Every finding on record at Colfax Nursing and Rehab, LLC

Based on observation and interview, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety by failing to:Ensure all food temperatures were checked prior to serving each meal; Ensure opened food items stored in the walk-in cooler were dated and unopened foods were fresh;Ensure foods stored in the walk-in cooler/freezer were shelved to allow circulation;Ensure freezer temperatures and walk-in cooler temperatures were monitored daily;Ensure meat was the appropriate temperature before serving; andEnsure thermometer was cleaned between checking food temperatures on all foods.Findings:Review of facility's undated policy titled, Food Receiving and Storage revealed, in part.Foods shall be received and stored in a manner that complies with safe food handling practices. 3. Potentially Hazardous Food (PHF) or Time/Temperature Control for Safety (TCS) Food means food that requires time/temperature control for safety to limit the growth of pathogens. 4. Food services, or other designated staff, always maintain clean and temperature/humidity-appropriate food storage areas. Dry Food Storage: 5. Food designated dry storage areas are kept at least six inches off of the floor and clear of sprinkler heads and vents. Refrigerated/Frozen Food Storage: 1. All foods stored in the refrigerator or freezer are covered, labeled, and dated. 5. Functioning of the refrigeration and food temperatures are monitored daily. 8. Frozen foods are maintained at a temperature to keep the food frozen solid.On 08/03/2026 at 8:59 a.m. observation of walk-in cooler with S5 Admin/DM revealed 1 opened, undated jar of chopped garlic; 1 opened, undated bag of parmesan cheese; 1 box of omelets with writing on the box of keep frozen or below zero; 1 unopened bag of wilted shredded lettuce and 1 bag of unopened, wilted regular lettuce. S5 Admin/DM confirmed the opened bag of parmesan cheese should have been dated, the jar of garlic should have been dated, the omelets should have been stored in the freezer, and the 2 bags of wilted lettuce should have been thrown away but had not been.On 08/03/2026 at 9:10 a.m., observation with S5 Admin/DM revealed the freezer temperature log had not been completed for August 2026 and the walk-in cooler temperature log had not been completed for July 2026 and not initiated for August 2026. S5 Admin/DM confirmed at the time of observation the logs were not completed but should have been. Observation also revealed 2 boxes of beef steaks were stored on the floor. S5 Admin/DM confirmed the boxes were stored on the floor in the freezer and should not have been. On 08/03/2026 at 11:45 a.m., observation revealed S13 Agency CNA (Cook Helper) checked temperatures of the lunch meal on the line. S13 Agency CNA (Cook Helper) stated, temperature for the chopped ground beef was 141.4 and the regular ground beef meatloaf was 139.2. While temperatures were being checked on all foods on the line, it was observed that S13 Agency CNA (Cook Helper) did not clean thermometer between temping each food. In an interview on 08/03/2026 at 2:38 p.m., S13 Agency CNA (Cook Helper) acknowledged he did not check the temperature of the pureed foods on the line prior to serving but should have.In an interview on 08/03/2026 at 4:00 p.m., S5 Admin/DM confirmed S13 Agency CNA (Cook Helper) did not check temperatures of the pureed foods on the line but should have. S5 Admin/DM also confirmed the ground beef on the line was not the correct temperature, it should have been 155 degrees or greater on the line and the thermometer was not cleaned between checking the temperatures of each food on the line but should have been.

Based on interview and record review the facility failed to include the Administrator or designee in the Quality Assessment and Assurance Process. Total sample size 39. Findings:Review of the facility's policy titled Quality Assurance Performance Improvement (QAPI) Program-Governance and Leadership, with a revision date of 03/2020 revealed in part. Policy Interpretation and Implementation:(6) The following individuals serve on the committee:Administrator, or designee who is in a leadership role.Director of Nursing Services;Medical Director;Infection PreventionistInterview and record review on 08/05/2026 at 1:45 p.m. with S8 Admin/RN revealed the facility's Administrator or designee had not been included on the Quality Assessment and Assurance Process Sign-in-sheets for 04/2026. Interview on 08/05/2026 at 1:50 p.m. with S1 CMO confirmed the facility had no documented evidence of the Administrator or designee attending the Quality Assessment and Assurance Process Quarterly meeting in 04/2026.

Based on observation and interview, the facility failed to ensure menus were followed in order to meet the nutritional needs of residents who required a puree diet. The facility failed to follow the established recipes to ensure the nutritional adequacy of the meal for 5 (Resident #4, Resident #12, Resident #34, Resident #50, and Resident #69) of 5 residents who received puree diets. Findings:Review of a facility's policy dated October 2017 and titled, Menus revealed the following in part . Menus are developed and prepared to meet resident choices including religious, cultural, and ethnic needs while following established national guidelines for nutritional adequacy.Observation on 08/03/2026 at 11:01 a.m. revealed S13 Agency CNA prepare the following pureed food items.Observed S13 Agency CNA (Cook helper) put meatloaf into the processor and added 1 cup of beef broth while it was blending. Observed S13 Agency CNA (Cook helper) pour black-eyed peas and juice into the processor.Observed S13 Agency CNA (Cook helper) pour the broccoli cuts and juice into the processor.Observed S13 Agency CNA (Cook helper) put 8 pieces of cake into processor, blend it, then add an unmeasured amount of milk into blender, blend it again, add 2 more pieces of cake and add additional unmeasured amount of milk. S13 Agency CNA stated, I need one more piece of cake for the right consistency. Next S13 Agency CNA added 1 more piece of cake and then blended it again.On 08/03/2026 at 11:10 a.m. Review of the facility's standardized recipe for puree beef meatloaf revealed the following in part.Preparation for beef meatloaf according to puree recipe: 1 serving-Put 4 oz of meatloaf in processor, drain any excess liquid from food. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist, and appropriate for pureed. Also, add 1 tablespoon of milk or appropriate liquids if it is needed. S13 Agency (CNA) did not follow the menu for liquid that was added. On 08/03/2026 at 11:10 a.m. Review of the facility's standardized recipe for black-eyed peas according to puree recipe: 1 serving- Drain any excess liquid from the food. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate for pureed. Also, add 1 tablespoon of milk or appropriate liquid if needed. S13 Agency CNA did not follow the menu for draining any excess liquid prior to placing the black-eye peas in the processor. On 08/03/2026 at 11:10 a.m. Review of the facility's standardized recipe for broccoli cuts according to puree recipe: 1 serving- Drain any excess liquid from the food, drain any excess liquid from food. Blend until smooth. Additional liquid and/or thickener may be needed to ensure puree is smooth, moist and appropriate for pureed. Also, add 1 tablespoon of milk or appropriate liquid if needed. S13 Agency CNA did not follow the menu for draining any excess liquid prior to placing the broccoli cuts in the processor. On 08/03/2026 at 11:10 a.m. Review of the facility's standardized recipe for pound cake with lemon glaze according to puree recipe: 5 servings- Place cake in food processor. Process until finely crumbled. In a separate bowl, place appropriate liquid that is thickened. Sprinkle finely crumbled cake over the thickened liquid. Gently stir to moisten all the crumbs. Moistened cake can be scooped or placed in mold to shape; chill 2-3 hours. S13 Agency CNA did not follow the menu to puree the cake appropriately. In an interview on 08/03/2026 at 2:38 p.m., S13 Agency CNA (Cook helper) acknowledged he did not follow the recipe menu to prepare puree meals. Surveyor asked S13 Agency CNA (Cook Helper) if he had received any training to work in the kitchen and he stated, no. S13 Agency CNA (Cook Helper) stated, I did not know I needed to use the recipe menu to prepare pureed meals. S13 Agency CNA stated the facility reached out to agency for staffing in the kitchen and because he had kitchen experience, he decided to pick up the shifts. In an interview on 08/03/2026 at 4:00 p.m., S5 Admin/DM confirmed S13 Agency CNA (Cook Helper) did not use the recipe menus to prepare the puree meals but should have.

Based on observations, interviews, and record review the facility failed to ensure that each resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 (Resident #3 and Resident #5) out of a total of 38 sampled Residents. The facility failed to ensure:Resident #3 was free of facial hair; andPrivacy was maintained during wound care and incontinent care for Resident #5. Resident #3 Review of a facility policy titled Dignity, with no revision date read in part. Policy Statement: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. Policy Interpretation and Implementation Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. For example, residents are: groomed as they wish to be groomed (hair style, nails, facial hair, etc). Review of Resident #3's medical record revealed an admit date of 08/19/2016 with diagnoses which included in part.Alzheimer's Disease, Cerebral Vascular Disease, Heart Failure Unspecified, Type 2 Diabetes Mellitus, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with an ARD of 06/17/2026 revealed she had no BIMS score. The MDS revealed Resident #3 required partial/moderate assistance with personal hygiene and was dependent with shower/bath. Review of Resident #3's care plan with a target date of 09/14/2026 revealed in part. The resident has an ADL self-care performance deficit related to activity intolerance, Cerebrovascular Accident with interventions that included the resident is totally dependent on (1-2) staff for personal hygiene. The resident has a communication problem related to choosing to be non-verbal at times, Alzheimer's/Dementia with interventions that included to anticipate and meet needs. Observation on 08/03/2026 at 10:00 a.m. revealed Resident #3 lying in bed. Resident #3 noted to have long facial hair to chin. Resident #3 revealed she had been bathed earlier that morning, and would have liked the long facial hair removed. Observation on 08/04/2026 at 9:00 a.m. revealed Resident #3 lying in bed. Resident #3 noted to have long facial hair to chin. Resident #3 revealed she had been bathed earlier that morning, but facial hair had not been removed. Interview on 08/04/2026 at 9:04 a.m. with S12 CNA revealed she had given Resident #3 a bed bath earlier that morning. S12 CNA confirmed she did not remove the long chin hair from Resident #3's face. Observation and interview on 08/04/2026 at 9:10 a.m. of Resident #3 with S2 DON in attendance confirmed Resident #3 had long facial hair to chin and should not have. Resident #3 stated to DON she would like facial hair removed. Findings: 2. Review of the facility's policy titled Resident [NAME] of Rights revealed in part.A. All nursing homes shall adopt and make public a statement of the rights and responsibilities of the residents residing therein and shall treat such residents in accordance with the provisions of the statement. The statement shall assure each resident the following: (8) The right to have privacy in treatment and in caring for personal needs; privacy of the resident's body shall be maintained during but not limited to toileting, bathing, and other activities of personal hygiene, except as needed for resident safety or assistance. Record Review revealed Resident #5 was admitted to the facility on [DATE] with a re-entry date of 01/19/2024 with diagnoses that included in part.Chronic Multifocal Osteomyelitis, Right Femur; Type 2 Diabetes Mellitus with Foot Ulcer; Unspecified Protein-Calorie Malnutrition; Major Depressive Disorder; Pressure Ulcer of Right Hip, Stage 4; Pressure Ulcer of Sacral Region, Stage 3; and Quadriplegia. Review of Resident #5's Annual MDS with an ARD of 07/08/2026 revealed Resident #5 had a BIMS of 15, which indicated intact cognition. Resident #5 was dependent for all ADLs and had urinary incontinence. Review of Resident #5's 08/2026 physician orders revealed in part . -08/04/2026: Abrasion right dorsum foot: Cleanse with WC and pat dry, apply zinc oxide daily until resolved every day shift for Wound Healing -08/04/2026: Right hip wound: Cleanse wound with wound cleanser and pat dry, lightly pack with 4x4 gauze and cover with ABD (abdominal) pads once daily and PRN (as needed). Review of Resident #5's care plan with a review date of 10/13/2026 read in part.Impaired Mobility/ADL deficit, total dependence on staff for care, and bed bound. Intervention included: assist resident with ADL care daily. Observation on 08/04/2026 at 09:38 a.m. revealed S4 Tx LPN and S11 CNA gathered items to perform wound care and incontinent care. Upon entering Resident #5's bedroom, Resident #32 was observed lying in her bed watching television, which was located on Resident #5's side of the room. S4 Tx LPN and S11 CNA removed Resident #5's cover which exposed an adult brief. S4 Tx LPN did not pull the privacy curtain while S11 CNA unfastened Resident #5's adult brief which exposed her perineum area, which was red and excoriated. S11 CNA continued to provide incontinent care on Resident #5 while Resident #32 remained in the bedroom watching television on Resident #5's side of the room. After S11 CNA performed incontinent care, she assisted in rolling Resident #5 over on her left side which exposed her sacral area and buttocks, privacy still was not maintained. S4 Tx LPN began to perform wound care and did not close the privacy curtain while Resident #32 remained in the bedroom. Observation revealed wound care and incontinent care performed on Resident #5 was fully visible to Resident #32 the entire time. Interview on 08/04/2026 at 10:00 a.m., S4 Tx LPN revealed she forgot to pull the privacy curtain while Resident #32 remained in the room while she and S11 CNA performed wound care and incontinent care for Resident #5. S4 Tx LPN confirmed she and S11 CNA did not maintain privacy while performing wound care and incontinent care for Resident #5, but should have. Interview on 08/04/2026 at 10:06 a.m., S11 CNA confirmed prior to performing incontinent care on Resident #5 she should have maintained privacy, but did not. Interview on 08/04/2026 at 11:18 a.m., Resident #5 stated she would have appreciated if S4 Tx LPN and S11 CNA pulled her privacy curtain while they performed her wound care and incontinent care since Resident #32 was in the room during that time.

Based on interview and record review the facility failed to notify the Ombudsman in writing of resident transfer/discharge for 1 (Resident #83) of 1 residents reviewed for transfer/discharge. The total sample size was 39. Findings:Review of Resident #83's medical record revealed an admission date of 06/26/2024 and a discharge date of 05/28/2026, which included diagnoses of Parkinson's Disease with Dyskinesia; Cardiomegaly; Chronic Rhinitis; and Anxiety Disorder.Review of Resident #83's 05/2026 physician's orders revealed the following order Resident to discharge from facility to another facility in [NAME], LA on 05.27.26. Plan of Care and all active orders, including medication and referrals/appointments to continue: one time only until 05/28/26 (order date of 05/27/2026).Review of Resident #83's Discharge Return Not Anticipated MDS with an ARD of 05/28/2026 revealed in part.planned discharge with a date of 05/28/2026 to a nursing home.Review of Resident #83's Discharge Instruction Form dated 05/27/2026 revealed the following in part .G. Housing Arrangements: Nursing Home. Review of a facility report on 08/05/2026 at 12:43 p.m. titled, Ombudsman Notification Log for 05/2026 revealed Resident #83's discharge on [DATE] was not included on the notification report. In an interview on 08/05/2026 at 11:09 a.m., S6 SSD revealed she was familiar with Resident #83's discharge. S6 SSD revealed that Resident #83 was discharged to another facility because his son wanted him closer to [NAME]. S6 SSD revealed this was a planned discharge.In an interview on 08/05/2026 at 12:49 p.m., S1 CMO (Chief Managing Officer) revealed he was responsible for completing the Ombudsman Notification Log each month. S1 CMO revealed he received guidance and had the new updated memo from the Ombudsman back in April 2026, which took effect on 05/2026. S1 CMO questioned surveyor about the process, who explained that he would need to review the regulations. S1 CMO reviewed the Ombudsman Notification Log to see if Resident #83 was listed on it. S1 CMO, accompanied with S3 Corp RN, acknowledged Resident #83's planned discharge was not submitted to the Louisiana Ombudsman Program.

Based on record review and interview, the facility failed to ensure a person-centered care plan was developed and implemented for 1 (Resident #3) resident who received oxygen therapy. Total sample size 39. Findings: Review of Resident #3's medical record revealed an admit date of 08/19/2016 with diagnoses which included in part.Alzheimer's Disease, Cerebral Vascular Disease, Heart Failure Unspecified, Type 2 Diabetes Mellitus, and Peripheral Vascular Disease. Review of Resident #3's Quarterly MDS with an ARD of 06/17/2026 revealed she had no BIMS score. The MDS revealed Resident #3 received oxygen therapy. Review of Resident #3's care plan revealed no documented evidence of a care plan for oxygen therapy. Interview on 08/04/2026 at 10:41 a.m. with S14 RN/MDS confirmed Resident #3 did not have a person-centered care plan developed with appropriate nursing interventions to address the use of oxygen therapy but should have.

Based on observation, interview and record review, the facility failed to ensure that a resident received the necessary care and services to maintain personal hygiene related to nail care for 1 (#15) of 39 sampled residents. The facility's total census was 83. Findings:Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE]. The resident's diagnoses included Mild Intellectual Disabilities.Review of Resident #15's Quarterly MDS dated [DATE] revealed a BIMS score of 4, which indicated severe cognitive impairment. Further review of the Quarterly MDS revealed the resident required substantial/maximal staff assistance with personal hygiene. Review of Resident #15's care plan, next review date of 10/22/2026, revealed in part. The resident has an ADL self-care performance deficit r/t Impaired balance, Limited mobility. Partial to substantial assistance of 1 staff. The interventions for this identified focus area included in part. check nail length and trim and clean on bath day and as necessary. Report any changes to the nurse. [CNA,LPN,RN] Observation on 08/03/2026 at 10:50 a.m. revealed Resident #15 was sitting in her wheelchair in the dining room. The resident was noted to have a black substance under the fingernails of both hands.Observation on 08/05/2026 at 8:40 a.m. revealed Resident #15 continued to have a black substance under the fingernails of both hands.Interview on 08/05/2026 at 8:43 a.m. with S10 CNA confirmed she was the CNA for the resident on this date. She stated she had already bathed the resident that morning but did not clean under her fingernails. S10 CNA confirmed the resident's fingernails needed cleaning, and she was responsible for cleaning them.

Based on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 1 (Resident #3) of 2 residents reviewed for respiratory care. The facility failed to ensure the posting of cautionary and safety signs indicating the use of oxygen. Findings: Review of Resident #3's medical record revealed an admit date of 08/19/2016 with diagnoses which included in part.Alzheimer's Disease, Cerebral Vascular Disease, Heart Failure Unspecified, Type 2 Diabetes Mellitus, and Peripheral Vascular Disease.Review of Resident #3's Quarterly MDS with an ARD of 06/17/2026 revealed she had no BIMS score. The MDS revealed Resident #3 received oxygen therapy.Review of Resident #3's Physician Orders dated 03/03/2026 revealed in part.02 at 2 Liters per nasal cannula for Shortness of Breath every 1 hour as needed for Shortness of Breath.Observation on 08/03/2026 at 10:00 a.m. revealed Resident #3 lying in bed with oxygen flowing at 2 liters per minute via nasal cannula. No cautionary or safety signs observed indicating the use of oxygen.Observation on 08/04/2026 at 9:00 a.m. revealed Resident #3 lying in bed with oxygen flowing at 2 liters per minute via nasal cannula. No cautionary or safety signs observed indicating the use of oxygen.Interview on 08/04/2026 at 9:10 a.m. with S1 DON during observation of Resident #3's room confirmed Resident #3 received oxygen therapy, and did not have any cautionary or safety signs which indicated the use of oxygen but should have.

Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infection by failing to ensure staff followed proper infection control practices during wound care for 2 (Resident #5 and Resident #8) of 2 residents observed during wound care. The facility failed to ensure:S4 Tx LPN properly sanitized her hands during wound care for Resident #5; andS4 Tx LPN contained biohazard materials in a sanitary manner during wound care for Resident #8. 1. Findings: Record Review revealed Resident #5 was admitted to the facility on [DATE] with a re-entry date of 01/19/2024 with diagnoses that included in part.Chronic Multifocal Osteomyelitis, Right Femur; Type 2 Diabetes Mellitus with Foot Ulcer; Unspecified Protein-Calorie Malnutrition; Major Depressive Disorder; Pressure Ulcer of Right Hip, Stage 4; Pressure Ulcer of Sacral Region, Stage 3; and Quadriplegia. Review of Resident #5's Annual MDS with an ARD of 07/08/2026 revealed Resident #5 had a BIMS of 15, which indicated intact cognition. Resident #5 was dependent for all ADLs and had pressure ulcers present. Review of Resident #5's 08/2026 physician orders revealed in part . -08/04/2026: Abrasion right dorsum foot: Cleanse with WC and pat dry, apply zinc oxide daily until resolved every day shift for Wound Healing -08/04/2026: Right hip wound: Cleanse wound with wound cleanser and pat dry, lightly pack with 4x4 gauze and cover with ABD (abdominal) pads once daily and PRN (as needed). Review of Resident #5's care plan with a review date of 10/13/2026 read in part. The resident has pressure ulcer and potential for pressure ulcer development r/t History of ulcers, Immobilitystage 4 to right hip that is chronic, open lesion to right lateral foot, stage 3 to sacrum, Lesion to left gluteal fold. Interventions: The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with 2 people; Heel protectors to bilateral feet, which she declines to wear; Monitor dressing to ensure it is intact and adhering. Report loose dressing to Treatment nurse. Observation of wound care on 08/04/2026 at 9:38 a.m. performed by S4 Tx LPN revealed she sanitized and prepped her tray with wound care supplies. S4 Tx LPN entered Resident #5's bedroom, sanitized hands, donned gown, and clean gloves. S4 Tx LPN revealed she'd be performing treatment on Resident #5's right hip and top of right foot. S4 Tx LPN stated Resident #5 had chronic wounds for a long time. She explained treatment for Resident #5 was to clean Resident #5's right hip with wound cleanser with a 4x4 gauze and then place an ABD pad over it. She revealed Resident #5 had an abrasion to the right top of foot and she'd apply zinc cream. S4 Tx LPN rolled Resident #5 on her left side which exposed a pressure ulcer to the right hip. S4 Tx LPN reached into a cup, grabbed her clean gauze, and cleaned the area. S4 Tx LPN grabbed the clean ABD pad with the same gloves and placed it on Resident #5's right hip. S4 Tx LPN removed gloves and donned a new pair of gloves without sanitizing her hands. She then grabbed a clean 4x4 gauze, cleaned Resident #5's top of right foot, removed gloves, donned new gloves without sanitizing her hands, and applied zinc cream to right foot. S4 Tx LPN continued with the same gloves and assisted S11 CNA with repositioning Resident #5 and placing a new pad underneath her. Interview on 08/04/2026 at 10:00 a.m., S4 Tx LPN confirmed she did not sanitize her hands when she changed gloves multiple times while she performed wound care for Resident #5, but should have. Findings: Review of an undated facility policy on 08/04/2026 at 1:52 p.m. titled, Dressings, Dry/Clean revealed the following in part. Steps in the Procedure. 3. Tape the biohazard or plastic bag on the bedside stand or use a waste basket below the clean field. 12. Wash and dry hands thoroughly. 13. Put on clean gloves. Resident #8 Review of Resident #8's medical record revealed an admission date of 01/28/2026 with diagnoses which included in part.Type 2 Diabetes Mellitus with Diabetic Neuropathy, Unspecified, Peripheral Vascular Disease, and Pressure Ulcer of Sacral Region. Review of Resident #8's 08/2026 Physician's orders revealed treatment orders in part for. (Start Date: 08/04/2026) Unstageable pressure ulcer to the sacrum cleanse with wound cleanser, pat dry, apply santyl to the wound bed, cover with a dry dressing and secure with tape daily and as needed until resolved. Review of Resident #8's current care plan revealed the following in part. (Date Initialed: 01/19/2026) Focus: The resident has potential/actual impairment to skin integrity related to unstageable sacral pressure ulcer. Review of Resident #8's Quarterly MDS with an ARD of 07/22/2026 revealed the resident had multiple unstageable pressure injuries. During observation on 08/04/2026 at 10:45 a.m., S4 Tx LPN completed Resident #8's treatment of the unstageable pressure ulcer of the sacrum. Observation revealed the red biohazard bag was placed on the resident's clean bed linens; next to Resident #8's lower back. Observed S4 Tx LPN putting biohazard materials (dirty gloves and other dirty treatment dressings) into the red biohazard bag. The red biohazard bag was observed overflowing with the dirty biohazard materials onto Resident #8's clean bed linens during the treatment. Treatment was completed and S4 Tx LPN was observed gathering the dirty biohazard materials and placed the materials back into the red biohazard bag. In an interview on 08/04/2026 at 10:59 a.m., S4 Tx LPN confirmed she placed the red biohazard bag on the resident's clean bed linens; next to the resident. S4 Tx LPN confirmed the dirty biohazard materials used during Resident #8's treatment were overflowing onto the resident's clean bed linens, but should not have been.

Based on observation and interview, the facility failed to maintain a clean, comfortable, and homelike environment by failing to ensure residents received housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Findings:Observation on 07/20/2026 at 9:26 a.m. Hall X revealed strong odors throughout hallway with hall floors having numerous areas of dirt and debris on floor. Interview on 07/20/2026 at 9:27 a.m. with S8CNA on Hall X revealed she was assigned to care for residents on Hall X. S8CNA revealed she performed CNA duties, but was also recently informed CNAs had to perform housekeeping duties because housekeeping department was short staffed. S8CNA stated she would not perform housekeeping duties. Observation on 07/20/2026 at 11:53 a.m. of Hall X revealed there was a strong urine and musky odor present on the hall. Observation of Room A revealed a large amount of black residue on the floor near the doorway that opened to the Hall X. The black residue was noted throughout the resident's room and bathroom. The black residue appeared as mildew with a large amount of dirt and debris throughout the floor. Observation on 07/20/2026 at 11:55 a.m. of Room B revealed a large amount of mildew on the privacy curtain. Observation on 07/20/2026 at 11:56 a.m. of Room C revealed a large amount of dirt and debris including food residue or particles throughout the floor in resident's room. Observation on 07/20/2026 at 11:58 a.m. of Room D revealed a strong feces odor on hallway near the resident's door. Observation revealed a trail of feces from resident's bed into bathroom. Observation of resident's bathroom revealed feces smeared on the floor, wall, and toilet. Interview and observation on 07/20/2026 at 12:09 p.m. of Hall X with S3DON confirmed the above findings. S3DON confirmed the rooms were unsanitary and were in need of cleaning. S3DON revealed she was instructed by S1Director of Operations since the facility was short staffed in housekeeping the CNAs were going to be assigned housekeeping duties. S3DON revealed she inserviced the CNAs and added it to their duties, but she would not enforce the house keeping responsibilities as she did not think it was fair. Interview on 07/20/2026 at 12:20 p.m. with S1Director of Operations revealed the facility did not have a current housekeeping supervisor. S1Director of Operations revealed he was responsible for the housekeeping department and overseeing staff completed their duties. Observation at time of interview for the above findings on Hall X with S1Director of Operations, acknowledged the rooms were unsanitary and in need of cleaning.

Based on interview and record review the facility failed to ensure a resident (#3) was free of chemical restraints by failing to:1. assess the resident prior to administering a chemical restraint for potential underlying causes of the resident's behavior,2. attempt a less restrictive alternative for the resident's behavior, and3. assess the resident after the chemical restraint was administered.This deficient practice was identified for 1(#3) of 3 sampled residents. The facility's total census was 81.Findings:Review of the facility's July 2022 Antipsychotic Medication Use policy revealed in part.Antipsychotic medications may be considered for residents with dementia but only after medical, physical, functional, psychological, emotional psychiatric, social and environmental causes of behavioral symptoms have been identified and addressed.The policy's Interpretation and Implementation section revealed in part.residents would only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective.Further review revealed in part.in the case of an emergency situation (that is, an acute onset or exacerbation of symptoms or immediate threat to the health or safety of a resident or others), pertinent non-pharmacological interventions must be attempted, unless contraindicated, and documented following the resolution of the acute psychiatric situation.Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Intermittent Explosive Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Pseudobulbar Affect.Review of Resident #3's Progress Notes revealed the following in part.:Psychosocial Note dated 06/12/2026 at 9:12 a.m. in which the nurse documented Upon entering the room, resident is sitting up in bed - placed BP cuff on resident's arm and as it was taking BP with trying to give medication, resident smacks this nurse's hand away and the medicine flew across the room, all over the floor. Tried to de-escalate with no success. Resident yelling, Get the f*** away from me. Refusing to give BP cuff back, had to quickly grasp the BP cup latch off resident as he began reaching out to hit this nurse. Upon leaving room resident began coming into hallway and cursing at the aide, F*** that B**** - and walking toward her. She tried to de-escalate the situation, but resident continued to walk toward her yelling, f*** that b****. Aide walks off and states he is becoming violent and is trying to starting to come after this nurse. Walking away from resident, he starts yelling down the hall to the aide, You fat b****. Unable to console, aide gets DON and she gets resident to go back into the room.Administration Note dated 06/13/2026 at 3:46 p.m. in which the nurse documented the resident had refused all meds as well as blood glucose monitoring.Psychiatry Note dated 06/15/2026 (Signed Date: 06/21/2026 at 4:09:31 PM) in which S5PNP documented Documentation indicates that on 06/16 the patient experienced significant behavior escalation requiring administration of a B52 (Diphenhydramine 50 mg, Haloperidol 5 mg, Ativan 2 mg) injection for acute agitation and behavioral dysregulation. Staff report that although he returned to baseline following intervention, episodes of irritability, verbal opposition, and noncompliance have continued to occur.Order Note dated 06/16/2026 at 12:04 p.m. which included in part.Diphenhydramine HCl Injection Solution 50mg/ml - Inject 50 mg intramuscularly one time only for aggressive behaviors toward staff for 1 day with Ativan 2mg (a central nervous system depressant) and Haloperidol 5 mg IM (an antipsychotic medication).Order Note dated 06/16/2026 at 12:06 p.m. which included in part.Haloperidol Lactate Injection Solution 5mg/ml - Inject 5 mg intramuscularly one time only for aggressive behaviors toward staff for 1 day with Diphenhydramine 50mg and Ativan 2mg IM.Review of Resident #3's June 2026 MAR confirmed S5PNP's note dated 06/15/2026 (signed 06/21/2026) which revealed the resident was administered the following medications on 06/16/2026 between 12:25 p.m. and 12:58 p.m.:Ativan Injection Solution 2mg/ml - Inject 2mg intramuscularly one time only for aggressive behaviors toward staff for 1 day with Diphenhydramine 50mg and Haloperidol 5mg IM,Diphenhydramine HCl Injection solution 50mg/ml - Inject 50 mg intramuscularly one tome only for aggressive behaviors toward staff for 1 day with Ativan 2 mg and Haloperidol 5 mg IM, andHaloperidol Lactate Injection 5mg/ml - Inject 5mg intramuscularly one time only for aggressive behaviors toward staff for 1 day with Diphenhydramine 50mg and Ativan 2mg IM.Review of Resident #3's progress notes revealed no documentation of the specific condition and/or behaviors he was exhibiting, attempts to identify possible underlying causes for the undocumented behaviors, or documentation of attempts to provide less restrictive alternatives, such as non-pharmacological interventions prior to the administration of the B52 injection. Further review revealed there was no assessment of the resident's condition, or resolution of symptoms, following the B52 injection.Further review of Resident #3's June 2026 MAR revealed there was no documentation of any behavior monitoring of the resident throughout the entire month; specifically for 06/16/2026.Interview on 07/22/2026 at 11:46 a.m. with S3DON confirmed there was no documentation in Resident #3's clinical record regarding his condition, or behaviors, prior to the administration of the B52 injection on 06/16/2026. S1DON also confirmed that she would expect to see an assessment of a resident prior to, and after, administration of a chemical restraint. S1DON confirmed the facility did not have a specific Chemical Restraint Policy and Procedure other than the Antipsychotic Medication Use policy which she had provided.Telephone interview on 07/22/2026 at 12:39 p.m. with S5PNP revealed she could not remember the details regarding the staff contacting her on 06/16/2026 for orders regarding the resident's behaviors but it was probably due to his usual behaviors of attempting to hit staff, intermittently refusing his medications or being verbally aggressive. She stated it was not unusual for them to call her requesting prn orders for Resident #3. S5PNP stated she usually attempted to treat residents in-house with medications such as a B52 injection prior to sending them to an in-patient psychiatric facility unless their behaviors were too violent. She stated that she would absolutely expect an assessment of the resident, including their vital signs, after receiving a heavy medication such as a B52 injection.Telephone interview on 07/22/2026 at 12:56 p.m. with S4LPN revealed she had administered the B52 injection to Resident #3 on 06/16/2026 due to his violent behaviors that day. She stated he had hit a CNA and threatened to kill her. S4LPN stated she was not the assigned nurse for the resident that day but she did administer the injection due to his assigned nurse was afraid of him. S4LPN confirmed she did not contact the physician for orders, document the resident's behaviors in the Progress Notes, or document if the medication was effective.

Based on interview and record review the facility failed to ensure resident assessments were completed accurately for 1 (Resident #1) of 3 residents sampled. Findings:Review of Resident #1's medical record revealed an admission date of 01/28/2026. Resident #1 had diagnoses that included in part. Alzheimer's Disease, Dementia Severe with other Behavioral Disturbance, Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, and Depression.Review of Resident #1's Discharge Return Anticipated MDS with ARD of 07/10/2026 revealed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment. Resident #1 had no behavioral symptoms exhibited which included no rejections of care. Review of the prior MDS lookback details revealed rejection of care had not been coded on previous MDS assessments dated 02/04/2026, 04/12/2026, and 05/05/2026.Interview on 07/21/2026 at 3:20 p.m. with S3DON revealed she was aware of Resident #1 having refusals of care, and he often did not take his medications. S3DON revealed since admission Resident #1 had refusals of taking his medications. S3DON revealed S2RN was responsible for MDS. Record Review of Resident #1's MDS with S3DON confirmed Resident #1's refusals of care should have been coded on MDS, and was not.Interview on 07/21/2026 at 4:02 p.m. with S2RN revealed she was responsible for completing MDS at the facility. Review of Resident #1's Discharge MDS with ARD of 07/10/2026 with S2RN revealed Resident # 1 had not been coded for refusals of care. S2RN stated if resident had been coded for refusals on any previous MDS it would not need to be coded again. Informed S2RN surveyor had reviewed all previous MDS assessments for coding of refusals, and reviewed the question detail tracking responses for this question on MDS, and it had not been coded since admission. S2RN acknowledged the refusal of care should have been coded on MDS.

Based on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by failing to adequately monitor a resident's behaviors related to his psychotropic medication use for 1 (#3) of 3 sampled residents. The facility's census was 81.Findings:Review of Resident #3's clinical record revealed he was admitted to the facility on [DATE]. The resident's diagnoses included Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance, Intermittent Explosive Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, and Pseudobulbar Affect.Review of Resident #3's Order Summary Report revealed he was receiving the following medications:Auvelity (an antidepressant) 45-105 mg 1 tablet by mouth one time a day related to Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms,Paroxetine HCl (an antidepressant) 20 mg by mouth one time a day for mood changes related to Intermittent Explosive Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms, andRisperidone (an antipsychotic) 1.5 mg by mouth two times a day for aggressive behaviors related to Unspecified Dementia, Unspecified Severity, with Other Behavioral Disturbance.Review of Resident #3's Care Plan with a target date of 10/07/2026 revealed an identified focus of The resident uses psychotropic medications r/t intermittent explosive disorder, pseudobulbar affect. The Interventions included in part.Observe for occurrence of target behaviors symptoms (delusions, hallucinations, pacing, wandering, disrobing, inappropriate response to verbal communication, agitation, aggression towards staff/others, etc.) and document per facility protocol.Review of Resident #3's June and July 2026 MARs revealed there was no documentation of behavior monitoring for Resident #3.Interview on 07/22/2026 at 10:18 a.m. with S3DON confirmed the resident did not have any behavior monitoring documented for June or July 2026.Interview on 07/22/2026 at 11:06 a.m. with S6LPNAdminNurse revealed Resident #3's behavior monitoring was not resumed after he returned from his hospital stay in May 2026. She confirmed she had added the monitoring to the physician's orders and MARs on this date after the DON had informed her it was missing.

Based on interviews and record reviews, the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents sampled with behavioral health diagnoses by failing to:1. Develop and implement a person-centered plan of care that addressed Resident #1's refusals of care including adherence to prescribed medication regimen;2. Ensure Resident #1's drug regimen remained free from an antipsychotic prescribed for undiagnosed Schizophrenia;3. Ensure Resident #1 had accurate monitoring of behaviors; and4. Notify the Psychiatric NP of Resident #1's refusals/non-adherence to prescribed medication regimen. Findings:Review of the facility's policy titled Behavioral Health Services dated 02/2019 on 07/22/2026 at 11:20 a.m. read in part. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. Review of the facility's policy titled Antipsychotic Medication Use dated 07/2022 on 07/22/2026 at 11:20 a.m. read in part. Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. Residents who are admitted from the community or transferred from a hospital and who are already receiving antipsychotic medications will be evaluated for the appropriateness and indications for use. Diagnoses alone do not warrant the use of antipsychotic medication. In addition to the above criteria, antipsychotic medications will generally only be considered if the following conditions are also met: The behavioral symptoms present a danger to the resident or others; AND: the symptoms are identified as being due to mania or psychosis (such as auditory, visual, or other hallucinations; delusions, paranoia or grandiosity); or behavioral interventions have been attempted and included in the plan of care, except in an emergency. Antipsychotic medications will not be used if the only symptoms are one or more of the following: Wandering; Poor self-care; Restlessness; Impaired memory; Mild anxiety; Insomnia; Inattention or indifference to surroundings; Sadness or crying alone that is not related to depression or other psychiatric disorders; Fidgeting; Nervousness; or Uncooperativeness. Review of the facility's policy titled Requesting, Refusing and/or Discontinuing Care or Treatment dated 07/2022 on 07/22/2026 at 11:20 a.m. read in part. The healthcare practitioner must be notified of refusal of treatment, in a time frame determined by the resident's condition and potential serious consequences of the request.Review of Resident #1's medical record revealed an admission date of 01/28/2026. Resident #1 had diagnoses that included in part. Alzheimer's Disease, Dementia Severe with other Behavioral Disturbance, Neurocognitive Disorder with Lewy Bodies, Type 2 Diabetes Mellitus, and Depression.Review of Resident #1's Discharge MDS with ARD of 07/10/2026 revealed Resident #1 had a BIMS of 3, which indicated severe cognitive impairment. Resident #1 had no behavioral symptoms exhibited which included no rejections of care. Review of the prior MDS lookback details revealed rejection of care had not been coded on previous assessments dated 02/04/2026, 04/12/2026, and 05/05/2026. Review of the MDS revealed Schizophrenia had not been coded as a diagnoses for Resident #1.Review of Resident #1's 07/2026 physician orders read in part.04/27/2026- Monitor for the following behaviors: itching, picking at skin, restlessness, agitation, hitting, increase in complaints, biting, kicking, spitting, foul language, elopement, stealing, delusions, hallucinations, psychosis, aggression, refusal of care every shift.04/27/2026- Quetiapine Fumarate (antipsychotic) Oral Tablet, give 25 mg by mouth at bedtime related to schizophrenia.04/27/2026- Risperidone (antipsychotic) Oral Tablet, give 1 mg by mouth two times a day for severe psychosis related to schizophrenia. Review of Resident #1's medical record revealed no evidence of a diagnoses of Schizophrenia.Review of Psychiatric evaluation completed prior to admission that was dated 01/09/2026 revealed an assessment of: Unspecified dementia, unspecified severity, with other behavioral disturbance. Review of an inpatient psychiatric evaluation dated 04/12/2026 revealed diagnostic impression: Mood disorder unspecified, dementia with behavioral disturbances. The psychiatric evaluations revealed no supporting evidence of a schizophrenia diagnosis.Review of Psychiatric evaluations completed by S5PNP dated 07/10/2026, 06/17/2026, and 06/10/2026 read in part. Review of nursing documentation confirms continued adherence to prescribed psychotropic medications. There was no supporting evidence by S5PNP of a schizophrenia diagnosis.Review of Resident #1's 06/2026 and 07/2026 EMARs revealed documented refusals of medication regimen. Review of 06/2026 EMAR revealed refusals of medication was documented on 17 out of 30 days. Review of the behavior monitoring for 06/2026 EMAR revealed refusals were documented 0 out of 30 days. Review of 07/2026 EMAR revealed refusals of medication was documented for 7 out of the 9 days the resident was in the facility. Review of the behavior monitoring for 07/2026 EMAR revealed refusals were documented 2 out of the 9 days.Review of Resident #1's current comprehensive plan of care with target completion date of 08/09/2026 revealed no evidence of a diagnoses of Schizophrenia, or rejections of care. Interview on 07/21/2026 at 3:20 p.m. with S3DON revealed she was aware of Resident #1 having refusals of care, and he often did not take his medications. S3DON revealed since admission Resident #1 had refusals of taking his medications. S3DON revealed S2RN was responsible for MDS and care planning for residents. Resident #1's MDS and Care Plan was reviewed with S3DON. S3DON confirmed Resident #1's refusals of care should have been care planned and coded on MDS, and was not. Reviewed Resident #1's medical record with S3DON, S3DON confirmed Resident #1 did not have a diagnosis of schizophrenia, so he should not receive medications that was ordered with an indication of schizophrenia. Interview on 07/21/2026 at 4:02 p.m. with S2RN revealed she was responsible for completing care plan and MDS at the facility. Review of Resident #1's current and previous care plans with S2RN confirmed the resident had not been care planned for refusals, and should have been. Review of Resident #1's medical record with S2RN revealed Resident #1 had been ordered Seroquel and Risperdal for diagnoses of schizophrenia. S2RN acknowledged Resident #1's medical record did not reflect a diagnosis of schizophrenia, therefore he should not receive medications indicating this diagnosis.Telephone interview on 07/22/2026 at 9:23 a.m. with S7NP revealed regarding Resident #1, no behaviors had been reported to her by facility staff including refusals of taking medications. S7NP stated if she had been notified, she would have left it up to S5PNP as to what other approaches should be taken with the resident.Interview on 07/22/2026 at 10:05 a.m. with S3DON revealed S3DON reviewed Resident #1's established diagnoses, orders, 06/2026 and 07/2026 EMARS, care plan, MDS, and recent inpatient psychiatric records with surveyor. S3DON confirmed during months of 06/2026 and 07/2026 Resident #1 often refused medications. S3DON confirmed this documentation was accurate and the administration of medications would not be located anywhere else in the resident's medical record. S3DON confirmed behavior monitoring of refusals should have been documented accurately each shift, but was not. Review of Resident #1's Care plan and MDS, S3DON confirmed these records should reflect refusals, so other interventions could be implemented. Review of current medications revealed Seroquel and Risperdal were ordered with indication of use listed as schizophrenia. S3DON reviewed medical record including inpatient psychiatric evaluations, and confirmed Resident #1 did not have a diagnosis of schizophrenia.Interview on 07/22/2026 at 11:05 a.m. with S6LPNAdminNurse confirmed during review of Resident #1's medical record that Resident #1 did not have diagnosis of schizophrenia, and stated the physician should have been contacted to clarify order, but was not.Telephone interview on 07/22/2026 at 12:30 p.m. with S5PNP revealed she recalled Resident #1 with diagnoses of Dementia. S5PNP revealed she could not recall if Resident #1 had a schizophrenia diagnosis. S5PNP stated after going to inpatient psychiatric stay resident could have come back with different diagnoses, but that would have been reflected in the inpatient psychiatric evaluation. S5PNP revealed she had not been made aware of Resident #1's medication refusals in recent months. S5PNP revealed she reviewed progress notes and relied on staff communications if refusal of medications were occurring. S5PNP revealed she did not review Resident #1's EMARs and relied on progress notes. S5PNP revealed she rounded at the facility 3 times a week, so if something was going on with residents, including refusals, she would expect to be notified by staff to increase visits.

Based on record review and interview, the facility failed to ensure the physician documented a clinical rationale for a denial of a gradual dose reduction for 4 (#5, #7, #12, #38) of 5 (#5, #7, #8, #12, and #38) residents reviewed for unnecessary medications. The facility failed to ensure the physician documented on the Pharmaceutical Consultant Report a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings:Resident #5 Review of Resident #5’s clinical record revealed an admission date of 11/21/2022 with a readmission date of 10/21/2024 with diagnoses that included in part., Cerebral Infarction; Bipolar Disorder, current episode manic without Psychotic features, Mild; Unspecified Dementia, without Behavioral disturbance, Psychotic disturbance, Mood disturbance, and Anxiety. Review of Resident #5’s Quarterly MDS with an ARD of 07/30/2025 revealed a BIMS score of 10, indicating moderately impaired cognition. Resident #5 received an antipsychotic and antidepressant medication. Review of Resident #5’s 08/2025 physician’s orders revealed the following: -Brexpiprazole Oral Tablet-give 1mg (milligram) by mouth at bedtime related to Bipolar Disorder (order date of 10/21/2024) -Sertraline HCl (Hydrochloride) Oral Tablet 100mg-give 1 tablet by mouth one time a day related to Bipolar Disorder, give with Sertraline 50mg to equal 150mg every day (order date of 01/07/2025) -Sertraline HCl Oral Tablet 50mg-give 1 tablet by mouth one time a day related to Bipolar Disorder, give with Sertraline 100mg to equal 150mg every day (order date of 01/07/2025) -Divalproex Sodium Oral Tablet Delayed Release give 750mg by mouth two times a day related to Bipolar Disorder (order date 01/06/2025) Review of the Pharmaceutical Consultant Report that was signed and undated by S11 NP (Nurse Practitioner), the pharmacy consultant requested a gradual dose reduction for the following medications: Brexpiprazole Oral Tablet-give 1mg at bedtime, Divalproex Sodium Oral Tablet Delayed Release-give 750mg by mouth two times a day, Sertraline HCl Oral Tablet 100mg-give 1 tablet by mouth one time a day, and Sertraline HCl Oral Tablet 50mg-give 1 tablet by mouth one time a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a hand written valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “NO” for if a dose reduction is appropriate. S11 NP failed to provide a hand written clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #38 Review of Resident #38’s clinical record revealed an admission date of 01/08/2024, with an initial admission date of 05/23/2022, and diagnoses that included, in part, Alzheimer’s Disease, Bipolar Disorder, unspecified, Major Depressive Disorder, recurrent, and Anxiety Disorder, unspecified. Review of Resident #38’s Quarterly MDS with an ARD of 08/20/2025 revealed that a BIMS was not completed because the resident was rarely understood. Resident #38 received an antipsychotic, an antianxiety, and an antidepressant medication. Review of Resident #38’s 08/2025 physician’s orders revealed the following: - Ativan Oral Tablet- Give 1 MG (milligram) by mouth four times a day for anxiety (order date of 04/27/2025) - Divalproex Sodium Oral Capsule Delayed Release Sprinkle 125 MG (milligram), Give 2 capsule orally two times a day related to Bipolar disorder, unspecified (order date 06/03/2024) - Quetiapine Fumarate Tablet 25 MG (milligram), Give 1 tablet by mouth two times a day related to Bipolar disorder, unspecified (order date 04/24/2025) Review of the Pharmaceutical Consultant Report dated 07/29/2025, that was signed with an undated signature by S11 NP (Nurse Practitioner), the pharmacy consultant requested a gradual dose reduction for the following medications: 1) Ativan Oral Tablet 1 MG (milligram) (Lorazepam) Give 1 mg by mouth four times a day; 2) Divalproex Sodium Capsule Delayed Release Sprinkle 125 MG Give 2 capsule orally two times a day; 3) Quetiapine Fumarate Tablet 25 MG Give 1 tablet by mouth two times a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten, valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “NO” for whether a dose reduction is appropriate, but did not indicate if the resident is receiving the minimal effective dose. S11 NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #7 Review of Resident #7’s clinical record revealed an admission date of 09/02/2021, and diagnoses that included, in part, Type 2 Diabetes Mellitus without complications, Unspecified Dementia, unspecified severity, with Anxiety, Chronic Obstructive Pulmonary Disease, unspecified, and Schizoaffective disorder, unspecified. Review of Resident #7’s Quarterly MDS with an ARD of 07/30/2025 revealed a BIMS score of 3, indicating severe cognitive impairment. Resident #7 received an antipsychotic and an antidepressant medication. Review of Resident #38’s 08/2025 physician’s orders revealed the following: - Haloperidol Decanoate IM (Intramuscular) Solution 50 MG (milligrams)/ML (milliliter), Inject 1 ml intramuscularly one time a day every 2 weeks on Wednesday related to Schizoaffective disorder, unspecified (order date of 6/06/2024) - Zoloft Oral Tablet 100 MG (milligrams) (Sertraline HCl), Give 1 tablet by mouth one time a day related to Schizoaffective Disorder (order date of 6/03/2025) Review of the Pharmaceutical Consultant Report dated 07/29/2025, that was signed with an undated signature by S11 NP revealed the pharmacy consultant requested a gradual dose reduction for the following medications: 1) Haloperidol Decanoate IM (Intramuscular) Solution 50 MG (milligrams)/ML (milliliter), Inject 1 ml intramuscularly one time a day every 2 weeks; 2) Zoloft Oral Tablet 100 MG (Sertraline HCl), Give 1 tablet by mouth one time a day. The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten, valid clinical rationale as to why the reduction is not desired at this time. S11 NP did not document whether a dose reduction was appropriate or if the resident was receiving the minimal effective dose. S11 NP also failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. Resident #12 On 08/27/2025, a review of the facility’s policy titled “Tapering Medications and Gradual Dose Reduction” last revised on 07/2022 revealed in part…13. For any individual who is receiving a psychotropic medication to treat a psychiatric disorder other than behavioral symptoms related to dementia (for example, schizophrenia, bipolar mania, or depression with psychotic features), the GDR may be considered contraindicated, if: a. the continued use is in accordance with relevant current standards of practice and the physician has documented the clinical rationale for why any attempted dose reduction would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying psychiatric disorder; or b. the resident’s target symptoms returned or worsened after the most recent attempt at a GDR within the facility and the physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident’s function or cause psychiatric instability by exacerbating an underlying medical or psychiatric disorder. Review of Resident #12’s medical record revealed an admit date of 12/12/2024 with diagnoses that included in part .Psychotic Disturbance, Mood Disturbance, and Anxiety; Schizoaffective Disorder, Depressive Type; and Depression. Review of Resident #12’s Quarterly MDS with an ARD date of 08/13/2025 revealed a BIMS score of 12, indicating moderately impaired cognition. Resident #12 received antianxiety, antidepressant, and antipsychotic medications. Review of Resident #12’s August 2025 physician’s order revealed the following:12/31/2024-Zoloft 100 MG give 2 tablets for depression once a day; 03/13/2025-Buspirone Hydrochloride Tablet 5 MG .1 tab twice a day related to Depression, Unspecified; 07/01/2025-Haloperidol Tab 5 MG…1 tablet one time a day related to Schizoaffective disorder, unspecified; 12/15/2024-Haloperidol Decanoate Intramuscular Solution 50mg/ml.inject 50mg intramuscularly one time a day starting on the 15th and ending on the 15th every month related to Schizoaffective Disorder, Depressive Type. Review of the Pharmaceutical Consultant Report dated 07/29/2025 revealed the pharmacy consultant requested a gradual dose reduction for Buspirone Hydrochloride 5mg, Haloperidol Decanoate Intramuscular Solution 50mg/ml, Haloperidol tablet 5mg, and Zoloft tablet 100mg (2 tablets). The report read, Note to Physician: According to CMS Interpretive Guidelines for Long Term Care Facilities, justification for not reducing a psychoactive must have a handwritten valid clinical rationale as to why the reduction is not desired at this time. S11 NP documented “No” for if a dose reduction was appropriate and signed her name but did not date it. S11 NP failed to provide a handwritten clinical rationale explaining why a dose reduction would be clinically contraindicated. On 08/27/2025 at 8:32 a.m., S2 DON confirmed that 07/2025 GDRs were not completed by the medical provider but should have been.

Based on observation and interview the facility failed to ensure nurse staffing data requirements were completed and posted appropriately. This deficient practice had the potential to affect all 74 residents residing in the facility. Findings:Observation on 08/25/2025 at 2:06 p.m. of the facility entrance revealed no display of the daily nurse staffing data. Observation on 08/26/2025 at 10:50 a.m. revealed no display of the daily nurse staffing data throughout the entire facility. In an interview on 08/26/2025 at 10:52 a.m., S7 Corporate revealed that the previous ADON was responsible for completion of the daily nurse staffing data form. S7 Corporate stated that since the ADON was no longer employed at the facility he was unaware of who was responsible for completion of the task currently. In an interview on 08/26/2025 at 10:55 a.m., S7 Corporate confirmed the daily nurse staffing data form was not completed and displayed appropriately. S7 Corporate stated, It's not posted, so it is not done. S7 Corporate revealed the previous ADON's last day of employment was 06/06/2025 and was unable to verify or provide evidence that the daily nurse staffing data had been completed since this date. S7 Corporate confirmed that the Administrator and/or DON were responsible for overseeing that the daily nurse staffing data was completed and posted, but did not.

Based on observations and interviews, the facility failed to provide drinks, including water, consistent with resident needs and preferences. The facility failed to ensure staff, in the dining room, provided water to 32 residents with their meal during lunchtime. Findings:Interview on 08/26/20025 at 11:36 a.m. with Resident #1 revealed that he eats most meals in the dining room. Resident#1 stated that water is never served with the trays unless it is asked for. Observation on 08/26/2025 at 12:10 p.m. revealed staff serving resident lunch trays in the dining room with only tea observed on the lunch tray. A resident in the dining area was heard hollering out for water, instead of the tea that was served. Interview on 08/25/2025 at 12:22 a.m. with S2 DON stated that residents are only served water with meals if they ask for it. S2 DON stated that residents are usually only given tea or the choice of beverage. Interview on 08/26/2025 at 1:00 p.m. S1 Administrator stated that the facility does not serve water on meal trays unless the resident specifically asks for it.

Based on observation, interview, and record review, the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 74 residents who resided in the facility. The facility failed to ensure:1. Kitchen staff did not handle food with dirty gloves during food preparation; and 2. Kitchen staff wore beard restraints to prevent hair from contacting food.Findings::On 08/26/2025, a review of the facility's undated policy titled Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices revealed in part.Employees must wash their hands:.after handling soiled equipment or utensils, during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks, and/or after engaging in other activities that contaminate the hands. Further review of the policy revealed.Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.On 08/25/2025 at 11:10 a.m., an observation was made in the kitchen of S5 Dishwasher rolling silverware in napkins. S5Dishwasher was noted to have a beard, which was not covered with a beard restraint. On 08/25/2025 at 11:18 a.m., S4 [NAME] was observed preparing the puree meals. S4 [NAME] was noted to have a beard which was not covered with a beard restraint. S4 [NAME] was then observed as he donned gloves, grabbed the garbage can by the handle and pulled it to the puree table area. S4 [NAME] then picked up the cooked chicken thighs and began to debone them to put in the blender wearing the same gloves. In an interview at that time, S4 [NAME] confirmed he had just moved the garbage can and then handled the chicken with the same gloves. On 08/25/2025 at 11:23 a.m., S3 Dietary Manager confirmed the above two kitchen employees were not wearing beard restraints because the facility did not have any on hand, but should have been. S3 Dietary Manager acknowledged S4 [NAME] had just touched the garbage can and then handled the chicken with the same, contaminated gloves, but should not have.

Based on observation, interview, and record review, the facility failed to implement/maintain infection control practices to help prevent and control the spread of infectious communicable diseases. The facility failed to ensure the following:1. Staff adhere to Enhanced Barrier Precautions (EBP) for Resident #4. 2. Staff follow the chemical manufacturer's dwell-time guidelines for proper sanitation.The total sample size was 43 residents.Review of the facility's undated policy titled, Enhanced Barrier Precautions revealed in part. Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multidrug-resistant organisms (MDRO's) to residents. EBPs employ targeted gown and glove use during high-contact care activities. Examples of high-contact resident care activities requiring the use of a gown and gloves for EBPs include, in part, changing briefs, providing hygiene, and wound care. EBPs are indicated for residents with wounds and/or indwelling medical devices regardless of MDRO colonization. Staff are trained prior to caring for residents on EBPs.Review of a facility policy titled, Cleaning and Disinfection of Environmental Surfaces last revised on 08/2019 revealed in part.Environmental surfaces will be cleaned and disinfected according to current CDC (Centers for Disease Control and Prevention) recommendations for disinfection of healthcare facilities. Non-critical surfaces will be disinfected with an EPA-registered intermediate or low-level hospital disinfectant according to the labels safety precautions and use directions. Most EPA-registered hospital disinfectants have a label contact time of 10 minutes. By Law, all applicable label instructions on EPA-registered products must be followed. 1.Review of Resident #4's medical record revealed an admission date of 06/12/2017 with diagnoses that included in part. Chronic Multifocal Osteomyelitis of the Right Femur, Stage 4 Pressure Ulcer of the Right Hip, Stage 3 Pressure Ulcer of the Sacral Region, and Quadriplegia.Review of Resident #4's Quarterly MDS with ARD of 08/06/2025 revealed a BIMS score of 15, which indicated intact cognition. Resident #4 was dependent on staff for toileting hygiene.Review of Resident #4's current Care Plan revealed in part. the resident had impaired mobility- quadriplegic, bedbound, and totally dependent on staff for care. Resident #4 had a chronic Stage 4 Pressure Ulcer to the right hip, an open lesion to the right lateral foot, a Stage 3 Pressure Ulcer to the sacrum, and Moisture-Associated Skin Damage (MASD) to bilateral feet.On 08/25/2025 at 10:01 a.m., observation revealed Resident #4 had an EBP sign posted above her bed. EBP sign indicated gown and gloves must be worn for all direct patient care for Resident #4.In an interview on 08/26/2025 at 12:18 p.m., S12 CNA revealed she provided incontinent care to Resident #4 throughout her shift. S12 CNA revealed she was unaware Resident #4 required the use of EBP during incontinent care. On 08/26/2025 at 12:42 p.m., S12 CNA accompanied the surveyor to Resident #4's room. S12 CNA acknowledged the EBP sign posted above Resident #4's bed. S12 CNA confirmed she did not wear a disposable gown earlier that day when she provided incontinent care to Resident #4, but should have.In an interview on 08/27/2025 at 9:59 a.m., S2 DON acknowledged the above findings. S2 DON confirmed that Resident #4 required EBP and S12 CNA should have worn a gown and gloves when providing incontinent care to Resident #32, but did not.2.In an interview on 08/27/2025 at 9:23 a.m., S15 Housekeeping revealed the resident room disinfecting process in part.Room Sense 200 Lemon Disinfectant cleanser was utilized for bathroom cleaning and wiped up after 2-3 minutes of contact time. After review of the Room Sense 200 Lemon Disinfectant cleanser bottle, with S15 Housekeeping, revealed a dwell time of 10 minutes. S15 Housekeeping confirmed she was unaware of the above chemical's 10-minute dwell time. In an interview on 08/27/2025 9:33 a.m., S14 Housekeeping revealed the resident room disinfecting process in part . Room Sense 200 Lemon Disinfectant Cleanser and hdqC2 Neutral Disinfectant were used for bathroom cleaning. S14 Housekeeping confirmed he was unaware that these chemicals had dwell times. On 08/27/2025 at 09:43 a.m., an interview was conducted in Hall X cleaning supply closet with S13 Maintenance Supervisor. S13 Maintenance Supervisor revealed he was also the Housekeeping Supervisor and provided training to the housekeeping staff. The above findings were discussed with S13 Maintenance Supervisor during review of Room Sense 200 Lemon Disinfectant Cleanser and hdqC2 Neutral Disinfectant bottles. S13 Maintenance Supervisor confirmed he was unaware of the proper 10-minute dwell time for the above chemicals, but should have been.

Based on observations and interviews, the facility failed to maintain an effective pest control program by having multiple flies in several areas of the facility including residents' rooms, dining room, and kitchen. There were 74 residents who resided in the facility according to the facility's census. Findings:Observation on 08/25/2025 at 8:45 a.m., of Resident #1 revealed two flies flying around him and landing on him. Observation on 08/25/2025 at 8:50 a.m. of Hall Y revealed multiple flies flying around. Interview on 08/25/2025 at 9:54 a.m., with Resident #29 revealed multiple flies flying around in his bedroom. Resident #29 stated there is a fly problem in the facility. Resident #29 stated “yea, I keep my fly swatter right over there”. Review of Resident #29's Quarterly MDS with an ARD of 08/20/2025 revealed a BIMS score of 15, which indicated intact cognition. Observation on 08/25/2025 at 10:12 a.m., of Hall Y revealed a fly in the hallway. Observation on 08/26/2025 at 8:11 a.m., of Resident #1 revealed him lying in bed and two flies sitting on top of him. Observation on 08/26/2025 at 12:39 p.m., of Hall Y revealed multiple flies flying around in the hallway. Dining observation on 08/26/2025 at 11:58 a.m., revealed multiple flies flying throughout the dining room during meal service. Observation of a Resident eating lunch and yelling loudly at flies flying around him and landing on his food. Staff members observed walking over to Resident to swat away the flies. At 12:08 p.m., another observation of a Resident pulling out her fly swatter, flies observed flying around her. Facility’s Pest Control policy reviewed on 08/26/2025 at 10:50 a.m. with a revision date of May 2008 revealed in part .Our facility shall maintain an effective pest control program to ensure that the building is kept free of insects and rodents. A kitchen observation on 08/25/2025 at 11:18 a.m. revealed a fly flying above the table where kitchen staff were preparing puree meals. At 11:33 a.m., flies were noted flying around steam table and landing on the rim of an uncovered glass of tea about to be served. Observation of Resident #10 on 08/25/2025 at 9:30 a.m. revealed in part…Four flies on Resident #10 lying in bed. Observation of Resident #10 on 08/25/2025 at 12:10 p.m. revealed in part…Resident #10 had multiple flies on top of her. Resident #10 interview on 08/26/2025 at 09:51 a.m. revealed Resident #10 stated she has flies in her room, and they are very bad. She stated, It’s because of that over there” and pointed to her roommate. Resident #10 stated her roommate eats in her bed and throws everything on the floor. Observation of Resident #10’s room on 08/26/2025 at 9:51 a.m. revealed 2 flies on the floor in Resident #10’s room. Review of the facility’s Pest Control contract on 08/26/2025 at 10:50 a.m. revealed in part .Basic Services which includes treatment of rats, mice, German, American, brown, Oriental and smokey brown cockroaches, earwigs, crickets, grasshoppers, carpenter ants, pharaoh ants and Argentinian ants. It also included 4 step to fire ant control. Dining observation on 08/26/2025 at 12:06 p.m. revealed a resident observed swatting at flies while eating. Dining observation on 08/26/2025 at 12:08 p.m. revealed a resident yelled out at this time Can't eat for the damn flies. Another resident sitting at the same table pulled out a fly swatter. A couple of flies observed flying in dining room. Observation of Resident #10's room on 08/27/2025 at 9:15 a.m. revealed 1 fly on Resident #10 while she was in bed, one fly on the privacy curtain, and one fly flying around the room. In a telephone interview with Facility’s Pest Control contractor on 08/27/2025 at 8:57 a.m., he stated monthly basic service includes control of flies and he sprayed recently around the dumpsters which is where the flies usually originate from. He also stated he told the facility to have the light bulbs changed in the fly lights, but the facility told him they didn't need to be changed. He says the bulbs in the fly lights typically should be changed every 9 months, the UV light still works but the UV light loses its attraction after this timeframe. He stated the facility can call him out for services anytime in addition to the monthly services and stated he provides receipts to the facility for every visit. Interview on 08/26/2025 at 2:00 p.m., S3 Dietary Manager acknowledged flies were observed in the kitchen on 08/25/2025 during lunch service around the steam table. She acknowledged the facility had a problem with flies, stating “They are everywhere.” S3 Dietary Manger stated she was unsure if the pest control sprays in the kitchen because she was not present when they came. In an interview on 08/27/2025 at 11:40 a.m., S1 Administrator confirmed that she can call the pest control company to come out in addition to the monthly services if needed. She acknowledged the last pest control visit was 08/04/2025. S1 Administrator stated she couldn’t remember if she had called the pest control company since then to come out for flies. Review of the QAPI meeting minutes dated 07/25/2025 revealed the Risk Management Company had identified issues with flies and cleanliness with a corrective measure put in place for department heads to continue rounding on rooms and addressing issues as they arise. Interview on 08/27/2025 at 2:33 p.m., S2 DON stated the facility’s Risk Management Company comes out quarterly to address problems in the facility. She confirmed the Risk Management Company identified the fly problem. S2 DON confirmed pest control can be called to come out whenever needed. Pest control invoices reviewed on 08/26/2025 at 10:50 a.m. revealed once per month services were provided in June, July, and August 2025, with the last visit made on 08/04/2025.

Based on record review and interview, the facility failed to consult with the resident's physician when there was a significant change in condition for 1 (#1) of 5 (#1, #2, #3, #4, & #5) residents reviewed for notification of change. The facility failed to timely consult with Resident #1's physician when Resident #1 experienced increased/worsening pain in her right lower extremity and a decline in ADLs due to increased pain, after treatment implemented by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and Mobic (non-steroidal anti-inflammatory) 7.5 MG PO BID x 30 days, Lasix (a diuretic) 40 MG PO Q Day x 30 days, and Potassium (electrolyte replacement) 10 MEQ PO Q Day x 30 days was prescribed. Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for all 82 Residents who reside in the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented: The Facility's plan to remove the immediate jeopardy situation included: 1. Root cause analysis nurse failed to notify physician immediately when there was a significant change in resident's condition. 2. NFA Managing Member, NFA and DON reviewed facility policy on Acute Condition Changes and found to be sufficient on 3/2/2023 at 2:45p.m. 3. The nursing staff will follow the clinical protocol to immediately notify the physician of any change of condition or worsening in pain. 4. All nursing staff will be in-serviced by NFA or designee beginning 3/2/2023 at 5:00p.m- 6:30 p.m. on notifying the physician when there is a significant change in residents' condition or worsening in pain and following Clinical Protocol. Nurses will receive a copy of Clinical Protocol for Pain Management and Acute Condition Changes at the time of their in-service. Each nursing staff will be in-serviced prior to beginning of their shift and receive a copy of the clinical protocol for Pain Management and Acute Condition Change with completion by 3/6/2023 at 6:00 p.m. NFA in-serviced CNA's beginning 3/2/2023 5:30pm-6:30pm on reporting any pain or change in residents' condition to the floor nurse, DON and NFA. Each CNA will be will be in-serviced prior to beginning of their shift with completion by 3/6/2023 at 6:00 p.m. Each new hire CNA will be trained during orientation. 33 residents who are currently taking pain medications or have an acute change in condition were reassessed with pain assessment by DON or designee ensuring their pain is relieved by medications beginning 3/2/2023 at 4:00p.m., completing on 3/2/2023 at 8:00p.m., and notification to MD if pain has worsened or not relieved. NFA in-serviced DON on 3/2/2023 at 4:45pm on Clinical Protocol for Pain Management and Acute Condition Changes by reassessing for increase in pain and notifying physician if pain worsens. NFA reiterated during In-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. NFA will monitor one nursing meeting weekly x 1 month. NFA will randomly question nursing staff weekly x I month on Clinical protocol for reporting changes in condition and unrelieved pain. 5. In order to monitor performance and assure solutions are sustained the NFA or designee will monitor nurses notes and shift reports for MD notification in change in resident condition 5 days a week for one month and then 3 times a week for or one month. Negative issues will be addressed with the respective employee at the time of occurrence. 6. Completion date 3/6/2023 Findings: Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol revealed in part . 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 9. The attending physician (or a practitioner providing backup coverage) will respond in a timely manner to notification of problems or changes in condition and status. a. The nursing staff will contact the Medical Director for additional guidance and consultation if they do not receive a timely or appropriate response. 10. The nurse and physician will discuss and evaluate the situation. Monitoring and Follow-Up 1. The staff will monitor and document the resident/patient's progress and responses to treatment, and the physician will adjust treatment accordingly. Review of the medical record for Resident #1 revealed an admitted [DATE], and diagnoses that included Parkinson's disease, Unspecified abnormalities of gait, Unspecified Dementia, and Pain. Review of Resident #1's significant change MDS with an ARD of 12/28/2022 revealed a BIMS score of 5, which indicated severely impaired cognition, and revealed Resident #1 required limited assistance by one person with bed mobility, transferring, toilet use, and walking. Review of Resident #1's current care plan revealed a problem onset of 01/26/2023 for impaired physical mobility due to right hip fracture/repair of closed right hip fracture with right hip precautions implemented. Approaches included notified S14 MD and new order to send to ER for treatment and evaluation related to x-ray findings. New diagnosis of Osteopenia and Osteoarthritis revealed via x-ray on 01/26/2023. Keep abduction pillow in place while in bed and chair. 02/28/2023-discontinue abduction pillow. 02/09/2023 - seen by Orthopedist, D/C staples, follow back up in 12 weeks, noted knee pain associated with hip fracture, obstructed nerve should resolve. Review of Physical Therapy notes dated 01/19/2023 (no time documented), revealed Resident #1 complained of throbbing pain rated 4 out of 10 to right lower extremity/knee with movement. Review of Occupational Therapy notes dated 01/23/23 and 01/25/2023 (no time documented), revealed Resident #1 reported throbbing, right knee pain of 8 out of 10 with movement, and pain of 3 out of 10 at rest. Review of physical therapy notes dated 01/23/23 (no time documented), revealed Resident #1 complained of throbbing pain of 5 out of 10 with movement, and 3 out of 10 at rest to right lower extremity. In an interview on 02/28/2023 at 1:10 p.m., S9 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift, and stated Resident #1 complained of leg and ankle pain during January 2023 (unsure of date). S9 CNA stated she reported it to S3 LPN, but S3 LPN already knew and would come check on her. In an interview on 02/28/23 at 1:15 p.m., S8 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S8 CNA stated when she left to go on vacation January 2nd or 3rd 2023, Resident #1 was ambulatory with her walker, but when she returned to work on January 16th or 17th 2023, Resident #1 was in the bed. S8 CNA stated she asked her coworkers why was Resident #1 in the bed, and was told she had started on some fluid pills for swelling in her feet and legs. S8 CNA stated when she would change Resident #1's position toward the window (right side), or change her brief, Resident #1 would cry out in pain. S8 CNA stated she reported it to S3 LPN, and stated the nurse would check on her. In an interview on 02/28/2023 at 1:30 p.m., S10 COTA stated Resident #1 had been receiving therapy 3 times per week since 12/21/2022 for functional decline, increased help with ADL's, and balance and safety. S10 COTA stated Resident #1 was ambulatory with a rolling walker, and would walk several times per day. S10 COTA stated therapy noticed Resident #1 had stopped walking as much in the later part of December 2022. S10 COTA stated in January 2023, Resident #1 started complaining of right knee pain, and it got to the point her knee pain was so bad they started treating her in bed because she did not want to get out of bed. S10 COTA stated Resident #1's right knee was swollen and therapy did ESTIM with her to help with the pain. S10 COTA stated at one point Resident #1 had quit walking, and they were just trying to treat her knee pain. S10 COTA stated Resident #1 would verbally say her knee was hurting, and grab and rub it. S10 COTA stated on 01/26/2023 on the morning shift, Resident #1 was trying to get up from a straight back chair in her room when S12 PTA noticed Resident #1's right leg was rotated. S10 COTA stated S12 PTA reported it to the floor nurse and both of them went to report it to S2 DON. S10 COTA stated S2 DON ordered X-rays that revealed a right hip fracture. In an interview on 02/28/2023 at 2:40 p.m., S3 LPN stated she has worked at the facility as a nurse for three years, and has never telephoned the physician. S3 LPN reported the process was to notify S2 DON and S2 DON notified the physician. S3 LPN stated she does not know how to contact the physician. S3 LPN stated Resident #1 was normally ambulatory with her walker, but noted Resident #1 kept saying her knees hurt, and grabbing the rail in the hallway during ambulation. S3 LPN stated she told S2 DON about Resident #1's difficulty walking and knee pain on 01/16/2023 at 11:35 a.m., and S2 DON told her Resident #1 was going to see the physician the next day. S3 LPN stated the physician made rounds on 01/17/2023, and started Resident #1 on new medications. S3 LPN stated within a couple of days Resident #1 was in the bed and not getting up. S3 LPN stated this was not normal because Resident #1 walked all the time. S3 LPN stated on 01/19/2023 at 2:40 p.m. she told S2 DON the new medications were not working, and asked could something different be tried for Resident #1, and S2 DON said ok. In an interview on 03/01/2023 at 8:47 a.m., S11 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S11 CNA stated Resident #1 was able to walk, dress herself, transfer, and toilet herself. S11 CNA stated she went on her off days and came back on 01/19/2023, and Resident #1 was no longer able to walk, transfer, or dress and toilet herself. S11 CNA stated Resident #1 complained of right knee pain when she would raise the head of her bed. In an interview on 03/01/2023 at 9:42 a.m., S4 LPN (who worked the 6:00 a.m. - 6:00 p.m. shift) revealed she cared for Resident #1 on 01/20/2023. S4 LPN stated therapy reported to her when they raised the head of the bed, Resident #1 complained of dizziness. S4 LPN stated Resident #1's blood pressure was a little low, Resident #1 looked pale, and didn't look right. S4 LPN stated she did not notify the doctor, but notified S2 DON on 01/20/2023 instead, who told her to raise Resident #1's head of bed and her feet, and to monitor her blood pressure. S4 LPN stated Resident #1 had bilateral leg edema with black X marks on the top of both feet as if she were being monitored for something. S4 LPN stated Resident #1 complained of knee pain. S4 LPN stated she does not talk to the physician, and stated the nurses report changes to S2 DON who notifies the physician and receives orders. S4 LPN stated when changes that need to be reported occur on the weekend, staff call S2 DON at home. S4 LPN stated sometimes they have to call 2 or 3 times before they reach S2 DON. In an interview on 03/01/23 at 10:44 a.m., S7 LPN revealed she took care of Resident #1 who complained of her knees hurting. S7 LPN stated she worked the 6:00 p.m. - 6:00 a.m. shift, and assessed Resident #1 on 01/19/2023. S7 LPN stated the CNA asked her to come look at Resident #1 because Resident #1 couldn't walk. S7 LPN stated when she assessed Resident #1, she discovered Resident #1's right leg was swollen, shiny, and cooler than her left leg. S7 LPN stated she notified S2 DON of her assessment of Resident #1 soon after. S7 LPN stated she never talked to the physician because the process was for the nurse to notify S2 DON, and S2 DON notifies the doctor. In an interview on 03/01/23 at 3:00 p.m., S12 PTA revealed Resident #1 was receiving therapy due to a functional decline, and had complained of right knee pain. S12 PTA stated Resident #1 had a tibia fracture years ago and had screws and a plate put in, and was aware Resident #1 was recently was prescribed Mobic for knee pain. S12 PTA stated on 01/26/2023 she was assisting Resident #1 to bed and noted her right leg was externally rotated. S12 PTA stated she notified nursing like she did each time a Resident had complaints. S12 PTA stated she did not remember who she notified. In an interview on 03/01/2023 at 4:10 p.m., S3 LPN reported she went to S2 DON on 01/26/2023 at 5:40 p.m., and asked her about obtaining an x-ray because Resident #1 kept complaining of pain. In an interview on 03/02/23 at 8:15 a.m., S5 LPN (worked the 6:00 p.m. - 6:00 a.m. shift), revealed she and S4 LPN went to check on Resident #1 on 01/20/2023 because the day shift nurse said Resident #1 had been dizzy earlier in her shift, and her blood pressure was low. S5 LPN stated Resident #1 seemed to be feeling bad like she was nauseated, so she checked on Resident #1 several times throughout the night. S5 LPN stated she never calls the doctor, but notifies S2 DON of problems, and S2 DON calls the doctor. S5 LPN stated if she could have called the doctor she would have. In a telephone interview on 03/02/2023 at 8:35 a.m., Resident #1's physician revealed he treated Resident #1 on 01/17/2023 for edema to bilateral knees with a diuretic, potassium, and an anti-inflammatory medication. Resident #1's physician stated he was aware Resident #1 was diagnosed with a fracture to her right hip on 01/26/2023. Resident #1's physician stated if he had been notified of Resident #1's decline in ADL's and leg pain, he probably would have ordered an x-ray. Resident #1's physician stated the facility does not notify him like they should, and he wished they would. In an interview on 03/02/2023 at 9:25 a.m., S2 DON reported on 01/19/2023, S7 LPN called her and stated Resident #1's pedal pulse was faint on the right side. S2 DON stated she told S7 LPN that Resident #1's was seen by her physician on 01/17/2023, and her pedal pulse was weak. S2 DON confirmed she did not notify the physician. S2 DON confirmed on 01/20/2023 S4 LPN notified her of Resident #1 having hypotension and dizziness. S2 DON stated she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1 before the x-ray was ordered on 01/26/2023, but did not remember the date or time. S2 DON acknowledged Resident #1's knee was still swollen, and Resident #1 was having pain with range of motion on 01/20/2023. S2 DON confirmed she did not notify the physician of Resident #1's continued knee pain and swelling. S2 DON confirmed their facility process for notifying the physician of resident changes in status was for the nurses to notify the DON, and the DON then notifies the physician. S2 DON confirmed Resident #1's physician was not notified of her continued leg pain, swelling, and decline in ADLs until 01/26/2023. In an interview on 03/03/2023 at 10:00 a.m., S1 Administrator revealed on 01/16/2023 S3 LPN stated Resident #1 was having right knee pain. S1 Administrator stated Resident #1 was already receiving therapy and ambulated in therapy on 01/16/23. S1 Administrator reported S3 LPN gave Resident #1 Tylenol on 01/16/2023, and the physician was going to see Resident #1 on 01/17/2023. S1 Administrator stated the physician ordered some medications for Resident #1, and from there she didn't know anything was wrong until the x-rays came back revealing a right hip fracture. S1 Administrator then acknowledged on 01/19/2023 the night CNAs told her Resident #1 was sitting on her roommate's bed with her walker, and Resident #1 could not bear weight when they attempted to assist her up. S1 Administrator stated therapy attends the facility's morning meetings and reports on residents' toleration of therapy, what each resident is doing in therapy, and where they stand with reaching their goals. S1 Administrator confirmed therapy reported Resident #1 was experiencing the same pain. S1 Administrator acknowledged she did not contact Resident #1's physician because she was unaware Resident #1 had continued to decline. S1 Administrator stated the facility nurses should have been aware they could call the physician if they needed to. S1 Administrator stated she was unaware the nurses in the facility were instructed to report all changes to the DON, and were not contacting the physician directly to report significant changes in condition.

Based on record review and interview, the facility failed to administer its resources effectively to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 (#1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: Ensure nursing staff consulted with Resident #1's physician in a timely manner when Resident #1 experienced a significant change in her condition, and pain treatment was ineffective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and treatment was prescribed Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for all 82 Residents who reside in the facility. S1 Administrator was notified of the Immediate Jeopardy situation on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews, interviews and observations that the Plan of Removal have been initiated and/or implemented. The Facility's plan to remove the immediate jeopardy situation included: l. Root cause analysis nursing staff failed to follow facility policy and procedure for notifying the MD of acute change in resident condition 2. Corporate Managing Member, NFA and DON reviewed facility policy on Acute Condition Changes and found to be sufficient on 3/2/2023 at 2:45p.m. 3. Facility will follow the Clinical Protocol to notify the physician in a timely manner of residents Acute Condition Change to receive care and treatment in a timely manner 4. On 3/2/2023 5p.m.-6:30p.m., the NFA in-serviced all nursing staff on notifying the physician of changes in residents' condition. Nurses received a copy of the Clinical Protocol for Acute Condition Changes at the time of in-service. Each nursing staff will be in-serviced prior to beginning of their shift and receive a copy of the clinical protocol for Acute Condition Changes with completion by 3/6/2023 at 6:00 p.m. Nursing staff will not be allowed to work until he or she receives training on the Clinical Protocol for Acute Condition Changes. All new hire nursing staff will be in-serviced during orientation. 5. NFA in-serviced DON on 3/2/2023 at 4:45pm on Clinical Protocol to Provide Pain Management and Acute Condition Changes by reassessing for increase in pain and notifying physician if pain worsens. NFA reiterated during In-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. NFA will monitor one nursing meeting weekly x 1 month. NFA will randomly question nursing staff weekly x 1 month on Clinical protocol for reporting changes in condition and unrelieved pain. 6. In order to monitor performance and sustain implemented practice, the facility shall monitor corrective actions by incorporating into regular QA meeting 3 times a week by NFA or QA designee with documentation in QA minutes. DON or designee will complete stand up nursing staff meeting 5 days a week documenting changes in resident conditions and unrelieved pain. The Administrator will review these stand-up nursing meeting x 1 month adding to weekly QA meeting and incorporate finding into Quarterly QAPI meeting including Medical Director. Negative issues will be addressed with the respective employee such as compliance is maintained. 7. In order to monitor performance and assure solutions are sustained Corporate Managing Member will monitor NFA and DON monthly for two months. Negative issues will be addressed with the respective employee at the time of occurrence 8. Completion date 3/6/2023 Findings: Cross Refer to F580. Cross Refer to F697. Review of the facility's policy titled, Acute Condition Changes-Clinical Protocol revealed in part . 7. Before contacting a physician about someone with an acute change of condition, the nursing staff will collect pertinent details to report to the physician; for example, the history of present illness and previous and recent test results for comparison. a. Phone calls to attending or on-call physicians should be made by an adequately prepared nurse who has collected and organized pertinent information, including the resident/patient's current symptoms and status. 8. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 10. The nurse and physician will discuss and evaluate the situation. In an interview on 03/02/2023 at 9:25 a.m., S2 DON reported on 01/19/2023, S7 LPN called her and stated Resident #1's pedal pulse was faint on the right side. S2 DON stated she told S7 LPN that Resident #1's was seen by her physician on 01/17/2023, and her pedal pulse was weak. S2 DON confirmed she did not notify the physician. S2 DON confirmed on 01/20/2023 S4 LPN notified her of Resident #1 having hypotension and dizziness. S2 DON stated she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1 before the x-ray was ordered on 01/26/2023, but did not remember the date. S2 DON acknowledged Resident #1's knee was still swollen, and Resident #1 was having pain with range of motion on 01/20/2023. S2 DON confirmed she did not notify the physician of Resident #1's continued knee pain and swelling. S2 DON confirmed their facility process for notifying the physician of resident changes in status was for the nurses to notify the DON, and the DON then notifies the physician. S2 DON confirmed Resident #1's physician was not notified of her continued leg pain, swelling, and decline in ADLs until 01/26/2023. In an interview on 03/03/2023 at 10:00 a.m., S1 Administrator stated the facility nurses should have been aware they could call the physician if they needed to. S1 Administrator stated she was unaware the nurses in the facility were instructed to report all changes to the DON, and were not contacting the physician directly to report significant changes in condition.

Based on observation, interview, and record review, the facility failed to provide pain management cons istent with professional standards of practice for 1 (Resident #1) of 5 (#1, #2, #3, #4, & #5) sampled residents. The facility failed to: 1. Intervene and ensure Resident #1 received the necessary treatment/interventions when Resident #1 voiced and exhibited increased/worsening pain to her right lower extremity, and became bedfast due to the increased pain, after initial treatment of the increased pain by the physician was not effective. This deficient practice resulted in an Immediate Jeopardy situation for Resident #1 that began on 01/19/2023. Resident #1, a severely cognitively impaired resident who required limited assistance by one person with ambulation, began complaining of pain in her right leg/knee/ankle on 01/16/2023, and became unable to ambulate on 01/17/2023 due to increased pain. Resident #1 was assessed by the physician on 01/17/2023, and treatment was prescribed. Resident #1's pain continued to worsen, and Resident #1 continued to decline in ADLs. On 01/19/2023, S7 LPN and S3 LPN reported to S2 DON that Resident #1's pain was not being relieved, and that her right leg was swollen, shiny, and cooler than the left leg. On 01/20/2023, S4 LPN reported to S2 DON that Resident #1 was dizzy, pale, and did not look right. Resident #1's change of condition on 01/19/2023 and 01/20/2023 was not reported to the physician until 01/26/2023. Resident #1 was x-rayed on 01/26/2023, which revealed an acute fracture and dislocation of the femoral neck of the right hip. Resident #1 required surgical intervention of a right bipolar hip arthroplasty on 01/27/2023. This deficient practice continued at a potential for more than minimal harm for 33 facility Residents who received treatment for pain. S1 Administrator was notified of the Immediate Jeopardy on 03/02/2023 at 2:20 p.m. The Immediate Jeopardy was removed on 03/03/2023 at 3:33 p.m. when the facility submitted an acceptable plan of removal, and the surveyors determined through record reviews and interviews that the Plan of Removal have been initiated and/or implemented: The Facility's plan of removal include the following: In-services were initiated for all staff by the Administrator and Corporate Managing Member on 03/02/2023 and 03/03/2023 and will be completed by 03/06/2023 at 6:30 p.m. The in-services covered the existing policy on the Clinical Protocol to Provide Pain management which includes: The staff well reassess the Residents pain and related consequences at regular intervals, at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. The staff will evaluate and report the Residents use of standing and PRN analgesics. The in-services also addressed to notify the physician of acute changes in a Residents condition and the policy on Acute condition changes-Clinical protocol which stated Direct care staff including nursing assistants will be trained in recognizing subtle but significant changes in the Resident and how to communicate these changes to the Nurse. The policy also states the Nurse shall assess and document/report the baseline information on Residents current level of pain, and any recent changes in pain level to the physician. Nurses received a copy of the Clinical Protocol for Pain at the time of their in-services. Nursing staff will not be allowed to work until he or she receives training on the Clinical Protocol for Pain Management. All new hire nursing staff will be in-serviced during orientation. A total of 33 Residents were reassessed with pain assessment by the DON or designee ensuring their pain is relieved by medications beginning 03/02/2023 at 4:00 p.m. and completed by 8:00 p.m. The NFA in-serviced CNA's beginning 03/02/2023 from 5:30 p.m.-6:30 p.m. on reporting any pain or change in Residents condition to the floor nurse, DON, and NFA. Each CNA will be in-serviced prior to beginning of their shift with completion by 03/06/2023 at 6:00 p.m. Each new hire CNA will be trained during orientation. NFA in-serviced DON on 03/02/2023 at 4:45 p.m. on the Clinical Protocol to Provide Pain Management by reassessing for increase in pain and notifying the physician of pain worsens. NFA reiterated during in-service training to DON that per facility policy nurses are to report changes of unrelieved pain or changes in condition to primary care physician. In order to monitor performance and assure compliance are sustained NFA or designee will monitor notes and pain checks 5 days a week x 1 month then three times a week for one month then as needed thereafter. Negative issues will be addressed with the respective employee at the time of occurrence. Completion date 03/06/2023 Findings: Review of the Facility's policy titled, Pain-Clinical Protocol revealed in part . Assessment and Recognition 1. The Physician and staff will identify Residents who have pain or who are at risk for having pain. a. The nursing staff will assess each Resident for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. Monitoring 1. The staff will reassess the Residents pain and related consequences at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain and at least weekly in stable chronic pain. Treatment/Management 1. The physician will help identify and authorize appropriate treatments. Monitoring and Follow-Up 1. The staff will monitor and document the Resident's progress and responses to treatment, and the physician will adjust treatment accordingly. Review of the medical record for Resident #1 revealed an admitted [DATE], and diagnoses that included in part .Parkinson's disease, Unspecified abnormalities of gait, Unspecified Dementia without behaviors, Pain Unspecified, Non-displaced fracture of base of neck of Right Femur. Review of Resident #1's Quarterly MDS with an ARD of 10/19/2022 revealed a BIMS score of 4 (indicating severely impaired cognition). The MDS revealed Resident #1 was independent with set up help only for: bed mobility, transfer, locomotion on and off unit, dressing, eating, toilet use, personal hygiene and bathing. No impairment of upper or lower extremity Range of Motion. Review of the MDS revealed no indication of pain. Review of Resident #1's Significant Change MDS with an ARD of 12/28/2022 revealed a BIMS score of 5, which indicated severely impaired cognition, and revealed Resident #1 required limited assistance by one person with bed mobility, transferring, toilet use, and walking. Review of Resident #1's Significant Change MDS with an ARD of 02/04/2023 revealed a BIMS score of 3 (indicating severely impaired cognition). The MDS revealed Resident #1 was coded as requiring extensive assistance of one person for bed mobility and personal hygiene, and locomotion on and off unit; extensive assistance of 2 persons with dressing, toilet use and bathing. Impairment of Range of Motion on both sides of lower extremities. Review of the MDS revealed Resident #1 was having occasional moderate pain. Review of Resident #1's current care plan revealed a problem onset of 01/26/2023 for impaired physical mobility due to right hip fracture/repair of closed right hip fracture with right hip precautions implemented. Approaches included notified S14 MD and new order to send to ER for treatment and evaluation related to x-ray findings. New diagnosis of Osteopenia and Osteoarthritis revealed via x-ray on 01/26/2023. Keep abduction pillow in place while in bed and chair. 02/28/2023-discontinue abduction pillow. 02/09/2023 - seen by Orthopedist, D/C staples, follow back up in 12 weeks, noted knee pain associated with hip fracture, obstructed nerve should resolve. Review of Resident #1's Comprehensive Plan of Care revealed a problem onset date of 09/02/2021 for alteration in comfort related pain due to Parkinson's pain with approaches to report any signs of: unrelieved pain or adverse effects of medications, report signs and symptoms of pain of flinching, moaning or crying. Assess for effectiveness of pain medications, notify the physician/nurse practitioner if relief not experienced. Assess characteristics of pain (location, duration, quality, aggravating/alleviating factors, radiation and intensity) and document. Resident #1 was not care planned for knee pain prior to 01/16/2023. Record review of Resident #1's Medication Administration Record for January 2023 revealed there was no documentation of pain medicine given. Record review of nurse's progress note dated 01/16/2023 at 11:35 a.m. for Resident #1 read in part . Resident #1 sitting in chair in room, visiting with roommate. Resident #1 complained of pain to bilateral knees and bilateral lower extremities. Resident #1 having difficulty ambulating with assistive device. Administered two 500 milligram Tylenol tablets (an oral analgesic) by mouth for pain. Record review of nurse's progress note dated 01/17/2023 at 4:27 p.m. for Resident #1 read in part . Physician made rounds - ordered new meds for Edema and Osteoarthritis. New medication orders: Meloxicam (a non-steriod anti-inflammatory) 7.5 MG PO BID x 30 days, Lasix ( a diuretic) 40 MG PO Q Day x 30 days, and Potassium (electrolyte replacement) 10 MEQ PO Q Day x 30 days. Tylenol given for pain not effective. Having difficulty ambulating with Rollator, put Resident #1 in a wheelchair to see physician for visit at the facility. Increase in assistance needed with ADL's due to increase in unsteadiness of gait and weakness in bilateral lower extremities. Record review of physician's progress note dated 01/17/2023 read in part: Resident #1 complained of bilateral leg/knee pain. Diagnosis: Edema. New orders: Meloxicam 7.5 MG PO BID x 30 days, Lasix 40 MG PO Q Day x 30 Days, and Potassium 10 MEQ PO Q Day x 30 days. Record review of Physical therapy note dated 01/19/2023 for Resident #1 read in part .Pain at rest=0/10, pain with movement=4/10. Frequency=intermittent; Location Right lower extremity/knee; pain description/Type: Throbbing. Record review of physical therapy note dated 01/20/2023 for Resident #1 read in part . Precautions=application of Biofreeze (pain relieving gel) to right knee and anterior aspect of proximal right lower extremity to alleviate Resident #1's complaints of pain. Pain at rest=4/10; Frequency=constant; Location: right lower extremity; pain description/Type: it hurts; Pain with movement=10/10 (worst pain possible); Frequency=constant; Location=right lower extremity; Pain description/Type: it hurts. Response to treatment=increased challenge with tasks due to pain. Record review of occupational therapy note dated 01/23/2023 for Resident #1 read in part . Pain at rest=3/10; Frequency=Intermittent; Location=right knee; Pain description/Type: Throbbing. Pain with movement=8/10 (intense pain); Frequency=Intermittent; Location=right knee; Pain description/Type=Throbbing. Record review of occupational therapy note dated 01/25/2023 for Resident #1 read in part . Pain at rest 3/10 (pain is noticeable); Frequency=Intermittent; Location=right knee; Pain description/Type=Throbbing. Pain with movement 8/10 (intense pain); Frequency=Intermittent (with movement of right knee); Location =right knee; Pain description/Type=Throbbing. Response to treatment: Resident #1 tolerated occupational therapy well with complaints of right knee pain, nursing notified. Record review of X-ray results obtained at the facility dated 01/26/2023 read in part . Procedure: Right Hip, Unilateral with Pelvis Impressions: Findings consistent with acute fracture dislocation in subcapital femoral neck. Follow-up as clinically indicated. Record review of hospital progress note dated 01/27/2023 read in part . Preoperative Diagnoses: Right hip pain and Right Femoral neck fracture. Procedure: Right bipolar hip hemiarthroplasty (this surgical procedure replaces the head of a damaged femur with an implant designed to stabilize the femur and restore hip function). Observation and Interview on 02/28/2023 at 10:00 a.m. revealed Resident #1 sitting in her room awake and alert, in a wheelchair. Resident #1 stated she was okay, but did not respond when asked what happened to her hip, or if she was in pain. Interview on 02/28/2023 at 10:10 a.m. with S15 CNA revealed she cared for Resident #1 and assisted her with bathing and dressing. S15 CNA stated since Resident #1 fell and broke her leg, she had not been eating as well as previously, and needed more encouragement to consume. S15 CNA stated before fall Resident #1 had complained of knee pain and S3 LPN was notified. Interview on 02/28/2023 at 1:10 p.m. with S9 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift, and stated Resident #1 complained of Right leg and ankle pain before 01/26/2023 (the date Resident #1 was sent to ER for x-ray results of a Right Hip Fracture). S9 CNA stated she reported Resident #1's complaint of Right leg and ankle pain to S3 LPN when she complained, but stated S3 LPN already knew about Resident #1's complaint of Right leg and ankle pain. Interview on 02/28/2023 at 1:15 p.m. with S8 CNA revealed she provided care for Resident #1 for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S8 CNA stated she left for vacation on 01/02/2023 or 01/03/2023, and returned to work on 01/16/2023 or 01/17/2023 (S8 CNA was unsure of the exact date) to find Resident #1 in the bed. S8 CNA revealed her co-workers informed her of Resident #1 having some swelling and pain to her feet and legs, and had been put on a fluid pill. S8 CNA stated when she repositioned or turned Resident #1 toward the window (right side), Resident #1 would cry out in pain. S8 CNA stated she reported Resident #1's right lower extremity pain to S3 LPN. Interview on 02/28/2023 at 1:30 p.m. with S10 COTA revealed Resident #1 started physical therapy (3 times a week) on 12/21/2023 for a decline in functional mobility and needing increased assistance with ADL's. S10 COTA stated Resident #1 started complaining of right knee pain on 01/19/2023, and it got to the point of the knee pain being so bad, Resident #1 did not want to get out of bed. S10 COTA stated therapy started treating Resident #1 in her room and began mainly addressing her pain. S10 COTA revealed Resident #1's right knee was swollen and therapy did ESTIM with Resident #1 to help with the pain. S10 COTA revealed Resident #1 would verbally state her right knee was hurting, as well as grab her right knee and rub it. S10 COTA stated Resident #1 eventually was unable to walk. S10 COTA stated on 01/26/2023 on the morning shift, Resident #1 was trying to get up from a straight back chair in her room when S12 PTA noticed Resident #1's right leg was rotated. S10 COTA stated S12 PTA reported it to the floor nurse and both of them went to report it to S2 DON. S10 COTA stated S2 DON ordered X-rays that revealed a right hip fracture. Interview on 02/28/2023 at 2:40 p.m. with S3 LPN revealed she provided care for Resident #1, and on 01/16/2023 Resident #1 started complaining of right knee pain. S3 LPN stated Resident #1 was normally ambulatory with her walker, but had begun using the side rails on the hallways to help with ambulation. S3 LPN stated she notified S2 DON on 01/16/2023 of Resident #1's right knee pain and difficulty ambulating. S3 LPN stated S2 DON revealed the physician was coming to the facility on [DATE] and could see Resident #1 then. S3 LPN revealed the physician put Resident #1 on Mobic (Non-steriod anti-inflammatory drug for arthritis), Lasix (a diuretic), and Potassium (electrolyte supplement). S3 LPN stated the new medications did not help Resident #1 with her right lower extremity pain, and by 01/19/2023 Resident #1 was in the bed and not wanting to get up. S3 LPN stated she notified S2 DON on 1/19/2023 of Resident #1 worsening pain to her right lower extremity, and asked S2 DON if something different could be tried for Resident #1's right lower extremity pain. S3 LPN revealed S2 DON replied okay. S3 LPN confirmed she did not notify the physician of Resident #1's worsening pain to her right lower extremity because the facility's process was the nurse notifies the S2 DON and the S2 DON notifies the physician. S3 LPN revealed she has been a nurse at the facility for 3 years and had never called the physician. S3 LPN revealed she didn't know how to notify the physician. S3 LPN stated she went on vacation after 01/19/2023, and when she returned to work on 01/24/2023 or 01/25/2023 not sure of exact date), Resident #1 was in the bed not getting up and continued to have worsening pain to her right lower extremity. Interview on 03/01/2023 at 8:47 a.m. with S11 CNA revealed she provided care for Resident #1 on the 6:00 a.m. - 6:00 p.m. shift. S11 CNA revealed Resident #1 was able to walk, dress herself and transfer prior to 01/16/2023. S11 CNA stated she went on her off days, and when she returned to the facility on [DATE] Resident #1 was no longer able to walk. S11 CNA stated Resident #1 complained of right knee pain when she would roll the head of the bed up. S11 CNA stated she reported Resident #1's complaints of knee pain to S3 LPN. Interview on 03/01/2023 at 9:42 a.m. with S4 LPN (who worked the 6:00 a.m. - 6:00 p.m. shift), revealed she provided care for Resident #1 on 01/20/2023. S4 LPN revealed therapy notified her on 01/20/2023 of Resident #1 complaining of dizziness when they rolled the head of her bed up. S4 LPN stated Resident #1's blood pressure was a little low and Resident #1 appeared pale and didn't look right. S4 LPN stated she notified S2 DON and S2 DON told her to raise the head of Resident #1's bed, elevate her feet and monitor her blood pressure. S4 LPN confirmed she did not notify the physician of Resident #1 having dizziness or hypotension. S4 LPN revealed the facility's process was to notify S2 DON of any changes, and S2 DON notifies the physician and receives orders. Interview on 03/01/2023 at 10:19 a.m. with S6 ward clerk revealed on 01/14/2023 Resident #1 ambulated to the nurse's station and stated her right ankle was hurting. S6 ward clerk stated Resident #1 is usually ambulatory with her walker without assistance. S6 ward clerk revealed S3 LPN had to assist Resident #1 back to her room due to right lower extremity pain. Telephone interview on 03/01/2023 at 10:44 a.m. with S7 LPN revealed she worked the 6:00 p.m. - 6:00 a.m. shift, and provided care for Resident #1 on 01/19/2023. S7 LPN stated Resident #1 complained of her knees hurting. S7 LPN stated the CNA asked her to come to Resident #1's room due to Resident #1 was saying she couldn't walk. S7 LPN stated she assessed Resident #1 at that time and found her right leg was swollen, shiny and cooler than the left, with a weaker pedal pulse. S7 LPN confirmed she did not notify the physician of her assessment of Resident #1's right lower extremity. S7 LPN revealed the facility's process was the nurse notifies S2 DON and S2 DON notifies the physician. S7 LPN revealed it had been times in an emergency situation when she S2 DON did not respond to her telephone call, and she would then call the Administrator. S7 LPN stated she notified S2 DON of her assessment of Resident #1's right leg. S7 LPN stated S2 DON said Resident #1 was seen by the physician on 01/17/2023 at the facility, and her pedal pulse was weak then also. Telephone interview on 03/01/2023 at 3:00 p.m. with S12 PTA revealed Resident #1 was receiving therapy due to a functional decline in ADL's. S12 PTA stated Resident #1 complained of right knee pain and revealed she had a tibia fracture years ago which required screws and a plate. S12 PTA stated on 01/26/2023 she was assisting Resident #1 to bed and noticed her right leg was externally rotated. S12 PTA stated she notified nursing staff like she did each time Resident #1 complained of right lower extremity pain. Interview on 03/01/2023 at 4:10 p.m. with S3 LPN revealed on 01/26/2023 she notified S2 DON again of Resident #1 having worsening pain to her right lower extremity, and asked S2 DON if Resident #1 could get an x-ray. S3 LPN revealed S2 DON said she could get an x-ray. S3 LPN confirmed Resident #1 only received Tylenol 500 mg (2 tabs) 1 time for right lower extremity pain between 01/16/2023 through 01/26/2023, and it was documented as ineffective. Telephone interview on 03/02/2023 at 8:15 a.m. with S5 LPN revealed she cared for Resident #1 on the 6:00 p.m. - 6:00 a.m. shift on 01/20/2023. S5 LPN revealed she and S4 LPN went to Resident #1's room to assess her due to complaints of dizziness and low blood pressure. S4 LPN stated Resident #1 appeared to be feeling bad, like she was nauseated. S4 LPN revealed she checked on Resident #1 several times throughout the night, but did not notify the physician. S4 LPN stated the facility's process was the nurse notifies S2 DON, and S2 DON notifies the physician of changes in residents' condition. S4 LPN revealed if she could have, she would have notified the physician. Interview on 03/02/2023 at 8:35 a.m. with Resident #1's physician revealed he treated Resident #1 on 01/17/2023 at the facility for edema to bilateral knees with Lasix (a diuretic), Potassium (electrolyte supplement), and Mobic (NSAID for arthritis). Resident #1's physician stated he was aware Resident #1 was diagnosed with a fracture to her right hip on 01/26/2023. Resident #1's physician stated he had not been notified of Resident #1's right knee pain worsening, not being able to walk, dizziness or hypotension. Resident #1's physician revealed he probably would have ordered an x-ray if he had been notified of Resident #1's worsening pain to her right lower extremity and declining condition. Resident #1's physician revealed the facility does not notify him of changes in his Residents like they should. Resident #1's physician stated he had received calls from the hospital wanting to know why his Resident was in the ER, and he had not been notified they had been sent. Resident #1's physician stated he wanted to know more about his Residents not less. Interview on 03/02/2023 at 9:25 a.m. with S2 DON revealed on 01/16/2023 S3 LPN reported to her Resident #1 was having knee pain. S2 DON revealed she talked to the physician on 01/16/2023, and the physician stated he would see Resident #1 on 01/17/2023 upon rounds at the facility, and she could take Tylenol for pain. S2 DON stated the physician started Resident #1 on Lasix (a diuretic), Mobic (NSAID for arthritis), and Potassium (electrolyte supplement), and after a few days she didn't hear anything about Resident #1 so she assumed the medications were working. S2 DON stated on 01/19/2023 S7 LPN notified her of Resident #1's pedal pulse being faint on the right side. S2 DON stated she informed S7 LPN of Resident #1's pedal pulse being weak on 01/17/2023 when the physician assessed her. S2 DON confirmed she did not notify the physician. S2 DON stated on 01/20/2023 S4 LPN notified her of Resident #1 having dizziness and hypotension and she told S4 LPN to check her vital signs and monitor Resident #1. S2 DON confirmed she did not notify the physician. S2 DON stated she assessed Resident #1's right lower extremity before she had x-rays on 01/26/2023 (did not remember the date or document assessment) and Resident #1's knee was still swollen and still having pain upon range of motion. S2 DON confirmed she did not notify the physician of Resident #1's continued swelling of right knee and pain with range of motion. S2 DON revealed S10 COTA reported to S3 LPN of Resident #1 having increased pain to her right lower extremity and S3 LPN reported to her, and she notified the physician. S2 DON stated the x-ray results from 01/26/2027 revealed Resident #1 had an acute right hip fracture. S2 DON confirmed Resident #1 only received one dose of Tylenol 500 mg (2 tabs) for pain between 01/16/2023 through 01/26/2023 and it was ineffective. S2 DON confirmed the facility's process of physician notification was for the nurse to call her and she notifies the physician. S2 DON stated she does not know if a floor nurse had ever called the physician. Interview on 03/03/2023 at 10:00 a.m. with S1 Administrator revealed on 01/16/2023 S3 LPN reported Resident #1 was having right knee pain. S1 Administrator stated Resident #1 was already receiving therapy, S3 LPN gave Resident #1 Tylenol for the pain, and she was going to see the physician on 01/17/2023. S1 Administrator stated on 01/17/2023 S2 DON tried to get Resident #1 out of her chair, but she couldn't stand, so she was assisted Resident #1 into a wheelchair to go see the physician. S1 Administrator stated the physician put Resident #1 on some medications and from there she didn't know anything until 01/26/2021 when x-rays results revealed Resident #1 had a right hip fracture. S1 Administrator confirmed the nurses should have followed the facility's policy and should have called the physician when there was an issue with a Resident. .

Based on observation, interview and record review, the facility failed to ensure that a resident who was identified as being at high risk for elopement, exhibited wandering and exit-seeking behaviors, and wore a secure care wander guard bracelet, was adequately supervised for 1 (#2) of 18 sampled residents (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18). This failed practice resulted in an immediate jeopardy situation for Resident #2 on 10/24/2021 at approximately 5:10 a.m. when Resident #2 exited the facility without staff's knowledge through an unlocked patio door on wing 2, and through an opening in the patio gate. Resident #2 was found by facility staff 1.5 miles away at a local gas station, and brought back to the facility at 6:22 a.m. On 11/07/2021 at 9:42 p.m., Resident #2 exited the facility again without staff's knowledge through an unlocked patio door on wing 3, and climbed over the patio fence. A person in the community saw the Resident #2 in the parking lot at a local grocery store and brought her to the local Sheriff's Department on 11/08/2021 at 12:57 a.m. S1 Administrator was informed of the Immediate Jeopardy situations on 12/09/2021 at 5:27 p.m. The Immediate Jeopardy situations were removed on 12/10/2021 at 6:06 p.m. after it was determined through observation, interview, and record review that the facility submitted and implemented a plan of removal that included the following: Action plan for 10/24/2021 Elopement with revision date of 12/10/2021 1. Resident #2 was placed on one to one by staff and every hour by nurse on unit until no longer needed; 2. Breached gate temporarily repaired; 3. Ordered a gate form (local fence company); 4. DON would monitor one on one supervision of staff and nurse twice a week for 2 weeks then weekly and as necessary; 5. All staff were in-service on elopement procedures, Code W procedures, monitoring wandering residents, daily monitoring of gates and facility grounds, 1:1 supervision, and secure care alarm bracelet for resident at risk for elopement. Action plan for 11/08/2021 Elopement with revision date of 12/10/2021 1. Resident #2 on strict one to one even while sleeping; 2. All staff in serviced on strict one to one even while sleeping 3. All chairs removed from patios; 4. Temporary door alarms added to patio doors all staff where in serviced on elopement procedures for the temporary door alarms. The temporary door alarms would continue until doors are securely locked with keypad; 5. Maintenance temporarily repaired fence where resident broke spikes off and used a chair to climb over the fence; 6. Administrator contacted a local medical company for estimate to install remote keypads secure alarms to all patio doors. Received estimate and forwarded to Director. The deficient practice continues at a potential for more than minimum harm for 18 of 95 residents who have been identified by the facility as being at risk for elopement. Findings: Review of the facility's Policy and Procedure titled Wandering and Elopements revealed in part .the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Review of a Progress Note from the discharging hospital dated 10/21/2021 at 7:15 p.m. revealed Resident #2 was seeking doors to find a way out. Review of Resident #2's medical record revealed she was admitted on [DATE] with diagnoses that included Dementia, [CONDITION(S)] not due to a substance, Seizures, Hypertension, Constipation and [CONDITION(S)]. Review of Resident #2's Elopement Risk assessment dated [DATE] revealed she was at risk for elopement, and a secure care wander guard bracelet was placed on Resident #2 on 10/22/2021. Review of Resident #2's Admission MDS with an ARD of 11/03/2021 revealed a BIMS score of 7, indicating severe cognitive impairment. Further review of the Admission MDS revealed a wander/elopement alarm was coded as being used daily. Review of Resident #2's Care Plan revealed a problem of Risk for injury related to elopement with wander guard to ankle to prevent leaving out of the front door. The problem onset date was 10/22/2021. Approaches included: census check every 2 hours and every 1 hour after elopement attempt for 24 hours or until settled, observe for behavior episodes and determine any possible underlying cause, code alert bracelet (check every shift for activation and placement), monitor resident for changes in orientation, level of consciousness, increased behavior problems, or changes in dietary habits, orient to surroundings and room number, refer to psych NP as needed, involve structured activities, observe for behaviors or expressions indicating planned elopement, keep picture on chart or computer file to have available if elopement occurs, and orient the (new) resident to surroundings and introduce to other residents. Review of the facility's investigation dated 10/24/2021 at 8:00 a.m. revealed S2 DON reviewed surveillance footage, and documented the following: The resident was seen throughout the night at the nurse's station talking to staff, and up and down the hallways through the night. Resident #2 was at the nurse's station at 5:00 a.m. talking to the nurse and at 5:10 a.m. resident #2 was seen walking down wing 1. Resident #2 was seen running toward the patio door the closer she got to the end of the hallway. She exited the patio door and was not seen on the camera again until 6:22 a.m. when she was brought back into the building through the front door by staff. At 7:30 a.m. S2 DON and S5 Maintenance supervisor walked the facility grounds and found a potential breach in the fence off wing 2 patio. Further review of investigation revealed a written statement from S3 LPN that revealed on 10/23/2021 at 10:30 p.m. she was informed by another resident that there was someone hiding in the bushes outside of wing 3 patio. The documentation revealed Resident #2 was found hiding in the bushes crouched down and stating a man in grey pants was going to shoot her in the face. S3 LPN assured Resident #2 that she was safe. The resident was at the nurse's station throughout the night having delusional thoughts saying that she was from the future, and she continued to have paranoid thoughts that a man in grey pants was after her. At 5:45 a.m. S3 LPN noticed Resident #2 had not been at the nursing station for the past few minutes. She documented that around 5:00 a.m., Resident #2 was seen at the nurse's station and she was confused, thinking she was from the future. Observation revealed Resident #2's bed was made and she was not in the facility. At 6:22 a.m. a staff member left the facility in their vehicle and returned to the facility with Resident #2. Review of local Sheriff's Office report dated 10/24/2021 revealed the following: 6:09 a.m. - Initial call made to Sheriff's office by facility Cannot find Resident #2. 6:20 a.m. - Received call for local store stating Resident #2 turned up there and nursing facility picked her up. 6:21 a.m. - Called local facility to confirm information. 6:23 a.m. - Nursing facility confirmed they found Resident #2 and picked her up from a local pantry. Observation of Resident #2 on 12/03/2021 at 9:50 a.m. revealed her sitting in the dining room at a table visiting with staff. Interview with Resident #2 at that time revealed she was confused, and Resident #2 stated she didn't remember anything about her leaving the facility. Observation on 12/08/2021 at 2:00 p.m. revealed that the facility was located next to a road frequently used by local citizens. Train tracks were observed approximately 1 mile down that road. Interview on 12/07/2021 at 10:44 a.m. with S6 Laundry staff revealed as she was clocking in around 5:00 a.m. on 10/24/2021, she was asked had she seen Resident #2. S6 Laundry staff stated she then left the facility with S7 Transportation in a private vehicle to look for Resident #2. Further interview of S6 Laundry staff revealed Resident #2 had crossed the tracks and was 1.5 miles from the facility at a local gas station. Interview on 12/07/2021 at 3:33 p.m. with S2 DON revealed Resident #2 entered the facility on 10/22/2021 stating I don't live here and I won't be staying. I am dropping someone off. S2 DON stated a wanderguard was placed on Resident #2 at that time because of her statement on admission. S2 DON stated on 10/24/2021 Resident #2 left the facility and was found by staff 1.5 miles from the facility. Interview on 12/07/2021 at 3:40 p.m. with S3 LPN revealed on 10/22/2021 while receiving report from S4 RN, Resident #2 walked up to the nurse's station and stated I got to go. S3 LPN stated that S4 RN informed her on 10/22/2021 that the resident's discharging facility advised him to watch Resident #2 closely because if she could find a way out of the facility, she would leave. S3 LPN stated on 10/23/2021 around 9:30 p.m. 3 male residents sitting on wing 4 patio informed her someone was outside in the bushes. S3 LPN stated Resident #2 exited wing 3 patio door and was found outside between wing 3 and wing 4 hiding in the bushes. S3 LPN stated Resident #2 was paranoid and very delusional, and sat at the nursing station most of the night of her own free will. Around 4:30 a.m. or 4:45 a.m. on 10/24/2021, S3 LPN stated she noticed she had not seen Resident #2 for about 30 minutes, and thought maybe she got tired and went to her room to lay down. S3 LPN stated that Resident #2 was not in her room, and staff could not locate her in the facility. Resident #2 was found by staff at a local gas station 1.5 miles from the nursing home. Interview on 12/08/2021 at 11:10 a.m. with S1 Administrator revealed the facility was not aware of the breach in the gate until after Resident #2 eloped on 10/24/2021. S1 Administrator stated Resident #2 was placed on 1:1 supervision. Interview on 12/08/2021 at 11:34 a.m. with S4 RN revealed he received report regarding Resident #2 from the discharging facility on 10/22/2021, and was told to monitor her closely because she would leave the facility. S4 RN stated he did not inform S1 Administrator or S2 DON of the information that he received from the discharge nurse. Interview on 12/08/2021 at 11:48 a.m. with S8 NP revealed he did a telehealth visit with Resident #2 on 10/25/2021 as a result of her elopement from the facility on 10/24/2021. S8 NP stated he adjusted her medications for delusional thoughts and restlessness, and stated he would have suggested a more secure unit if he would have known Resident #2's intentions to get out of the facility were so strong. Interview on 12/08/2021 at 12:00 p.m. with S5 Maintenance Supervisor revealed he started working at the facility in March 2021, and the facility had several residents with wanderguards. S5 Maintenance Supervisor stated the gate on Wing 2 was used often by the facility to bring in heavy equipment, and confirmed Resident #2 breached the gate and was able to leave the grounds. Interview with S1 Administrator on 12/09/2021 at 11:53 a.m. revealed the front door and back door had key pad system that would alarm if a resident wearing a wanderguard exited through those doors. S1 Administrator stated wings (1, 2, 3, and 4) that lead to the patio did not have key pad system to alarm if a resident wearing a wanderguard exited through those doors. Review of the facility's investigation dated 11/08/2021 revealed S1 DON reviewed surveillance video footage that revealed the following: On 11/07/2021 at 9:42 p.m., S10 CNA left the facility due to a family emergency. S9 LPN remained 1:1 with Resident #2 until he assisted her to her room for bed at 10:04 p.m. S9 LPN returned to the nurse's station where he had a clear view of Resident #2's room. S9 LPN was observed to make rounds at 10:46 p.m. and 11:27 p.m. At 11:34 p.m. resident #2 exited her room and went out of wing 3 patio door. At 12:48 a.m. surveillance footage showed S9 LPN rounding down wing 3 and he noticed Resident #2 was not in her room. S9 LPN was observed to search other rooms and alert staff by calling a code W (elopement). S9 LPN discovered a chair had been placed against a fence and the decorative spikes where broken on wing 3 patio. S9 LPN was seen to exit the facility on 11/08/2021 at 1:20 a.m., and he was seen to return with Resident #2 at approximately 1:47 a.m. Review of local Sheriff's Office report dated 11/08/2021 revealed the following: 12:51 a.m. - Initial call made to Sheriff's office by reporter. 12:53 a.m. - Reporter headed to Sheriff's Department. 12:57 a.m. - Resident #2 dropped off at the Sheriff's Department. 1:12 a.m. - Nursing Facility called Sheriff's Department looking for Resident #2. 1:13 a.m. - Nursing Facility informed Resident #2 sitting in the lobby of the Sheriff's Department. 1:23 a.m. - Nurse enroute to pick up Resident #2. 1:41 a.m. - Nurse retrieved Resident #2. Interview on 12/07/2021 at 8:55 a.m. with S10 CNA revealed she worked 1:1 with Resident #2 on 11/07/2021. However, on 11/07/2021 around 10:30 p.m. or 11:00 p.m., she received an emergency family phone call and she had to leave the facility. S10 CNA stated Resident #2 was lying in bed, but not asleep, and stated she gave report to S9 LPN before leaving. Interview on 12/09/2021 at 11:53 a.m. with S1 Administrator revealed Resident #2 had been 1:1 since 10/24/2021. She stated on 11/08/2021, S9 LPN thought Resident #2 was asleep and he felt comfortable not to assign someone 1:1 due to Resident #2 sleeping. S1 Administrator stated S9 LPN agreed to monitor the resident until the CNAs completed making rounds. S1 Administrator stated it was the floor nurse's responsibility to ensure a staff monitored the resident, and it would be the nurse's responsibility to provide 1:1 if the nurse was unable to find anyone. S1 Administrator stated the nurse should always call the DON if there was an issue with staffing. S1 Administrator further stated that the DON would call her if it was something that she could not handle. Interview on 12/10/2021 at 9:14 a.m. with S9 LPN revealed Resident #2 was 1:1 after the 10/24/2021 elopement, and he was instructed by S2 DON to make hourly checks on Resident #2 after her elopement on 10/24/2021. S9 LPN stated he worked 6:00 p.m. to 6:00 a.m. on 11/07/2021. When he arrived to work, Resident #2's 1:1 staff was with her, and the resident was saying that she was leaving the facility. S9 LPN stated the facility was short of staff on 11/07/2021; however, everyone usually worked together to provide care. S9 LPN stated Resident #2's 1:1 CNA left; however, another CNA was supposed to take over sitting 1:1 with Resident #2. S9 LPN stated on 11/08/2021 at 12:00 a.m. or 1:00 a.m., he made a room check and Resident #2 was not in the room. Telephone interview on 12/07/2021 at 12:42 p.m. with a local citizen revealed on the night of 11/08/2021(not sure of a the time), he was pumping gas at the local store next to the nursing facility when Resident #2 walked up to his truck and told him she needed a ride to the hospital. He stated he asked Resident #2 did she come from the nursing home next door and she stated No. He stated he called 911 and was told it would be 45 minutes before anyone would arrive, so he dropped Resident #2 off at the Sheriff's Department. Interview on 12/10/2021 at 9:48 a.m. with S2 DON revealed the 1:1 CNA should report off to the floor nurse when 1:1 supervision could not be provided. The floor nurse would be responsible for assigning someone else to provide the 1:1 supervision. If the nurse could not find anyone to provide the 1:1 supervision, then the nurse would have to provide the 1:1 supervision She stated their residents with wander guards have q 2 hour checks; however, if a resident had an actual elopement, licensed staff had to perform q 1 hour checks until the resident was no longer a high risk. She stated S9 LPN was responsible for sitting 1:1 with Resident #2 on 11/08/2021. She stated when she interviewed S9 LPN, he stated Resident #2 was sleeping; therefore, he didn't feel like anyone needed to sit 1:1 with the resident.

Based on observations, interviews, and record reviews, the facility failed to ensure a resident receives care consistent with professional standards of practice to prevent the development of avoidable pressure ulcers for 1 (#78) of 4 (#31, #63, #71, #78) sampled residents reviewed for pressure ulcers by failing to perform weekly body audits on a resident at risk for developing pressure ulcers. Findings: This deficient practice resulted in an actual harm for Resident #78 on 04/11/2021, when during an observation with S11 Treatment Nurse and S12 RN/Weekend Supervisor, Resident #78 was observed to have an undated, yellow, soiled gauze to the left heel. When the gauze was removed, there were two unstageable, foul-smelling pressure ulcers to the bottom and lateral side of the left heel. Both of the pressure ulcers contained gray and yellowish tissue, greenish-brown drainage, and redness around the ulcers. S11 Treatment Nurse stated he was responsible for conducting weekly body audits, and he could not recall the last time he performed a head to toe body audit on Resident #78. Findings: Review of the facility's Policy for Prevention of Pressure Ulcers revealed, in part Risk Assessment: 1. Assess the resident on admission (within 8 hours) for existing pressure injury risk factors. Repeat the risk assessment weekly and upon any changes in condition. 2. Use a standardized pressure injury screening tool to determine and document risk factors. Skin Assessment: 1. Conduct a comprehensive skin assessment upon (or soon after) admission, with each risk assessment, as indicated according to the resident's risk factors. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. 2. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Further review of the document revealed a score of 7-39 required implementation of the facility's Pressure Sore Protocol. There were no pressure sore risk assessments completed after 10/08/2020 in the resident's medical record. Review of the facility's Pressure Ulcers/Skin Breakdown clinical protocol revealed, in part . Assessment and Recognition: 1. The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers. 2. In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and e. All active diagnoses. 3. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. Review of the resident's Braden Risk Assessment Report, the standardized assessment tool used by the facility, dated 12/10/2020 and documented as an Admission Assessment, revealed a risk score of 15, which indicated the resident's risk for skin impairment was mild. Further review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #78's Significant Change MDS Assessment with an ARD of 03/05/2021 revealed a BIMS score of 3, indicating the resident had severe cognitive impairment. Further review revealed the resident required extensive assistance of 2 or more persons for transfers, bed mobility, dressing and toileting, and was totally dependent on staff for bathing and personal hygiene. The resident used a manual wheelchair for mobility. Review of the resident's Comprehensive Care Plan with a target date of 06/05/2021, revealed the resident had a problem of Actual Skin Impairment, which included: Stage 3 PU to sacrum (02/15/2021), and Stage 3 Left Heel resolved (02/26/2021). Approaches included: Braden risk assessment quarterly, annually, and with significant change, Use pillows or wedges to reposition resident, float heels, and protect bony prominences. Review of the resident's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .NWB to LLE, Bilateral heel protectors to be worn in bed, cleanse wound to right hip with wound cleanser, apply [MEDICATION(S)] and cover with dressing daily until healed; and Cleanse stage 3 pressure ulcer to sacral area with NS or wound cleanser and apply [MEDICATION(S)] daily and prn until resolved (start date of 02/24/2021). There were no orders for wound care to the left heel documented. Review of the resident's March eTAR revealed an order dated 02/24/2021 for application of a bulky dressing to the left heel as a protective measure every Monday and Thursday and as needed for 2 weeks. Further review of the March eTAR revealed the order was discontinued on 03/26/2021. Review of resident #78's eMARs and eTARS, for the months of February 2021, March 2021, and April 2021 revealed no order for or documentation of weekly body audits. Body audits were documented in the eMAR or eTAR for residents for whom weekly body audits were ordered. Resident #78's Wound Assessment Reports completed by S11 Treatment Nurse with the following dates revealed in summary: 02/26/2021- Stage 3 pressure ulcer to the left heel was resolved. 03/08/2021- Assessment of a Stage 3 pressure ulcer to the left heel; identified on 10/09/2020 was present upon admission. Wound resolved. review of the resident's medical record revealed [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's nurses' notes revealed she was transferred to a local hospital'sER on [DATE] at 12:45 p.m., for difficulty breathing, remained in the ER for observation for 13 hours, then was returned to the facility. Review of a Facility to Hospital Transfer form dated 04/04/21 at 12:33 p.m. revealed the section labeled Risk Alerts contained check marks next to falls, aspiration, pressure ulcers, and limited/non-weight bearing. There were no risk alerts for the section labeled Skin/Wound Care (pressure ulcer stage, location, appearance, treatments). Review of a Non-Trauma EMS Field Report for resident #78 dated 04/04/2021 at 1:12 p.m. revealed the resident had [CONDITION(S)] to LLE, and bleeding to her left ankle. Review of resident #78's Emergency Patient Record notes dated 04/04/2021 at 1:39 p.m. revealed documentation by the ER RN that stated foul smelling decubitus ulcer noted to left heel. Further review of the ER record, including the discharge assessment, revealed no further documentation of care to the resident's left heel and no wound care orders. Review of resident #78's nurses' notes dated 02/24/2021 at 2:09 a.m. and documented by S14 LPN revealed the resident was readmitted to the facility on [DATE] at 6:30 p.m. after a hospitalization . S14 LPN documented that a full body assessment was completed, with scabbing noted to left knee and a dressing in place to left heel. No Braden Risk Assessment was observed to be completed after the resident's readmission, and no order for weekly body audits was obtained. Review of resident #78's nurses' notes dated 04/05/2021 at 2:16 a.m. by S15 LPN revealed the resident returned to the facility after being transferred to a local ER for evaluation and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation of resident #78 on 04/11/2020 at 10:51 a.m. revealed her lying on a low bed with her legs and feet uncovered. She was alert and confused. Her left heel was wrapped with a gauze dressing that covered the ball of her foot to just below her ankle. The dressing was unraveled in some areas, yellow in color, soiled and not dated. The area of dressing that covered the heel was noted to have a baseball sized area of brown discoloration and drainage that had seeped through the layers of the gauze dressing, and a foul odor was present. The resident was not wearing heel protectors, and none were observed in her room. The resident's heels were not floated. Interview with S22 CNA on 04/11/2021 at 3:25 p.m. revealed she was the CNA assigned to resident #78 and dressed the resident, placed socks on both of her feet, and transferred her into her wheelchair this morning. She stated she saw the brownish discoloration on the heel of the dressing, but did not report it because she thought the treatment nurse was taking care of it. Interview with S11 Treatment Nurse on 04/11/2021 at 2:30 p.m. revealed he worked Monday through Friday and every other week-end as treatment nurse. S11 Treatment Nurse stated that he was responsible for performing weekly skin audits on residents who were at risk for pressure ulcers. He stated that resident #78 had a Stage 3 PU to her sacrum, and a DTI on her right hip that was discovered on 04/10/2021. S11 Treatment Nurse stated the resident currently had no other pressure ulcers. Interview with S12 RN/Weekend Supervisor on 04/11/2021 at 2:35 p.m. revealed she worked every other week-end and performed wound care treatments. She stated she had applied a dressing to resident #78's right hip wound and had observed the sacral area and applied [MEDICATION(S)] to it today (04/11/2021). S12 RN/Weekend Supervisor stated she was not aware of a PU on the resident's left heel, and there were no orders for wound care to the resident's left heel. Observation of resident #78 on 04/11/2021 at 2:40 p.m. with S11 Treatment Nurse and S12 RN/Weekend Supervisor revealed the resident lying in bed, fully dressed and wearing socks. This surveyor requested the resident's socks to be removed, that revealed a yellowed, undated gauze dressing to her left heel. A baseball sized area of brown discoloration was noted to the entire heel of the dressing, and a foul odor from the area was apparent. S11 Treatment Nurse removed the dressing to reveal two pressure ulcers to the bottom and lateral side of the heel that contained gray and yellowish tissue, foul smelling greenish-brown drainage, and redness to the skin that surrounded the ulcers. S11 Treatment Nurse was observed to gather supplies, and as he began to clean the ulcers with gauze and wound cleanser, resident #78 called out, no, no, stop! The areas were measured and staged by S11 Treatment Nurse as follows: 1. Left heel - 4.1cm L x 5cm W x 0.2cm D, with 100% Slough and Unstageable. 2. Lateral aspect of left foot/heel - 2.5cm L x 2.4 cm W x 0.2cm D, with 90% Eschar and 10% Slough, and Unstageable. Interview with S11 Treatment nurse on 04/11/2021 at 2:48 p.m. revealed he was not aware of the dressing and pressure ulcers to resident #78's heel and that he had resolved a left heel pressure injury weeks ago. S11 Treatment nurse stated there were no orders for wound care in place for resident #78's left heel. He stated he last observed the resident's left heel on 03/08/2021, and it contained 100% epithelial tissue. He further stated he continued dressing the heel with a bulky dressing twice weekly, after it was documented as resolved on 03/08/2021, as a protective measure, until the order was discontinued on 03/26/2021. He confirmed the dressing removed from the resident's heel on 04/11/2021 had no date or initials on it and stated he didn't know how long the dressing had been in place. He stated he was responsible for performing weekly body audits on residents, in which he assessed the residents' skin from head to toe. He stated he did not recall when he had last performed a body audit on resident #78. When questioned regarding a Wound Assessment Report that revealed the left heel wound was resolved on 02/26/2021, and another Wound Assessment Report that revealed the wound was resolved on 03/08/2021, S11 Treatment Nurse stated the left heel wound was resolved on 03/08/2021, with no further comment. Interview with S15 LPN on 04/11/2021 at 5:10 p.m. revealed he worked 6:00 p.m. - 6:00 a.m. shifts and worked the night of 04/05/2021 when the resident returned from an ER visit. S15 LPN stated the resident had a dressing on her left heel. He further stated he could not recall a time when her heel wasn't dressed. He stated he didn't really pay attention to the dressing because he was not responsible for assessing existing wounds. S15 LPN stated he had never observed resident #78's heel and had never applied a dressing to it, because the treatment nurse was responsible for that. Interview on 04/11/2021 at 4:00 p.m. with S2 Interim DON and S3 RN AIT confirmed that resident #78 had no current orders for wound care to her left heel, and no documentation that the resident currently had wounds on her left heel. S2 Interim DON stated that the facility's wound care doctor would have to be notified because she felt the resident would need some type of debridement therapy for her heel. She stated it was the responsibility of the nurse who admitted /readmitted and assessed the resident to perform the Braden assessment, and if the assessment indicated the resident was at moderate or high risk for pressure ulcers, then it was a nursing measure to initiate weekly body audits. She further stated that if a resident was admitted /readmitted with wounds, it was the admitting nurse's responsibility to notify the treatment nurse, who was responsible for the assessment and care of the wound. S2 Interim DON confirmed that weekly body audits were not being performed on resident #78 and should have been. S2 Interim DON confirmed that the last Braden assessment performed on resident #78 was dated 12/10/2020. She stated the resident had not had a Braden assessment performed from the time she returned to the facility from a hospital stay on 02/23/2021, or quarterly, and should have. Both S2 Interim DON and S3 RN AIT stated that S14 LPN and S11 Treatment Nurse had not followed the facility's policy for completion of skin and risk assessments, as specified in the Pressure Ulcer Prevention policy, and that resident #78's pressure ulcer could have been prevented. Interview with S14 LPN on 04/12/2021 at 1:30 p.m. revealed she readmitted resident #78 upon her return from the hospital on 02/23/2021. S14 LPN stated she completed a full body assessment on the resident when she returned from the hospital, and the resident had a dressing to her left heel. She stated she could not recall if the dressing was dated or timed. She stated the treatment nurse was responsible for evaluating wounds, and she did not remove the dressing. She further stated she could not recall a time when the resident did not have a dressing to her left heel. S14 LPN stated she had not completed a Braden risk assessment, nor had she entered an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She further stated she thought it was the treatment nurse's responsibility to complete Braden assessments and to order and perform weekly body audits.

Based on observation, interview and record review the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan to ensure that the resident attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#5) of 5 (#1, #2, #3, #4, and #5) sampled residents, in a total facility census of 104. This deficient practice resulted in an actual harm for resident #5, who was non-verbal and had a BIMS of 99, was found lying on the floor by S4CNA near her wheelchair on 6/5/19. S4CNA placed the resident back into the wheelchair, wheeled the resident to her room, and did not report the incident to the resident's nurse, S3LPN, until later on in the shift. When S3LPN was made aware of the incident, she did not conduct an assessment on the resident, document the incident, notify the resident's physician or inform the on-coming shift nurse of the incident. On 6/8/19 during care, the resident gasped as if she was hurting and when she was assessed by S11LPN, there were negative findings. On 6/10/2019, the resident was observed by S6CNA to have swelling in the right hip area. S3LPN was notified; however, there was no documented assessment, or evidence that the physician was notified. On 6/11/19 between 6:30 a.m. and 6:45 a.m., a nurse observed that the resident appeared to be in pain. An assessment was done at that time, and the resident was noted to have swelling to her right upper thigh and bruising to her right inner thigh. The physician was notified and the resident was sent to a local hospital where she was diagnosed with [REDACTED]. Findings: Review of the facility's Assessing Falls and Their Causes procedure revealed the following: 1. If a resident has fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck spine and extremities. 2. Obtain and record VS as soon as safe. 3. If there is evidence of injury provide appropriate first aid and/or obtain medical treatment immediately. 4. If an assessment rules out significant injury, help the resident to a comfortable sitting, lying, or standing position and then document relevant details. 5. Notify the resident's attending physician and family. 6. Observe for delayed complications of a fall for approximately 48 hours after observed or suspected fall, and document findings in the medical record. 7. Document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility; and any changes in level of responsiveness/consciousness and overall function. Note the presence or absence of significant findings. 8. Complete an incident report for resident falls no later than 24 hours after the fall occurs. The incident report form should be completed by the nursing supervisor on duty at that time and submitted to the DON. review of the resident's medical record revealed [REDACTED]. Review of the resident's Quarterly MDS Assessment with an ARD of 5/17/19 revealed the resident had a BIMS of 99 (unable to complete interview), and required extensive physical assistance of two or more persons for bed mobility, transfers, dressing, toileting and personal hygiene. The assessment revealed the resident was unsteady and only able to stabilize with staff assistance for surface to surface transfers (transfer between bed and chair or wheelchair). Review of the resident's Comprehensive Plan of Care with a goal date of 10/2/19 included a problem of: Trauma - potential for fall related to the resident having the [DIAGNOSES REDACTED]. Last fall was on 1/23/19. Interview with S4 CNA on 7/22/19 at 12:00 p.m. revealed the following: she worked on C-Hall on 6/5/19 on the 6:00 a.m. to 6:00 p.m. shift when resident #5 was found on the floor in the C-Hall lounge, and didn't know if the resident fell or slid out of her chair onto the floor. She stated she went to find assistance, but did not see anyone, so she must have gone back in and put the resident back in her chair. Further interview with S4 CNA revealed she worked with the resident the next day (6/6/19) and the resident acted like her normal self. Interview with S3 LPN on 7/22/19 at 12:15 p.m. revealed that S4 CNA reported to her sometime after lunch that resident #5 had fallen, and that she picked her up and put her back in the wheelchair. S3 LPN stated that she instructed S4 CNA to put the resident in bed and she would be there to assess her in just a little while. S3 LPN stated she forgot about the report of the fall on 6/5/19, so she didn't assess the resident, didn't notify the MD or RP, report the incident to the on-coming staff, or document the incident and complete an incident report. S3 LPN further stated that she was the resident's nurse on 6/6/19, 6/9/19 and 6/10/19, and did not remember that the resident had fallen on 6/5/19. S3 LPN confirmed she did not do an assessment of the resident on 6/6/19 and 6/9/19. However, on 6/10/19 after lunch, S6 CNA reported to her that the resident's right calf looked swollen. She stated she assessed the resident's right hip and leg and noticed the lower calf of the right leg was swollen. She stated she did not report the swelling to the physician because she thought the resident's leg may have been swollen from sitting up in the wheelchair. S3 LPN stated that it was not until S2 DON started the investigation of the resident having a fracture to her right hip on 6/11/19, that she remembered S4 CNA had reported a fall on 6/5/19. Interview with S2 DON on 7/22/19 at 1:40 p.m. revealed she was not aware that resident #5 had fallen on 6/5/19, until after she started an investigation as a result of being informed by S1 Medical Director that the resident had an acute fracture to her right hip. Further interview of S2 DON revealed the staff had not followed the fall policy and procedure. Interview with S7 CNA on 7/23/19 at 8:45 a.m. revealed she worked the weekend of 6/7/19, 6/8/19 and 6/9/19 on the 6:00 p.m. to 6:00 a.m. shift. S7 CNA stated on 6/8/19 she helped S9 CNA get the resident up for a shower, and noticed the resident did not want to stand and pivot to get in the shower chair. S7 CNA stated that the resident did not act as if she was in pain. S9 CNA further stated that she did not report anything at that time to the resident's nurse. Telephone interview with S10 CNA on 7/23/19 at 9:28 a.m. revealed she was the resident's CNA on the 6:00 p.m. to 6:00 a.m. shift the weekend of 6/7/19, 6/8/19 and 6/9/19. S10 CNA stated on 6/8/19 resident #5 gasped as if she was hurting while care was being provided, so she reported it to S11 LPN. Interview with S5 LPN on 7/23/19 at 10:10 a.m. revealed that on 6/11/19 between 6:30 - 6:45 a.m., she was called to resident #5's room by an office staff nurse who was no longer employed at the facility. S5 LPN stated that the office nurse told her that the resident's looked as if she was in pain. S5 LPN stated they assessed the resident's vital signs, and assessed the resident's body, and noticed her right upper thigh was swollen twice it's normal size, and there was a round bruise to the inside of her thigh. S5 LPN stated she notified the MD and the RP, then sent the resident by ambulance to the hospital. S5 LPN stated she was unaware that the resident had fallen on 6/5/19. Telephone interview with S11 LPN on 7/24/19 at 9:55 a.m. confirmed she worked the C-Hall the weekend of 6/7/19, 6/8/19 and 6/9/19 on the 6:00 p.m. - 6:00 a.m. shift, and confirmed she cared for resident #5 during that time. S11 LPN stated that on 6/8/19 S10 CNA reported that the resident was not acting herself. S11 LPN stated she assessed the resident's vital signs and there was nothing abnormal, so she instructed the CNA to encourage fluids. S11 LPN stated that the resident did not look as if she was in any distress or pain. S11 LPN stated later in the shift S10 CNA told her the resident was feeling better. S11 LPN stated she followed up throughout the weekend with the CNAs to see if the resident was still feeling better, and had no negative reports. S11 stated that she was not aware the resident had fallen on 6/5/19. Telephone interview with S1 Medical Director on 7/24/19 at 11:15 a.m. revealed he was the facility's Medical Director. S1 Medical Director stated he received a call from the Orthopedic Surgeon on 6/11/19, informing him that resident #5 was at the hospital, and an x-ray revealed the resident had a fracture to her right hip. S1 Medical Director stated he and the Orthopedic Surgeon discussed how the fracture could have occurred, and concluded the resident had sustained a fall within the past 5-10 days. S1 Medical Director confirmed that when he contacted S2 DON, there was no documentation or reports of a fall within that time period. S1 Medical Director stated as a result, S2 DON conducted an investigation with the finding that an unobserved fall involving resident #5 had not been reported on 6/5/19. S1 Medical Director stated the swelling and pain to the right hip could have occurred days after the fall, and with the resident being non-verbal, it made it difficult to determine if something was wrong, without having knowledge that the fall occurred.

Based on record review and interview, the facility failed to ensure that Resident #70 was adequately supervised when he was allowed to exit the front door of the facility unattended, and subsequently eloped from the facility for 1 (Resident #70) of 3 residents (#2 #29 and #70) reviewed for elopement, in a total sampled of 21 residents. This deficient practice resulted in an Immediate Jeopardy situation for Resident #70 on 4/14/19 at 12:09 p.m. when the resident,who was severely cognitively impaired and wore a secure care wander guard bracelet, exited the facility without staff knowledge. The resident was found by the DON on 4/14/19 at 4:58 p.m. in a town located approximately 25 miles away from the facility. The Administrator was notified of the Past Noncompliance Immediate Jeopardy situation on 5/24/19 at 11:33 a.m. The facility implemented corrective actions prior to the State Agency's investigation therefore, it was determined to be a Past Noncompliance citation. Findings: Review of Resident #70's clinical record revealed that the resident was admitted to the facility on [DATE] with the following diagnoses; Unspecified Dementia, [MEDICAL CONDITIONS] without behavioral disturbance, Alcohol Dependence, Hypertension, [MEDICAL CONDITIONS], GERD, Cerebral Infarction, Pacemaker, [MEDICAL CONDITIONS], Major [MEDICAL CONDITIONS], and Cognitive Communication Deficit. Review of Resident #70's care plan dated 4/5/2019, revealed he was care planned for potential for social isolation, potential for falls related to [DIAGNOSES REDACTED]. Review of the quarterly assessments revealed that Elopement risk assessments were completed on 4/5/19 and 4/10/19 with resident deemed at risk for elopement on both assessments. Review of the Quarterly MDS dated [DATE] revealed a Brief Interview Mental Status (BIMS) of 4, indicating severe cognitive impairment. Observation on 5/20/19 at 10:30 am revealed the resident to be sitting in a chair at his bedside. The resident was noted to be dressed appropriately and in a pleasant mood. Interview with resident at that time found him to be oriented to person only with a wander guard bracelet in place on his right ankle. Review of the facility's investigative reports revealed an incident regarding resident #70 dated 4/14/19. The investigative report revealed that at approximately 3:30 p.m. on 4/14/19, resident #70 was discovered missing from the facility. A search of the facility and grounds was completed by staff, and a community search by local police failed to locate the resident. Interview with S6 LPN, on 5/21/19 at 3:00 p.m. revealed that she was on duty on 4/14/19 for the 6 a.m. to 6 p.m. shift. S6 LPN stated that resident #70 resided on her hall, and on the morning of 4/14/19 had packed a small bag of clothing and was asking staff and visitors to take him to different places. S6 LPN further stated that she administered medications to the resident around 12:00 p.m., and at that time S7 CNA told the resident to go to his room and change his pants which were soiled. The resident entered his room and S6 LPN stated she continued passing her meds. S6 LPN confirmed that this is the last time that she saw the resident. S6 LPN revealed that she heard a door alarm while she was passing her 12:00 p.m. medications but did not respond because somebody turned it off. She reported that at approximately 3:15 p.m. S7 CNA came to the nurses' station and asked her if she had seen resident #70 because she couldn't find him. S6 LPN stated that a search of the entire facility and grounds was done at that time, and they could not locate the resident. At that point she called S2 RN DON and S1 Administrator to inform them that they couldn't resident #70. S6 LPN stated that she believes that S2 RN DON called the police. Interview with S7 CNA on 5/21/19 at 3:27 p.m. confirmed that she was on duty on 4/14/19 for the 6 a.m. to 6 p.m. shift, and was assigned to provide care for resident #70. S7 CNA stated that resident #70 was a fairly new resident and would pack up his stuff, carry it around, and often ask which way is Alexandria. S7 CNA stated she saw the resident around 11:00 a.m. in the dining room for lunch. S7 CNA confirmed that the last time she saw the resident was around 12:00 p.m. when she was passing lunch trays on the hall. She stated that she told the resident at that time that he needed to change his pants and she saw him enter his room. S7 CNA stated she returned to the resident's room at around 3:00 p.m. and did not see him there. S7 CNA stated after searching the resident's room and bathroom, she went to the nurse's station and told the nurse that she could not find him. S7 CNA further stated that they searched the whole building and then the nurse called the DON. S7 CNA confirmed hearing the front door alarm go off on 4/14/19 while passing lunch trays on her hall and confirmed that she received an alert to her pager reading front door, but did not go to check it. Interview on 5/22/19 at 9:17 a.m. with S2 RN DON revealed that on 4/14/19 at approximately 3:45 p.m. she was notified by S6 LPN that they were unable to locate Resident #70. S2 RN DON stated that she immediately headed towards the facility and contacted S1 Administrator and local law enforcement. S2 RN DON stated that she had the nurse give her the resident's last known address and headed in that direction to look for him. S2 RN DON confirmed that she picked the resident up at around 5:00 p.m. while he was sitting on a curb in a city approximately 25 miles away from the facility. S2 RN DON stated that the resident had no apparent injuries other than a sunburn she noted on the top his head, and that the resident could not tell her how he had gotten to that location. Further interview with S2 RN DON on the above date and time revealed that she returned to the facility with the resident at 5:30 p.m. Upon her arrival she viewed the video footage with S1 Administrator which showed a visitor entering the facility by entering the code into the front entrance keypad and holding the door open, thereby allowing the resident to exit the facility at 12:09 p.m. Further review of the video footage revealed that S10 LPN reset the facility's front door alarm. Interview with S10 LPN on 5/24/19 at 8:16 a.m. confirmed that she was on duty on 4/14/19 on the 6 a.m. to 6 p.m. shift. S10 LPN stated that she saw resident #70 in the dining room around 11:00 a.m. on 4/14/19 eating his lunch and did not see the resident again after that. S10 LPN stated that she heard the door alarm around 12:00 p.m. or maybe a few minutes later while she was sitting in the nurses station charting. She further stated that she went to door, reset the alarm and returned to the nurse's station. S10 LPN confirmed that around 3:00 p.m. S7 CNA came up to the nurses station and asked if they had seen resident #70, then they proceeded to do a search of the facility for the resident. Throughout the survey from 5/20/19 thru 5/24/19, random interviews of staff were conducted. Staff members were asked if they knew what to do if they heard a secure care door alarm or if a resident was unable to be located. All staff questioned stated that they had received training and that there was a binder in the nurses stations with pictures of all the residents that wear wander guard bracelets for easy identification. Staff stated that in the event of a possible elopement they would check their assigned locations in the facility as well as the facility grounds and that the alarm would not be silenced until all residents at risk had been located. The facility implemented the following actions to correct the deficient practice: 1. (MONTH) 14, 2019, Employees directly involved with incident counseled and disciplined. Resident #70 placed on every 30 minute checks for 24 hours. 2. A monitoring tool was put into place for all 12 residents identified to be at risk for elopement to ensure compliance with response to alarms for seven days after the occurrence. This monitoring tool was initiated on 4/14/19 at 9:30 p.m. thru 4/21/19 at 9:15 p.m. 3. (MONTH) 15,2019, QA started for Department heads with weekly meetings. 4/15/2019-inservices on elopement, schedule wander drill, employee counseling. 4/22/2019-continue monitor elopement procedure changes. No changes to corrective action. 4/29/2019-elopement risk/procedures, discussed corrective actions. No changes, no elopement attempts, continue plan. 5/6/2019-discussed elopement corrective action. Resident #70 seems better since room change. No new incidents. 5/15/2019- reviewed corrective action plan. No changes or revisions. 5/20/2019-discussed corrective action of elopement procedures, discuss elopement procedures to new hires. 4. (MONTH) 15, 2019 @ 1:30 p.m., all staff in-service Subject: Do not give door code to anyone other than employees, every visitor must be let in by ward clerk. In the event the door alarms, facility must be locked locate all residents at risk for elopement before resetting the alarm. Employees should limit their visitors while on duty and meet any visitor in the parking lot. 5. (MONTH) 15, 2019 Addendum added to Elopement policy and procedure which includes steps to take in the event of a Door Alarm Sound. Elopements Policy Interpretation and Implementation 4. If an employee discovers that a resident is missing from the facility,he/she shall : a. Determine if the resident is out on authorized leave or pass; b. If the resident was not authorized to leave,initiate a search of the building(s) and premises; c. If the resident is not located,notify the Administrator and the Director of Nursing Services,the resident's legal representative (sponsor), the Attending Physician,law enforcement officials, and (as necessary) volunteer agencies (i.e. Emergency Management,Rescue Squads,etc;) d. Provide search teams with resident identification information; and e. Initiate an extensive search of the surrounding area. 6. (MONTH) 15, 2019 All staff in-service Subject: Elopement. 7. (MONTH) 18, 2019 Letters sent out to family members informing them that the door codes had been changed and that all visitors would have to buzz into and out of the facility to maintain the safety of the residents. 8. (MONTH) 19, 2019 Resident #70 moved to a different area for his safety. DON states that with the room change the resident does not have to pass the front entrance to go to the dining room for meals and activities. The resident also would have to pass in front of the nurse's station to exit the facility. DON also states that since the room change the resident has not made any attempts to go to the front exit. 9. (MONTH) 22, 2019 Daily Team Talk QA-New Elopement procedure related to Resident #70. 10. (MONTH) 23, 2019 All departments Subject: Dementia training and Elopement training-New Policy and Procedure. 11. (MONTH) 24, 2019 Department: CNA In-service Subject: #8 New Elopement Policy and Procedure. 12. (MONTH) 25, 2019 All departments Subject: Wander Drill (Code W) drill/demonstration. -Door alarm sounds -Contact wardclerk -Call code W -All employees locate residents identified at risk for elopement -Once all identified,reset alarm -Cancel Code W 13. (MONTH) 10, 2019 Service call completed by [NAME] Storm Medical Equipment to check doors, nurse call system and pagers. Copy of invoice obtained from Administrator. 14. (MONTH) 15, 2019 QA meeting Why's Worksheet Problem: Resident Elopement. 15. (MONTH) 23, 2019 Department: Maintenance/Housekeeping In-Service Subject: Employee is to ensure that the facility is secure an outside gates are locked at all times when not in use. Employee is to check gates daily and after deliveries to ensure that they are closed and locked. Also discussed policy and procedures of elopement. 16. (MONTH) 23, 2019, Department: All In-service Subject; Door code is not to be given to anyone other than employee of CRNF. All gates are to be closed and locked at all times. Discussed elopement new policy and procedure. 17. (MONTH) 23, 2019, Letters sent out to all part-time/as needed staff informing them that they will be unable to return to work until they complete the in-service on the revised policy and procedure for elopement. 18. Every 2 hour visual checks for all other residents identified as at risk for elopement with Echeck system documentation noted. 19. (MONTH) 24,2019 Wander drill (Code W) conducted. This drill was observed by surveyor and it was noted that staff searched all rooms,departments and facility grounds.

Based on observation, interview and record review, the facility failed to immediately consult with the resident's physician and legal representative or interested family member, when a resident (#3) exhibited aggressive behaviors and threatened to harm another resident (#5) with potentially hazardous objects that were brought into the facility (Channel Lock Pliers). The facility failed to: 1. Implement their policy and procedure for Residents with Aggressive Behavior, and notify the MD, Psychiatrist, and responsible party/interested family member of a situation, and of a resident's behavior that occurred on 03/02/14. The survey sample was 5 (#1, #2, #3, #4 and #5) and the total facility census was 127. According to Departmental Notes documented by S3 LPN on 03/02/14 at 8:00 p.m., resident #5 approached the nurse and stated the man in room b needed to turn his TV down. Review of the Departmental Notes reflected around 8:10 p.m., the CNA assigned to care for resident #3 approached the nurse and informed her that resident #3 asked the CNA the room location of resident #5, and stated he was going to" blow that mother f___k___'s head off." The note further reflected the CNA stated there was something under resident #3's shirt, and he was worried it could be a weapon. The Administrator was notified and arrived to the facility with 2 police officers. The resident's room was searched and a pair of pliers were found and removed from the resident's room. The note reflected the resident was cooperative and non-combative. According to an interview of the Administrator on 03/07/14 at 1:05 p.m. revealed resident #3's room was searched and Channel Pliers were found, along with other tools. An Immediate Jeopardy situation began on 03/02/14 at 8:00 p.m. when resident #3 was observed by staff to have an object that was later determined to be channel lock pliers hidden under his shirt. The Administrator was notified of the Immediate Jeopardy on 03/07/14 at 5:50 p.m. The facility submitted a plan of removal which included: 1. Revision of their policy and procedure for residents with aggressive behavior. 2. Following the policy and procedure by contacting the Psychiatrist and Behavioral Hospital. Neither were contacted until 03/07/14. 3. Resident #3's agreement to be voluntarily admitted to the Behavioral Hospital. 4. Providing one to one supervision of resident #3 until his discharge to the hospital (was discharged to the Behavioral hospital on [DATE] at 7:35 p.m.). 5. Revision of the resident's comprehensive plan of care to include a problem of "mood/social interaction, impaired related to [DIAGNOSES REDACTED]. The plan of care also included specific interventions in reference to the resident's aggressive behaviors. 6. A plan to in-service staff on policy and procedure pertaining to residents with aggressive behaviors. The Immediate Jeopardy situation was removed on 03/07/14 at 7:05 p.m. when observations revealed the plan was being implemented, and resident #3 was awaiting transfer to a Behavioral Hospital. The resident voluntarily consented to be admitted to a Behavioral hospital on [DATE] at 7:35 p.m. The deficient practice remains at a potential for more than minimal harm. Findings: Review of the facility's Policy and Procedure for Residents with Aggressive Behavior reflected the objective was to keep residents safe from bodily harm. The procedure included: notify MD and Psychiatrist of the situation and the resident's behavior; obtain order to send aggressive resident to in-patient psych unit for evaluation; obtain PEC if resident will not go voluntarily; notify responsible party of situation and resident behavior; document all actions; and complete incident and Accident form. Review of resident #3's Face Sheet reflected he was admitted to the facility on [DATE]. Review of the resident's current Physician order [REDACTED]. Review of resident #3's Quarterly MDS Assessment signed as completed by the RN Assessment Coordinator on 12/03/13 reflected the following: The resident's hearing was coded as 0 (no difficulty in normal conversation, social interaction, listening to TV); usually is understood and usually understands others; BIMS score of 14; coded as independent with no physical help from staff for ADLs; No ROM impairment; and used a wheelchair mobility device. Review of resident #3's nurses' notes reflected S3 LPN made an entry on 03/3/14 at 12:05 a.m., for 03/02/14 at 8:00 p.m. The note reflected the following: the nurse was informed by resident #5 to ask resident #3 to turn down his television so that he (resident #5) could hear his television. The S3 LPN went to resident #3 and asked that he turned down the volume on his television, and he did so without incident. As S3 LPN was leaving resident #3's room, resident #5 walked by resident #3's room and was yelling that he needed to turn his television down. S3 LPN informed resident #5 that she had spoken with resident #3, and he had turned his television down. Further review of the note reflected around 8:10 p.m., hall (a) CNA approached the nurse and informed her resident #3 asked which room resident #5 was in, and stated he was going to blow his mother f____g head off. The note reflected the CNA informed the nurse resident #3 had something under his shirt at that time, and he was worried it was a weapon. S3 LPN documented she alerted the Administrator, and he arrived with 2 officers from the Sheriff's Office. The note reflected the Administrator and the officers conversed with the resident, checked his room, and a pair of pliers was found and removed at that time. The nurse's note further reflected the resident was cooperative and non-combative, and at 12:05 a.m. was in his room resting at that time, calm with no signs of distress or agitation. Review of Departmental Notes dated 03/03/14 at 2:05 p.m., and documented by S4 SSD reflected she spoke with the resident about the incident that occurred the prior night. The note reflected the resident was apologetic and stated he had apologized to the resident. The S4 SSD documented she educated the resident regarding proper communication with other residents, and that if he had a problem he needed to let staff know instead of attempting to handle things by himself. The entry further reflected the resident stated he was sorry he caused trouble, and he was embarrassed it happened. The note further reflected the S4 SSD would continue to observe him for behaviors. Observation during the initial tour of the facility on 03/07/14 at 10:50 a.m. revealed resident #3 and #5 were observed to reside on hall (a), next door to each other. Further observation on 03/07/14 at 10:50 a.m. revealed resident #3 sitting in his room in a wheelchair watching television. The volume on the resident's TV was very loud. The resident turned the volume down when the surveyor attempted to speak with him. The resident was alert and oriented to person, place and time. Interview of resident #3 on 03/07/14 at 10:50 a.m. revealed the following: The resident stated that he has been a resident at the facility for 2 years; however, he wanted to leave because he was not happy anymore. The resident stated his problem was not with staff, but with another resident. Resident #3 stated that one time he told another resident that he was going to "blow his brains out", and someone at the desk heard him say that. He stated the person at the desk told him that he couldn't do that, and called a Behavioral Hospital. He stated the next thing he knew, he was sent to the Behavioral Hospital. He stated the resident in room c was always in his room stealing. He further stated he didn't associate with the other residents. Further interview of resident #3 at the above time revealed there was another incident about 2 weeks ago that he had a pair of Channel Locks, and the facility thought it was a gun. He stated he put the Channel Locks under his shirt, and he guess they thought it was a gun handle. He stated the Administrator showed up at the facility and wanted to know what was under his shirt, and took the Channel Locks and his other tools. Resident #3 further stated he didn't tell the Administrator, but he was going to use the Channel Locks and pull the resident in room c's balls off. Interview with S2 DON on 03/07/14 at 1:00 p.m. confirmed the police was called to the facility this past weekend (weekend of 02/28/14 to 03/02/14) because resident #3 told a CNA that he was going to blow resident #5's brains out. She stated the CNA was concerned, reported this, and the Administrator was called. She further stated resident #3 could transfer, but could not walk distances, and resident #5 could ambulate well. Interview of the S1 Administrator on 03/07/14 at 1:05 p.m., revealed a CNA contacted him and stated resident #3 was really angry because resident #5 complained about his TV being loud. The CNA stated resident #3 turned the TV down and was fine, but later came back to him and asked where resident #5's room was, because he was going to"blow his f_____g brains out". S1 Administrator stated he instructed the CNA to take the nurse and go back to the resident and talk to him to see if he had a weapon, and call him back. When the CNA called him back, he told him that he thought the resident had gun, and that he had talked the resident into locking whatever he had up in his closet. S1 Administrator stated the CNA was convinced the resident had a gun. He stated he instructed the CNA not to leave the resident's room. He stated upon his arrival, the resident's room was searched and all tools were removed. S1 Administrator stated the resident had no connections to bring him a gun. The S1 Administrator further stated the resident had a van that he kept a lot of his possessions in, and thought that maybe the resident could have had a weapon in the van. So, he was concerned that the possibility did exist. Interview of S4 SSD on 03/07/14 at 1:05 p.m. revealed she and another police officer approached resident #3 on the evening of 03/02/14, and talked to him about the comments he made about having a gun. She stated the resident told them he had a gun, and when she asked him to show it to her, he pointed to the channel locks and stated that was his Smith & Wesson gun. S4 SSD stated the resident said he wasn't going to do anything, he was just upset because people were stealing his money. Review of resident #3's clinical record reflected there was no evidence the resident's physician was immediately consulted with regarding the resident's aggressive behavior and threats to harm another resident, as directed by the facility's policy and procedure for Resident's with Aggressive Behaviors. Interview of S2 DON on 03/07/14 at 1:59 p.m. confirmed there was no documentation that reflected the nurse contacted resident #3's physician, and confirmed the nurse did not contact the physician. She stated she did not know why the nurse didn't call the physician when the incident occurred on 3/2/14, but she should have. Interview/observation of sampled resident #4 (resident #3's roommate) on 03/10/14 at 11:15 a.m. revealed him in his room sitting by the door in his wheelchair. The resident stated he had been at this facility for about 8 months, and resident #3 had been his roommate since he had been there. Resident #4 stated resident #3 turns his TV on loud, and that one night resident #3 " flew off the handle" because someone outside the door shouted loud for him to turn off the TV. He stated he did not see whether resident #3 had anything on him like a weapon, but heard that he had a wrench and that was why he had to go. Resident #4 stated resident #3 kept all kinds of stuff in the closet, but he did not see it, and was not aware that he ever hurt anybody. He further stated resident #3 did not bother him. Resident #4 further stated that on that night (didn't know the date), he was laying on his bed and heard someone in the hall shout loud for resident #3 to turn off his TV. He stated resident #3 "flew off the handle" and went out into the hall, but in no time came back in the room. The resident further stated the nurse and the guy that runs the place came. He further stated he did not see anything else and did not hear what they talked about, but resident #3 was mad.

4Based on observation, interview and record review the facility failed to ensure the residents environment remained as free of accident hazards and failed to provide adequate supervision and monitoring after 1 resident (#3) exhibited physically aggressive behaviors (threatening to use channel lock pliers as a weapon) towards another resident (#5). The facility failed to: 1. evaluate and analyze a situation in which a resident with aggressive behaviors (#3) brought potentially hazardous objects into the facility and threatened to harm another resident (#5), 2. develop targeted interventions to reduce the risk of resident #3 from bringing such hazardous objects (channel lock pliers, a small hammer, and other tools) into the facility in the future, and 3. respond to the aggressive behaviors of resident #3 according to the facility policy and procedures for Residents with Aggressive Behavior and the Protection of a Targeted Resident (#5). The survey sample was 5 (#1, #2, #3, #4 and #5) and the total facility census was 127. According to Departmental Notes documented by S3 LPN on 03/02/14 at 8:00 p.m., resident #5 approached the nurse and stated the man in room b needed to turn his TV down. Review of the Departmental Notes reflected around 8:10 p.m., the CNA assigned to care for resident #3 approached the nurse and informed her that resident #3 asked the CNA the room location of resident #5, and stated he was going to" blow that mother f___k___'s head off." The note further reflected the CNA stated there was something under resident #3's shirt, and he was worried it could be a weapon. The Administrator was notified and arrived to the facility with 2 police officers. The resident's room was searched and a pair of pliers were found and removed from the resident's room. The note reflected the resident was cooperative and non-combative. According to an interview of the Administrator on 03/07/14 at 1:05 p.m. revealed resident #3's room was searched and Channel Pliers were found, along with other tools. An Immediate Jeopardy situation began on 03/02/14 at 8:00 p.m. when resident #3 was observed by staff to have an object that was later determined to be channel lock pliers hidden under his shirt. The Administrator was notified of the Immediate Jeopardy on 03/07/14 at 5:50 p.m. The facility submitted a plan of removal which included: 1. Revision of their policy and procedure for residents with aggressive behavior. 2. Following the policy and procedure by contacting the Psychiatrist and Behavioral Hospital. Neither were contacted until 03/07/14. 3. Resident #3's agreement to be voluntarily admitted to the Behavioral Hospital. 4. Providing one to one supervision of resident #3 until his discharge to the hospital (was discharged to the Behavioral hospital on [DATE] at 7:35 p.m.). 5. Revision of the resident's comprehensive plan of care to include a problem of "mood/social interaction, impaired related to [DIAGNOSES REDACTED]. The plan of care also included specific interventions in reference to the resident's aggressive behaviors. 6. A plan to in-service staff on policy and procedure pertaining to residents with aggressive behaviors. The Immediate Jeopardy situation was removed on 03/07/14 at 7:05 p.m. when observations revealed the plan was being implemented, and resident #3 was awaiting transfer to a Behavioral Hospital. The resident voluntarily consented to be admitted to a Behavioral hospital on [DATE] at 7:35 p.m. The deficient practice remains at a potential for more than minimal harm. Findings: Review of the facility's Policy and Procedure for Residents with Aggressive Behavior reflected the objective was to keep residents safe from bodily harm. The procedure included: provide one on one with aggressive resident until transferred; notify MD and Psychiatrist of the situation and the resident's behavior; obtain order to send aggressive resident to in-patient psych unit for evaluation; obtain PEC if resident will not go voluntarily; notify responsible party of situation and resident behavior; document all actions; and complete incident and Accident form. Further review of the policy and procedure reflected the facility was to provide protection of targeted residents by: remove resident from area; provide TLC/reassurance; notify MD/Psychiatrist of incident; notify responsible party; document all findings; and complete incident and accident form. Review of resident #3's Face Sheet reflected he was admitted to the facility on [DATE]. Review of the resident's current Physician order [REDACTED]. Review of resident #3's Quarterly MDS Assessment signed as completed by the RN Assessment Coordinator on 12/03/13 reflected the following: The resident's hearing was coded as 0 (no difficulty in normal conversation, social interaction, listening to TV); usually is understood and usually understands others; BIMS score of 14; coded as independent with no physical help from staff for ADLs; No ROM impairment; and used a wheelchair mobility device. Review of resident #3's nurses' notes reflected S3 LPN made an entry on 03/3/14 at 12:05 a.m., for 03/02/14 at 8:00 p.m. The note reflected the following: the nurse was informed by resident #5 to ask resident #3 to turn down his television so that he (resident #5) could hear his television. The S3 LPN went to resident #3 and asked that he turned down the volume on his television, and he did so without incident. As S3 LPN was leaving resident #3's room, resident #5 walked by resident #3's room and was yelling that he needed to turn his television down. S3 LPN informed resident #5 that she had spoken with resident #3, and he had turned his television down. Further review of the note reflected around 8:10 p.m., hall (a) CNA approached the nurse and informed her resident #3 asked which room resident #5 was in, and stated he was going to blow his mother f____g head off. The note reflected the CNA informed the nurse resident #3 had something under his shirt at that time, and he was worried it was a weapon. S3 LPN documented she alerted the Administrator, and he arrived with 2 officers from the Sheriff's Office. The note reflected the Administrator and the officers conversed with the resident, checked his room, and a pair of pliers was found and removed at that time. The nurse's note further reflected the resident was cooperative and non-combative, and at 12:05 a.m. was in his room resting at that time, calm with no signs of distress or agitation. Review of Departmental Notes dated 03/03/14 at 2:05 p.m., and documented by S4 SSD reflected she spoke with the resident about the incident that occurred the prior night. The note reflected the resident was apologetic and stated he had apologized to the resident. The S4 SSD documented she educated the resident regarding proper communication with other residents, and that if he had a problem he needed to let staff know instead of attempting to handle things by himself. The entry further reflected the resident stated he was sorry he caused trouble, and he was embarrassed it happened. The note further reflected the S4 SSD would continue to observe him for behaviors. Review of the Psychotherapy Progress Notes dated 03/03/04, and documented by the contracted LCSW reflected staff reported resident #3 needed to be evaluated and treated due to becoming agitated with another resident. The note reflected resident #3 was in bed and unable to see her. The note reflected she would follow-up on next visit. Review of the resident's clinical record reflected the contracted LCSW did not see the resident prior to his admission to the Behavioral hospital on [DATE] at 7:35 p.m. Observation during the initial tour of the facility on 03/07/14 at 10:50 a.m. revealed resident #3 and #5 were observed to reside on hall (a), next door to each other. Further observation on 03/07/14 at 10:50 a.m. revealed resident #3 sitting in his room in a wheelchair watching television. The volume on the resident's TV was very loud. The resident turned the volume down when the surveyor attempted to speak with him. The resident was alert and oriented to person, place and time. Interview/Observation of sampled resident #5 the resident who was the victim of the treats on 03/07/14 at 5:15 p.m. revealed he and another resident were ambulating from the dining room. Resident #5 stated he did not know resident #3, did not know resident #3's room number, and did not remember any incident on the evening of 03/02/14. Interview of resident #3 on 03/07/14 at 10:50 a.m. revealed the following: The resident stated that he has been a resident at the facility for 2 years; however, he wanted to leave because he was not happy anymore. The resident stated his problem was not with staff, but with another resident. Resident #3 stated that one time he told another resident that he was going to "blow his brains out", and someone at the desk heard him say that. He stated the person at the desk told him that he couldn't do that, and called a Behavioral Hospital. He stated the next thing he knew, he was sent to the Behavioral Hospital. He stated the resident in room c was always in his room stealing. He further stated he didn't associate with the other residents. Further interview of resident #3 at the above time revealed there was another incident about 2 weeks ago that he had a pair of Channel Locks, and the facility thought it was a gun. He stated he put the Channel Locks under his shirt, and he guess they thought it was a gun handle. He stated the Administrator showed up at the facility and wanted to know what was under his shirt, and took the Channel Locks and his other tools. Resident #3 further stated he didn't tell the Administrator, but he was going to use the Channel Locks and pull the resident in room c's balls off. Interview with S2 DON on 03/07/14 at 1:00 p.m. confirmed the police was called to the facility this past weekend (weekend of 02/28/14 to 03/02/14) because resident #3 told a CNA that he was going to blow resident #5's brains out. She stated the CNA was concerned, reported this, and the Administrator was called. She further stated resident #3 could transfer, but could not walk distances, and resident #5 could ambulate well. Interview of the S1 Administrator on 03/07/14 at 1:05 p.m., revealed a CNA contacted him and stated resident #3 was really angry because resident #5 complained about his TV being loud. The CNA stated resident #3 turned the TV down and was fine, but later came back to him and asked where resident #5's room was, because he was going to"blow his f_____g brains out". S1 Administrator stated he instructed the CNA to take the nurse and go back to the resident and talk to him to see if he had a weapon, and call him back. When the CNA called him back, he told him that he thought the resident had gun, and that he had talked the resident into locking whatever he had up in his closet. S1 Administrator stated the CNA was convinced the resident had a gun. He stated he instructed the CNA not to leave the resident's room. He stated upon his arrival, the resident's room was searched and all tools were removed. S1 Administrator stated the resident had no connections to bring him a gun. The S1 Administrator further stated the resident had a van that he kept a lot of his possessions in, and thought that maybe the resident could have had a weapon in the van. So, he was concerned that the possibility did exist. Interview of the S1 Administrator on 03/07/14 at 1:05 p.m. revealed in reference to the incident on Sunday night (03/02/14), he saw no need for an Incident Report. He stated it was charted in the nurses' notes, and he instructed the S4 SSD to followup the following morning. He stated the 2 residents (#3 and #5) had never had an altercation, and resident #5 never knew resident #3 made the comment about him. He stated the resident was on the list to be seen by the LCSW on her next visit. He stated the resident was calm and apologetic after the incident, and he talked with both residents together regarding the incident and they both understood. S1 Administrator stated resident #3 said he never would have hit the resident with the tool. Further interview revealed the CNA and the nurse watched the resident, but weren't assigned 1:1, because the resident showed no signs of aggression after the incident and if he had, there would have been no problem getting him PEC'd. He stated that an incident report could have been done and he guessed he could have done one, but he didn't see the need to do one because there was no harm done. He stated he felt the facility's actions were prompt and correct, and he didn't know what completing an Incident Report would have changed. Interview of S4 SSD on 03/07/14 at 1:05 p.m. revealed she and another police officer approached resident #3 on the evening of 03/02/14, and talked to him about the comments he made about having a gun. She stated the resident told them he had a gun, and when she asked him to show it to her, he pointed to the channel locks and stated that was his Smith & Wesson gun. S4 SSD stated the resident said he wasn't going to do anything, he was just upset because people were stealing his money. A subsequent interview of S1 Administrator on 03/10/14 at 9:55 a.m. revealed resident #3 asked if he could park his van on the parking lot when he initially came to the nursing home; however, it had been moved because it was such an eye sore. S1 Administrator stated all of resident #3's possessions were in the van, and that he had gone out to the van with the resident and looked in it. He stated there were a lot of mostly junk and books. He stated he saw Channel Lock pliers, another pair of pliers, a small hammer in the van along with other tools, but did not see a gun. The S1 Administrator stated he did not know exactly what was in the resident's closet, and had not searched his closet prior to it being searched on 03/02/14. He further stated resident #3 was confused, got along with his roommate, and did not have aggressive contact with anyone. He stated he considered the actions of resident #3 on 03/02/14 as more of general frustration, or a " fit " . He stated he knew his residents really well, and probably would have acted differently if he didn't. The S1 Administrator stated that after the incident on 03/02/14, the contracted LCSW was contacted and was supposed to see both resident #3 and resident #5, but the residents were asleep when she came to see them. He further stated the LCSW comes weekly, and she was to see the residents on her next visit. The S1 Administrator stated he did not know the date of the LCSW's visit, but she visited weekly. Interview/observation of sampled resident #4 (resident #3's roommate) on 03/10/14 at 11:15 a.m. revealed him in his room sitting by the door in his wheelchair. The resident stated he had been at this facility for about 8 months, and resident #3 had been his roommate since he had been there. Resident #4 stated resident #3 turns his TV on loud, and that one night resident #3 " flew off the handle" because someone outside the door shouted loud for him to turn off the TV. He stated he did not see whether resident #3 had anything on him like a weapon, but heard that he had a wrench and that was why he had to go. Resident #4 stated resident #3 kept all kinds of stuff in the closet, but he did not see it, and was not aware that he ever hurt anybody. He further stated resident #3 did not bother him. Resident #4 further stated that on that night (didn't know the date), he was laying on his bed and heard someone in the hall shout loud for resident #3 to turn off his TV. He stated resident #3 "flew off the handle" and went out into the hall, but in no time came back in the room. The resident further stated the nurse and the guy that runs the place came. He further stated he did not see anything else and did not hear what they talked about, but resident #3 was mad. The following interviews of all staff that worked the evening shift on 03/02/14 (LPNs were scheduled 7:00 p.m. to 7:00 a.m., and CNAs were scheduled 6:00 p.m. to 6:00 a.m.) were attempted or obtained via telephone: S3 LPN was contacted via telephone on 03/10/14 at 11:57 a.m. Interview revealed she was passing meds down hall (a) at 8:00 p.m. Resident #5 approached her and said resident #3's TV was too loud. She stated resident #3 didn't have a problem with it, and turned his TV down. As she was walking out of resident #3's room, resident #5 was going to his room and yelled out that resident #3 needed to turn his TV down. She stated that about 15 minutes went by, and the CNA assigned to hall (a) told her resident #3 said he was going to blow resident #5's "MF" head off. She stated the CNA said resident #3 had something under his shirt, and he didn't know what was under his shirt, and wanted to know where that guy was. The Administrator and policemen arrived, went into resident #3's room and closed the door. She stated they brought out a pair of pliers. She said resident #3 was always very polite, no problems, and usually goes to bed early. She stated he went to bed after she gave his medicine that night, and there were no problems the rest of the night. S9 CNA on 03/10/14 at 11:58 a.m. in an interview revealed she worked hall (e). S9 CNA stated she was sitting at the nursing station. Resident #5 came to the nurses' station and was fussing because a resident's TV was too loud, and stated the resident told hall (a)'s CNA, and hall nurse. She stated she heard the Administrator was called because resident #3 had a gun. She stated she doesn't know anything that happened after that. S10 CNA on 03/10/14 at 12:03 p.m. in an interview revealed she worked hall (f) on 03/02/14. She stated hall (a) CNA came and told her that resident #3 had a gun, and that he saw the gun. She stated she did not go down there. She stated she saw the Administrator and the police come to the building. She stated she did not hear anything after that. Review of resident #3's clinical record and nurses' notes reflected there was no further documentation or evidence the facility increased monitoring/supervision of resident #3 for aggressive behavior, and threats to harm another resident after the incident on 03/02/14 at 8:15 p.m., up to the residents voluntary admission to a Behavioral hospital on [DATE] at 7:35 p.m. There was no evidence the facility evaluated the fact that resident #3 had hazardous objects (channel lock pliers, a small hammer and other tools) in his room closet, how those objects were brought into the facility, and no evidence that targeted interventions were put in place to reduce the risk of the resident from bringing other hazardous objects into the facility in the future.

Based on observation, record review and interview, the facility failed to revise the comprehensive plan of care after a resident exhibited aggressive behavior with threats to harm another resident (#3) for 2 incidents (01/01/14 and 03/02/14). The facility failed to: 1. Revise the comprehensive plan of care to identify the problem of resident #3's aggressive behavior., 2. Develop resident specific targeted care plan approaches/interventions that addressed the resident's behavior, monitoring of those behaviors, and staff's response, 3. Develop targeted care plan interventions that reduced the risk of resident #3 bringing hazardous objects and other tools into the building (Channel Lock Pliers and other tools), The survey sample was 5 (#1, #2, #3, #4 and #5), and the total facility census was 127. Review of nursing Departmental Notes documented by a LPN, and dated 01/01/14, resident #3 was yelling and stated "you m_____ f_____, you stole my $800.00." The note reflected the nurse was unsuccessful when she tried to redirect the resident, and asked him to go to his room. The resident called the nurse a b__ch. Review of Departmental notes documented by the SSD dated 01/01/14 at 7:45 a.m. reflected the resident had threatened to kill another resident. The SSD documented the resident's bed was turned sideways and trapeze tilted over on his dresser. The resident stated "maybe if I barricade my closet in this damn place them nig___s would stop stealing from me." The note reflected resident #3 threatened to get even with the resident, and stated he was going to "blow his f____ing head off." Further review reflected the resident refused all medications, and was PEC'd to a Behavioral hospital on [DATE] at 10:25 a.m. The resident was readmitted back to the nursing facility on 01/14/14 with [DIAGNOSES REDACTED]. Further review of Departmental Notes documented by S3 LPN on 03/02/14 at 8:00 p.m., revealed resident #3 again exhibited aggressive behavior when another resident (#5) told him to turn his TV down. The note reflected the CNA informed the nurse that resident #3 wanted to know resident #5's room number, and had something under his shirt. The note reflected the resident said he was going "blow that mother f___k__'s head off." The Administrator was notified and arrived to the facility with 2 police officers. The resident's room was searched and a pair of pliers were found and removed from the resident's room. The note reflected the resident was cooperative and non-combative. Review of the resident's comprehensive plan of care reflected a problem of the resident on [MEDICAL CONDITION] Medication: Observation of side effects. The Administrator was notified of the Immediate Jeopardy on 03/07/14 at 5:50 p.m. The facility submitted a plan of removal which included: 1. Revision of their policy and procedure for residents with aggressive behavior. 2. Following the policy and procedure by contacting the Psychiatrist and Behavioral Hospital. Neither were contacted until 03/07/14. 3. Resident #3's agreement to be voluntarily admitted to the Behavioral Hospital. 4. Providing one to one supervision of resident #3 until his discharge to the hospital (was discharged to the Behavioral hospital on [DATE] at 7:35 p.m.). 5. Revision of the resident's comprehensive plan of care to include a problem of "mood/social interaction, impaired related to [DIAGNOSES REDACTED]. The plan of care also included specific interventions in reference to the resident's aggressive behaviors. 6. A plan to in-service staff on policy and procedure pertaining to residents with aggressive behaviors. The Immediate Jeopardy situation was removed on 03/07/14 at 7:05 p.m. when observations revealed the plan was being implemented, and resident #3 was awaiting transfer to a Behavioral Hospital. The resident voluntarily consented to be admitted to a Behavioral hospital on [DATE] at 7:35 p.m. The deficient practice remains at a potential for more than minimal harm. Findings: Review of resident #3's Face Sheet reflected he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Review of the resident's current Physician order [REDACTED]. Review of the resident's comprehensive plan of care reflected a problem of [MEDICAL CONDITION] Medication: Observation of side effects for Doneperil 5 mg PO Q hs, [MEDICATION NAME] 25 mg PO Q hs, and [MEDICATION NAME] 30 mg PO Q day. Approaches included to monitor for side effects. Review of resident #3's Quarterly MDS Assessment signed as completed by the RN Assessment Coordinator on 12/03/13 reflected the following: The resident's hearing was coded as 0 (no difficulty in normal conversation, social interaction. listening to TV); usually is understood and usually understands others; BIMS score of 14; coded as independent with no physical help from staff for ADLs; No ROM impairment; and used a wheelchair mobility device. Review of Departmental Notes reflected an incident that occurred on 01/01/14 at 7:28 a.m. The note reflected a LPN documented resident #3 was in the dining room yelling "you mother f____r, you stole my $800.00". The note reflected the nurse attempted to redirect the resident, and asked him to go to his room when he continued to yell. The note reflected the resident called the nurse a "b___h". Review of Departmental Notes documented by S4 SSD, and dated 01/01/14 at 7:45 a.m., reflected the floor nurse approached the SSD regarding resident #3's behavior. The S4 SSD documented she entered the resident's room and noticed his bed was turned sideways and the trapeze was tilted to the side on top of the bedside dresser. Resident #3 told the nurse that "if I barricade the closet in this damn place them nig____s would stop stealing from me". The note reflected resident #3 stated he left the facility the day before, and someone stole $900.00 that his brother had sent to him. The SSD documented resident #3 then told her "I am going to blow his f______g head off". "I'm tired of him coming in here and taking my sh__. Besides, it means it's one last nig___I have to worry about". The note further reflected resident #3 did not leave the facility the day prior, and when the resident's brother was contacted, he informed the facility that he had not sent the resident any money. Further review of nurses' notes reflected the resident refused all medications, and was PEC'd to a Behavioral hospital on [DATE] at 10:25 a.m. Review of resident #3's psychiatric evaluation dated 01/02/14, and documented by a psychiatrist at the Behavioral Hospital's reflected resident #3 was referred due to "increased agitation, threatened to harm this person who apparently took his money, + Delusions re: people stealing from him, + Cognitive deficits." Further review of the evaluation reflected a Diagnostic Impression of: Axis I: [MEDICAL CONDITION] NOS; Impulse Control Disorder NOS; and Dementia NOS versus Alzheimer's; Axis II: Deferred; and Axis III: HTN, Prostate CA and [MEDICAL CONDITION]. Review of discharge orders from the Behavioral Hospital dated 01/14/14 reflected the resident was discharged back to the nursing facility on 01/014/14. [DIAGNOSES REDACTED]. I. Dementia, Alzheimer's Type Mild to Moderate, with Behavioral Disturbances. II. Deferred. III. HTN, Prostate CA, [MEDICAL CONDITION], and [MEDICAL CONDITION]. Review of the Behavioral Hospital's Continuing Care Plan dated 01/14/14 reflected the patient was admitted for increased agitation, threatening a resident, poor impulse control, paranoia, and delusional thinking. The care plan further reflected at the time of discharge, the patient's mood was less labile, no agitation, decreased paranoia, and compliant with staff and medications. Diagnosis: [REDACTED]. Review of the discharged Medication Reconciliation Orders dated 01/14/14 reflected the resident was discharged on the following [MEDICAL CONDITION] medications: [REDACTED]. Further review of the resident's nurses notes reflected S3 LPN made an entry on 03/3/14 at 12:05 a.m., for 03/02/14 at 8:00 p.m. The note reflected the following: the nurse was informed by resident #5 to ask resident #3 to turn down his television so that he (resident #5) could hear his television. The S3 LPN went to resident #3 and asked that he turned down the volume on his television, and he did so without incident. As S3 LPN was leaving resident #3's room, resident #5 walked by resident #3's room and was yelling that he needed to turn his television down. S3 LPN informed resident #5 that she had spoken with resident #3, and he had turned his television down. Further review of the note reflected around 8:10 p.m., hall (a) CNA approached the nurse and informed her resident #3 asked which room resident #5 was in, and stated he was going to blow his mother f____g head off. The note reflected the CNA informed the nurse resident #3 had something under his shirt at that time, and he was worried it was a weapon. S3 LPN documented she alerted the Administrator, and he arrived with 2 officers from the Sheriff's Office. The note reflected the Administrator and the officers conversed with the resident, checked his room, and a pair of pliers was found and removed at that time. The nurse's note further reflected the resident was cooperative and non-combative, and at 12:05 a.m. was in his room resting at that time, calm, no signs of distress or agitation. Further observation on 03/07/14 at 10:50 a.m. revealed resident #3 sitting in his room in a wheelchair watching television. The volume on the resident's TV was very loud. The resident turned the volume down when the surveyor attempted to speak with him. The resident was alert and oriented to person, place and time. Interview of resident #3 on 03/07/14 at 10:50 a.m. revealed the following: The resident stated that he has been a resident at the facility for 2 years; however, he wanted to leave because he was not happy anymore. The resident stated his problem was not with staff, but with another resident. Resident #3 stated that one time he told another resident that he was going to "blow his brains out", and someone at the desk heard him say that. He stated the person at the desk told him that he couldn't do that, and called a Behavioral Hospital. He stated the next thing he knew, he was sent to the Behavioral Hospital. He stated the resident in room c was always in his room stealing. He further stated he didn't associate with the other residents. Further interview of resident #3 at the above time revealed there was another incident about 2 weeks ago that he had a pair of Channel Locks, and the facility thought it was a gun. He stated he put the Channel Locks under his shirt, and he guess they thought it was a gun handle. He stated the Administrator showed up at the facility and wanted to know what was under his shirt, and took the Channel Locks and his other tools. Resident #3 further stated he didn't tell the Administrator, but he was going to use the Channel Locks and pull the resident in room c's balls off. Interview of the S1 Administrator on 03/07/14 at 1:05 p.m., revealed a CNA contacted him and stated resident #3 was really angry because resident #5 complained about his TV being loud. The CNA stated resident #3 turned the TV down and was fine, but later came back to him and asked where resident #5's room was, because he was going to"blow his f_____g brains out". S1 Administrator stated he instructed the CNA to take the nurse and go back to the resident and talk to him to see if he had a weapon, and call him back. When the CNA called him back, he told him that he thought the resident had gun, and that he had talked the resident into locking whatever he had up in his closet. S1 Administrator stated the CNA was convinced the resident had a gun. He stated he instructed the CNA not to leave the resident's room. He stated upon his arrival, the resident's room was searched and all tools were removed. S1 Administrator stated the resident had no connections to bring him a gun. The S1 Administrator further stated the resident had a van that he kept a lot of his possessions in, and thought that maybe the resident could have had a weapon in the van. So, he was concerned that the possibility did exist. A subsequent interview of S1 Administrator on 03/10/14 at 9:55 a.m. revealed resident #3 asked if he could park his van on the parking lot when he initially came to the nursing home; however, it had been moved because it was such an eye sore. S1 Administrator stated all of resident #3's possessions were in the van, and that he had gone out to the van with the resident and looked in it. He stated there was a lot of mostly junk and books. He stated he saw Channel Lock pliers, another pair of pliers, a small hammer in the van along with other tools, but did not see a gun. The S1 Administrator stated he did not know exactly what was in the resident's closet, and had not searched his closet prior to it being searched on 03/02/14. He further stated resident #3 was confused, got along with his roommate, and did not have aggressive contact with anyone. He stated he considered the actions of resident #3 on 03/02/14 as more of general frustration, or a " fit " . He stated he knew his residents really well, and probably would have acted differently if he didn't. The S1 Administrator stated that after the incident on 03/02/14, the contracted LCSW was contacted and was supposed to see both resident #3 and resident #5, but the residents were asleep when she came to see them. He further stated the LCSW comes weekly, and she was to see the residents on her next visit. Review of Departmental Notes dated 03/03/14 at 2:05 p.m., and documented by S4 SSD reflected she spoke with the resident about the incident that occurred the prior night. The note reflected the resident was apologetic and stated he had apologized to the resident. The S4 SSD documented she educated the resident regarding proper communication with other residents, and that if he had a problem he needed to let staff know instead of attempting to handle things by himself. The entry further reflected the resident stated he was sorry he caused trouble, and he was embarrassed it happened. The note further reflected the S4 SSD would continue to observe him for behaviors. Review of resident #3's current comprehensive plan of care reflected the resident had not been care planned for his [DIAGNOSES REDACTED]. Further review of the plan of care reflected there were no resident specific targeted approaches/interventions for his aggressive behavior documented in the comprehensive plan of care after the 01/01/14 and 03/02/14 incidents. Additionally, there were no approaches/interventions in the comprehensive plan of care that addressed reducing the risk of the resident bringing hazardous objects (Channel Lock Pliers) and other tools into the building. Interview of S2 DON on 03/07/14 at 1:59 p.m. confirmed there was no plan of care in the resident's comprehensive plan of care that addressed the resident's aggressive behaviors, and should have been. She confirmed the incidents on 01/0/14 and 03/02/14 should have be care planned.

Based on observation, record review and interview the facility failed to ensure that a resident with an existing pressure sore and who was also at risk for development of new pressure sores did not develop new pressure sores (#68) for 1 of 5 residents in the facility with pressure sores. Out of a total of 41 stage 2 sampled residents, 3 residents were reviewed for pressure sores. The facility failed to: 1. follow their Skin Integrity Preventive Protocol policy and procedure by failing to apply a pressure relieving device/heel protectors to the resident's feet and 2. follow the comprehensive plan of care and physician's orders [REDACTED]. Resident #68 was admitted to the facility on [DATE] with a stage IV pressure sore to her right heel. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the hospital twice and received surgical procedures to her right heel to include partial calcanectomy and surgical debridement. On 5/28/12 the resident returned from the hospital and was assessed for pressure sore potential and was found to be a risk for development of new pressure sores. A comprehensive plan of care was in place for the resident to include a physician's orders [REDACTED]. Multiple observations of the resident revealed the facility was not following the comprehensive plan of care and physician's orders [REDACTED]. The resident was observed to be in bed without the use of heel protectors or other pressure relieving device to her feet. Observations of the resident further revealed that she had developed a stage IV Deep Tissue Injury pressure sore to her left heel of which the facility was not aware until after surveyor intervention on 6/27/12. The resident was also observed to have developed a stage II pressure sore to her right buttock of which the facility was not aware. Multiple interviews with staff confirmed the facility was not aware that the resident had developed the stage IV to her left heel and stage II to her right buttock until after surveyor intervention on 6/27/12. After surveyor intervention, the facility's RN assessed the resident's left heel, applied bilateral heel protectors and documented a left heel Deep Tissue Injury measuring 4.5 cm x 3 cm. The physician was notified, and orders were received to treat the new pressure sore to the resident's left heel and the right buttock. The facility failed to follow failed to follow their Skin Integrity policy and procedure prevention protocol for the use of heel protectors. Findings: Review of the facility's Skin Integrity Policy and Procedure reflected body pressure points to be relieved of pressure included a resident's heels. The policy further reflected a Prevention Protocol for the use of appropriate preventive measures to relieve pressure from the heels which included the use of heel protectors. Review of the Assessment of Pressure Sore Potential for resident #68 dated 4/11/12, 5/9/12 and 5/28/12 reflected the resident was moderately impaired mentally, chair bound, and had a history of [REDACTED]. Review of Wound Assessment Sheet dated 6/25/12 reflected the resident was being treated for [REDACTED]. Review of Body Audit Sheets dated 6/21/12 reflected no new area of skin impairment. Review of physician's orders [REDACTED]. Review of the current Care Plan (with a goal date of 8/7/12) reflected heel protector to left foot at all times while in bed, the resident was to be checked hourly for wetness, and any red or open areas were to be reported. Review of physician's progress notes dated 6/25/12 reflected the resident had Fungal [MEDICAL CONDITION] across the buttocks. Review of Additional Care Plan Issues dated 6/25/12 reflected the physician visited the resident, and the resident's fungal [MEDICAL CONDITION] to the buttocks were improving. Observations of resident #68 on 6/27/12 at 11:50 a.m. and 1:08 p.m. revealed the resident was lying in bed. During each observation, the resident's feet were noted to be positioned in direct contact with the bed mattress with no heel protectors, heel lifts or pressure relief device in place. Observation of the resident on 6/27/12 at 3:10 p.m. with S12LPN Treatment Nurse, S14 and S15 CNA's, revealed the resident remained in bed without having a pressure relieving device in place to her heels and feet. S12LPN Treatment Nurse was observed at that time to provide wound care to a large stage IV pressure ulcer to the resident's right heel. Further observations of the resident at that time revealed a dark red purple colored area of deep tissue injury to her left heel measuring approximately 4cm x 3cm in size. The surrounding skin was observed to be red and non-blanchable. The resident was also observed to have a dark red purple colored open area to her right buttock, stage II, measuring approximately 2 cm x 3 cm. The surrounding skin was observed to be red and non-blanchable. Interview with S12LPN Treatment Nurse at the time of the above observation revealed she was only providing treatment to the resident's right heel stage IV pressure ulcer, 2 arterial ulcers to her right foot and cream to her buttocks for fungal [MEDICAL CONDITION]. S12LPN confirmed at that time that she was not aware that the resident had a pressure ulcer to her left heel and to her right buttock. S12LPN stated that no one had reported to her these new areas, and that she last saw the resident's buttocks yesterday when she applied cream, but she did not see see a broken area. S12LPN further revealed that body audits are done weekly, and she last saw the resident's left foot last week and did not see a pressure ulcer. S12LPN further confirmed at that time that the resident was not wearing pressure relief devices to her heels. Further observation of the resident at that time revealed S3RN ADON was called to the resident's bedside to assess the resident. S3RN ADON confirmed the resident had a new pressure ulcer of Deep Tissue Injury to her left heel and a stage II to her right buttock. Interview with S3RN ADON at that time revealed that no one had reported the new areas to her. S3RN ADON confirmed that the resident was not wearing pressure relief devices to her heels and should have been. Interview at that time with S13LPN (the staff nurse caring for the resident) revealed she was not aware of the new areas and no one had reported them to her. Further interview during the above observation on 6/27/12 at 3:10 p.m. with S14 and S15 CNA's (the 2 CNA's caring for the resident) confirmed the resident was not wearing heel protectors and should have them on her feet. S14CNA was observed to begin looking in the room for the resident's heel protectors, and one heel protector was found in the resident's closet. S14CNA was observed to applied the heel protector to the resident's right heel, and the left heel remained without a pressure relief device. Further interview at that time with the S14 and S15 CNA's revealed they cared for the resident today, and they had not seen the new areas to the resident's left heel and right buttock. They further stated that the shower aide had bathed the resident. Observation on 6/27/12 at approximately 3:30 p.m. revealed S3RN ADON applied bilateral heel protectors to the resident's feet, after surveyor intervention. Interview on 6/29/12 at 11:42 a.m. with S16CNA (shower aide) revealed she bathed the resident on Tuesday (6/26/12), and she did not see a broken area to the resident's buttocks or the redness to her left heel. Interview with S2DON on 6/29/12 at 2:30 p.m. confirmed the facility Skin Integrity policy and procedure was not followed for resident #68 concerning pressure relieving devices to her heels, and that heel protectors should have been in place to the resident's heels. Review of Departmental Notes documented by S12LPN Treatment Nurse dated 6/27/12 at 3:45 p.m. reflected the resident was noted to have Deep Tissue Injury to the left heel measuring 4.5 cm x 3 cm, dusky dry with intact skin. A new physician's orders [REDACTED]. The note further reflected a stage II to the right buttock measuring 2.5 cm x 2 cm x <0.5 cm, granulating, red, moist and without exudate. A new physician's orders [REDACTED].

Based on observation, record review and interview the facility failed to ensure that the comprehensive plan of care and physician's orders were followed to apply a heel protector to a resident's left heel to prevent the development of new pressures sores for a resident with an existing pressure sore and at risk for development of new pressure sores (#68) for 1 of 5 residents in the facility with pressure sores, and failed to follow the plan of care for a resident's eye glasses (#23). Out of a total of 41 stage 2 sampled residents, 3 residents were reviewed for pressure sores and vision. The facility failed to: 1. follow the comprehensive plan of care and physician's orders to apply heel protectors to the resident's left foot at all times while in bed (#68) and to apply a resident's eyeglasses (#23). Resident #68 was admitted to the facility on [DATE] with a stage IV pressure sore to her right heel. The resident's [DIAGNOSES REDACTED]. The resident was admitted to the hospital twice and received surgical procedures to her right heel to include partial calcanectomy and surgical debridement. On 5/28/12 the resident returned from the hospital and was assessed for pressure sore potential and was found to be a risk for development of new pressure sores. A comprehensive plan of care was in place for the resident to include a physician's order to apply a heel protector to her left foot at all times while in bed to prevent the development of pressure sores to the left heel. Multiple observations of the resident revealed the facility was not following the comprehensive plan of care and physician's orders to keep a heel protector on her left heel at all times while she was in bed. The resident was observed to be in bed without the use of heel protectors or other pressure relieving device to her feet. Observations of the resident further revealed that she had developed a stage IV Deep Tissue Injury pressure sore to her left heel of which the facility was not aware until after surveyor intervention on 6/27/12. The resident was also observed to have developed a stage II pressure sore to her right buttock of which the facility was not aware. Multiple interviews with staff confirmed the facility was not aware that the resident had developed the stage IV to her left heel and stage II to her right buttock until after surveyor intervention on 6/27/12. After surveyor intervention, the facility's RN assessed the resident's left heel, applied bilateral heel protectors and documented a left heel Deep Tissue Injury measuring 4.5cm x 3 cm. The physician was notified, and orders were received to treat the new pressure sore to the resident's left heel and the right buttock. Findings: 1. Review of the Assessment of Pressure Sore Potential for resident #68 dated 4/11/12, 5/9/12 and 5/28/12 reflected the resident was moderately impaired mentally, chair bound, and had a history of [REDACTED]. Review of Wound Assessment Sheet dated 6/25/12 reflected the resident was being treated for [REDACTED]. Review of Body Audit Sheets dated 6/21/12 reflected no new area of skin impairment. Review of physician's orders for June, 2012 reflected the CNA's were to check the resident hourly for wetness, and a heel protector to the left heel at all times while in bed. Review of the current Care Plan (with a goal date of 8/7/12) reflected heel protector to left foot at all times while in bed, the resident was to be checked hourly for wetness, and any red or open areas were to be reported. Observations of resident #68 on 6/27/12 at 11:50 a.m. and 1:08 p.m. revealed the resident was lying in bed. During each observation, the resident's feet were noted to be positioned in direct contact with the bed mattress with no heel protectors, heel lifts or pressure relief device in place. Observation of the resident on 6/27/12 at 3:10 p.m. with S12 LPN Treatment Nurse, S14 and S15 CNA's revealed she remained in bed and continued to not have a pressure relieving device in place to her heels and feet. S12 LPN Treatment Nurse was observed at that time to provide wound care to a large stage IV pressure ulcer to the resident's right heel. Further observations of the resident at that time revealed a dark red purple colored area of deep tissue injury to her left heel measuring approximately 4cm x 3cm in size. The surrounding skin was observed to be red and non-blanchable. The resident was also observed to have a dark red purple colored open area to her right buttock, stage II, measuring approximately 2 cm x 3 cm. The surrounding skin was observed to be red and non-blanchable. Interview with S12LPN Treatment Nurse at the time of the above observation revealed she was only providing treatment to the resident's right heel stage IV pressure ulcer, 2 arterial ulcers to her right foot and cream to her buttocks for fungal [MEDICAL CONDITION]. S12 LPN confirmed at that time that she was not aware that the resident had a pressure ulcer to her left heel and to her right buttock. S12LPN stated that no one had reported to her these new areas, and that she last saw the resident's buttocks yesterday when she applied cream, but she did not see a broken area. S12LPN further revealed that body audits are done weekly, and she last saw the resident' left foot last week and did not see a pressure ulcer. S12LPN further confirmed at that time that the resident was not wearing pressure relief devices to her heels. Further observation of the resident at that time revealed S3RN ADON was called to the resident's bedside to assess the resident. S3RN ADON confirmed the resident had a new pressure ulcer of Deep Tissue Injury to her left heel and a stage II to her right buttock. Interview with S3RN ADON at that time revealed that no one had reported the new areas to her. S3RN ADON confirmed that the resident was not wearing pressure relief devices to her heels and should have been. Interview at that time with S13LPN (the staff nurse caring for the resident) revealed she was not aware of the new areas and no one had reported them to her. Further interview during the above observation on 6/27/12 at 3:10 p.m. with S14 and S15 CNA's (the 2 CNA's caring for the resident) confirmed the resident was not wearing heel protectors and should have them on her feet. S14CNA was observed to begin looking in the room for the resident's heel protectors, and one heel protector was found in the resident's closet. S14CNA was observed to applied the heel protector to the resident's right heel, and the left heel remained without a pressure relief device. Further interview at that time with S14 and S15 CNA's revealed they cared for the resident today, and they had not seen the new areas to the resident's left heel and right buttock. They further stated that the shower aide had bathed the resident. Observation on 6/27/12 at approximately 3:30 p.m. revealed S3RN ADON applied bilateral heel protectors to the resident's feet, after surveyor intervention. Interview on 6/29/12 at 11:42 a.m. with S16CNA (shower aide) revealed she bathed the resident on Tuesday (6/26/12), and she did not see a broken area to the resident's buttocks or the redness to her left heel. Interview with S2DON on 6/29/12 at 2:30 p.m. confirmed the care plan and physician's orders were not followed, and heel protectors should have been in place to the resident's heels. Review of Departmental Notes documented by S12LPN Treatment Nurse dated 6/27/12 at 3:45 p.m. reflected the resident was noted to have Deep Tissue Injury to the left heel measuring 4.5 cm x 3 cm, dusky dry with intact skin. A new physician's order was received to treat the left heel wound with [MEDICATION NAME] of [MEDICATION NAME] and wrap with a bulky dressing. The note further reflected a stage II to the right buttock measuring 2.5 cm x 2 cm x <0.5 cm, granulating, red, moist and without exudate. A new physician's order was received to treatment the buttock wound with "Zinc/[MEDICATION NAME]/[MEDICATION NAME]" every shift. 2. Observation of resident #23 on 06/28/12 at 11:30 a.m. revealed the resident was sitting in the dining room in her wheelchair, being fed by her daughter. The resident did not have on eyeglasses. Interview of the resident's daughter on the above date and time revealed the resident had a [DIAGNOSES REDACTED]. She stated the resident was not admitted to the facility with glasses, and did not wear glasses. She stated she had no need for them due to her diagnoses. Review of the resident's Physician's Orders dated 06/12 reflected [DIAGNOSES REDACTED]. Review of the Comprehensive Care Plan with a goal date of 08/07/12 reflected a problem of sensory perception altered, vision moderately impaired, wears glasses, and [DIAGNOSES REDACTED]. Interview of S21 SSD on 06/28/12 at 11:45 a.m. revealed the resident was not admitted with eyeglasses, and was able to maneuver without them. S21 revealed at present, her disease processes had progressed, and she did not read or do anything without assistance. Interview of S22 SSD on 06/28/12 at 12:30 p.m. revealed that she found the resident's glasses in her drawer, cleaned them and put them on the resident. S22 SSD stated the resident said she could see, but she was not sure because of her Alzheimer's. Further interview with S22 on 6/28/12 at 1:15 p.m. revealed the resident had an eye doctor appointment scheduled for 07/06/12. Observation of the resident on 06/28/12 at 12:45 p.m. revealed the resident was wearing eyeglasses. The resident stated she was able to see that the door was open. Interview of S7 CNA Supervisor on 06/28/12 at 1:55 p.m. revealed that she found the resident's glasses, cleaned them and put them on her. S7 CNA Supervisor stated the resident was able to correctly answer questions with her glasses on such as: "Am I holding up fingers, can you see me."