Every finding on record at Colonial Oaks Skilled Nursing and Rehabilitation

Based on record review and interview, the facility failed to ensure a MDS assessment was transmitted timely for 1 (#44) of 1 sampled resident reviewed for resident assessment.Findings: On 07/22/2026 a review of Resident #44's quarterly MDS assessment, with an ARD of 05/10/2026, revealed in part a status of export ready. Further review of Resident #44's quarterly MDS assessment, with an ARD of 05/10/2026, failed to reveal the assessment had been transmitted. During an interview on 07/22/2026 at 7:55 a.m., S3MDS Nurse and S4Clinical Reimbursement Specialist confirmed the facility failed to transmit Resident #44's quarterly MDS Assessment timely.

Based on record review, observation, and interviews, the facility failed to ensure a resident's narcotic record was maintained and reconciled for 1 (#47) of 4 residents' Individual Narcotic Record reviewed.Findings: Observation on 07/22/2026 at 9:00 a.m. with S2 LPN revealed Resident #47's Individual Narcotic Record for Diazepam 2mg tablet had a documented count of 13. Review of Resident #47's narcotic card of Diazepam 2mg revealed an actual count of 12.During an interview on 07/22/2026 at 9:00 a.m. S2 LPN reported Diazepam 2mg was administered this morning. S2 LPN reported Diazepam 2mg was not signed out when removed from Resident #47's Individual Narcotic Record card and should have been. During an interview on 7/22/2026 at 9:15 a.m. S1 Corporate Nurse confirmed Resident #47's Diazepam 2mg should have been signed out on Resident #47's Individual Narcotic Record at the time it was removed from the narcotic card.

Based on record review and interviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to have an effective system in place to obtain and provide pain management for Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. with instructions related to longstanding chronic pain management. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings, Cross reference F600 and F697: During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining Narcotics for a new admit was for the nurse to fax the hard script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give Narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard copy script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported he had been notified numerous times via fax to his phone by the facility regarding Resident #331 needing a hard script for narcotic pain medication. S13Medical Director reported he was out of town and was informed by S19NP Resident #331 was out of the facility on 05/29/2025. S13Medical Director reported he had not been informed of Resident #331's return to the facility. S13Medical Director acknowledged Resident #331 was admitted to the facility on [DATE] and did not receive narcotic pain medication until 06/02/2025 and should have. S13Medical Director reported Resident #331 would have been in significant pain related to her fracture. S13 Medical Director further reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotic. During a telephone interview on 06/04/2025 at 3:45 p.m., S19NP reported there had been a misunderstanding of Resident #331 being in the facility on 05/29/2025. S19NP reported on the morning of 05/29/2025 he was informed by staff of a new admit from the 05/28/2025 evening shift who had been sent out by EMS. S19NP reported he assumed Resident #331 had been admitted to the hospital and failed to clarify. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:15 a.m., S19NP confirmed Resident #331 was in the facility on 05/29/2025 when he rounded. S19NP acknowledged he failed to see Resident #331 and provide a hard script for Norco. During an interview on 06/05/2025 at 10:45 a.m., S3DON reported she was aware Resident #331 called EMS to get pain medicine and the issue was discussed in the morning meeting on 05/29/2025. S3DON reported S4ADON (Assistant Director of Nursing) was responsible for admit orders and ensuring medications are received and should have taken care of the issue regarding Resident #331's pain medication. S3DON reported she did not follow up and should have. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication by failing to obtain a hard copy script for Norco. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by lack of administrative oversight. Administrator did not ensure that the staff obtained hard script for ordered narcotic pain medication at the time of admission or for 4 days after for Resident #331. The DON did not ensure that nursing responded appropriately for Resident #331's complaints of pain and ensure medication was available. RN (Registered Nurse) QI (Quality Improvement) nurse implemented medication orders for controlled substance prescriptions policy and procedure on 06/05/2025. Administrator will attend the clinical morning meeting with the administrative nurses and DON twice weekly to ensure the 24 hour report was reviewed and pain addressed timely and neglect is not present. Corporate QI RN will in-service Administrator on 06/05/2025 on validating that 24 hour report was reviewed and pain addressed timely and neglect is not present. Corporate QI RN will in-service DON or nursing responsibilities and staff oversight regarding ordering of pain medication. Corporate QI RN will provide oversight that the Administrator has attended the clinical morning meeting and reviewed the morning clinical QA (Quality Assurance) meeting form which includes the 24 hour report review by the DON to ensure accuracy and any issues were followed up on timely and neglect is not present. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director, facility Administrator, Director of Nursing and Social Services Director to review the Plan of Removal. The Administrator will complete the clinical meeting audit tool (which will ensure the 24 hour report was reviewed by DON) weekly times 4 weeks and report findings to QAPI team along with any concerns identified in monitoring for this Plan of Removal monthly times 3 then as directed by QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.

Based on record review and interviews the facility failed to provide pain management consistent with professional standards of practice for a resident, following a fractured right hip, for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. Nursing staff failed to ensure severe pain was managed for Resident #331 by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Pain Assessment and Management policy revised March 2025 revealed in part: Purpose: The purposes of this procedure are to help the staff identify pain in the residents, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain General Guidelines: 1. The pain management program is based on a facility-wide commitment to resident comfort. 2. Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. 3. Definitions of different pain include: Acute Pain refers to pain that is usually sudden in onset and time-limited with a duration of less than 1 month and often is caused by injury, trauma, or medical treatments such as surgery . 2. Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, whining. Assessing Pain: b. Characteristics of pain: (1) Intensity of pain (Pain scale 0-10 or nonverbal pain). 2. Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including: (4) Fractures; and (2) Surgical incision. Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. 4. Be familiar with the physiologic and behavioral (non-verbal) signs of pain. For example: a. Verbal expressions such as groaning, crying, whining: The following equipment and supplies will be necessary when performing this procedure; a. Explanation of pain scale severities of 0-10 or nonverbal indicators of pain scale; Steps in the Procedure 3. Conduct an abbreviated pain assessment if there has been not change of condition since the previous assessment . b. Verbal and non-verbal signs of pain; 5. Administer pain medications as ordered. Resident #331 was admitted to the facility on [DATE] with diagnoses, which included in part, other fracture of right femur, subsequent for closed fracture with routine healing, pain, depression, and anxiety disorder. Review of Resident #331's Nursing admission assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review of Resident #331's Nursing admission assessment dated [DATE] and baseline care plan revealed Resident #331 was totally dependent on staff for bed mobility, transfer, dressing and toilet use. Review of Resident #331's hospital records revealed in part a discharge medication reconciliation dated 05/28/2025 for the continuation of Hydrocodone-acetaminophen 10-325 mg; take 1 tablet by oral route every 4 to 6 hours as needed for pain. Review of S13Medical Director's 2025 Standing Orders revealed in part: admission Orders: 1. Continue all orders from hospital including meds, if there are questions, contact NP (Nurse Practitioner)/AP (Advanced Practitioner). PRN Medications: c. Pain/minor complaints/fever: Tylenol 650 mg q 6 hours prn, notify NP if not effective after 2 doses. Review of Resident #331's Physician orders failed to reveal an order for narcotic pain medication until 06/02/2025 when Hydrocodone-acetaminophen tablet 10-325 mg; give 1 tablet by mouth every 4 hours as needed for pain was ordered via an original hard copy prescription (hard script) signed by S19NP. Review of Resident #331's May and June 2025 MARs (Medication Administration Record) revealed in part, on a pain intensity scale of 1 to 10, a pain level of 8 on 05/28/2025's night shift; a pain level of 2 on 05/31/2025's dayshift; and a pain level of 8 on 06/02/2025's evening shift had been documented. Further review of May and June 2025 MARs failed to reveal Tylenol 650 mg or Hydrocodone-acetaminophen 10-325 mg pain medication had been administered. Review of Resident #331's paper Narcotic Administration Record revealed Resident #331 received an initial dose of Hydrocodone-acetaminophen 10-325 mg on 06/02/2025 at 9:00 a.m. Review of Resident #331's Interdisciplinary notes revealed in part, standing order pain medication was administered on 05/28/2025 at 10:02 p.m. and 05/29/2025 at 10:19 p.m. Further review of Resident #331's Interdisciplinary notes revealed a note by S14LPN (Licensed Practical Nurse) on 05/29/2025 at 1:09 a.m. which read in part: Writer (S14LPN) assessed Resident #331 at beginning of shift. Resident alert and oriented x 3. Complained of right hip pain of an 8 on pain scale. Writer (S14LPN) informed Resident #3 that her pain medication has been ordered but did not come in and offered Tylenol. Tylenol 650 mg administered per S13Medical Director's standing orders. Resident took medication without difficulty . Writer (S14LPN) went to room and Resident #331 was on phone with a 911 (Emergency Medical Services) . Resident #331 stated she needs something for pain because the Tylenol is not helping . Further review of Resident #331's Interdisciplinary notes revealed Resident #331 received Tramadol and Norco in the ED prior to returning to the facility on [DATE] at 4:09 a.m. During an interview on 06/02/2025 at 8:00 a.m., Resident #331 reported she was in severe pain all over and had not received her pain medicine because the facility was out of her medicine. During an interview on 06/03/25 08:08 a.m., Resident #331 reported facility did not have her prescription pain medicine until yesterday, 06/02/2025. Resident #331 further reported she had been given Tylenol and stated it did not help. During an interview on 06/04/2025 at 9:30 a.m. Resident #331 reported she was told by her nurses the facility did not have her pain medication and she felt she was getting the run around. Resident #331 reported her hip pain became unbearable so she called EMS (on 05/29/2025) to come get her. During an interview on 06/04/2025 at 11:00 a.m., S15CNA (Certified Nursing Assistant) reported she took care of Resident #331 on 05/29/2025 and stated Resident #331's pain was through the roof. S15CNA further stated Resident #331 was crying and would scream when staff touched or turned her. During an interview on 06/04/2025 at 11:10 a.m., S16LPN reported the process for a new admit needing pain medication, was for the discharging hospital to send a hard script for the narcotic to be filled by the pharmacist. S16LPN further reported the facility had not received a hard script for Resident #331's narcotic pain medication upon admission and had to wait on S13Medical Director to provide one in order for Resident #331 to receive her pain medication. During an interview on 06/04/2025 at 12:20 p.m., S18PT (Physical Therapist) reported he evaluated Resident #331 on 05/29/2025 for a closed right hip fracture. S18PT further reported Resident #331 exhibited a high level of pain when touched and was unable to participate at the time. During a telephone interview on 06/04/2025 at 1:00 p.m. S14LPN reported she worked the 11-7 shift beginning 05/28/2025 and was informed by the evening nurse a request for hard copy script for pain medication had been sent to S13Medical Director. S14LPN reported Resident #331 had received Tylenol but called EMS to take her to the ED because she was in pain. S14LPN further reported at this time Resident #331 was at an 8 pain level. S14LPN stated I truly believe she was in pain or she wouldn't have called EMS. S14LPN confirmed she was not able to administer Norco without a hard copy script even if available in the emergency back-up system. During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining narcotics for a new admit was for the nurse to fax the hard copy script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotics. During a telephone interview on 06/04/2025 at 3:45 p.m. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:00 a.m., S12LPN reported the first day she was assigned to take care of Resident #331 was 06/02/2025. S12LPN further reported upon initial morning assessment, Resident #331 reported a 10 out of 10 pain. S12LPN further reported Resident #331 informed her she had been asking for pain medication since she was admitted and had not received any narcotic pain medication. S12LPN reported she checked the medication cart and discovered Resident #331 did not have a Norco blister package of doses in the medication cart. During an interview on 06/05/2025 at 9:30 a.m., Resident #331 reported she quit asking for pain medicine because she felt like no one was helping her. Resident #331 stated I'm [AGE] years old and I knew Tylenol was not going to work for this kind of pain. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by noncompliance. Staff did not assure that hard script for pain medication was available upon admission and during the first four days of stay. Processes and systems for improvement include admission and administrative follow-up for narcotic availability for all admitting residents. The admission's director will forward hospital discharge orders to all administrative nurses, including the DON. Once hospital discharge orders are received, the ADON will request that copies of hard scripts for all narcotics be emailed to our admission's director and forwarded to administrative nurses. The DON or designee will ensure that all hard scripts are received prior to admission. If the hard script is not received, the DON or designee will contact the medical director to request a hard script for any narcotic order. The DON or designee will communicate with charge nurse, who is assigned to the admitting resident, until the prescribed narcotics are delivered to facility. Training for all nurses began immediately. Nurses in attendance on 06/05/2025 will be educated/in-serviced on the Medication Orders: Controlled Substance Prescriptions Policy and Procedures. All nurses will also be in- serviced on medication availability and proper notification to DON when medications, including narcotics, are not available. Nurses who are unavailable for training on this date will not be allowed to return to work until all training is complete. RN (Registered Nurse) DON and LPN MDS (Minimum Data Set) will provide education/training. Monitoring by the DON will be in place for receipt of hard scripts and narcotic medications for all admitting patients. The nursing administration will review 24-hour reports which include resident changes of conditions, new physician orders, and any documented indications of pain, during the morning meeting for five days weekly for four weeks. Any concerns identified during the morning meeting will be addressed immediately to the parties responsible for correction and the QA (Quality Assurance) committee. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director, facility administrator, director of nursing, and social worker to review the plan of removal. The DON will complete the nursing audit tool monthly and report the findings to the QAPI team along with any concerns identified in monitoring for this plan of removal monthly times three then as directed by QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.

Based on record review and interviews, the facility failed to protect the resident's right to be free from neglect for 1 (#331) of 6 (#25, #75, #231, #281, #331 and #381) residents reviewed for pain. The facility failed to ensure Resident #331 received needed services and treatment for pain management of a right fractured hip by failing to ensure narcotic pain medication was obtained and administered to Resident #331 as ordered. The deficient practice resulted in an Immediate Jeopardy for Resident #331 on 05/28/2025 at 4:45 p.m. when Resident #331 was admitted to the facility for routine surgical healing and therapy after a fractured right hip. Resident #331 was discharged from the hospital on [DATE] with an order for Hydrocodone-acetaminophen (Norco) 10-325 mg (milligrams) po (by mouth) q (every) 4 hours prn (as needed) for pain. Resident #331 called EMS (Emergency Medical Service) on 05/29/2025 at 1:00 a.m. and requested to be taken to the ED (Emergency Department) for unrelieved pain after receiving Tylenol 650 mg. Resident #331 returned to the facility on [DATE] at 4:09 a.m. with instructions related to longstanding chronic pain management. Resident #331 continued to experience severe right hip pain and was only provided standing order pain medication of Tylenol 650 mg. The facility did not administer narcotic pain medication ordered for Resident #331 until 06/02/2025 at 9:00 a.m. when Resident #331 was at a pain level of 10 on a 1-10 pain intensity scale. This deficient practice has the likelihood to affect all other residents with medication orders. S1Administrator and S2Corporate Nurse were notified of the Immediate Jeopardy on 06/05/2025 at 1:45 p.m. The Immediate Jeopardy was removed on 06/05/2025 at 10:00 p.m. The facility implemented an acceptable Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Review of the facility's Abuse and Neglect - Clinical Protocol policy revised October 15, 2022 revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Definitions: Neglect, as defined at §483.5, means the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of goods or services that a resident(s) requires but fails to provide them to the resident(s), that has resulted in or may result in physical harm, pain, mental anguish, or emotional distress. Neglect includes cases where the facility's indifference or disregard for resident care, comfort or safety, resulted in or could have resulted in, physical harm, pain, mental anguish, or emotional distress. Treatment/Management: 1. The facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Purpose: The purpose of this procedure is to provide guidelines for assessing the resident's level of pain prior to administering analgesic pain medication. 4. Be familiar with the physiologic and behavioral (non-verbal) signs of pain. For example: a. Verbal expressions such as groaning, crying, whining: The following equipment and supplies will be necessary when performing this procedure; a. Explanation of pain scale severities of 0-10 or nonverbal indicators of pain scale; Steps in the Procedure 3. Conduct an abbreviated pain assessment if there has been not change of condition since the previous assessment . b. Verbal and non-verbal signs of pain; 5. Administer pain medications as ordered. Resident #331 was admitted to the facility on [DATE] with diagnoses, which included in part, other fracture of right femur, subsequent for closed fracture with routine healing, pain, depression, and anxiety disorder. Review of Resident #331's Nursing admission assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15, indicating intact cognition. Further review of Resident #331's Nursing admission assessment dated [DATE] and baseline care plan revealed Resident #331 was totally dependent on staff for bed mobility, transfer, dressing and toilet use. Review of Resident #331's hospital records dated 05/28/2025 for surgical repair of right hip fracture revealed in part a discharge medication reconciliation for the continuation of Hydrocodone-acetaminophen 10-325 mg; take 1 tablet by oral route every 4 to 6 hours as needed for pain. Review of Resident #331's medical record failed to reveal ED hospital records from 05/29/2025 had been acquired by the facility. Review of Resident #331's ED hospital records dated 05/29/2025 obtained by surveyor revealed in part a history of present illness as: Resident #331 presents to the ED with c.o. (complaint of) right leg pain. EMS reports that they transported patient (Resident #331) from rehabilitation facility for uncontrolled pain. EMS states that patient (Resident #331) recently had hip surgery to the right side, and was discharged from the hospital yesterday. It (Resident #331) reports that she has only received Tylenol from the facility she has been with, but states that it has not been helping . Further review of Resident #331's ED hospital records dated 05/29/2025 revealed in part, Resident #331 had been prescribed longstanding chronic pain medication and last filled a 30 day supply of Hydrocodone-acetaminophen 10-325 mg on 04/30/2025. ED instructions included in part for Resident #331's family to bring Resident #331's bottle of pain medication to the facility to be administered. Review of S13Medical Director's 2025 Standing Orders revealed in part: admission Orders: 1. Continue all orders from hospital including meds, if there are questions, contact NP (Nurse Practitioner)/AP (Advanced Practitioner). PRN Medications: c. Pain/minor complaints/fever: Tylenol 650 mg q 6 hours prn, notify NP if not effective after 2 doses. Review of Resident #331's Physician orders failed to reveal an order for narcotic pain medication until 06/02/2025 when Hydrocodone-acetaminophen tablet 10-325 mg; give 1 tablet by mouth every 4 hours as needed for pain was ordered via an original hard copy prescription (hard script) signed by S19NP. Review of Resident #331's May and June 2025 MARs (Medication Administration Record) revealed in part, on a pain intensity scale of 1 to 10, a pain level of 8 on 05/28/2025's night shift; a pain level of 2 on 05/31/2025's dayshift; and a pain level of 8 on 06/02/2025's evening shift had been documented. Further review of May and June 2025 MARs failed to reveal Tylenol 650 mg or Hydrocodone-acetaminophen 10-325 mg pain medication had been administered. Review of Resident #331's paper Narcotic Administration Record revealed Resident #331 received an initial dose of Hydrocodone-acetaminophen 10-325 mg on 06/02/2025 at 9:00 a.m. Review of Resident #331's Interdisciplinary notes revealed in part, standing order pain medication was administered on 05/28/2025 at 10:02 p.m. and 05/29/2025 at 10:19 p.m. Further review of Resident #331's Interdisciplinary notes revealed a note by S14LPN (Licensed Practical Nurse) on 05/29/2025 at 1:09 a.m. which read in part: Writer (S14LPN) assessed Resident #331 at beginning of shift. Resident alert and oriented x 3. Complained of right hip pain of an 8 on pain scale. Writer (S14LPN) informed Resident #3 that her pain medication has been ordered but did not come in and offered Tylenol. Tylenol 650 mg administered per S13Medical Director's standing orders. Resident took medication without difficulty . Writer (S14LPN) went to room and Resident #331 was on phone with a 911 (Emergency Medical Services) . Resident #331 stated she needs something for pain because the Tylenol is not helping . Further review of Resident #331's Interdisciplinary notes revealed Resident #331 received Tramadol and Norco in the ED prior to returning to the facility on [DATE] at 4:09 a.m. Further review revealed the Pharmacy was notified of non-delivery of narcotic medication on 05/29/2025 at 10:27 p.m. and a hard script request was faxed to S13Medical Director's office on 05/29/2025 at 10:42 p.m. During an interview on 06/02/2025 at 8:00 a.m., Resident #331 reported she was in severe pain all over and had not received her pain medicine because the facility was out of her medicine. During an interview on 06/03/25 08:08 a.m., Resident #331 reported facility did not have her prescription pain medicine until yesterday, 06/02/2025. Resident #331 further reported she had been given Tylenol and stated it did not help. During an interview on 06/04/2025 at 9:30 a.m. Resident #331 reported she was told by her nurses the facility did not have her pain medication and she felt she was getting the run around. Resident #331 reported her hip pain became unbearable so she called EMS (on 05/29/2025) to come get her. During an interview on 06/04/2025 at 11:00 a.m., S15CNA (Certified Nursing Assistant) reported she took care of Resident #331 on 05/29/2025 and stated Resident #331's pain was through the roof. S15CNA further stated Resident #331 was crying and would scream when staff touched or turned her. During an interview on 06/04/2025 at 11:10 a.m., S16LPN reported the process for a new admit needing pain medication, was for the discharging hospital to send a hard script for the narcotic to be filled by the pharmacist. S16LPN further reported the facility had not received a hard script for Resident #331's narcotic pain medication upon admission and had to wait on S13Medical Director to provide one in order for Resident #331 to receive her pain medication. During an interview on 06/04/2025 at 12:20 p.m., S18PT (Physical Therapist) reported he evaluated Resident #331 on 05/29/2025 for a closed right hip fracture. S18PT further reported Resident #331 exhibited a high level of pain when touched and was unable to participate at the time. During a telephone interview on 06/04/2025 at 1:00 p.m. S14LPN reported she worked the 11-7 shift beginning 05/28/2025 and was informed by the evening nurse a request for hard copy script for pain medication had been sent to S13Medical Director. S14LPN reported Resident #331 had received Tylenol but called EMS to take her to the ED because she was in pain. S14LPN further reported at this time Resident #331 was at an 8 pain level. S14LPN stated I truly believe she was in pain or she wouldn't have called EMS. S14LPN confirmed she was not able to administer Norco without a hard copy script even if available in the emergency back-up system. During an interview on 06/04/2025 at 2:30 p.m., S3DON (Director of Nursing) reported the process for obtaining Narcotics for a new admit was for the nurse to fax the hard script to the facility's pharmacy. S3DON reported the nurse was responsible for contacting the physician to obtain a hard script if one was needed. S3DON further reported nurses cannot give Narcotics from the emergency locked pharmacy system without a hard script for the narcotic in hand. S3DON reported nursing staff should have called S13Medical Director to receive a hard copy script in a timely manner and did not. During a telephone interview on 06/04/2025 at 3:25 p.m., S13Medical Director reported he had been notified numerous times via fax to his phone by the facility regarding Resident #331 needing a hard script for narcotic pain medication. S13Medical Director reported he was out of town and was informed by S19NP Resident #331 was out of the facility on 05/29/2025. S13Medical Director reported he had not been informed of Resident #331's return to the facility. S13Medical Director acknowledged Resident #331 was admitted to the facility on [DATE] and did not receive narcotic pain medication until 06/02/2025 and should have. S13Medical Director reported Resident #331 would have been in significant pain related to her fracture. S13 Medical Director further reported the nurse should have called him or S19NP to get a hard script for Resident #331's narcotic. During a telephone interview on 06/04/2025 at 3:45 p.m., S19NP reported there had been a misunderstanding of Resident #331 being in the facility on 05/29/2025. S19NP reported on the morning of 05/29/2025 he was informed by staff of a new admit from the 05/28/2025 evening shift who had been sent out by EMS. S19NP reported he assumed Resident #331 had been admitted to the hospital and failed to clarify. S19NP acknowledged Resident #331 went without narcotic pain medication from 05/28/2025 to 06/02/2025 and should not have. During an interview on 06/05/2025 at 9:00 a.m., S12LPN reported the first day she was assigned to take care of Resident #331 was 06/02/2025. S12LPN further reported upon initial morning assessment, Resident #331 reported a 10 out of 10 pain. S12LPN further reported Resident #331 informed her she had been asking for pain medication since she was admitted and had not received any narcotic pain medication. S12LPN reported she checked the medication cart and discovered Resident #331 did not have a Norco blister package of doses in the medication cart. S12LPN further reported a request for a hard script for Norco was then faxed to S13Medical Director. During an interview on 06/05/2025 at 9:15 a.m., S19NP confirmed Resident #331 was in the facility on 05/29/2025 when he rounded. S19NP acknowledged he failed to see Resident #331 and provide a hard script for Norco. During an interview on 06/05/2025 at 9:30 a.m., Resident #331 reported she quit asking for pain medicine because she felt like no one was helping her. Resident #331 stated I'm [AGE] years old and I knew Tylenol was not going to work for this kind of pain. Resident #331 reported yesterday, 06/04/2025 was the first day she could tolerate getting out bed to go to therapy. During an interview on 06/05/2025 at 10:45 a.m., S3DON reported she was aware Resident #331 called EMS to get pain medicine and the issue was discussed in the morning meeting on 05/29/2025. S3DON reported S4ADON (Assistant Director of Nursing) was responsible for admit orders and ensuring medications are received and should have taken care of the issue regarding Resident #331's pain medication. S3DON reported she did not follow up and should have. During an interview on 06/05/2025 at 10:50 a.m., S4ADON reported she was aware Resident #331 did not receive ordered pain medication and S5Unit Manager was responsible for obtaining hard script. During an interview on 06/05/2025 at 11:00 a.m. S5Unit Manager reported she was aware resident #331 still did not have pain medication on 06/02/2025 and S4ADON was responsible to ensure a hard script was received. S5Unit Manager further reported she notified the S19NP on 06/02/2025 when she realized Resident #331's Norco had never been delivered. During an interview on 06/05/2025 at 11:50 a.m., S3DON acknowledged there had been a system failure for Resident #331 getting her pain medication at admission. S3DON further acknowledged she was ultimately responsible for following through to ensure Resident #331 received her narcotic pain medication and did not. During an interview on 06/05/2025 at 1:45 p.m. S1Administrator acknowledged there were issues identified for Resident #331 related to pain management and a communication failure between the MD, NP and nursing staff to obtain a hard script for narcotic medication. During an interview on 06/05/2025 at 8:30 p.m., S2Corporate Nurse reported the system failure for Resident #331 was due to S3DON and S4ADON (Assistant Director of Nursing) not following through to ensure Resident #331 received prescribed pain medication by failing to obtain a hard copy script for Norco. S2Corporate Nurse further reported DONs are trained by S2Corporate Nurse upon hire and training includes responsibilities and duties. The facility's Plan of Removal: Resident #331 and all new admissions with narcotic pain medications may be impacted by noncompliance. Staff did not obtain hard script for ordered narcotic pain medication at the time of admission or for 4 days after for Resident #331. Medication audit performed on 06/02/2025 by Administrative nurses to ensure all ordered narcotic medications were on the medication cart and available for residents. On 06/04/2025 all medication cars were audited again by QI (Quality Improvement) Nurse/DON and Administrative nurses and all narcotic medications were present. Medication orders for controlled substance prescriptions policy and procedure will be implemented 06/05/2025 by QI Nurse. To ensure residents are free from neglect and provided with the necessary goods and services of ordered narcotic pain medication DON and LPN/MDS (Minimum Data Set) nurse will be in-serviced on the Medication Orders Controlled Substance Prescriptions policy and procedure by RN (Registered Nurse)/QI Nurse. All other Administrative Nurses and staff nurses will be in-serviced on this policy and procedure by RN DON and/or LPN/MDS. In-service will be completed on 06/05/2025 for all staff nurses currently working on shift. Nurses unavailable for in-service on 06/05/2025 will be unable to work until training has been completed. Nursing administration will review 24 hour report, which includes resident change in conditions and new physician orders, during morning meeting five days a week x 4 weeks to ensure any pain is addressed and neglect is not present. Any concerns identified will be addressed immediately with parties responsible for correction and reported to the Quality Assurance Committee. An Ad Hoc QAPI (Quality Assurance Performance Improvement) meeting will be held with the Medical Director to review Plan of Removal. The DON will complete Narcotic Audit tool on a monthly basis and report findings to QAPI team along with any concerns identified in monitoring for this Plan of Removal monthly times 3 then as directed by the QAPI team. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 06/05/2025.

Based on record review and interview the facility failed to have the six required staff members present for quarterly QAA (Quarterly Assessment Assurance) Committee meetings. Findings: Review of the facility's Quality Assessment and Assurance Committee Summary meetings 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025 sign-in sheets revealed the DON (director of nursing), IP (infection preventionist), MD (medical director), and Administrator were present. Further review failed to reveal the required two additional staff members were present for QAA meetings on 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025. During an interview on 06/05/2025 5:30 p.m. S1 Administrator confirmed the required two additional facility staff members were not present for QAA meetings on 07/23/2024, 10/23/2024, 01/24/2025, and 04/16/2025.

Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required. Findings: Review of PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 1 2025 (October 1-December 31) revealed triggers for the following: star staffing rating equals 1 and excessively low weekend staffing. Review of the facility's weekend staffing patterns for FY Quarter 1 2025 (October 5, 2024-Decemeber 29, 2024) revealed the facility had adequate amount of staffing hours. During an interview on 06/04/2025 at 11:50 a.m. S1 Administrator reported payroll was completed in the facility and ultimately sent to CMS by the Corporate Office. S1 Administrator reported the facility had above the required staffing hours for FY Quarter 1 2025. S1 Administrator reported the discrepancy with the staffing hours occurred when agency staff do not clock in on the facility clocking system and agency staffing hours have to be manually added to the payroll and/or facility employees have mispunched hours in the clocking system.

Based on record reviews and interviews, the facility failed to provide pharmaceutical services that assure the accurate administering of medications for 2 (#44 and #331) of 2 (#44 and #331) residents whose medications were reviewed. The facility failed to ensure administration of pain medication was accurately documented. Findings: Record review of the facility's Administering Pain Medications policy revised July 7, 2019 revealed in part: Document the following in the resident's medical record: 1. Results of the pain assessment 2. Medication 3. Dose 4. Route of administration; and 5. Results of the medication (adverse or desired). Review of Resident #44's medical record revealed an admit date of 07/22/2023 with diagnoses of but not limited to muscle wasting and atrophy, Parkinson's disease without dyskinesia, Crohn's disease, and primary generalized osteoarthritis. Review of Resident #44's Quarterly MDS (Minimum Data Set) dated 03/27/2025 revealed Resident #44 was assessed to have a BIMS (brief interview mental status) score of 13 indicating intact cognition. Further review revealed Resident #44 was assessed to have received scheduled pain medication during the seven day look back period. Review of Resident #44's June 2025 Physicians Orders revealed an order for Hydrocodone-Acetaminophen (Norco) oral tablet 10-325 mg (milligrams). Give 1 tablet by mouth every six hours for pain. Review of Resident #44's May 2025 MAR (Medication Administration Record) failed to revealed documentation of administration of Resident #44's 2:00 a.m. dose of Hydrocodone 10-325 mg on 05/03/2025, 05/04/2025, 05/06/2025 and 05/31/2025. During an interview on 06/05/2025 at 2:00 p.m. S2 Corporate Nurse confirmed Resident #44's Hydrocodone 325 mg should have been documented as administered on the MAR on 05/03/2025, 05/04/2025, 05/06/2025 and 05/31/2025. Resident #331 Resident #331 was admitted to the facility on [DATE] with diagnoses, which included in part, other fracture of right femur, subsequent for closed fracture with routine healing, pain, depression, and anxiety disorder. Review of S13Medical Director's 2025 Standing Orders revealed in part: admission Orders: 1. Continue all orders from hospital including meds, if there are questions, contact NP (Nurse Practitioner)/AP (Advanced Practitioner). PRN Medications: c. Pain/minor complaints/fever: Tylenol 650 mg q (every) 6 hours prn (as needed), notify NP if not effective after 2 doses. Review of Resident #331's hospital records revealed in part a discharge medication reconciliation dated 05/28/2025 for the continuation of Hydrocodone-acetaminophen 10-325 mg; take 1 tablet by oral route every 4 to 6 hours as needed for pain. Review of Resident #331's May and June 2025 MARs failed to reveal Tylenol 650 mg or Hydrocodone-acetaminophen 10-325 mg pain medication had been administered. Review of Resident #331's paper Narcotic Administration Record revealed Resident #331 received a dose of Hydrocodone-acetaminophen 10-325 mg on 06/02/2025 at 9:00 a.m. and on 06/03/2025 at 8:00 a.m. Review of Resident #331's Interdisciplinary notes revealed in part, standing order pain medication was administered on 05/28/2025 at 10:02 p.m. and 05/29/2025 at 10:19 p.m. During an interview on 06/04/2025 at 2:30 p.m. S3 DON (Director of Nursing) acknowledged doses of prn pain medication were written in the notes but should have been documented on Resident #331's MAR and were not. During an interview on 06/04/2025 at 3:20 p.m., S2 Corporate Nurse acknowledged the prn pain medication doses and Norco doses should have been documented as administered on Resident #331's MAR. During an interview on 06/05/2025 at 9:00 a.m., S12 LPN (Licensed Practical Nurse) acknowledged she had not documented the 06/02/2025 9:00 a.m. and the 06/03/2025 8:00 a.m. doses of Norco on Resident #331's MAR and should have.

Based on record reviews and interviews the facility failed to develop resident's comprehensive person-centered care plans with a focus and appropriate approaches on bed rails/side rails for 3 (#8, #12, and #27 ) of 3 (#8, #12, and #27) residents reviewed for physical restraints. Findings: Resident #8 Review of Resident #8's face sheet revealed an admission date of 05/01/2020 with diagnoses of fusion of lumbar spine, sequelae of cerebral infarction, rheumatoid arthritis, muscle wasting to multiple sites, unsteadiness on feet, lack of coordination, abnormalities of gait and mobility. Review of Resident #8's June 2025 physician orders revealed an order dated 04/04/2025: may have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning. Review of Resident #8's Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed bed rails not in use. Review of Resident #8's care plan failed to reveal a focus with appropriate interventions on bed rails/side rails. Observation on 06/02/2025 at 3:23 p.m. revealed Resident #8 in bed with bilateral side rails raised to head of the bed. During an interview on 06/02/2025 at 3:23 p.m. Resident #8 reported the hand assist rails were used to assist to turn and reposition. Resident #12 Review of Resident #12's face sheet revealed an admission date of 05/01/2020 with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, epilepsy, weakness, contracture of muscle right/left thigh, generalized muscle weakness, cognitive communication deficit, unspecified dementia, severity, with mood disturbance, muscle wasting and atrophy to multiple sites, lack of coordination, and abnormalities of gait and mobility. Review of Resident #12's June 2025 physician orders revealed an order dated 04/04/2025: may have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning. Review of Resident #12's Annual MDS assessment dated [DATE] revealed bed rails not in use. Review of Resident #12's care plan failed to reveal a focus with appropriate interventions on bed rails/side rails. Observation on 06/02/2025 at 10:00 a.m. revealed Resident #12 in bed with bilateral side rails raised to head of the bed. Observation on 06/04/2025 12:40 p.m. revealed Resident #12 in bed with bilateral side rails raised to head of the bed. Resident #27 Review of Resident #27's face sheet revealed an admit date of 05/08/2023 with medical diagnoses parkinson's disease without dyskinesia, without mention of fluctuations, muscle wasting and atrophy to multiple sites, unspecified abnormalities of gait and mobility, generalized muscle weakness, cognitive functions following cerebral infarction, and epilepsy. Review of Resident #27's June 2025 physician orders revealed an order dated 04/04/2025: revealed may have bilateral assist rails to promote independence in bed mobility. Check for placement and functioning. Review of Resident #27's significant change MDS dated [DATE] revealed bed rails not in use. Review of Resident #27's care plan failed to reveal a focus with appropriate interventions on bed rails/side rails. Observation on 06/02/2025 at 2:34 p.m. Resident #27 revealed raised hand assist rails to both sides of the head of the bed. During an interview on 06/02/2025 at 2:34 p.m. Resident #27 reported the hand assist rails were used while in bed to assist to turn and reposition. During an interview on 06/04/2025 at 3:45 p.m. S6 MDS nurse reviewed Resident #8, #12, and #27's care plan and confirmed Resident #8, #12, and #27's care plan did not have a focus with appropriate interventions for bed rails/side rails.

Based on record reviews and interviews the facility failed to ensure quarterly statements were provided for 2 residents (#35, #54) of 2 (#35, #54) residents whose personal funds accounts were reviewed. The facility failed to provide quarterly statements to residents and or their responsible parties. Findings: Review of the facility's Resident Trust Fund Agreement included in the facility's admission packet revealed on page 13 the statement: I will receive a statement of any account at least quarterly. Resident #35 Review of Resident #35's medical record revealed an admit date of 02/16/2018 with diagnoses of but not limited to cerebral infarction, chronic obstructive pulmonary disease, polyneuropathy, abnormalities of gait and mobility and anxiety disorder. Review of Resident #35's Quarterly MDS (Minimum Data Set) dated 04/12/2025 revealed a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. During an interview on 06/02/2025 at 3:47 p.m. Resident #35 reported she did not receive quarterly statements from the facility. Review of Resident #35's face sheet revealed resident's daughter was Resident #35's RP (responsible party)/emergency contact #1. During a telephone interview on 06/03/2025 at 8:35 a.m. Resident #35's RP reported not recieving quarterly personal funds statements from the facility in the past 6 months to a year. During an interview on 06/04/2025 at 12:45 a.m. S7 BOM (Business Office Manager) reported quarterly statements should have been hand delivered to residents in the facility who were their own responsible party or mailed to the person named on top of the quarterly statement. S7 BOM further reported residents' quarterly statements should have been sent out two weeks after the closing of the quarterly account and reported there was no tracking in place for verification that resident's quarterly statements were mailed out to Resident #35's responsible party. Resident #54 Review of Resident #54's medical record revealed an admit date of 09/20/2021 and a re-admission date of 12/14/2021 with diagnoses of but not limited to primary generalized arthritis, chronic obstructive pulmonary disease, major depressive disorder, essential hypertension and congestive heart failure. Review of Resident #54's Quarterly MDS dated [DATE] revealed Resident #54 revealed a BIMS score of 15 indicating intact cognition. During an interview on 06/02/2025 at 9:05 a.m. Resident #54 reported not ever receiving a quarterly personal funds statement from the facility. During an interview on 06/03/2025 at 12:20 p.m. S7 BOM reported Resident #54 signed a Resident Trust Fund Agreement when admitted and confirmed the facility did not have evidence or documentation showing Resident #54 was provided a quarterly statement of Resident #54's personal trust fund account.

Based on record review and interviews, the facility failed to provide services that met professional standards for 1 (#51) of 36 sampled residents. The facility failed to ensure safe medication administration practices by leaving medication at the bedside. Findings: Review of facility's Self-Administration of Medications policy revised December 2016 revealed in part: Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation: 1. As part of their overall evaluation the staff with the assistance from the practitioner will assess each resident's mental and physical abilities to determine whether self-administering medications is clinically appropriate for the resident. 2. In addition to general evaluation of decision-making capacity the interdisciplinary team will perform an assessment of Self-Administration of Medications Form, or equivalent including (but not limited to) the resident's; a. ability to read and understand medication labels; b. Comprehension of the purpose and proper dosage and administration time for his or her medications; c. Ability to remove medications from a container and to ingest and swallow (or otherwise administer) the medication; and d. Ability to recognize risks and major adverse consequences of his or her medications. 4. If the resident is determined to self-administer, then he/she will be capable and willing to assume control and responsibility for his/her medication. The resident must sign the Consent for Administration Of Medication Form regarding and agree to abide by the restrictions for handling and storage of medication according to one of the following plans. 5. Any bedside medications will meet all the required labeling specifications and guidelines required of any medications in the facility. 6. All medications are kept in a locked cabinet (night stand) in the resident's room where it is not accessible by other residents. 7. Staff shall identify and give to the Charge Nurse any medications found at the bedside that are not authorized for self-administration, . 10. Nursing staff will review the self-administration record (MAR) appropriately noting that the doses were self-administered. 11. The staff will evaluate the resident who wishes to self-administer medications upon request or admission, readmission, routine quarterly, significant change MDS (Minimum Data Set) and PRN (as needed) in order to reevaluate a resident's ability to continue to self-administer medications. Review of resident #51's medical record revealed an admit date of 04/07/2022 with diagnoses that include in part acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, acute pulmonary edema, chronic diastolic (congestive) heart failure, atrial fibrillation, and shortness of breath. Review of resident #51's physician orders revealed in part: 05/05/2025 Nebulizer: Assess after administering Nebulizer Treatment Document Lung Sounds as 1=Clear 2=Rales 3=Congested 4=Crackles 5=Rhonci 6=Rubs 7=Wheezing 8=Diminished six times a day 05/05/2025 Ipratropium-Albuterol Solution 0.5-2.5 (3) MG (milligram)/3ML (milliliter) 3 ml inhale orally six times a day related to chronic obstructive pulmonary disease. Review of resident #51's medical record failed to reveal resident #51 had been assessed for self-administration of medications, to have medications at the bedside or was consented to have medications at the bedside. Review of resident #51's quarterly MDS dated [DATE] revealed in part a brief interview for mental status score of 15 indicating intact cognition. During an interview on 06/04/2025 at 4:45 p.m. S3 DON (Director of Nursing) and S2 Corporate Nurse confirmed resident #51 had been self-administering his nebulizer treatments, had not been assessed for self-administration, did not have a doctor's order for self-administration, and did not have a consent for self-administration of medications and should have. During an interview on 06/05/2025 at 4:40 p.m. resident #51 confirmed he had been self-administering his nebulizer medication daily.

Based on observations and interviews the facility failed to ensure facility's daily census and nurse/CNA (Certified Nurse Assistant) staffing information was clearly displayed in a visible place for residents and visitors to view at any given time. Findings: Observation of the facility on 06/02/2025 at 2:00 p.m. failed to reveal the facility's daily census/staffing information was posted. Observation of the facility on 06/03/2025 at 10:30 a.m. failed to reveal the facility's daily census/staffing information was posted. Observation of the facility on 06/04/2025 at 2:30 p.m. failed to reveal facility's daily census/staffing information was posted. During an interview on 06/04/2025 at 2:30 p.m. S17 CNA/Ward Clerk reported daily census, nurse/ CNA staffing information should be posted in a locked bulletin board in the facility breezeway. S17 CNA/Ward Clerk reported S1 Administrator had a key to the locked bulletin board and nurse/CNA staffing information was not posted on the weekend and have not been posted this week. During an interview on 06/04/2025 2:30 p.m. S1 Administration confirmed daily census, nurse/CNA staffing information should be posted daily and was not.

Based on record review, observations, and interview the facility failed to provide appropriate treatment and services for 1(#52) resident of 1(#52) resident reviewed for tube feedings. The facility failed to ensure Resident #52's tube feeding bag was changed every 24 hours. Findings: Review of the facility's Enteral Feedings-Safety Precautions policy with a revision date of November 2018 revealed in part: 1. Change administration sets for open-system enteral feedings at least every 24 hours, or as specified by the manufacturer. Review of Resident #52's Physician Orders revealed an order dated 02/01/2024 to enteral feed every shift; Isosource 1.5. 45 ml (milliliter) per hour for 22 hours via feeding pump. Observation on 06/02/2025 at 8:15 a.m. revealed Resident #52's tube feeding bag infusing at 45 ml per hour dated 06/01/2025 at 4:00 a.m Observation on 06/02/2025 at 9:20 a.m. with S5 LPN (Licensed Practical Nurse) MDS (Minimum Data Set) Nurse revealed Resident #52's tube feeding bag infusing at 45 ml per hour and dated 06/01/2025 4:00 a.m During an interview on 06/02/2025 9:20 a.m. S5 LPN MDS Nurse acknowledged Resident #52's tube feeding bag was infusing at 45 ml per hour and dated 06/01/2025 at 4:00 a.m S5 LPN MDS Nurse confirmed the tube feeding bag should have been changed after 24 hours of use.

Based on record review, observation and interviews the facility failed to store, prepare, distribute and serve food under sanitary conditions. The facility failed to ensure: 1. Kitchen staff properly monitored the chemical levels in the third compartment sanitization sink 2. the chest freezer remained free from ice buildup 3. expired/outdated food was removed from the chest freezer and 4. The chest freezer was free of spilled food items. This had the potential to affect any of the 77 residents who received trays out of the kitchen on 06/02/2025. Findings: Review of the facility policy titled Manual Cleaning and Sanitizing Utensils and Portable Equipment dated 10/01/2018 revealed in part: 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75 degrees Fahrenheit. 9. Test and record the parts per million concentration of the solution. A sample Test Strip Log for Three-Compartment sink follows this policy. Review of the facility policy titled Refrigerators, Coolers and Freezers dated 10/01/2018 revealed in part: Policy: The facility will maintain refrigerators, coolers and freezers in a clean and sanitary manner to minimize the risk of food hazards. Refrigerators, coolers and freezers will be kept clean on a daily basis and will be thoroughly cleaned every month or more often as needed. 2. Dispose of all outdated food and discard all leftover items greater than 72 hours old. Observation on 06/02/2025 at 8:00 a.m. revealed the following: 1. Accurately monitoring sanitization of the three compartment sink. 2. A large chest freezer with ice buildup all the way around the inside top of the freezer from the seal to approximately 5-10 inches deep. 3. Two large bags of frozen okra that appeared discolored and dry/freezer burned with a label dated 02/14/2023 and one large bag of greens that appeared discolored/gray and dry/freezer burned with a label dated 11/04/2024 and 4. open/unbagged frozen vegetables loosely scattered in the bottom of the chest freezer During an interview on 06/02/2025 at 8:42 a.m. S11 Dietary Aide reported she used a thermometer to check the temperature in the third compartment sanitization sink and not a chemistry strip to check the chemicals like she should have. During an interview on 06/02/2025 at 8:30 a.m. S10 Dietary Manager confirmed and agreed with the findings.

Based on record reviews and interviews, the facility failed to ensure a resident fall was reported according to facility policy and procedure for 1 (#1) of 3 (#1, #2, #3) sampled residents for falls. Findings: Review of facility's policy Accidents and Incidents- Investigating and Reporting dated November 2024 revealed, in part: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. Policy Interpretation and Implementation 1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall initiate and document investigation of the accident or incident. 3. The Charge Nurse or designee shall complete an Incident Report form and submit the original to the Director of Nursing Services within 24 hours of the incident or accident. Review of Resident #1's medical record revealed in part, an admitted [DATE] with diagnoses including muscle wasting and atrophy not elsewhere classified multiple sites, other specified disorders of bone density and structure of unspecified site, difficulty in walking not elsewhere classified, abnormalities of gait and mobility, and unspecified dementia. Review of resident #1's Quarterly and State MDS (Minimum Data Set) assessments dated 10/29/2024 revealed a BIMS (Brief Interview for Mental Status) score of 5, which indicated severely impaired cognitive skills. Review of Resident #1's progress notes for November 2024 failed to reveal documentation of a fall and a post fall assessment on 11/18/2024. Review of facility's Incidents listed by Incident Type report for dates 06/24/2024 to 12/09/2024 failed to reveal an incident on 11/18/2024 involving Resident #1. During an interview on 12/11/2024 at 9:20 a.m. S1Administrator reported S3LPN did not report that Resident #1 sustained a fall on 11/18/2024. S1Administrator further reported S3LPN did not follow the facility's policy and procedure by not reporting a resident's fall and was terminated. During an interview on 12/11/2024 at S2DON confirmed after an investigation was conducted by the facility, it was determined Resident #1 did fall on 11/18/2024. S2DON further confirmed S3LPN did not report Resident #1's fall and did not complete a facility's incident report regarding Resident #1's fall on 11/18/2024 and should have.

Based on record reviews and interviews the facility failed to ensure services were provided to meet professional standards of quality as evidenced by failing to document a resident's fall and failing to assess a resident after a fall for 1 (#1) of 3 (#1, #2, #3) sampled residents. S3LPN failed to document a fall Resident #1 sustained on 11/18/2024. Findings: Review of Resident #1's medical record revealed in part, an admitted [DATE] with diagnoses including muscle wasting and atrophy not elsewhere classified multiple sites, other specified disorders of bone density and structure of unspecified site, difficulty in walking not elsewhere classified, abnormalities of gait and mobility, and unspecified dementia. Review of resident #1's Quarterly MDS (Minimum Data Set) assessments dated 10/29/2024 revealed a BIMS (Brief Interview for Mental Status) score of 5, which indicated severely impaired cognitive skills. Review of Resident #1's progress notes for November 2024 failed to reveal documentation of a fall and post fall assessment on 11/18/2024. Review of facility's Incidents listed by Incident Type report for dates 06/24/2024 to 12/09/2024 failed to reveal an incident on 11/18/2024 involving Resident #1. During an interview on 12/11/2024 at 9:20 a.m. S1Administrator reported S3LPN did not report that Resident #1 sustained a fall on 11/18/2024. S1Administrator further reported S3LPN did not follow the facility's policy and procedure by not reporting a resident's fall and was terminated. During an interview on 12/11/2024 at S2DON confirmed S3LPN did not document Resident #1's fall on 11/18/2024 nor did S3LPN document an assessment and should have.

Based on record review and interviews the facility failed to implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act within 24 hours to the state agency for 1 (#2) of 4 (#1,#2, #3, #4) residents reviewed for misappropriation of resident property. Findings: Review of Facility's Abuse and Neglect Policy (revised October 15, 2022) revealed in part: Policy Statement: The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Policy Interpretation and Implementation: Definitions Misappropriation of resident property as defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings or money without the resident's consent. Treatment/ Management 2. The management and staff, with the physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies. Review of face sheet revealed Resident #2 was admitted to the facility on [DATE] with the following medical diagnoses, but not limited to sequelae of cerebral infarction, dysphagia-oropharyngeal phase, schizophrenia, and metabolic encephalopathy. Further review of Resident #2's face sheet revealed Resident #2's daughter was the Responsible Party/ Power of Attorney, Financial/ Emergency Contact #1. Review of Quarterly MDS (Minimum Data Sets) dated 05/22/2024 revealed Resident #2 had a BIMS (Brief Interview of Mental Status) of 12 out of 15 indicating moderate impairment. During an interview on 06/24/2024 at 3:30 p.m. when Resident #2 was asked if she had an account with the facility or any issues with the facility account; Resident replied, I do not know, you would have to ask my daughter. During a telephone interview on 06/25/2024 at 11:23 a.m., Resident #2's daughter reported during a visit to the facility in May 2024 she inquired with the business office about Resident #2's account balance and credit card. Resident #2's daughter reported a credit card was left at the facility when Resident #2 was admitted in the year 2021 to pay Resident #2's monthly account. Resident #2's daughter reported Resident #2's account balance owed to the facility in May 2024 was $10,000 and the credit card could not be located. Resident #2's daughter reported a couple of days later she requested Resident #2's credit card account statements from the bank and there were charges starting in September 2021 for ATM (Automated Teller Machine) withdrawals, fast food restaurants, and utility bills and the facility account had not been paid. Resident #2's daughter verified the nursing home was not being paid. Resident #2's daughter reported S5 Bookkeeper's name was identified on one of the charges. Resident #2's daughter further reported this information about the credit card charges was reported to S1 Administrator at the end of May 2024. Resident #2's daughter reported a police report was made as soon as she received the credit card statement. Review of facility's incident investigation reports from July 2023 through June 2024 failed to reveal an allegation of misappropriation of funds related to Resident #2. During an interview on 06/25/2024 at 12:30 p.m., S1 Administrator reported Resident #2's daughter stopped him in the hallway sometime in the end of May 2024 after she received a bill from the nursing home. S1 Administrator reported Resident #2's daughter had a representative on the phone from a ______ banking company inquiring about charges. S1 Administrator reported he told Resident #2's daughter he would look into the inquiries and wrote it up as a grievance since S5 Bookkeeper had not been employed at the facility since February 2024. During an interview on 06/25/2024 at 4:00 p.m. S1 Administrator and S2 Regional [NAME] President reported the allegation of Resident #2's missing credit card, facility account balance, and questionable charges on the credit card statement was not reported to the state agency since S5 Bookkeeper was no longer employed at the facility. During an interview on 06/26/2024 at 3:33 p.m. S3 Corporate Nurse reported the allegation of Resident #2's missing credit card, facility account balance, and questionable charges on the credit card statement should have been reported to the state agency.

Based on record reviews and interview, the facility failed to electronically submit accurate direct care staffing information, based on payroll, to CMS (Centers for Medicare and Medicaid Services) as required. Findings: Review of the PBJ (Payroll Based Journal) Report for FY (Fiscal Year) Quarter 1 2024 (October 1 - December 31) revealed triggers for the following: One Star Staffing Rating and Excessively Low Weekend Staffing. Review of the facility's weekend staffing pattern forms for FY Quarter 1 2024 (October 1 - December 31) revealed in part, the facility provided 185.8 hours of direct care on 12/03/2023 and provided 189.6 hours of direct care on 12/10/2023. Review of the facility's consolidated data submitted to CMS for FY Quarter 1 2024 revealed in part, the facility submitted 175.85 hours of direct care for 12/03/2023 and 181.6 hours of direct care for 12/10/2023. During an interview on 04/23/2024 at 11:55 a.m., S1 Corporate Nurse reported the facility provided 185.8 hours of direct care on 12/03/2023 not 175.85 hours as reported to CMS and provided 189.6 hours of direct care on 12/10/2023 not 181.6 hours as reported to CMS. S1 Corporate Nurse confirmed inaccurate direct care data was submitted to CMS for 12/03/2023 and 12/10/2023.

Based on record reviews and interview, the facility failed to ensure Quarterly assessments were completed no later than 14 days after the ARD (Assessment Reference Date) for 5 (#54, #14, #18, #7, #46) of 8 residents (#54, #14, #17, #27, #18, #7, #46, #52) reviewed for Resident Assessment. Findings: Review of Resident #54's medical record revealed a Quarterly MDS (Minimum Data Set) with an ARD of 03/03/2024 and a completion date of 04/16/2024. Review of Resident #14's medical record revealed a Quarterly MDS with an ARD of 03/17/2024 and a completion date of 04/16/2024. Review of Resident #18's medical record revealed a Quarterly MDS with an ARD of 03/14/2024 and a completion date of 04/16/2024. Review of Resident #7's medical record revealed a Quarterly MDS with an ARD of 02/29/2024 and a completion date of 04/16/2024. Review of Resident #46's medical record revealed a Quarterly MDS with an ARD of 02/23/2024 and a completion date of 04/16/2024. During an interview on 04/23/2024 at 9:05 a.m., S2 MDS Nurse reviewed Resident #54, #14, #18, #7, and #46's Quarterly MDS assessments and confirmed the assessments were not completed no later than 14 days after the ARD.

Based on record reviews, observations and staff interviews, the facility failed to develop an individualized, person-centered plan of care to meet the needs of 1 (#15) resident out of 15 residents (#1, #3, #9, #15, #19, #24, #38, #45, #65, #69, #70, #71, #53, #56, and #322 ) who were reviewed for plan of care. There were 69 residents residing in the facility. The facility failed to ensure the plan of care included an accurate assessment of resident (#15) that he did not have teeth when he does have teeth and required assistance with his oral care. Findings: Review of resident #15's clinical record revealed an admitted to this facility 09/08/2023. Diagnoses include but not limited to hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, dysphagia following cerebral infarction, and type 2 diabetes mellitus without complication. Review of resident #15's Comprehensive Plan of Care revealed the resident has an ADL (Activities of Daily Living) self-care performance deficit related to Hemiplegia. The Comprehensive Plan of Care inaccurately states resident #15 has no teeth and does not wear dentures. Review of resident #15's MDS (Minimum Data Set) with assessment reference date 03/05/2024 revealed Section C - Cognitive Patterns a BIMS (Brief Interview for Mental Status) Summary Score of 12 that indicates his cognitive status is moderately intact. Observation on 04/21/2024 at 10:10 a.m. revealed Resident #15's did have bottom teeth. Further observation of Resident #15's teeth revealed they were discolored, brownish with a yellowish buildup of old food particles on and between his teeth. During an interview on 04/21/2024 at 10:15 a.m. Resident #15 reported he could not remember the last time his teeth had been brushed. Resident #15 reported he did not have a tooth brush or tooth paste. Observations on 04/21/2024 at 10:30 a.m. of resident #15's bedside table with S4 CNA (Certified Nursing Assistant) failed to reveal a tooth brush or tooth paste for resident 15. During an interview on 04/21/2024 at 10:30 a.m. S4 CNA reported she had not done oral care for resident #15. Observation on 04/22/2024 at 3:40 p.m. of resident #15's mouth with S3 ADON (Assistant Director of Nursing) revealed resident does have bottom teeth. S3 ADON agreed resident #15 did have teeth and the Comprehensive Plan Care was not accurate. During an interview on 04/22/2024 at 3:50 p.m. S2 MDS Nurse reported resident #15's Comprehensive Plan of Care had been completed inaccurately.

Based on record reviews and interviews the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 (Resident #1) of 6 (Residents #1, #2, #3, #4, #5, #6) sampled residents. The deficient practice resulted in actual harm of Resident #1 on 10/10/2022 when the resident was found on the floor in Hall A bathroom area. Resident #1 reported S3 CNA (Certified Nursing Assistant) threw her out of her wheelchair and beat her up. Resident #1 was assessed by S5 LPN and S7 LPN and found to have injuries including dark red scratches across the front of her neck, a large contusion to back of her head, and blue colored bruising to her left forearm. Resident #1 complained of pain to her right lower back and left forearm near her wrist. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility policy Abuse Prevention Program with revision date of October 2022 revealed in part: Policy Statement: Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation: As part of the resident abuse prevention, the administration will: 1. Protect out residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. Review of Resident #1's progress notes revealed in part: Nursing note dated 10/10/2022 at 10:05 p.m. signed by S7 LPN (Licensed Practical Nurse) read as follows: Late note for 8:15 p.m. Called from room ___ overhead that a Hall D resident had fallen in the bathroom of Hall A. As I got to the nurse's station I observed S5 LPN pushing the resident up Hall A in her wheelchair. Resident #1 had a large hematoma to back of her head and two scratches to her throat area. Resident #1 stated That black b***h threw me to the floor and beat me. Review of hand written statement dated 10/10/2022 by S5 LPN in summary revealed in part: S5 LPN was coming out the doors of Hall B and was approached by S6 Ward Clerk and S3 CNA reporting Resident #1 had fallen in the hall bathroom on Hall A. S3 CNA stated I don't know why she trying to go down there, I told her she not to go in there. S5 LPN went down Hall A to assess the resident, the resident was observed on the floor with knees bent. S5 LPN asked Resident #1 what happened and resident reported she threw me out of my chair . S5 LPN observed a large red hematoma to the back of resident's head. Police arrived, S5 LPN and S6 Ward Clerk took police to Resident #1's room where resident was found to be sleeping, but was easily aroused. When S5 LPN tried to assist Resident #1 with rolling to her back, Resident #1 grimaced and reported her back and neck were hurting and further reported the black girl pounced on her. Resident #1 also stated I think she broke my arm. S5 LPN assessed both arms and found blue bruising to top of left forearm near wrist. Police asked Resident #1 about the scratches on her neck and Resident #1 replied she attacked me like a grizzly bear. Police took pictures of all marks found on resident. Review of hand written statement dated 10/10/2022 by S6 Ward Clerk revealed in part: S6 Ward Clerk was at the nurse's station and heard a loud scream. Resident #1 was screaming stop, stop, stop then paused. S3 CNA came walking up the hall saying that woman is on the floor. When S3 CNA was asked to write a brief statement, S3 CNA stated This not making no f*****g sense and she isn't f******g coming back and what yawl going to do about Resident #1 she isn't in her f******g right mind and what yawl going to do about S5 LPN cause she wasn't on the hall all evening this don't make no f*****g sense and I won't be back. Review of hand written statement dated 10/10/2022 by S7 LPN revealed in part: I was at room ___ when the nurse on Hall C called to say I had a resident on Hall A in the bathroom on the floor. When I got to the nurse's station I saw S5 LPN pushing Resident #1 up Hall A. I took Resident #1 to her room ___ to look at her. Resident #1 stated, That black b***h threw me on the floor and beat me up. Resident #1 had a large knot to the back of her head and scratches to her throat area. Area cleaned and ice pack applied to back of head. Earlier in the evening at 7:15 p.m., I gave resident #1 her 8:00 p.m. meds and she did not have any scratches to her neck. Review of _______Police Department Incident/Investigation Report dated 10/10/2022 revealed in part: Location of Resident #1's wheelchair and the neat position it was in against the wall was not indicative she fell out of it. The wheelchair would have been in the center of the space with the resident . The wheelchair and resident were nowhere near the bathroom where the resident would have been trying to get out of the chair to the toilet . S5 LPN stated she took pictures of Resident #1's head and neck and showed me the injuries . The head contusion was large and clearly could be seen through Resident #1's hair without the hair being held away from it . Numerous dark red scratches were visible across the front of Resident #1's neck . S5 LPN, S7 Ward Clerk, and myself made contact with Resident #1, who had fallen asleep in her room . At first she was groggy from sleeping, but then she remembered being hurt . I heard Resident #1 state That woman threw me to the ground and savagely attacked me! She was twisting and pulling on me all over and it hurt badly! . When S5 LPN asked Resident #1 where she hurt, she immediately said the back of her head and the back of her neck . When being assisted upright so that the nurses could recheck her contusion, Resident #1 cried out in pain and grabbed the right side of her ribs, just above her right hip . When they asked her to point to where it was hurting, she pointed to the lower rib area and the right side of her lower spine . There were small circular bruises to Resident #1's forearms, but on her left forearm there was darker bluish-purple bruising and swelling underneath the circular bruises. The left forearm was slightly bigger from swelling than the right forearm . During an interview on 12/13/2022 at 2:05 p.m. S5 LPN reported, she was notified by S6 Ward Clerk a resident had fallen in bathroom area on Hall A. S5 LPN further reported she went down Hall A she found Resident #1 in the floor near the bathroom area. S5 LPN asked Resident #1 what happened and Resident #1 stated that S3 CNA had thrown her out of her chair and beat her. S5 LPN reported Resident #1 was assisted back into wheelchair and once Resident #1 was in the wheelchair she noticed a hematoma on the back of Resident #1's head. S5LPN reported she wheeled Resident #1 to her room and Resident #1's nurse, S7 LPN, came into room and took over the assessment. S5 LPN further reported she notified S1 Administrator and S2 DON (Director of Nursing) Resident #1 was reporting she was thrown out of the chair. During an interview on 12/13/2022 at 2:15 p.m. S6 Ward Clerk reported S3 CNA came up to the desk and reported Resident #1 was on the floor in the bathroom area on Hall A. During an interview on 12/13/2022 at 4:05 p.m. S7 LPN reported when she asked Resident #1 what happened the resident told her S3 CNA had beat her up. S7 LPN reported she observed a hematoma to the back of Resident #1's head and scratches to the front of resident's neck. S7 LPN further reported Resident #1 did not have scratches on her neck when she gave Resident #1 medications earlier that evening. S7 LPN further reported resident likes to stay up at night and will go all over the facility. During a telephone interview on 12/14/2022 at 10:50 a.m. S8 Police Detective reported he had received the report from the responding officer but had not been able to investigate the incident as of yet. During an interview on 12/14/2022 at 11:02 a.m. S2 DON reported when she and S1 Administrator were notified of the incident measures were immediately put into action. Resident #1 was assessed, police were notified, family was notified, and physician was notified. S2 DON reported she talked to Resident #1 at least once a day for days after the incidence to be sure resident felt safe and Resident #1 was able to recall and tell the same story for five days after the incident. During an interview on 12/14/2022 at 4:30 p.m. S1 Administrator, S2 DON, S4 Corporate Nurse and state surveyors reviewed facility video for the date of the incidence. S3 CNA was the only person other than Resident #1 seen entering and leaving the hall the incident occurred on. All agreed the video confirmed S3 CNA was the only person seen entering and leaving the restroom with Resident #1. S1 Administrator revealed it appeared S3 CNA was moving Resident #1's wheelchair as if to place it in a position to make it appear Resident #1 sustained a fall. S2 DON further reported S3 CNA had been reported to the Certified Nursing Assistant Registry. During an interview on 12/14/2022 at 4:45 p.m. S1 Administrator reported he attempted to interview S3 CNA about the incident and why S3 CNA did not immediately report Resident #1 was on the floor in the bathroom. S1 Administrator confirmed S3 CNA was argumentative throughout the interview and did not provide any information on the incident. During a telephone interview on 12/15/2022 at 8:10 a.m. S3 CNA reported she found Resident #1 on the floor of the short hallway leading to the bathroom on Hall A. S3 CNA was not able to explain how Resident #1 ended up on the floor or how she sustained a contusion to the back of her head or scratches to the front of her neck. Review of the facility's corrective Action Plan dated 10/20/2022 revealed: Problem Identified: Facility substantiated abuse by an employee. Plan of Action: Employee terminated 10/10/2022. Resident was assessed, Police contacted, and X-rays obtained. Facility questioned interviewable residents and performed body audits on non-interviewable residents. Administrator and Director of Nursing spoke with Resident #1 daily for at least one week following incident to ensure the resident felt safe and reassured resident that the employee would not be returning to work. Facility performed an in-service with staff on 10/11/2022 regarding abuse and neglect along with monitoring resident for signs and symptoms of abuse. Facility continued to use resident abuse questionnaires to interview residents capable of being interviewed. Weekly body audits will act as monitoring for signs and symptoms of abuse for non-interviewable residents. Monitoring: The Quality Assurance Committee will review the abuse monitoring quarterly to determine if monitoring is effective to prevent reoccurrence.

Based on record review, interview and observation, the facility failed to ensure residents were free from sexual abuse by other residents for one (#2) of six residents (#1-#6) sampled residents investigated for abuse: The facility failed to: 1. Ensure Resident #1 was monitored/supervised from 8-10-2019 through 8-13-2019, 2. Provide evidence of additional in-service education/training to staff on resident abuse and inappropriate behaviors, and 3. Interview all residents throughout the facility regarding concerns of sexual abuse by other residents. This failed practice resulted in an Immediate Jeopardy situation on 8-10-2019 at 8:00 AM for Resident #2, who was not capable of making decisions for herself, was observed being kissed and having her breast touched by Resident #1 in the chapel of the facility. Prior to this incident, staff observed Resident #1, who was cognitively intact with a history of hypersexual like behavior, motioning for resident #2 to come into the chapel; however, the staff did not take immediate action to prevent Resident #2 from entering into the chapel with Resident #1. After this incident, Resident #1 was allowed to continue to ambulate throughout the facility with no monitoring or supervision until 8-14-2019. S1 Administrator was notified of the Immediate Jeopardy on 8-29-9 at 2:45 PM. The Immediate Jeopardy was removed on 8-30-19 at 11:40 AM. The facility presented an acceptable Plan of Removal. Through observations, interviews, and record review the surveyors confirmed the following components of the plan of removal had been initiated and/or implemented prior to exit: * Initiated in-services regarding abuse reporting with all staff: -How to handle abuse - What to do if you see residents engaging in inappropriate/abusive behavior? -intervene first -Prevent abuse - separate residents engaged in inappropriate/abusive behavior *Who to report abuse to -notify the nurse, DON (Director of Nursing), Administration * One-on-one supervision - What does one-on-one supervision mean? * Different types of abuse: Physical, Verbal, Sexual, and Mental * Initiated one-on-one monitoring for Resident #1 upon return to the facility: -Resident #1 is supervised by CNA (Certified Nursing Assistant) every shift. -Monitoring Log for Resident #1 documented every 15 minutes. Monitoring will continue until 9-2-19 and resident will be re-evaluated for behavior monitoring. This deficient practice continued at a potential for more than minimal harm for the other 30 residents in the facility who were incapable of making decisions for themselves. Findings: Record Review of the Facility's Abuse/Neglect Reporting Policy revealed the following: *Sexual Abuse: this includes but is not limited to non-consensual sexual contact of any type with a resident, sexual harassment, sexual coercion or sexual assault. 4. The facility will take all necessary steps to prevent further abuse while the investigation is in progress . 5. During and after the investigation, the residents will be protected from harm through supervision by staff . 6. (a.) The investigation will include the following: (i.) Necessary corrective/preventative action. Resident #2 was admitted on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #2's Quarterly MDS (Minimal Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 00. Review of Resident #2's Comprehensive Care Plan revealed the following problems and approaches: *Problem: Impaired thought process; Approaches: Provide instruction to resident using clear voice, simple sentences. *Problem: I have trouble finding my room; Approaches: Give me verbal cues/reminders when I cannot remember and staff will redirect me to my room. *Problem: I wonder into unsafe situations; Approaches: Place me in area where frequent observation is possible and monitor and document my behavior. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #1's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14, indicating resident's cognition was intact. Review of Resident #1's Comprehensive Care Assessment revealed problem onset dated 8-1-19 resident displays socially inappropriate/disruptive behavior. Interventions put in place are to monitor and document behavior and remove from public area when behavior is disruptive and unacceptable. Review of the Facility's Investigative Report revealed on 8-10-19 at 8:00 AM S5 LPN (Licensed Practical Nurse)and S6 LPN witnessed Resident #1 kissing Resident #2 and touching her breast. Further review of the investigation revealed the allegation was substantiated by the Administrator on 8-10-19 with a summary as follows: On the morning of 8-10-19, male Resident #1 was found in facility chapel with female Resident #2 kissing her and rubbing on her breast. Female resident has [DIAGNOSES REDACTED].#1 was sent to _______Behavioral Center. Victim Resident #2 received increased supervision. Review of Resident #1's Physician's Progress Notes revealed the following entries: *7-22-19 - Impression: Hypersexual Activity; Plan - We will continue the [MEDICATION NAME] for [MEDICAL CONDITION] but will allow the supply to run out & not reorder it. We will then monitor for hypersexual like behavior & discuss this with the nursing team. *6-21-19 - Plan: In (MONTH) we started [MEDICATION NAME] 50mg (milligram) PO (by mouth) qd (everyday) for [MEDICAL CONDITION]. Upon speaking with the nursing staff she reports no incidence that she can recall regarding such behavior in the past month. We will continue to finish off the current supply of [MEDICATION NAME] however once it runs out we will discontinue this order and see how he does. *5-31-19 - Current: Per RN (Registered Nurse) report, patient has been hypersexual with the other residents. Plan: Start patient on [MEDICATION NAME] 50mg PO qd for [MEDICAL CONDITION]. Review of Resident #1's Nurses Notes revealed the following entries: *5-16-19 at 2:30 AM - F/U (Follow up) behavior late noted: Resident was observed on 5-15-19 at 6:15 AM using inappropriate behavior. Resident was observed grabbing another female resident's hand and placing it in his genital area. When noticed I informed resident of his behavior and separated both residents .Resident has previously been observed as well touching on several female resident breast and using sexual language trying to get them to allow him to touch them inappropriately. Resident has been told several times by myself and other staff during shift to not use inappropriate language nor touch female residents in anyway. *8-10-19 2:25 PM - Writer was informed that resident was found in the chapel with resident in room ___touching her breast and kissing her. When nurse S5 LPN and nurse S6 LPN went into the chapel Resident #1 left quickly on his walker. RN (Registered Nurse) on duty ____was notified and contacted DON. Writer contacted Dr. _____regarding behavior. Dr. _____wanted writer to call around to locations to see if they had room. While RN ____was calling behavior places. Dr. _____called back stating that last month he stopped order of [MEDICATION NAME] 50mg (milligram). He gave N.O. (New Order) [MEDICATION NAME] 50mg PO (by mouth) daily . *8-21-19 2:21 PM Social Service - Late entry for 8-15-19. Resident was sent out to Behavioral Medicine for inpatient stay due to inappropriate behaviors at the facility. Review of Resident #1's (MONTH) 2019 physician's orders [REDACTED].>*8-10-19 - [MEDICATION NAME] 50 mg PO Q (every) day *8-10-19 - Call around to behavior places to find a bed and send him if he is willing to go *7-17-19 - When present supply runs out, D/C (discontinue) Bicalmutide ([MEDICATION NAME]) *6-14-19 - When present supply of [MEDICATION NAME] runs out, please D/C order *5-15-19 - [MEDICATION NAME] 50mg PO daily; hypersexual Review of Resident #1's May, June, (MONTH) and (MONTH) 2019 MAR's (Medication Administration Records) revealed: *May 2019: Bicalutamide ([MEDICATION NAME]) 50mg tablet was given as ordered; No monitoring for [MEDICAL CONDITION] documented for May. *June 2019: Bicalutamide ([MEDICATION NAME]) 50mg tablet was given was given as ordered; No monitoring for [MEDICAL CONDITION] documented for June. *July 2019: Bicalutamide ([MEDICATION NAME]) 50mg tablet was given (MONTH) 1-19th; No monitoring for [MEDICAL CONDITION] documented for July. *August 2019: Bicalutamide ([MEDICATION NAME]) 50mg tablet was given (MONTH) 10-14th; No monitoring for hypersexual behaviors documented for August. Review of Resident #1's Monitoring Form revealed monitoring completed every 30 minutes from 11:30 AM on 8-14-19 through 9:00 AM 8-15-19. During an interview on 8-29-19 at 9:10 AM, S7 CNA stated Resident #1 has touched and bothered several female residents in the past. S7 CNA further stated that only Resident #2 was being supervised after the incident on 8-10-2019. During an interview on 8-29-19 at 9:18 AM, S8 CNA stated on 8-10-19 Resident #2 was walking down the hall towards the chapel and Resident #1 was peeking out of the chapel moving his hand in a come here motion to get Resident #2 to come in. S9 CNA acknowledged staff did not intervene until Resident #2 was inside of the chapel with Resident #1 observed kissing the resident and touching her breasts. During an interview on 8-29-19 at 9:20 AM, S5 LPN stated the day of the incident, the clerk was at the desk and told her to come there. S5 LPN further stated when she got to the desk, the clerk said watch this and at that moment Resident #1 was peeking his head out of the chapel motioning at Resident #2 who was coming down the hall to come in the chapel. S5 LPN stated once Resident #2 entered the chapel they got up to go check on them and saw them kissing and Resident #1 had his hand on her breast. S5 LPN stated that after the incident occurred, Resident #2 was monitored every 30 minutes. During an interview on 8-29-19 at 10:55 AM, S2 DON stated after the incident on 8-10-19 Resident #2 was initially monitored and Resident #1 was not monitored until 8-14-19. S2 DON stated she placed Resident #2 on increased supervision because she was concerned about Resident #2 wandering. S2 DON further acknowledged nothing was put in place to monitor other residents in the facility with low BIMS scores or wanderers. S2 DON acknowledged all residents in the facility with a low BIMS score were at risk, not just Resident #2. S2 DON stated Resident #2 was unable to give consent for anything and unable to make decisions. S2 DON stated Resident #1 was aware of what he had done. S2 DON stated she interviewed females on the 200 Hall where the incident occurred but did not interview females on other halls within the facility. S2 DON stated Resident #1 was ambulatory and able to walk around the facility. S2 DON stated verbal training was given following the incident but S2 DON was unable to produce documentation. During an interview on 8-29-19 at 11:10 AM, S4 NP (Nurse Practitioner) stated she has interacted with Resident #1 while he was on his [MEDICATION NAME] and he has always been pleasant. S4 NP further stated Resident #1 should not have been taken off the [MEDICATION NAME] because of his behavior and the type of facility he is in. S4 NP stated the other residents in the facility would not be safe if the resident did not continue to take [MEDICATION NAME]. During an interview on 8-29-19 at 11:40 AM, S6 LPN stated Resident #1 was ambulatory with a walker and able to get around the facility well. S6 LPN stated she witnessed Resident #1 going in the chapel with Resident #2. S6 LPN then stated she went to the chapel to see what they were doing and Resident #1 and Resident #2 were kissing each other and Resident #1 had his hand on Resident #2's breast. During an interview on 8-29-19 at 12:00 PM, S3 ADON stated all staff knew of the situation (incident) with Resident #1 and it was discussed in QA (Quality Assurance) meetings. S3 ADON stated there was no documented evidence of monitoring for Resident #1's behavior prior to 8-14-19. S3 ADON stated everyone knew to watch out for him and staff should have led Resident #2 away from the chapel. S3 ADON stated Resident #1 was able to ambulate around the facility. During an interview on 8-29-19 at 12:48 PM, S1 Administrator acknowledged the incident was sexual abuse and agreed Resident #2 could not consent. S1 Administrator further stated following the incident, the staff monitored Resident #2 but did not monitor Resident #1 or other vulnerable residents at the facility. S1 Administrator completed an investigation and stated he interviewed the clerk who witnessed the event happening and she told him she did not want to make a scene by intervening with Resident #1 and Resident #2 so she notified the nurse on duty. S1 Administrator stated S9 Corporate Nurse instructed staff to train regarding the incident but was unable to produce documentation of the training. During an interview on 8-29-19 at 2:10 PM, S9 Corporate Nurse stated she instructed administration to conduct training following the incident with Resident #1. S9 Corporate Nurse further stated during in-service 8-29-10 she presented, the staff did not know the meaning of one on one or when to intervene when abuse was observed. S9 Corporate Nurse stated when asked, staff verbalized notifying the nurse prior to intervening and diffusing an inappropriate/abusive situation. During an interview on 8-30-19 at 11:32 AM, S7 CNA stated she was not instructed to closely monitor or supervise Resident #1 immediately following the incident. During an interview on 8-30-19 at 11:32 AM, S8 CNA stated she was not instructed to closely monitor or supervise Resident #1 immediately following the incident. During an interview on 8-30-19 at 11:35 AM, S16 LPN stated she was not instructed to closely monitor or supervise Resident #1 immediately following the incident.