDICAL CONDITION] and depression. After fall stated she was trying to go outside. Will continue to monitor." 2. On 02/25/11, "resident was fof (found on floor) next to bed d/t attempting self transfer. Stood up from w/c (wheel chair) in beauty shop and fell to knees. That evening res (resident) sitting at nurses station in w/c slid out of w/c to knees. Spoke c/ (with) physician who ordered [MEDICATION NAME] prn and [MEDICATION NAME]. Spoke with POA (power of attorney) who explained that resident... has [MEDICAL CONDITION] and 'hears' voices that tell her to harm herself and others." 3. On 03/8/11, "will obtain order for labs to be drawn and consult c/ (name of physician) re: (regarding) medications due to residents noted increase in restlessness and agitation." 4. On 03/16/11, "elopement attempt on 03/15/11 at 1550 (3:50 pm). Resident went out north hall exit door other resident's family member kept resident from getting off patio and detained her from exiting thru (sic) chain linked fence gate. Resident returned to nurses station immediately. Resident wanting to go home. Transferring resident to secured unit." G. Review of the Patient Care Plan dated 02/11 revealed the following areas of concern: 1. "02/11, cognitive loss/dementia: short term and long term memory loss, dx: [MEDICAL CONDITION]." 2. "02/11, mood state: [MEDICAL CONDITION] c/ ho (history of) hallucinations and paranoia, dx anxiety c/ ho restlessness." 3. "02/11, depression: dx depression and hx (history) of depression." 4. "02/11, behavioral symptoms: related dx [MEDICAL CONDITION] hallucinations and paranoia anxiety ho restlessness." 5. "02/23/11, Elopement Care Plan.... wanders, leaves unit, verbalized intent of going home, wants to go outside." No staff approaches were marked except a handwritten entry for "2-23-11 Wanderguard, check once q week for battery." H. Review of Social Work Progress Notes revealed an entry 03/14/11, "has wanderguard in place as she is attempting to go to door and go outside." I. During an interview on 03/15/11 at 3:46 pm, the Director of Nursing (DON) reported that the facility was aware Resident #111 was an elopement risk but only for the front door. When asked why just for the front door, she reported that the wanderguard unit only worked for the front door. J. During an interview on 03/15/11 at 3:50 pm, Resident #120 and Family Member #1 and #2 reported that Resident #111 came out onto the patio, that the chain-link gate was not latched. Resident #111 removed a loosely wrapped chain from the gate and proceeded to attempt to leave the area from the now-open gate. Resident #120 reported she grabbed onto the back of Resident #111's wheelchair and (Name of Family Member #2) came to assist her in holding the back of Resident #111's wheelchair to prevent her from leaving the area. Resident #120 and Family Member #1 and #2 confirmed there were no staff members on the patio at the time of the incident. K. During an interview on 03/15/11 at 4:25 pm, the DON, ADON and MDS Coordinator were asked to review the current Care Plan for Resident #111 and asked if the only intervention for the resident was the wanderguard. The ADON confirmed that was the only intervention in place for Resident #111's elopement risk. L. During an interview on 03/15/11 at 4:50 pm, Certified Nursing Assistant (CNA) #4 was asked if Resident #111 had previously attempted to leave the facility. She confirmed that the resident had attempted before and reported the behaviors started the week she arrived at the facility. M. During an interview on 03/15/11 at 5:00 pm, CNA #7 and #8 were asked if Resident #111 attempted to leave the building. Both confirmed that the resident had tried to get out of all the doors except those at the end of the 100 hall and that this was a regular behavior of the resident. N. During an interview on 03/17/11 at 10:20 am, Licensed Practical Nurse (LPN) #3 reported that Resident #111 exhibited exit seeking behaviors the "last few weeks... wandered a lot and tried all of the exits... she repeatedly said she wanted to go and go home... especially after her mother would leave, she would want to leave too." O. During an interview on 03/17/11 at 3:03 pm, the DON was asked if Resident #111's Care Plan should have been personalized for her exit seeking behaviors. She replied, "Yes." The ADON reported that when Resident #111 first arrived, she was aware of the exit seeking behavior but had thought it had subsided. She reported that if staff had notified her of continued behavior, "It would have been a different issue." Both the ADON and DON agreed they would have put other approaches in place had they known of the continued behavior.