Every finding on record at Copper Ridge Health Care

Based on interview and record review, the facility failed to provide adequate supervision to prevent accidents for 1 of 8 sampled residents (Resident 8). Specifically, facility staff failed to respond to a wander guard alarm, failed to communicate with one another, and failed to implement the facility's elopement procedure when Resident 8, a cognitively impaired resident with known exit-seeking behaviors, eloped from the building. Resident 8 was found by police approximately 1.5 hours later near a fast-food restaurant two miles away, having sustained a self-reported fall and facial bruising. This noncompliance placed Resident 8 at risk for serious injury, serious harm, serious impairment, or death, constituting an Immediate Jeopardy.It was determined the provider's noncompliance with the requirements of participation had caused a situation that constituted Immediate Jeopardy. The noncompliance was related to the State Operations Manual, Appendix PP, S483.25(d)(2) Adequate supervision to prevent accidents, F689, at a scope and severity of J. Notice of the Immediate Jeopardy was given verbally and in writing to the facility Administrator, Director of Nursing, and Clinical Resource Nurse on 6/23/2026 at 10:55 AM. On 6/23/2026 2:33PM the Administrator provided the following additional abatement plan for the removal of the IJ effective on 6/23/2026 10:55AM. The facility's abatement plan, which was developed and implemented by 06/22/2026, included the following measures: Resident 8's care plan and elopement risk assessment were updated, and Resident 8 was placed on 15-minute visual checks; an audit of all exit-seeking residents was conducted to identify individuals with elopement risk; elopement binders were updated with current photographs and face sheets; wander guards and exit doors were inspected to ensure 100% functionality; the elopement policy was revised to require an immediate physical inspection of the location upon any alarm activation; mandatory staff re-education on the revised protocol was initiated; and daily audits along with random mock elopement drills were implemented to monitor compliance. The survey team verified that all these interventions were completed and fully implemented resulting in the removal of the Immediate Jeopardy on 6/22/2026.Resident 8 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, Paranoid Schizophrenia, and Dementia.Review of Resident 8's medical record revealed an elopement assessment dated [DATE], which indicated that the resident was At risk of elopement and had a physician's order for a wander guard.Review of Resident 8's care plan revealed a focus area created on 03/25/2025, which stated, Elopement risk/wanderer r/t [related to] impaired safety awareness, paranoid schizophrenia, dementia. Interventions included: assess for fall risk, document wandering behavior and attempted diversional interventions, identify patterns of wandering, monitor for fatigue and weight loss, monitor wander guard placement, and provide structured activities.Review of a nurse's progress note dated 06/19/2026, revealed that Resident 8 exhibited exit-seeking behaviors and staff notified the medical provider. The facility did not put additional interventions or supervision in place following this behavior.Review of a nurse's progress note dated 6/22/2026 stated, The resident eloped from the facility this morning.She was noted to have some bruising on her right cheek and reports she stumbled. She stated she just wanted to go on a walk. She was not able to provide much more detail.Review of an initial incident report submitted by the facility on 6/22/2026 at 9:05 AM stated, Police came to facility at 7:00am 6/22/2026 that they found [Resident 8] at [fast food restaurant location]. She had her wanderguard band on her when found. Notified family, provider, ombudsman, etc. Further investigating the situation. The resident was taken to the hospital for treatment. The immediate action taken by the facility was reported as confirming that the wanderguard system was working properly and that all other residents were accounted for in the building. During an interview on 06/23/2026 at 8:56 AM, Registered Nurse (RN) 1 stated that she heard the wander guard alarm system sound between 4:00 AM and 5:00 AM on 06/22/2026. RN 1 stated that she pressed the camera button at her nurses station to check the monitor, but the monitor screen displayed monitoring in progress. RN 1 stated she assumed the other nurses station was already viewing the camera feed because only one monitor could be viewed at a time. RN 1 stated she left the alarm sounding and another staff member shut it off shortly after.During an interview on 06/23/2026 at 9:23 AM, RN 2 stated that she heard the alarm sound around 5:30 AM on 06/22/2026. RN 2 stated that she checked her camera monitor and it displayed monitoring in progress. RN 2 stated she thought the other nurse was actively looking at the camera feed, so she silenced the audible alarms at her nurses station.During an interview on 06/23/2026 at 4:45 PM, Licensed Practical Nurse (LPN) 1 stated that she arrived at the facility for work at 6:01 AM on 06/22/2026. LPN 1 stated that she walked past the front entrance door and noticed that the door alarm was actively sounding. LPN 1 stated a hospice Certified Nursing Assistant (CNA) was waiting outside to get into the building. LPN 1 stated she opened the door and the hospice worker stated she might have set off the alarm while trying to get in. LPN 1 stated she assumed the door alarm was due to the visitor trying to enter and not that a resident had eloped. LPN 1 stated she stepped outside the front door to look around the immediate area for residents, did not see anyone, and turned off the alarm.During an interview on 06/22/2026 at 5:00 PM, the Director of Nursing (DON) stated that RN 1 and RN 2 both checked the camera monitors at their respective nurses stations at the exact same time, which caused both screens to read monitoring in progress. The DON stated that RN 1 and RN 2 both assumed the other nurse was following the facility elopement procedure. The DON stated that staff silenced the alarm at the nurses station, but the alarm continued to sound locally at the front door until LPN 1 arrived for work. The DON stated that LPN 1 silenced the front door alarm after assuming it was accidentally triggered by an arriving hospice CNA. The DON stated that local police arrived at the facility at approximately 7:00 AM on 06/22/2026, to inform staff that they had located Resident 8 near a fast-food restaurant approximately 2 miles away from the facility. The DON stated that Resident 8 self-reported a fall to the police and the police observed bruising on the resident's face. The DON stated that the police transported Resident 8 to the hospital, where she was diagnosed with a Urinary Tract Infection (UTI).The facility failed to prevent the elopement due to staff failure to coordinate monitoring responsibilities, communicate alarm statuses, or visually verify the exit perimeters.

Based on observation, interview, and record review, for 1 out of 43 sampled residents, the facility did not ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, a resident did not have a physician order for their use of oxygen. Resident identifier: 29.Findings included:Resident 29 was admitted to the facility on [DATE] with diagnoses which included acute pyelonephritis, pneumonia due to other specified infectious organisms, and acute kidney failure.On 9/7/25 at 10:39 AM, an observation was made of resident 29, she was wearing a nasal cannula, and an operating oxygen concentrator set at 5 liters (L) was next to resident 29's bed.On 9/9/25 at 11:50 AM, an observation was made of resident 29, she was returning to the facility, she had on a nasal cannula with a portable oxygen tank set at 4 L. On 9/10/25 at 10:04 AM, an observation was made of resident 29, she was resting in bed wearing a nasal cannula, the oxygen concentrator was placed in the bathroom and was set at 4 L.Review of resident 29's medical record was completed on 9/7/25 through 9/10/25.Resident 29's oxygen saturation record revealed she received oxygen via nasal cannula since admission.Resident 29's physician orders were reviewed. There were no physician orders for use of oxygen found.On 9/10/25 at 8:28 AM, an interview with Registered Nurse (RN) 1 was conducted. RN 1 stated that during the admission process, he would get a nurse-to-nurse report from the discharging facility letting them know if a resident was on oxygen. RN 1 stated that oxygen should be listed on the admission orders. RN 1 stated that if a resident was admitted with oxygen and oxygen was not listed in the previous facility's discharge orders, the nurse would need to call the in-house physician and get an order for oxygen. RN 1 stated that oxygen always needed a physician's order.On 9/10/25 at 8:56 AM, an interview with RN 2 was conducted. RN 2 stated that during the nursing report was when he would learn if a resident was on oxygen. RN 2 stated that there should always be an order for oxygen. RN 2 stated that admitting orders were usually entered before the resident was admitted to the floor. RN 2 stated that if he noticed there was not an order for oxygen he would search for a written order, if the order was not verified, he would contact the physician and get an order in place for oxygen.On 9/10/25 at 10:28 AM, an interview was conducted with the Director Of Nursing (DON). The DON stated that she expected that when a resident was on oxygen, the resident would have a physician's order in place for oxygen. The DON stated if there was not a physician's order, she expected the nursing staff to contact the physician with regards to the resident's oxygen and obtain an order for the use of oxygen.

Based on interview and record review, for 1 out of 43 sampled residents, the facility did not file in the resident's clinical record laboratory reports that were dated and contained the name and address of the testing laboratory. Resident identifier: 89Findings Included: Resident 89 was admitted to the facility on [DATE] and readmitted to the facility on [DATE] with diagnoses which included, spastic hemiplegia, immobility syndrome (paraplegic), and metabolic encephalopathy. Resident 89's medical record was reviewed on 9/7/25 through 9/10/25. A review of resident 89's progress notes revealed:On 6/24/25 at 5:35 PM, a nursing note documented, Resident was seen provider [sic] today, order received to get KUB [kidney, ureter, bladder x-ray] and UA [urinalysis]. Sample sent to lab and KUB performed, Results were related to provider.On 6/25/25 at 12:40 PM, a laboratory/radiology note documented, 6/23/24 [sic] UA [urinalysis] results back, provider notified. Set up for culture.On 6/28/25 at 7:34 AM, a nursing note documented, UA results w/ [with] culture received. MD [medical doctor] notified. ABX [antibiotics] started.A urine culture laboratory report was unable to be located in resident 89's medical record.On 9/9/25 at 9:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that all records were uploaded by the medical records staff into the chart. The DON stated lab results should be in a resident's medical record. On 9/9/25 at 2:34 PM, an interview was conducted with the Health Information Manager (HIM). The HIM stated that labs were uploaded to the medical record in a timely manner and no more than one week after she received them. The HIM stated she did not know why the lab result was not in the medical record.

Based on interview and record review, for 1 out of 43 sampled residents, the facility did not arrange services with an outside agency in a timely manner. Specifically, a resident did not have a follow up appointment scheduled within the timeline ordered by the provider after a surgical procedure. Resident identifier: 18.Findings included:Resident 18 was admitted to the facility on [DATE] with diagnoses which included right femur fracture, unspecified protein-calorie malnutrition, and dementia.On 9/7/25 at 10:28 AM, an interview was conducted with resident 18's family member. Resident 18's family member stated that the facility forgot about resident 18's orthopedic follow-up visit. The family member stated that resident 18's follow up visit was supposed to be two weeks after her surgery was performed. Resident 18's family member stated that the information was given to the facility when she was admitted .Resident 18's medical record was reviewed on 9/7/25 through 9/10/25. Resident 18's hospital discharge orders were reviewed. The Skilled Nursing Facility Instructions contained the orthopedic clinic's contact information and the statement: Please contact the clinic to ensure follow-up visit within 14 days of surgery for wound check and x-rays. According to the discharge orders resident 18's surgery was performed on 8/24/25. [Note: 9/7/25, was 14 days after resident 18's surgery.]On 9/8/25 at 10:23 AM, an interview was conducted with the Director of Transportation (DT). The DT stated that when a new resident was admitted to the facility he looked at the discharge paperwork for any follow-up appointments that had been ordered or scheduled. If an ordered appointment was not scheduled the DT stated that he called to set one up. The DT stated that he maintained a spreadsheet that tracked if residents' appointments had been scheduled. The DT stated that once the appointment was scheduled he would enter it into the resident's electronic medical record and the transportation calendar. The DT looked at resident 18's information on the spreadsheet and in resident 18's medical record. The DT stated that he still needed to schedule an appointment for resident 18's 14-day follow-up with the orthopedic clinic. The DT stated that he was also a Certified Nursing Assistant (CNA) Coordinator, that he had been assisting with training a new CNA Coordinator, and that the training had slowed him down.On 9/8/25 at 2:11 PM a follow up interview was conducted with the DT. The DT stated that he was able to schedule an appointment for resident 18's follow up with the orthopedic clinic on 9/19/25. [Note: 9/19/25, was 26 days after 8/24/25, the date of resident 18's surgery.] The DT stated that the appointment was not scheduled within the ordered 14 day window because training the new CNA Coordinator had taken time away from his scheduling responsibilities.On 9/9/25 at 3:10 PM, an interview was conducted with the Director of Nursing (DON) and the DT. The DON stated that they had been unable to get ahold of the orthopedic clinic to schedule resident 18's appointment, but they had left voicemail messages that had not been returned. The DON stated that they did not have control over a clinic's appointment availability, or if a clinic did not return calls. The DT stated that he had left voicemail messages at the orthopedic clinic previously, and his calls were never returned. The DON stated that progress notes were not made regarding the previous attempts to contact the clinic, and that education had been provided to the DT to make progress notes regarding phone calls.No progress notes regarding attempts to schedule resident 18's follow-up appointment at the orthopedic clinic could be located in the medical record.On 9/9/25 at 3:40 PM, a follow up interview was conducted with the DON. The DON stated that they were able to contact the orthopedic clinic and reschedule resident 18's appointment for 9/11/25. [Note: 9/11/25, was 18 days after 8/24/25, the date of resident 18's surgery.]

Based on observation, interview, and record review, the facility did not ensure that medication error rates were not 5 percent or greater. Observations of 25 medication opportunities, on 11/2/23, revealed 3 medication errors which resulted in a 12.00% medication error rate. Specifically, two blood pressure medications were not administered to a resident and a medication was administered at the wrong time. Resident identifier: 63. Findings included: Resident 63 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included acute and chronic respiratory failure, chronic kidney failure stage 4, type 2 diabetes, morbid obesity, essential hypertension, and hypothyroidism. Resident 63's medical record was reviewed on 11/2/23. On 11/2/23 at 9:00 AM, an observation was made of Registered Nurse (RN) 1 during morning medication administration on the bottom of the 200 hallway. RN 1 had dispensed five medications for resident 63 into a medication cup, Synthroid was observed to be one of these medications. RN 1 was observed to hold Bumetanide 2 milligram (mg) tablet and Metoprolol Succinate extended release (ER) 24 hour Sprinkle 50 mg. On 11/2/23 at 9:02 AM, an interview was conducted with RN 1. RN 1 stated he was aware Synthroid should have been administered at 7:00 AM, before breakfast, but he was running behind and was still going to administer it to resident 63. RN 1 stated resident 63 had already eaten her breakfast a little while ago. RN 1 also stated that resident 63's blood pressure was low earlier in the morning and it needed to be checked again before the Bumetanide and Metoprolol could be administered so he would hold them until the result was obtained. An observation was made of RN 1. RN 1 entered resident 63's room at 9:05 AM, and obtained a blood pressure reading of 117/73 millimeter of mercury from resident 63's left arm. RN 1 was then observed to return to the medication cart, with the medication cup which held the five previously dispensed medications. RN 1 obtained the medication cards for Bumetanide and Metoprolol and placed them on top of the medication cart. RN 1 was observed to access resident 63's medical record and entered the blood pressure data. RN 1 was then observed to place the medication cards for Bumetanide and Metoprolol back inside the mediation cart without dispensing any medications. RN 1 was then observed to return to resident 63's room and administered the five medications to resident 63, which included the Synthroid. Resident 63's Medication Administration Record for November 2023 was reviewed and revealed the following: a. Bumetanide Oral Tablet Give 2 mg by mouth one time a day for edema. b. Metoprolol Succinate Oral Capsule ER 24 Hour Sprinkle 50 mg Give 1 capsule by mouth one time a day related to essential hypertension; atrial fibrillation. if systolic blood pressure is less than 110 heart rate less than 60. c. Synthroid Tablet 112 micrograms (mcg) give 112 mcg by mouth in the morning related to hypothyroidism. [Note: The medication was ordered to be administered at 7:00 AM.] On 11/2/23 at 11:57 AM, an interview was conducted with RN 2. RN 2 stated Synthroid was given before meals, to help with absorption. On 11/2/23 at 12:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated medications should be given on time, with meals within the hour before or after the time they were ordered. The DON stated Synthroid was supposed to be given before breakfast to help with absorption and that each resident was to get the medications as ordered by the physician to maintain each resident's health. On 11/2/23 at 12:52 PM, an interview was conducted with RN 1. RN 1 stated he had returned to resident 63's room and administered the two blood pressure medications that he had not administered earlier. Review of the Nursing 2022 Drug Handbook guidance stated to give Synthroid medication at the same time each day on an empty stomach, preferably 1/2 to 1 hour before breakfast. Wolters Kluwer. (2022). Nursing 2022 Drug Handbook. Philadelphia, PA. 42nd Edition, p. 878.

Based on interview and record review, the facility did not ensure residents were free of any significant medication errors. Specifically, for 1 out of 31 sampled residents, a resident's Humalog was administered when it should have been held, Lantus was not increased to 78 units, hold blood glucose (BG) parameters were not lowered to 160, and an as needed (PRN) Humalog order was not initiated. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. Resident 54's medical record was reviewed on 10/31/23. On 6/22/23, a physician's order documented Lantus Subcutaneous Solution 100 UNIT/ML [milliliters] (Insulin Glargine) Inject 74 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY .;TYPE 2 DIABETES MELLITUS WITH DIABETIC CHRONIC KIDNEY DISEASE. On 8/3/23, a physician's order documented HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human)) [sic] Inject 30 unit subcutaneously in the morning related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY . Hold if < [less than] 170 [blood glucose]. On 8/3/23, a physician's order documented HumaLOG Solution 100 UNIT/ML (Insulin Lispro (Human)) [sic] Inject 40 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS WITH DIABETIC POLYNEUROPATHY . Hold if <170. The October 2023 Medication Administration Record was reviewed. a. On 10/5/23, the PM administration BG was 160, Humalog 40 units was administered. b. On 10/11/23, the PM administration BG was 140, Humalog 40 units was administered. On 8/16/23 at 8:15 AM, a Physician Progress Note documented . Lantus 74 units sc [subcutaneous] qd [daily], increase to 78 units (may need to do it bid if sugars do not improve since it could be absorption related) Humalog 30 units subcu [subcutaneous] before breakfast and 40 units subcu before lunch and dinner, hold for BG <160 Humalog 10 units subcu qd prn for BG > [greater than] 400 . On 9/5/23 at 12:37 PM, a Nurse Practitioner (NP) / Physician Assistant (PA) Progress Note documented . Lantus 74 units sc qd, increase to 78 units (may need to do it bid if sugars do not improve since it could be absorption related) Humalog 30 units subcu before breakfast and 40 units subcu before lunch and dinner, hold for BG <160 Humalog 10 units subcu qd prn for BG >400 . On 9/10/23 at 8:38 AM, a NP / PA Progress Note documented . Lantus 74 units sc qd, increase to 78 units (may need to do it bid if sugars do not improve since it could be absorption related) Humalog 30 units subcu before breakfast and 40 units subcu before lunch and dinner, hold for BG <160 Humalog 10 units subcu qd prn for BG >400 . On 10/11/23 at 11:25 AM, a Physician Progress Note documented Late Entry: Note Text: Reason for Visit Regulatory . Lantus 74 units sc qd, increase to 78 units (may need to do it bid if sugars do not improve since it could be absorption related) Humalog 30 units subcu before breakfast and 40 units subcu before lunch and dinner, hold for BG <160 Humalog 10 units subcu qd prn for BG >400 . A review of the Order Summary Report revealed that the Lantus was not increased to 78 units, hold BG parameters were not lowered to 160, and a PRN Humalog order was not initiated. These orders were to be implemented according to the Physician Progress Note dated 8/16/23. On 11/2/23 at 11:26 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated if the provider had new orders they would come and talk to the floor nurse about the resident. RN 2 stated the provider gave a verbal order yesterday but the provider also spoke with Director of Nursing (DON)and Assistant Director of Nursing (ADON). RN 2 stated by the time she had sent the DON and ADON a message the DON was messaging RN 2. On 11/2/23 at 11:46 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated they use the electronic medical records system for orders. LPN 1 stated the provider was supposed to put the orders into the message system that was directed to the nurse on duty. LPN 1 stated the nurse on duty would look at the messages for their residents and put the order into the system and call whoever was needed. LPN 1 stated the DON and administration were supposed to go back in and double check the orders and make sure the orders were put in the system correctly and then they remove the order from the message system. LPN 1 stated the facility had the system for about a year. On 11/2/23 at 11:47 AM, an interview was conducted with the DON. The DON stated if the provider had new orders they would send the orders over a secured text message. The DON stated that the facility did not take any verbal orders. The DON stated that all new orders would go through the secured text message and daily the DON would run an order listing report which included discontinued, current, and completed orders like antibiotics. The DON stated that after the orders were completed the nurse would close the secured text conversation. The DON stated that the provider had forgotten in the past to send orders. The DON stated the facility did not do PRN blood sugar orders because there was no way for those orders to trigger in the electronic medical record.

Based on observation, interview, and record review, the facility did not provide procedures that assure the accurate recording of narcotics. Specifically, for 2 out of 9 sampled residents, licensed nursing staff did not reconciliate narcotics in accordance with professional standards and principles. Resident identifiers: 32 and 67. Findings included: 1. Resident 32 was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included spastic hemiplegic cerebral palsy, chronic kidney disease, dementia, cognitive communication deficit, pain in left hip, muscle weakness, and major depressive disorder. Resident 32's medical record was reviewed on 11/2/23. Resident 32's physician's orders included an order for Oxycodone HCL [hydrochloride] 5 mg [milligrams], give 2.5 mg three times a day by mouth for PAIN, 1/2 tab [tablet]. The paper narcotic record on the Bottom of the 200 Hallway medication cart revealed that resident 32 had the following anomaly on the Controlled Drug Receipt Record. On 11/2/23 at 9:08 AM, the narcotic record revealed the count for resident 32's Oxycodone 5 mg to be at 27. The narcotic card revealed only 25 pockets of the narcotic card held a medication. On 11/2/23 at 9:15 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated he had forgotten to sign out the Oxycodone for resident 32. RN 1 was observed to sign out the Oxycodone that brought the narcotic count to 26. RN 1 stated he probably just pushed out more than was needed this morning, but he only gave the resident 1/2 tablet as ordered. RN 1 stated two nurses had performed the narcotic count at change of shift that morning and the count was correct. RN 1 stated the process was for the on coming nurse to do narcotic count with the off going nurse. When RN 1 was asked why there continued to be an extra Oxycodone tablet in the narcotic card the response given by RN 1 was, I guess, we must have counted incorrectly this morning. RN 1 was then observed to dispense the Oxycodone from pocket 26 of the narcotic card, place it in a medication cup and waste it with a fell ow nurse. On 11/2/23 at 11:54 AM , an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated RN 1 had crushed the Oxycodone tablet, mixed it in the liquid protein supplement drink and placed it in the waste bin. LPN 1 stated the process when passing narcotics was for the nurse to sign out the medication when it was given and if a medication needed to be wasted then two nurses were required to be present. LPN 1 stated when a narcotic was wasted he would crush the medication, mix it with applesauce, and place it in the waste bin. LPN 1 stated the narcotics could also be given to the Director of Nursing (DON) to waste them. On 11/2/23 at 11:58 AM, the narcotic sheet for resident 32's Oxycodone was observed to have two nurse signatures by the wasted Oxycodone tablet. 2. Resident 67 was admitted to the facility on [DATE] with diagnoses which included fibromyalgia, chronic respiratory failure with hypoxia, complete atrioventricular block, type II diabetes, chronic congestive heart failure, edema, and major depressive disorder. Resident 67's medical record was reviewed on 11/2/23. Resident 67's physician's orders included an order for Oxycodone HCL oral tablet 5 mg, give 1 tablet by mouth every 6 hours as needed for PAIN. The paper narcotic record on the Bottom of the 200 Hallway medication cart revealed that resident 67 had the following anomaly on the Controlled Drug Receipt Record. On 11/2/23 at 9:20 AM, the narcotic record revealed the count for resident 67's Oxycodone 5 mg to be at 44. The narcotic card revealed only 43 pockets of the narcotic card held a medication. On 11/2/23 at 9:22 AM, an interview was conducted with RN 1. RN 1 stated he did not sign out the narcotic for resident 67 but he gave it to her at 8:00 AM. RN 1 stated the process was to sign out the narcotics when they were given to the residents. The November 2023 Medication Administration Record for resident 67 revealed the Oxycodone was administered to resident 67 at 7:20 AM. RN 1 was then observed to sign out the Oxycodone for resident 67. The narcotic record for resident 67's Oxycodone then revealed the narcotic count to be correct at 43. On 11/2/23 at 11:57 AM, an interview was conducted with RN 2. RN 2 stated narcotics were wasted if not used or the resident refused them. RN 2 stated the medications were placed in a container that would dissolve the narcotic or some nurses would place them in the sharps container. On 11/2/23 at 12:15 PM, an interview was conducted with the DON. The DON stated the nurses were expected to sign out a narcotic when it was administered to keep the count accurate. If a resident refused the medication it was supposed to be wasted with another nurse. The DON stated the narcotics could be flushed or placed in the blue bin in her office that would dispose of the narcotics. The DON stated accurate count of narcotics was important to the safety of the residents and the staff.

Based on interview and record review, the facility did not ensure that each resident's drug regimen was free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose; or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Specifically, for 1 out of 31 sampled residents, a resident's cardiac medication for hypertension was not held when the systolic blood pressure (SBP) was below the physician's ordered parameters. Resident identifier: 30. Findings included: Resident 30 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, spina bifida with hydrocephalus, major depressive disorder, separation anxiety disorder of childhood, post traumatic stress disorder, and dependence on wheelchair. Resident 30's medical record was reviewed on 10/31/23. On 6/28/23, a physician's order documented Isosorbide Mononitrate ER [extended release] Tablet Extended Release 24 Hour 30 MG [milligrams] Give 30 mg by mouth one time a day for hypertension Hold if SBP < [less than] 100. A review of the October 2023 Medication Administration Record (MAR) documented the following. A SBP was documented on the MAR for the propranolol medication but not the isosorbide. a. On 10/27/23, the AM SBP was 99. The isosorbide was administered. b. On 10/28/23, the AM SBP was 97. The isosorbide was administered. On 11/2/23 at 12:09 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that the electronic medical record did not alert the staff if the physician's ordered parameters were outside of the parameters. The DON stated the administration would be human error. The DON stated that the nursing staff must enter the blood pressure prior to the administration of the medication.

Based on interview and record review, the irregularities noted by the pharmacist during the drug regimen review must be reported to the attending physician and the facility's Medical Director (MD) and Director of Nursing (DON), and these reports must be acted upon. Specifically, for 1 out of 31 sampled residents, a pharmacy recommendation to discontinue a resident's medication was not acted upon when the MD agreed with the pharmacy recommendation. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. Resident 54's medical record was reviewed on 10/31/23. The pharmacy Patient Reviews Log dated 6/24/23, documented This resident has an order for Aspirin 81 mg [milligrams] daily for cardio protection, and a review of the PMH [patient medical history] could not find any history of MI [myocardial infarction] or CVA [cerebral vascular accident]. Recent evidence suggests that the use of Aspirin for primary prevention in ages over 60 or 70 incur a greater risk than benefit. The appropriate duration of treatment has been met with Aspirin. This was discussed with the medical director, and the following has been approved: 1. DC [discontinue] Aspirin. The log was signed and dated by the MD on 7/3/23. The October 2023 Medication Administration Record (MAR) was reviewed. A physician's order dated 4/20/23, documented Aspirin Oral Capsule 81 MG (Aspirin) Give 1 capsule by mouth one time a day. The MAR documented that resident 54 continued to receive the Aspirin and the medication had not been discontinued as recommended. On 11/2/23 at 12:03 PM, an interview was conducted with the DON. The DON stated that the pharmacist would review the residents monthly and would email the reports to her. The DON stated that she would complete the recommendations. The DON stated that the recommendation for resident 54 was missed.

Based on observation and interview, the facility did not label all drugs and biological's used in the facility in accordance with currently accepted professional principles, and include appropriate accessory instructions and the expiration date when applicable. Specifically, an insulin pen was not labeled with a resident identifier or an open date and was open and available for use. In addition, narcotics were repackaged into the narcotic cards. Findings included: 1. On 11/2/23 at 9:00 AM, an observation was made of the bottom of the 200 hallway medication cart with Registered Nurse (RN) 1. A pre-filled pen of Basaglar 100 units/milliliter was open and available for use. The pen had no resident identifier information and no open date could be seen. On 11/2/23 at 9:04 AM, an interview was conducted with RN 1. RN 1 stated there was no name on the insulin ben and that he did not know who the insulin pen belonged to. RN 1 was observed to place the insulin pen back into the medication cart for future use. 2. On 11/2/23 at 9:20 AM, an observation was made of the 100 hallway medication cart with Licensed Practical Nurse (LPN) 1, the following medications were located inside: a. A medication card which held Tramadol 50 milligrams (mg) had the back of pocket number 30 taped, a white tablet was observed to have been taped back into place in pocket 30. b. A medication card which held Oxycodone 5 mg had the back of pocket number 15 taped, no medication was located inside the pocket. On 11/2/23 at 9:20 AM, an interview was conducted with LPN 1. LPN 1 stated the nurses do not tape medications back into the medication cards because the incorrect medication may be put back into the card. LPN 1 stated it was unsafe. LPN 1 stated the nursing staff were supposed to waste the narcotic medication with another nurse. On 11/2/23 at 11:57 AM, an interview was conducted with RN 2. RN 2 stated when medications were wasted the nursing staff destroyed them. RN 2 stated they would place them in a container that would dissolve them or sometimes they would put them in the sharps container. RN 2 stated the nurses were supposed to waste the narcotics not tape them back into the medication card. On 11/2/23 at 12:15 PM, an interview was conducted with the Director of Nursing (DON). The DON stated the nurses were expected to waste the narcotics with another nurse. They could flush the medication, or they could bring the medication to the blue bin in the DON's office to dispose of. The DON stated the nurses were not supposed to place the narcotics back into the cards at anytime.

Based on interview and record review, the facility did not ensure that residents who used psychotropic drugs received gradual dose reductions (GDR) unless clinically contraindicated, in an effort to discontinue these drugs. A GDR must be attempted in two separate quarters, with at least one month between attempts, within the first year in which an individual was admitted on a psychotropic medication or after the facility had initiated such medication, and then annually. Specifically, for 1 out of 31 sampled residents, a resident taking psychotropic that were last increased on 12/16/21 and 6/14/21, had not received a GDR and the medication was not clinically contraindicated. Resident identifier: 54. Findings included: Resident 54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included, but were not limited to, pain in thoracic spine, dementia, bipolar 2 disorder, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease stage 3, generalized anxiety disorder, major depressive disorder, and chronic pain. Resident 54's medical record was reviewed on 10/31/23. On 8/23/21, a physician's order documented busPIRone HCl [hydrochloride] Tablet 10 MG [milligrams] Give 10 mg by mouth three times a day related to GENERALIZED ANXIETY DISORDER. [Note: Resident 54 had not had a dosage change since the buspirone was increased on 6/14/21.] A clinical contraindication was unable to be located. On 11/28/22 at 11:25 AM, a Psychotropic Interdisciplinary Team (IDT) note documented LATE ENTRY Note Text : DNS [Director of Nursing Services], Adon [Assistant Director of Nursing], Activities, RA [Resident Advocate], Pharmacist and Medical director present Resident is on Lexapro, Bupropion HCl ER [extended release] and Buspar. She has dx [diagnoses] of MDD [major depressive disorder] and anxiety. She has had some family issues with her daughter. She has had increase in depressive symptoms but doesnot [sic] want med [medication] changes at this time. She is being followed by [name removed]. No medication changes at this time. On 2/20/23 at 12:44 PM, a Psychotropic IDT Note documented . Resident is on Lexapro, Bupropion HCl ER and Buspar. She has dx of MDD and anxiety. No med changes at this time. She is stable, no mood changes observed. She is being followed by [name removed]. Resident is on the lowest effective dose at this time. No GDR. On 4/26/23, a physician's order documented BuPROPion HCl ER (XL [extended release]) Tablet Extended Release 24 Hour 300 MG Give 1 tablet by mouth in the morning related to BIPOLAR II DISORDER .; MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED . [Note: Resident 54 had not had a dosage change since the bupropion was increased on 12/16/21.] A clinical contraindication was unable to be located. On 5/22/23 at 3:06 PM, a Psychotropic IDT Note documented . Resident is on Lexapro, Bupropion HCl ER and Buspar. She has dx of MDD and anxiety. No med changes at this time. She continues to be stable, no mood changes noted. She is being followed by [name removed]. Resident is on the lowest effective dose at this time. No GDR. On 8/21/23 at 1:18 PM, a Psychotropic IDT Note documented . Resident is on Lexapro, Bupropion HCl ER, Buspar and Trazodone. She has dx of MDD, anxiety and insomnia. no [NAME] [sic] in medications at this time. She is stable, no mood changes observed. She is being followed by [name removed]. Resident is on the lowest effective dose at this time. No GDR. The August, September, and October 2023 Treatment Administration Record was reviewed. a. A physician's order dated 8/23/21, documented (AA [anti-anxiety)- MONITOR EPISODES OF ANXIETY AEB [as evidenced by]: 0=NONE 1=AGITATION 2=RESTLESSNESS 3=VERBALIZATION OF ANXIETY every shift for USE OF ANTI-ANXIETY MEDICATION. Resident 54 had no documented behaviors for the month of August, September, and October 2023. b. A physician's order dated 8/23/21, documented (AA)- MONITOR SIDE EFFECTS OF ANTI-ANXIETY MEDICATION Q [every] SHIFT: 0. NO S/E [side effect], 1. DROWSINESS, 2. SEDATION, 3. ATAXIA, 4. DIZZINESS, 5. NAUSEA/VOMITING, 6. CONFUSION, 7. HEADACHE, 8. BLURRED VISION, 9. SKIN RASH every shift for USE OF ANTI-ANXIETY MEDICATION. i. August: One episode of drowsiness and eight episodes of sedation and dizziness. ii. September: One episode of drowsiness and seven episodes of sedation and dizziness. iii. October: One episode of drowsiness, sedation, ataxia, dizziness, and confusion. Thirteen episodes of sedation and dizziness c. A physician's order dated 8/23/21, documented (AD [antidepressant])- MONITOR EPISODES OF DEPRESSION AEB: 0= NONE 1=TEARFULNESS/CRYING 2=ISOLATION 3=VERBALIZATION OF SADNESS every shift for USE OF ANTIDEPRESSANT MEDICATION. Resident 54 had one episode of tearfulness/crying in August, and no documented behaviors for the month of September and October 2023. d. A physician's order dated 8/23/21, documented (AD)- MONITOR SIDE EFFECTS OF ANTIDEPRESSANT MEDICATION Q SHIFT: 0. NO S/E, 1. DROWSINESS, 2. SEDATION, 3. TACHYCARDIA, 4. HEADAHCE, 5. WEIGHT GAIN, 6. TREMORS, 7. AGITATION, 8. SKIN RASH, 9. PHOTOSENSITIVITY every shift for USE OF ANTIDEPRESSANT MEDICATION. i. August: One episode of drowsiness and two episodes of tremors. ii. September: One episode of tremors. iii. October: None. On 11/2/23 at 11:47 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that the psychotropic meeting was held monthly but the team would talk about the resident's medications quarterly and look at the last GDR for the medications. The DON stated she would do a clinically contraindicated form, update the care plan, and make a progress note. The DON stated resident 54 was doing well with Abilify and was seen by a behavioral health provider. The DON stated that prior to the Abilify being introduced resident 54 would isolate in her room in the dark and would not come out. The DON stated that resident 54 should have a progress note in August 2023 regarding a clinical contraindication. The DON stated that resident 54 had been super stable.

Based on observation and interview it was determined the facility did not ensure that ventilation in the hallways was sufficient to keep foul odors from the hallways. Specifically, odors of urine and feces were observed in the hallways and resident common areas. Findings include: 1. On 1/11/22 at 11:42 AM, a stool odor was observed in the 300 East hall. 2. On 1/11/22 at 1:44 PM, a strong odor of urine and smoke was observed in the 300 hall between rooms 304 to 309. 3. On 1/11/22 at 1:46 PM, a strong odor of feces was observed outside rooms 214-218. 4. On 1/11/22 at 1:50 PM, a strong odor of feces was observed in the hallway outside room 209. 5. On 1/12/22 at 10:11 AM, a strong feces odor was observed in the front lobby. 6. On 1/12/22 at 10:14 AM, a strong feces odor was observed outside rooms 217-214. 7. On 1/12/22 at 10:30 AM, an odor of cigarette smoke and urine was observed in the 300 hallway. 8. On 1/12/22 at 12:45 PM, an observation that visitor restrooms ventilation system was not working. On 1/12/22 at 2:23 PM, an interview with the Director of Nursing (DON) was conducted. The DON stated that she had noticed urine smells in 200 hall. The DON stated that she tracked the odor down to a resident who had a hole in her down drain bag for her catheter. The DON stated that they were working to get ventilation system for restrooms repaired.

Based on interview and record review it was determined, for 2 of 5 sampled facility staff, that the facility did not ensure that routine testing of staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of unvaccinated staff for COVID-19 at a frequency of two times per week during periods of high levels of community transmission, based on the positivity rate of the county the facility was located in, was not followed. Staff identifiers: Staff 1 and Staff 5. Findings include: On 1/11/22, the facility's staff vaccination log and staff testing log was provided. Staff 1 and Staff 5 were documented as having refused to be vaccinated against COVID-19. The testing log records for October 2021, November 2021, December 2021, and January 2022 were reviewed. According to the Centers for Disease Control and Prevention (CDC) the community transmission where the facility is located was high, identified as red, for the weeks of 12/6/21, 12/13/21, 12/20/21, 12/27/21, 1/3/22, and 1/10/22. (Source: https://covid.cdc.gov/covid-data-tracker/#county-view?list_select_state=Utah&data-type=Risk&list_select_county= .) According to Table 2 in CMS Memo QSO-20-38-NH, titled Routine Testing Intervals by County COVID-19 Level of Community Transmission, the facility should test unvaccinated staff twice a week. On 1/11/22 the facility's staff testing log for October 2021, November 2021, December 2021, and January 2022 were reviewed. a. Staff 1 was tested on ce during the week of 1/3/2022, with a test date of 1/6/22. Staff 1 was not tested during the week of 12/27/21. Staff 1 was tested on ly once during the week of 12/20/21, with a test date of 12/23/21. b. Staff 5 was tested on ce during the week of 12/27/21, with a test date of 12/27/21. On 1/11/22 at 3:30 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that Staff 1 and Staff 5 were not fully vaccinated. The DON facility guidelines and protocols were that unvaccinated staff were to be tested twice a week during periods of high community transmission and are unable to refuse testing. Upon reviewing the staff testing log, the DON stated twice weekly testing was missed. The DON stated that both staff were scheduled to work more than once per week on the weeks they were tested on ce or not tested .

Based on observation and interview it was determined the facility did not establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, staff were not using N95 masks for a resident with isolation precautions, staff were not wearing appropriate eye protection and staff taking soiled gowns through the hallway after leaving an isolation room. Findings include: 1. On 1/11/22 at 12:01 PM, an observation was made of room [ROOM NUMBER]. There was a sign that revealed droplet precautions and a sign indicating to see the nurse before entering. Speech, Language, Pathologist (SLP) 1 was exiting room [ROOM NUMBER] with fabric gown on and a water mug. SLP 1 was observed to place the mug on top of a plastic bin with Personal Protective Equipment (PPE) inside the bin. SLP 1 was observed to removed the fabric gown and place it between his legs. SLP 1 was observed to wipe his eye protection with a sanitizer wipe. SLP 1 was observed to walk down the hall to the hopper room with the fabric gown and mug in his hands. SLP 1 was observed to enter the hopper room with the mug and then filled the mug with water. SLP 1 was observed to enter room [ROOM NUMBER] and set the mug on the over bed table next to the resident. SLP 1 was observed to exit room [ROOM NUMBER] and wipe down his eye protection. SLP 1 was interviewed. SLP 1 stated there was a Certified Nurses Aide (CNA) that tested positive after working with the residents in room [ROOM NUMBER]. SLP 1 stated that the resident in bed A was not vaccinated. SLP 1 stated staff were to hand sanitizer, have a face mask, goggles, and a gown just because. SLP 1 stated that a surgical mask was fine and the gown was disposed of down the hall in the hopper room. On 1/11/22 at 2:14 PM, an interview was conducted with SLP 2. SLP 2 stated she understood that there were different signs that were used for isolation. SLP 2 stated with droplet isolation all staff should wear a gown, goggles and face mask. SLP 2 stated a surgical mask unless there was specification that a respirator N95 was needed. 2. On 1/12/22 at 1:00 PM, an observation was made of the Activities Director (AD). The AD was observed in the hallway without goggles or face shield. The AD was observed in regular glasses. The AD was observed to push a resident in wheelchair outside. The AD was observed to enter the building and walk through the halls within 6 feet of residents with regular glasses on. On 1/11/21 at 3:00 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that all staff should wear surgical masks and eye protection at all times. The DON stated that the resident in room [ROOM NUMBER] was unvaccinated and was exposed to COVID-19 so the room was placed on droplet precautions. The DON stated that N95 masks were to be worn into room [ROOM NUMBER].

Based on observation, interview and record review it was determined, for 7 of 31 sample residents, that the facility did not provide food and drink that was palatable, attractive, at at a safe and appetizing temperature. Specifically, residents complained of the food quality, a test tray was not palatable, and there were complaints of food quality in resident council. Resident identifiers: 9, 21, 24, 47, 57, 77 and 82. Findings include: 1. On 1/10/22 at 1:48 PM, resident 77 was interviewed. Resident 77 stated that the food was Nasty. On 1/11/22 at 3:24 PM, resident 82 was interviewed. Resident 82 stated the food was not good. On 1/10/22 at 10:57 AM, resident 24 was interviewed. Resident 24 stated that the food was not very good. A follow up interview was conducted on 1/12/22 at 7:57 AM, resident 24 that they only serve salty things, and the same thing over and over. On 1/10/22 at 1:43 PM, resident 57 was interviewed. Resident 57 stated that the food was too salty and sometimes not edible. Resident 57 stated that the facility did not provide him alternative food items. On 1/10/22 at 11:00 AM, resident 21 was interviewed. Resident 21 stated that all the food tasted bad. Resident 21 stated She did not like any of it and wished she could have healthier food. On 1/10/22 at 1:08 PM, resident 47 was interviewed. Resident 47 stated that food was not very good and frequently served cold. On 1/10/22 at 12:30 PM, resident 9 was interviewed. Resident 9 stated It just tastes rotten- no flavor, it's just cold mush and the options they give me are nothing good for me. 2. On 1/11/22 at 12:13 PM, an observation was made of the facility kitchen. There were 3 dietary staff members serving food from the tray line. At 12:23 PM, the last meal was plated and a test tray was requested. The meal cart with the test tray was delivered to the 300 hall at 12:26 PM. The last tray served was at 12:35 PM. The test tray's temperature was obtained at 12:37 PM. The following temperatures were in degree Fahrenheit: a. The pork was 122.0. The pork was though to chew with a bland flavor. There was a brown sauce over the pork. b. The sweet potatoes were 135.5. The sweet potatoes had some lumps in them and were warm to the taste. The sweet potatoes had good flavor. c. The green beans were 131.6. The green beans were warm to the taste with good flavor. d. The pureed pork was 125.8. The pureed pork was warm to the taste but difficult to chew and swallow with a bland flavor. e. The pureed green beans were 122.4. The green beans were warm to the taste. f. The pureed sweet potatoes were 122.7. The pureed sweet potatoes were warm to the taste. g. The shredded pork for the mechanical soft diet was 119. The pork was hard to chew with a bland flavor. h. A red gelatin salad was 71.0. The red gelatin was a liquid texture, warm to the taste with mushy strawberries. 3. Resident council minutes were reviewed and revealed the following regarding dietary: a. On 7/13/21, residents requested that hot and cold foods not be mixed together on the same plate. Residents also asked for their bread or rolls to be separate from the plate so they were not soggy. The Dietary department response form revealed that staff were inserviced not to mix on the plate. The cooks were going to be inserviced to place rolls or bread sticks in bags. b. On 8/9/21, residents stated the food was too spicy. The Dietary department response form revealed that the resident was visited and updated food preferences. c. There were no October 2021 resident council minutes d. On 11/9/21, residents stated the food was cold and cook rice less. The Dietary department response from revealed there were hot plates bought for the whole building and the Dietary Manager (DM) was monitoring meal temps. e. On 12/14/21, residents stated rice and pasta are over cooked, baked potato under cooked, food always cold, use plate warmers. The Resident Council Follow-up Form revealed the plate warmer was broken but it was fixed. The DM and Assistant DM were working with staff on proper cooking of rice, pasta and baked potato. f. On 1/11/22, residents stated food was cold even coffee. The Resident Council Follow-up Form revealed that the coffee was 150 degrees when left the kitchen and can not be higher related to safety. On 1/12/22 at 2:47 PM, an interview was conducted with the DM. The DM stated there was a resident committee meeting monthly to review the menus and discuss what the residents want on the menus. The DM stated that there was a resident choice meal monthly. The DM stated that the food supply chain had made it hard to get good food items. The DM stated that if a food item was out of stock, then the company substituted items that were not as good. The DM stated she was not sure if the pork was substituted.

Based on observation it was determined the facility did not ensure hand rails were completely secured to the wall. Specifically, hand rails were not secured throughout the facility. Findings included: On 1/11/22 at 12:05 PM, an observation was made of the 300 hallway. The handrails between room 205 and the North Door Exit were not secured to the wall. There were handrail between room 101 and corner of hall that were not secured to the wall. There were handrails out side room 300 not secured.

Based on interview, and record review it was determined, for 2 of 31 sample residents, the facility did not conduct periodic comprehensive, accurate, standardized reproducible assessment not less than once every 12 months. Specifically, resident's annual Minimum Data Set (MDS) assessments were not completed. Resident identifier: 1 and 2. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 1's annual MDS had an assessment reference date (ARD) of 10/25/21. The MDS was ready for export and had not been submitted. 2. Resident 2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 2's annual MDS assessment had an ARD of 11/17/21. The MDS was ready for export and had not been submitted. On 1/13/22 at 2:00 PM an interview with the MDS coordinator was conducted. The MDS coordinator stated that she was overwhelmed with the number of MDS's that were due, and did not have time to finish them. The MDS coordinator stated that she was working on Resident 2's MDS at that moment.

Based on interview and record review it was determined, for 2 of 5 sample residents, that the facility did not ensure residents were free of significant medication errors. Specifically, a resident was not administered the physician ordered dosage of [MEDICATION NAME] and [MEDICATION NAME]. In addition, another resident was administered [MEDICATION NAME] outside of parameters. Resident identifiers: 2 and 3. Findings include: 1. Resident 3 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 3's medical record was reviewed on 12/2/2020. a. A physician's orders [REDACTED]. The instructions were to administer 1 tablet by mouth in the the morning related to generalized anxiety disorder. A review of resident 3's October 2020 Medication Administration Record [REDACTED]. According to resident 3's Controlled Drug Record form, the pharmacy delivered 60 half tablets of 0.5 mg of the [MEDICATION NAME]. The half tablets were 0.25 mg. Nursing staff documented administering 1 of the 1/2 tablets on 10/18/2020, 10/19/2020, 10/21/2020, 10/22/2020, 10/23/2020, 10/24/2020, 10/29/2020, 10/31/2020, 11/1/2020 and 11/2/2020. There were no tablets signed out for administration on the Controlled Drug Record form on 10/25/2020 and 10/27/2020. b. A physician's orders [REDACTED]. The instructions were to administer 1 tablet by mouth every 6 hours as needed for pain. A review of resident 3's October 2020 MAR indicated [REDACTED]. According to resident 3's Controlled Drug Record the pharmacy provided the facility [MEDICATION NAME]-APAP 5-325 mg tablets. The form further revealed that a 5 mg tablet was administered to resident 3 on 10/18/2020, 10/23/2020 and 10/26/2020. 2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical records were reviewed on 12/2/2020. A physician's orders [REDACTED]. The instructions were to give 1 tablet by mouth two times a day related to essential hypertension and hold for systolic blood pressure (SBP) less than 120. A review of resident 2's November 2020 MAR indicated [REDACTED] a. On 11/3/2020 PM dose with a SBP of 110, b. On 11/6/2020 PM dose with a SBP of 111, c. On 11/16/2020 AM dose with a SBP of 109, d. On 11/17/2020 AM dose with a SBP of 115, e. On 11/20/2020 PM dose with a SBP of 111, f. On 11/24/2020 AM dose with a SBP of 111, and g. On 11/27/2020 PM dose with a SBP of 116. On 12/2/2020 at 1:10 PM, a phone interview was conducted with Registered Nurse (RN) 1. RN 1 stated that the Admission Director, Director of Nursing (DON) or Assistant Director of Nursing (ADON) reviewed new resident's orders prior to admission. RN 1 stated that the floor nurse confirmed the orders were entered correctly by comparing the hospital discharge orders to the orders entered into the electronic medical record. RN 1 stated if the resident was readmitted from a hospital the medications were reviewed and any changes were sent to the pharmacy for new medications to be delivered to the facility. RN 1 stated that the pharmacy provided 1/2 tablets. RN 1 stated if the pharmacy had not provided 1/2 tablets and the order was for half then the nurse would half the tablet and waste the other half with another nurse as a witness. On 12/2/2020 at 1:20 PM, a phone interview was conducted with RN 2. RN 2 stated that the Admissions Director obtained hospital discharge orders for a new resident. RN 2 stated that the Admission Director entered the medications into the electronic medical record. RN 1 stated that the nurse managers verified the orders were correct. RN 1 stated that the Admissions Director faxed the orders to the pharmacy. RN 1 stated that when a resident was readmitted to the facility the process was the same, if the resident was out of the facility for over 24 hours. RN 1 stated if the resident was out of the facility for less than 24 hours, then the resident usually returned with the same medication orders. RN 1 stated that the pharmacy usually halved tablets for them. RN 1 sated if there was a dosage change when a resident was readmitted , the nurse called the the pharmacy to send the correct dose. On 12/2/2020 at 3:12 PM, a phone interview was conducted with the DON. The DON stated the Medical Record Director or the Admissions Director received orders for new admissions and the nurse management verified the orders. The DON stated that the orders were then faxed to the pharmacy. The DON stated if a resident was out of the facility, at the hospital for 24-36 hours, then the facility staff kept their medications at the facility. The DON stated the pharmacy reviews orders upon admission and readmission. The DON stated that when a resident readmitted to the facility with a dosage change for controlled medications like [MEDICATION NAME] and [MEDICATION NAME], the pharmacy required a new hand written script. The DON stated that the hospital did not provide a script for resident 3's [MEDICATION NAME] or [MEDICATION NAME]. The DON stated that the local hospital should not have increased the dosages on the medications. The DON stated that the orders provided by the hospital were from prior to resident 3's admission to the facility. The DON stated that the nurses should have verify the dosage on the MAR indicated [REDACTED]. The DON verified that resident 2's MAR indicated [REDACTED]. The DON stated that the nurse's needed to read the MAR.

Based on interview and record review, the facility failed to inform residents, their representatives and families of those residing in the facility by 5 PM the next calendar day, of the occurrence of three or more residents or staff with new-onset of respiratory symptoms occurring within 72 hours of each other. Findings include: During an interview on 6/18/20 at approximately 10:00 AM, the administrator stated that he was aware of the regulation to notify residents and their representatives and families when there was an occurrence of three or more residents or staff with new-onset of symptoms occurring within 72 hours of one another. The administrator stated the facility was prepared to make the notifications by telephone to the resident representatives/families on the same day the criteria was met. Review of facility policy titled, Notification of Residents and Family dated 5/8/20 revealed: If there is a positive COVID-19 test on a resident or staff member, or three suspected cases reported in 72 hour period all residents or responsible parties will be notified by 1700 (5 PM) the following day. If required reporting in necessary, the procedure will go as follows: Department Heads will notify the rooms they are assigned to. The assignments are listed on the daily census sheets and provided in morning meeting. The notification will include the resident and responsible POA (Power of Attorney) to include anyone the resident requests to get notified. Notifications are preferred face to face, but family members can be notified by phone and as a last resort email. Review of the Line Item Infection spreadsheets for residents and employees revealed: - Resident 1 symptom onset on 6/12/20 - Resident 2 symptom onset on 6/13/20 - Employee 7 symptom onset on 6/12/20 During an interview on 6/18/20 at approximately 4:15 PM, the administrator stated the facility had not noticed the cluster of three individuals displaying symptoms within a 72 hour period. The administrator stated he thought the separation of surveillance logs by resident and employee may be the cause of the oversight. The administrator stated the facility would complete the notifications according to regulation and facility procedure and make sure to document their efforts. According to §483.80(g) COVID-19 reporting. This information must- (i) Not include personally identifiable information; (ii) Include information on mitigating actions implemented to prevent or reduce the risk of transmission, including if normal operations of the facility will be altered; and (iii) Include any cumulative updates for residents, their representatives, and families at least weekly or by 5 p.m. the next calendar day following the subsequent occurrence of either: each time a confirmed infection of COVID-19 is identified, or whenever three or more residents or staff with new onset of respiratory symptoms occur within 72 hours of each other.

Based on observation, interview and record review, it was determined, for 1 of 39 sample residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, one resident who had been assessed as unsafe to have his cigarettes and lighter had them in his possession, and had cut himself with his razor and had a razor in his possession. Resident identifier: 36. Findings include: Resident 36 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. 1. On 8/26/19 at 9:28 AM, resident 36 was observed in his room with a pack of cigarettes and a lighter. On 8/27/19 at 8:36 AM, resident 36 was observed in his room with a pack of cigarettes and a lighter. On 8/28/19 at 10:40 AM, resident 36 was observed in his room with a pack of cigarettes and a lighter. On 8/28/19 at 1:00 PM, resident 36 was observed in the hallway near his room with a pack of cigarettes and a lighter. On 8/29/19 at 9:06 AM, resident 36 was observed in his room with a pack of cigarettes and a lighter. Resident 36 had 6 cigarettes in the pack. On 8/29/19, a review was completed of resident 36's electronic medical record. A Speech Therapy (ST) evaluation was completed on 4/21/19 for resident 36. Resident 36's cognition was assessed. His problem solving impairment was assessed as profound - total dependence. Resident 36's memory impairment was assessed as profound - total dependence. A Minimum Data Set (MDS) assessment was completed on 7/2/19 for resident 36 and revealed that resident 36 had short-term and long-term memory problems. Resident 36 was severely impaired in making decisions regarding tasks of daily life. Resident 36's smoking care plan, completed on 7/14/19, stated that resident 36 has the potential for injury r/t (related to) smoking. Resident 36's goals were to have no injuries related to smoking and will be compliant with smoking protocols and individual smoking plan until next review. The interventions included the following: a. Resident 36 may smoke independently in designated areas. b. Complete smoking assessment. c. Explain smoking policy. d. Maintain smoking materials at nurses' station or other designated area. e. Monitor to assess compliance with facility smoking policy/individual plan. f. Report non-compliance or unsafe smoking habits to Medical Director (MD) and responsible party. On 7/15/19 at 1:32 PM, a smoking evaluation was completed for resident 36. Resident 36 had special instructions to receive cigarettes from the nursing cart. A previous smoking evaluation, completed on 7/8/19, revealed that resident 36 had cognitive loss, and stated that cigarettes and lighter are held at the nurses station. On 8/28/19 at 10:00 AM, an interview was conducted with resident 36. Resident 36 indicated that he had his cigarettes and lighter. Resident 36 was observed to have six cigarettes in his pack. On 8/28/19 at 10:42 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 36 smoked independently. On 8/28/19 at 10:43 AM, an interview was conducted with Registered Nurse (RN) 1. RN 1 stated that resident 36 had his lighter with him. RN 1 was not aware that resident 36 had a package of cigarettes with him. On 8/28/19 at 1:05 PM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated that the smoking protocol for resident 36 was that he was given two cigarettes at a time so that staff could monitor him for burn marks on his fingers and clothes. LPN 1 stated that resident 36 had to be monitored for safety each time he asked for cigarettes. On 8/28/19 at 1:36 PM, an interview was conducted with RN 1. RN 1 stated that resident 36 required increased supervision regarding his smoking safety, so his cigarettes were locked up. RN 1 stated that resident 36 had not always followed the rules when he smoked, such as smoking too close to the building. On 8/29/19 at 7:36 AM, an interview was conducted with RN 2. RN 2 stated that he did not know how many cigarettes resident 36 had. RN 2 stated that resident 36 smoked independently. On 8/29/19 at 9:18 AM, an interview was conducted with an Occupational Therapist (OT) 1. OT 1 stated that resident 36 had cognitive limitations. OT 1 stated that resident 36 was unable to utilize his right arm, and had a decrease in his cognitive abilities over the past couple months. On 8/29/19 at 9:29 AM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 36's cigarettes were locked in the nursing area, and that resident 36 asked for cigarettes from the nurses. The DON stated that resident 36 occasionally smoked too close to the building. 2. On 8/29/19 at 7:36 AM, resident 36 was observed in the east hallway of the facility with a razor in his hand. On 8/29/19, a review was completed of resident 36's medical record. A MDS assessment was completed on 7/2/19 for resident 36 and revealed that resident 36 required extensive assistance, one person physical assistance with hygiene. The care area of Cognitive loss and dementia was indicated as an issue for resident 36. On 7/14/19, resident 36's personal hygiene care plan was initiated. The care plan revealed that resident 36 required one person staff participation with personal hygiene and oral care. On 8/14/19 at 5:53 PM, a nursing note revealed, Resident came up to the nurses station with a cut on his right hand. Followed him to his room and he had dropped his razor while shaving. Cleaned, ointment applied and Band-Aid applied. The plan of care response history for resident 36's hygiene, which included shaving, revealed that for the past 30 days (7/31/19 to 8/28/19), resident 36 required full staff assistance three times, extensive assistance ten times, limited assistance seven times, and supervision six times. Resident 36 was able to perform hygiene care one time independently. On 8/28/19 at 2:10 PM, the Social Worker (SW) was interviewed. The SW stated that hygiene included combing hair, brushing teeth, shaving, and washing/drying face and hands. The minimum assistance resident 36 required was supervision. The SW stated that resident 36 had at least 3 episodes of requiring extensive assistance. On 8/29/19 at 7:36 AM, an interview was conducted with RN 2. RN 2 stated that resident 36 only gets a razor when we help shave him. RN 2 stated that he did not know resident 36 had a razor. RN 2 stated that he was unaware that resident 36 had cut himself. On 8/29/19 at 9:29 AM, an interview was conducted with the DON. The DON stated that he was not aware of how resident 36 had received a razor and that resident 36 should not have had the razor in his possession. The DON stated that staff needed additional education.

Based on observation, interview and record review it was determined for 2 of 9 sampled residents, that the facility did not ensure that the resident's environment remained as free of accident hazards as was possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Specifically, a resident fell and sustained a wrist fracture after staff did not respond to her call light timely. A second resident fell during staff-assisted cares and sustained a fracture. The deficient practice identified for both residents was found to have occurred at a harm level. Resident identifiers: 2 and 3. Findings include: 1. Resident 3 was admitted to the facility on [DATE] and discharged on [DATE] with [DIAGNOSES REDACTED]. A review of resident 3's medical record was completed on 6/26/18. On 2/1/18 at 5:00 AM, Registered Nurse (RN) 1 documented the following in a progress note: Unwitnessed Fall: At approx. (approximately) (11:45 PM) aid notified this nurse that pt (patient) was on the floor. Upon assessment pt was sitting upright in front of her closet with walker in front of her. Pt reported she hit her head when she fell and that she was experiencing pain in her left wrist. Wrist is swollen, no bruising but pain with ROM (Range of Motion). Pt reported that she was trying to change her pants without assistance and lost her balance. Pt was educated prior in the shift on the call light. Neuro (neurological) checks initiated. Pt assisted into wheelchair with two person extensive assist. Denies any pain in lower extremities related to fall. Ice was applied to wrist and pain pills were given. Family will be notified in the AM, MD (Medical Doctor) notified via communication board. Will continue to monitor for pain. Resident 3's x-ray results dated 2/1/18 at 6:13 AM, documented the following information: History: Left wrist injury, initial evaluation X-Ray findings: Bones: Mildly displaced comminuted intra-articular distal radius fracture. Soft Tissues: Wrist soft tissue [MEDICAL CONDITION]. Impression: Mildly displaced intra-articular distal left radius fracture. On 2/1/18 at 3:02 PM, nursing staff documented the following in a progress note: Resident transported to (emergency room ) via (ambulance) pain medication prior to leaving transported via stretcher (vital signs) stable NP (nurse practitioner) examined resident prior to transport. On 2/1/18 at 8:15 AM, a NP note documented the following information: Initial NP visit, fall . (Resident 3) is a [AGE] year old female admitted to (the facility) on (MONTH) 31st (YEAR) for skilled PT/OT (Physical Therapy/Occupational Therapy). She had a left total knee arthroplasty performed on (MONTH) 29th, (YEAR) . She fell this morning in her room she states she was reaching for something in her closet and over extended herself, falling on her left wrist. x-ray completed: mildly displaced communited intra-articular distal radial fracture. She denies hitting her head . Left wrist is swollen she is unable to flex or bend related to pain, she is able to wiggle her fingers .Left wrist (fracture) send to ER for eval (evaluation) . The call light event report for 1/31/18 included the following call lights over five minutes: a. Resident 3 turned her call on at 7:05 PM, it was cleared 16 minutes later at 7:21 PM. b. Resident 3 turned her call light on at 9:05 PM, it was cleared 12 minutes later at 9:17 PM. c. Resident 3 turned her call light on at 11:08 PM, it was cleared 37 minutes later at 11:45 PM. It was noted that this was the time resident 3 was found on the floor by the aide. On 2/6/18, RN 1 documented the following information in a statement regarding the fall. .The daughter also told me she waited for someone to answer the call light and when no one came she assisted her mom to the bathroom herself. At this time I explained how the call light worked and how important it was for her to wait until we arrive to assist her to the bathroom. I was notified by the aide that the resident had fallen in front of her closet. (Resident 3) told the aide that she had needed to go to the bathroom and she had pushed her call light. She reported that we did not get to her fast enough so she had an accident. She self transferred from her bed and when (sic) to her closet to change her pants. When we arrived she sitting (sic) on her bottom with the new pants up to her knees. I assessed her for injuries and three of us assisted her to her feet and then into the wheelchair. Upon assessment (resident 3) reported she hit her head so neuro checks were initiated. When assessing her left wrist she reported tenderness but was still able to move it. Ice was applied to wrist. There was no swelling or redness at this time. When I entered the room a little later with pain medication the wrist appeared to be swollen. No redness or bruising noted to wrist. (Resident 3) and I decided an x-ray would be appropriate at this time. I notified the MD through the communication board. I contacted (name of mobile x-ray company) and ordered a STAT (immediate) x-ray of her wrist. The x-ray was completed but the results were not back as my shift ended. On 6/26/18 at 7:30 AM, RN 1 was interviewed. RN 1 recalled that resident 3 was a new admit to the facility. RN 1 recalled that early in her shift resident 3 was upset that she (RN 1) did not come in earlier with a pain pill for resident 3. RN 1 recalled that she had a misunderstanding with resident 3 and thought resident 3 would use her call light when she was ready for more pain medication. RN 1 recalled that she explained to resident 3 that she should use her call light. RN 1 stated that when she entered the room, after the aide alerted her, resident 3 was on the floor. RN 1 stated that she thought resident 3 had been changing her pants because she had had an accident, but she was unsure. RN 1 stated that resident 3 would often not push her call light until she HAD to go to the restroom. RN 1 stated that she would only expect resident 3 to have waited 3 to 5 minutes for assistance after pushing her call light. RN 1 stated that if the aides were unable to get to a call light she would have check on the resident. RN 1 stated that she immobilized and iced resident 3's wrist. RN 1 stated that initially resident 3 had good ROM in her wrist. RN 1 stated that she offered to send resident 3 to the ER for a sooner x-ray. On 6/28/18 at 12:15 PM, resident 3 was interviewed. Resident 3 recalled the following information about her admission to the facility. Before the fall it took two hours to get pain my pain medication. When I got to the facility my daughter had to talk to the nurse and ask her to bring me my pain medication. I had pressed the call light earlier and the CNAs (Certified Nursing Aides) would come in. I told the CNAs I needed pain medication. I had rung them about four different times. My daughter had left . I was sitting up in bed with my legs over the edge. I waited and waited and waited and I finally just urinated on the bed. I continued to wait and nobody came. I just had to go so I got my walker and went into the bathroom. The room was kind of dark. I did not know where the light switch was. I went to the bathroom. I took off my wet clothes. I waited in the bathroom for a period, still nobody came. I decided that I needed to get some clean clothes on. So with the walker, I went to the cabinet where my clothes were and I found pants, but I could not find underwear. I wondered if they had been left in my bag . So I reached up to get that, with both hands off the walker, and when the bag started coming I started to loose my balance. So I took a step back with my right leg, my left leg with the knee replacement didn't move so I fell backwards. I hit my head on the wheelchair and I laid there for a while and I waited. And I sat up and checked my head to see if it was bleeding. I waited again for quite a while and my wrist was really hurting. I got the pants I had found and I was able to get them up as far as i could. I tried to think of different ways that I could get up because nobody had come yet. I realized with my wrist that I couldn't. (Resident 3 clarified that her wrist was too painful to attempt to put enough pressure on it to get up.) So I just sat for a really long time The CNA came in. I had left the bathroom light on. The CNA was looking around for me. I said I'm over here on the floor. She looked at me and she says I'm going to have to go get help. So she left. The nurse came in shortly after. One got on each side of me and picked me up. I said I think I've broken my wrist and the nurse said no I don't think so. They put me back in bed by that time the sheets where dry the nurse said 'well you're just going to have to lay here because we don't have anyone to take an x-ray.' So they left and nobody came back for my medications or anything. Until the morning, a man came with a machine and said 'I understand you think you broke your wrist.' I said yes and he took an x-ray. So, I texted my husband and asked him to come and that I had broken my wrist. Resident 3 stated that a staff member came and told her they called for transportation to take her to the ER because she had broken her wrist. Resident 3 stated that at the ER they did what she thought was a false cast and told her she would need surgery. Resident 3 further stated that she told her husband she did not want to return to the facility because of what happened so he took her home. Resident 3 stated that she had an appointment at the orthopedist the following Monday and he confirmed that she needed surgery on her wrist. Resident 3 stated that she had surgery on her wrist that Thursday. Resident 3 stated that the nurse did no ice her wrist, wrap her wrist, give her pain medications or do anything to assess her. Resident 3 stated that she was not offered earlier to be taken to the ER. Resident 3 stated that no one at the facility asked her what happened when she fell . 2. Resident 2 was admitted to the facility on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. Resident 2's medical record was reviewed on 6/26/18. A Quarterly Minimum Data Set (MDS) assessment dated [DATE], documented that resident 2 required extensive assistance with two plus persons for bed mobility, toilet use, and personal hygiene. The MDS also documented that bed rails were not in use for resident 2. A fall report dated 5/26/18, documented Heard CNA (Certified Nursing Assistant) calling help on radio in resident?s (sic) room @ (at) 2140 (9:40 PM). Entering the room, found resident sitting on the floor beside her bed, with her left arm leaning on the edge of the bed. Her legs were bending, right feet with socks and heel protector was stuck under the air-condition box. Resident was crying and yelling out. A Nursing Progress Note dated 5/27/18, documented Heard CNA calling help on radio in resident's room @ 2140. Entering the room, found resident sitting on the floor beside her bed, with her left arm leaning on the edge of the bed. Her legs were bending, right feet with socks and heel protector was stuck under the air-condition box. Resident was crying and yelling out. Removed the bed, relieved her feet, and transferred her back to bed with 2 nurses and 4 CNA's assistance. VS (vital signs) 144/100 (blood pressure), 56 (pulse), 98.2 (temperature), 93% (oxygen saturation) on RA (room air) Pain level was 8 on PAINAD (Pain Assessment in Advanced Dementia) scale. PRN (as needed) [MEDICATION NAME] administered. Redness noted on right heel and lateral foot. Knees were sensitive to touch. Ordered low extremities X-ray @ 2230 (10:30 PM). Her son (name removed) notified. X-ray finished @ 0100 (1:00 AM), right femoral fracture noted on the image. Notified on call doctor (name removed), ordered send resident to hospital @ 0155 (1:55 AM), resident was transferred to (name of local hospital) by (name of transportation company). Gave report to the ED (Emergency Department) nurse by phone. Her son (name removed) notified. ADON (Assistant Director of Nursing) (name removed) notified. 0230 (2:30 AM) X-ray results back, impression 'displaced, angulated distal right femoral fracture with overlapping fracture fragments. A review of the X-ray final report dated 5/27/18 at 12:14 AM, documented Displace, angulated distal right femoral fracture with overlapping fracture fragments. A review of the hospital History and Physical Reports dated 5/27/18, documented . 1. Traumatic right periprosthetic distal femur fracture: Continue Buck's traction. Continue [MEDICATION NAME] for pain control. [MEDICATION NAME] to be used for muscle spasm. Patient to undergo a surgical correction of this right femur fracture with (name of doctor removed) later today. 2. Left traumatic periprosthetic distal femur fracture: Likely non-surgical at this time. Place knee immobilizer. Orthopedic consultation appreciated. A review of the Orthopedic Progress Note dated 5/30/18, documented . Surgery: Right open reduction and internal fixation of distal femur periprosthetic fracture . A review of the Surgical Documentation note dated 5/29/18, documented . Left side: This fracture appears nondisplaced. I recommended nonoperative treatment. We will place her initially in a knee immobilizer. Later we will advance her to increased range of motion while in a hinged knee brace. On 6/27/18 at 2:32 PM, CNA 1 was interviewed. CNA 1 stated that she was doing rounds and entered resident 2's room with CNA 2 to complete a brief change. CNA 1 stated that she was the CNA cleaning resident 2 and CNA 2 was standing on the opposite side of the bed closest to the wall holding resident 2. CNA 1 stated that resident 2 was rolled onto her left side facing the wall and resident 2's legs slide off the side of the bed. CNA 1 stated that CNA 2 was holding resident 2's upper body and trying to protect resident 2's head from falling off the bed. CNA 1 stated that she went to the opposite side of the bed closest to the wall to assist CNA 2. CNA 1 stated that they were unable to get resident 2 back in the bed because resident 2's feet were caught under the air-condition floor unit. CNA 1 stated that she called for assistance from the other staff and they responded to assist resident 2 back in bed. CNA 1 stated that a positioning rail was attached to resident 2's bed. CNA 1 further stated that resident 2 was positioned near the edge of the bed closest to the wall and resident 2's body was not centered in the bed prior to the brief change.

Based on observation, interview, and record review it was determined that the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility did not ensure that residents, residing on the secure unit, with known hyper-sexual behaviors and severe impaired cognitive functioning were monitored at a level necessary to prevent incidents of sexual touching. The deficient practice identified for residents 71 and 105 was found to have occurred at an Immediate Jeopardy level. Additionally, residents did not receive incontinence care in a timely manner, residents waited for an extended amount of time for their meal trays, one resident (Resident 25) sustained a fracture after a transfer due to inadequate training and assistance from staff and the facility was utilizing agency staffing nurses and certified nursing assistants to care for residents. The agency staffing nurses and certified nursing assistants were not adequately trained or educated to provide the necessary services for the facility residents. Resident identifiers: 7, 10, 25, 37, 44, 79, 100, 108, 120, 121, and 165. NOTICE: The Notice of Immediate Jeopardy was given verbally to the Administrator on 5/9/17 at approximately 1:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to abuse. PLAN: On 5/15/17 at 2:40 PM, the Administrator provided the state survey team with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 5/11/17 revealed the following: Please accept this letter and credible allegation of the facility's abatement plan for the immediate jeopardy that was identified by the survey team on May 9, 2017. The facility believes the immediate jeopardy was fully abated on May 11, 2017 at 5:00p.m. Re: [MEDICATION NAME] Ridge Health Care ABATEMENT PLAN The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations, and is intended to serve as a credible allegation of our intent to correct the practices alleged to be deficient. The Plan of Correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in the Medicare! Medicaid program(s). F 223-483.12 Residents are Free from Abuse and F226- 483.12 !bl (1)- (3) Facility must Develop and Operationalize Policies and Procedures to Prevent Abuse 1. Resident Specific: Resident #105 was immediately placed on increased monitoring on 05/09/17. Resident was initially checked q (every) 15 minute by the nursing staff, and then placed on 1:1 (one to one) supervision on 5/10/17 until discharged from the facility. Resident #28 and #71 were interviewed by a Department Manager, and reported no complaints or concerns; similarly, there were no objective signs and symptoms of fear or distress. Residents were interviewed in their room and were calm and pleasant and able to respond. A Licensed Social Worker conducted follow up assessments on 5/11/17 of Resident #28, Resident #71, and other female residents on the secured unit to assess for any signs or symptoms of psychological impact or related distress. None were noted. 2. Identification of Others: All residents had the potential of being affected by these two deficiencies. On 05/09/17, within 2 hours of notification of the issue, more than twelve (12) leaders (Directors of Nursing, Administrators, and Clinical Resources) from surrounding affiliated facility arrived to help. All residents were immediately interviewed to determine if anyone had been inappropriate with them, if they were in fear of anyone, or if they had any other concerns related to their general safety and well-being at the facility. Non-verbal residents were closely observed for facial expression of fear, anxiety or discomfort. Information received from the residents which required intervention or follow-up were reported to the Administrator for immediate investigation and response. In addition, information received which was consistent with an allegation of abuse or neglect was reported to the Department of Health as per the applicable regulations. Residents with concerns or who reported allegations consistent with abuse or neglect will receive 1:1 psychosocial support from the resident advocate. Staff will provide ongoing monitoring of their psychosocial status of affected residents. 3. Systems and Measures: Facility policy and procedure specific to abuse identification, prevention and reporting was reviewed by Clinical Resource on 05/09/17. Clinical Resources and/or designees provided education on policy and procedure for abuse identification, prevention and reporting to the Executive Director and Director of Nurses on 5/9/17. Director of Nurses and Clinical Resources provided facility and agency staff with education on behavior monitoring, interventions to prevent behaviors, and the policy on abuse identification, prevention and reporting starting on 05/09/17. Calls were made to staff not present and 1:1 training was conducted over the phone. All-Staff meetings were held on 5/10/17 and again on 5/11/17 for face-to-face training. Facility or registry staff who have not received the training and education on Abuse policies and procedures will receive training prior to their next scheduled shift. Registry staff were immediately required to go to a designated nursing station upon arrival for their shifts and read the policy and sign that they had read and understood it prior to going to their assigned unit. Further, Director of Nurses/designee will provide staff education over these same topics upon hire and annually. The abuse policy was also printed for reference on the back of the employee badges. 4. Monitoring: The Director of Nurses/designee will be responsible for ensuring that audits are completed 7 days a week on the secured unit to confirm that behaviors are being monitored, interventions are being implemented to prevent behaviors, and the policy regarding abuse identification, prevention and reporting is being followed. The Director of Nurses/designee will ensure that the plans of care for the affected residents will contain interventions to minimize the risk of further occurrence, and that the identified interventions have been implemented. The IDT (Interdisciplinary Team) will monitor the effectiveness of the interventions and modify them as needed. These audits were discontinued on 5/12 upon closure of the unit. The Inter-Disciplinary team will further ensure that the Policy and Procedure to Prevent Abuse is fully operationalized in the facility operation. Risk Management will be reviewed in morning stand up meeting Monday through Friday to ensure proper reporting and documentation. The IDT will also review 24/72-hour documentation during the stand-up meeting, Monday through Friday, for potential incidents meeting the definition of any form of abuse. Issues identified will be reviewed during the monthly QAPI (Quality Assessment Performance Improvement) meeting for the purpose of process improvement. F 353 Sufficient 24-hr Nursing Staff per Care Plans/Qualified and Sufficient Nursing Staff 1. All residents have the potential to be affected. 2. Facility daily staffing schedules on the secured unit were modified to include at least two (2) Certified Nursing Assistants on all shifts beginning 5/09/17. 3. DON/designee met with direct care staff and discussed issues of resident safety and staffing. In addition, the DON, Clinical Resource, Administrator and Resident Advocate met with the Ombudsman assigned to the facility on [DATE] to discuss and address these same issues. 4. In order to reduce facility dependency on Registry and have sufficient staff, the facility determined that the best alternative was to reduce census. The Interdisciplinary Team discussed this decision with the Ombudsman and determined that the best option was to close the Haven (secure unit). Residents and Resident Representatives were notified of the closure and offered alternate placement options designed to meet each resident's specific needs. All residents in secured unit were assessed for the risk of elopement on 5/10/17. Discharge planning was initiated in accordance to the preferences of the Resident Representatives and individual resident needs. Fourteen residents were discharged as a result of this effort: a. Resident #105 was discharged to an acute hospital on [DATE] where the sexual aggression could be evaluated and treated. b. Following assessment, one resident was deemed appropriate for placement to an unsecured unit within the facility. By 1700 (5:00 PM) hours on 5/11/17, all but one of the residents on the Haven had been placed in facilities of their choosing, and the last was placed on the morning of 5/12/17. c. On the morning of 5/12/17, with the last resident safely discharged , the secured unit was closed down enabling the staff on that unit to assist in the rest of the facility. d. During the afternoon of 5/12/17, the facility Resident Advocate placed calls to each of the discharged Residents Representatives to ensure that placement had gone well and that needs were being met in their new locations. All responded affirmatively and most indicated a desire to return to the facility on ce the staffing issues were resolved. 5. Registry Staff on duty were provided a facility orientation. Any new registry staff will complete this same orientation, and will be specifically in-serviced on the policy regarding abuse identification, prevention and reporting before the start of an assigned shift. Agency staff are required to review and sign the facility abuse policy prior to working the floor. 6. Additionally, to further reduce dependence on Registry staff, affiliated facilities are providing assistance with nursing staffing until the Facility is able to hire additional regular, full time staff. 7. Actual and projected nurse staffing levels were reviewed by the Clinical Resource team for oversight beginning May 10, 2017, and continuing thereafter until the Facility has been returned to a state of substantial compliance. 8. The facility has retained a recruiting resource to assist with its efforts in identifying and hiring qualified nursing candidates. 9. Clinical Resource support has been in the Facility beginning on May 9, 2016, to provide nursing support and general oversight of the facility staffing. Prior to leaving the facility on 5/16/17, the state surveyors confirmed the components, outlined above in the written plan of action, had been implemented. During the survey on 5/16/17, the surveyors confirmed the removal of the Immediate Jeopardy situation as of 5/11/17. Deficient practice with actual harm and potential for more than minimal harm remained for sufficient staffing. Findings include: 1. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/17 resident 25's medical record was reviewed. A nurse's note dated 10/26/16 revealed X-ray results back from tibia and fibula 2V (two views) Portable x-ray. Findings: Bones: Nondisplaced spiral [MEDICAL CONDITION] tibial shaft extending into the metaphysis. There also appears to be a subtle [MEDICAL CONDITION] fibular shaft Impression: Nondisplaced distal tibial shaft spiral fracture An incident report dated 10/26/16 and revised 10/31/16 revealed Daughter came to nurse and said she thinks that (Resident 25) hurt or fractured her right shin last night when she and one CNA (Certified Nursing Assistant) were transferring resident into bed. Resident denied pain this morning in bed but after being up in w/c reports pain right shin. Right shin has some malformation to it and is red and warm. Resident stated that she felt pain in her shin when she was standing up last night Right leg assessed, some malformation, redness, warmth noted. Resident has [DIAGNOSES REDACTED]. Impression: Nondisplaced distal tibial shaft spiral fracture. Subtle distal fibular deformity consistent with a nondisplaced fracture On 5/8/17 at 4:00 PM, an interview was conducted CNA 10. CNA 10 stated that she was new today from the staffing agency and that this was the first day on the floor. CNA 10 stated that she did not receive any training from facility staff prior to working on the floor today. On 5/10/17 at 9:12 AM, a telephone interview was conducted with resident 25's daughter. Resident 25's daughter stated that her sister had assisted CNA 11 with the transfer to the toilet on the night of 10/25/16 because there was nobody else around to help and mom requires two people to transfer. Resident 25's daughter stated that the facility needed more staff. Resident 25's daughter stated They are short on staff and have been since day one. On 5/12/17 at 4:04 PM, a call was placed to CNA 11. (NOTE: CNA 11 was the CNA who participated in the transfer with resident 25's daughter.) CNA 11 stated that the facility was frequently short staffed and that was the reason for the daughter assisting with the transfer of resident 25. CNA 11 stated that she was alone on the hallway and needed help to assist resident 25 to the toilet. 2. On 5/8/17 at 3:12 PM, an observation was made as resident 121 activated the call light in the bathroom. The call light was observed to be answered by Registered Nurse (RN) 4. RN 4 was observed to turn off the call light and to tell resident 121 that someone would be in to help him. On 5/8/17 at 3:22 PM, an observation was made of a CNA as she entered resident 121's bathroom to assist him off the toilet. On 5/9/17 at 8:35 AM, an interview was conducted with resident 121. Resident 121 stated that the CNAs are overworked and understaffed. Resident 121 stated that when RN 4 answered the call light yesterday, that was not normal. Resident 121 stated that he usually had to wait up to 45 minutes for staff to answer his call light. 3. On 5/9/17 at 10:08 AM, an interview was conducted with resident 165. Resident 165 stated that she had to wait at times for about 30 minutes before my call light is answered. Resident 165 stated that the wait time seemed to increase at night to about an hour. Resident 165 stated that she has had urine incontinent episodes while waiting for facility staff to answer the call light and that I would rather make it to the bathroom. 4. On 5/8/17 at 1:52 PM, an interview was conducted with resident 120. Resident 120 stated that the facility had reconstructed and reorganized the staff and that I liked it better before. Resident 120 stated that she had to wait for about 30 minutes before staff would answer the call light. Resident 120 stated that at times staff would tell her that they could not help her to the toilet or answer the call light, turn it off and tell her that they would return and not come back. Resident 120 stated that she felt like she basically was told not to call on my light unless it was a dire emergency. 5. On 5/9/17 at 10:30 AM, an interview was conducted with resident 7. Resident 7 stated that she had to wait about 30 minutes for someone to answer the call light. Resident 7 stated that she had had an episode of bowel incontinence while waiting for facility staff to answer the call light. Resident 7 stated that she did not like being incontinent and that she would rather get to the bathroom. 6. On 5/8/17 at 3:20 PM, an interview was conducted with resident 37. Resident 37 stated that it would take facility staff up to 30 minutes to answer the call light. Resident 37 stated that because of her medical condition, she would call on the call light because of her incontinence and needed to be cleaned up. 7. On 5/9/17 at 9:10 AM, an observation was made of the call light on in room [ROOM NUMBER]. The call light was observed to be answered at 9:19 AM. 8. On 5/9/17 at 9:10 AM, an observation was made of the call light on in room [ROOM NUMBER]. The call light was observed to be answered at 9:20 AM. 9. On 5/8/17 at 2:23 PM, an interview was conducted with resident 56. Resident 56 stated that there were not enough staff to assist her. Resident 56 stated that staff did not change her brief for 6 hours the day before. Resident 56 stated she felt miserable when she was in a soiled brief for 6 hours. 10. On 5/11/17 at 3:05 PM, an interview was conducted with resident 44's family member. Resident 44's family member stated that there were not enough staff and that resident 44 had been in urine soaked briefs for long periods of time. Resident 44's family member stated that there were not enough staff and the 300 hall had been staffed with only 1 CNA. Resident 44's family member stated that the 300 hall needed to have three CNAs to meet the needs of the residents. 11. Resident 79 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/10/17 at approximately 12:30 PM, an observation was made of resident 79. Resident 79 was in the Special Needs Unit (SNU). Resident 79 was observed to reach over the nurses station and pick up wipes and a fanny pack. Resident 79 was observed to take it down the hall and open the fanny pack in the dining room. Resident 79 was observed to take items out of the fanny pack. CNA 9 was observed to take the fanny pack away after 10 minutes. CNA 9 stated that the fanny pack had CNA's equipment. CNA 9 stated that resident 79 must have taken it from the nurses station when staff were not watching her. An observation was made of the contents inside the fanny pack. There were 7 alcohol wipes that had a warning, keep out of reach of children. A care plan dated 5/12/17 revealed the following Focus (Resident 79) is planning to stay LTC (Long Term Care). She requires 24 hr (hour) nursing care (and) supervision. One of the goals was, She will have optimal quality of life. One of the interventions developed was, (Resident 79) wants to keep as much independence as possible. Give her all opportunities to do as much for herself as possible with ADLs (Activities of Daily Living) 12. On 5/9/17 at 7:41 AM, an observation was made of call light from room [ROOM NUMBER] alarming. At 7:46 AM, an observation was made of RN 1 entering room [ROOM NUMBER]. RN 1 stated to resident 100, It will be a few minutes. RN 1 was observed to turn off resident 100's call light. At 8:13 AM, resident 100 was yelling out. At 8:18 AM, resident 100's call light was alarming. Facility staff were observed to turn off resident 100's call light. At 9:00 AM, resident 100 was delivered breakfast by staff. On 5/9/17 at 8:05 AM, an interview was conducted with CNA 7. CNA 7 stated that there were only 2 CNAs to provide care to the residents on the 300 hall. CNA 7 stated that one of the CNAs did not show up to work. CNA 7 stated that she was unable to answer call lights and assist residents timely with only 2 CNAs. 13. On 5/8/17 at 1:26 PM, an interview was conducted with resident 10. Resident 10 stated that there were not enough staff and her call light alarmed for long periods of time. Resident 10 stated that she waited for 2 hours before staff responded to her call light and had incontinent episodes waiting for staff assistance. 14. On 5/8/17 at 1:34 PM, an interview was conducted with resident 108. Resident 108 stated that there were not enough staff. Resident 108 stated that agency staff have not shown up for their shifts and CNAs work short staffed. Resident 108 stated that agency staff were not informed of how to care for residents when they started a shift. 15. Resident 100 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/9/17 at 9:30 AM, an interview was conducted with resident 100. Resident 100 stated that it was difficult in the morning to get her brief changed and help with her dentures because, they don't have enough staff to help. Resident 100 stated that evening medications were frequently late, stating that on 5/7/17, her evening medications that included a sleeping pill were not given to her until 1:27 AM the next morning. Resident 100 stated that when she initiated her call light, no one comes. Resident 100 stated that on 3 occassions she initiated her call light for staff to come help her roomate transfer from her wheel chair to the bed, but there was, no response. Resident 100 stated that her room mate fell and hit her head after which resident 100 initiated her call light for help, and it took 40 minutes for someone to respond. (Cross refer to F-223, F-226, F-241, F-311, F-312, F-315, and F-323.)

Based on interview, observation, and medical record review it was determined, for 3 of 43 sample residents, that the facility failed to implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property. Specifically, the facility did not ensure that incidents of sexually inappropriate behaviors between dementia residents and incidents of unknown origin were reported to Administration and investigated by administration. The deficient practice identified for residents 71 and 105 was found to have occurred at an Immediate Jeopardy level. The deficient practice identified for resident 25 was found to have occurred at a Harm Level and will not be included in the Immediate Jeopardy. Resident identifiers: 25, 28, 71, and 105 NOTICE: The Notice of Immediate Jeopardy was given verbally to the Administrator on 5/9/17 at approximately 1:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to abuse. PLAN: On 5/15/17 at 2:40 PM, the Administrator provided the state survey team with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 5/11/17 revealed the following: Please accept this letter and credible allegation of the facility's abatement plan for the immediate jeopardy that was identified by the survey team on May 9, 2017. The facility believes the immediate jeopardy was fully abated on May 11, 2017 at 5:00 p.m. Re: [MEDICATION NAME] Ridge Health Care ABATEMENT PLAN The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations, and is intended to serve as a credible allegation of our intent to correct the practices alleged to be deficient. The Plan of Correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in the Medicare! Medicaid program(s). F 223-483.12 Residents are Free from Abuse and F226- 483.12 !bl (1)- (3) Facility must Develop and Operationalize Policies and Procedures to Prevent Abuse 1. Resident Specific: Resident #105 was immediately placed on increased monitoring on 05/09/17. Resident was initially checked q (every) 15 minute by the nursing staff, and then placed on 1:1 (one to one) supervision on 5/10/17 until discharged from the facility. Resident #28 and #71 were interviewed by a Department Manager, and reported no complaints or concerns; similarly, there were no objective signs and symptoms of fear or distress. Residents were interviewed in their room and were calm and pleasant and able to respond. A Licensed Social Worker conducted follow up assessments on 5/11/17 of Resident #28, Resident #71, and other female residents on the secured unit to assess for any signs or symptoms of psychological impact or related distress. None were noted. 2. Identification of Others: All residents had the potential of being affected by these two deficiencies. On 05/09/17, within 2 hours of notification of the issue, more than twelve (12) leaders (Directors of Nursing, Administrators, and Clinical Resources) from surrounding affiliated facility arrived to help. All residents were immediately interviewed to determine if anyone had been inappropriate with them, if they were in fear of anyone, or if they had any other concerns related to their general safety and well-being at the facility. Non-verbal residents were closely observed for facial expression of fear, anxiety or discomfort. Information received from the residents which required intervention or follow-up were reported to the Administrator for immediate investigation and response. In addition, information received which was consistent with an allegation of abuse or neglect was reported to the Department of Health as per the applicable regulations. Residents with concerns or who reported allegations consistent with abuse or neglect will receive 1:1 psychosocial support from the resident advocate. Staff will provide ongoing monitoring of their psychosocial status of affected residents. 3. Systems and Measures: Facility policy and procedure specific to abuse identification, prevention and reporting was reviewed by Clinical Resource on 05/09/17. Clinical Resources and/or designees provided education on policy and procedure for abuse identification, prevention and reporting to the Executive Director and Director of Nurses on 5/9/17. Director of Nurses and Clinical Resources provided facility and agency staff with education on behavior monitoring, interventions to prevent behaviors, and the policy on abuse identification, prevention and reporting starting on 05/09/17. Calls were made to staff not present and 1:1 training was conducted over the phone. All-Staff meetings were held on 5/10/17 and again on 5/11/17 for face-to-face training. Facility or registry staff who have not received the training and education on Abuse policies and procedures will receive training prior to their next scheduled shift. Registry staff were immediately required to go to a designated nursing station upon arrival for their shifts and read the policy and sign that they had read and understood it prior to going to their assigned unit. Further, Director of Nurses/designee will provide staff education over these same topics upon hire and annually. The abuse policy was also printed for reference on the back of the employee badges. 4. Monitoring: The Director of Nurses/designee will be responsible for ensuring that audits are completed 7 days a week on the secured unit to confirm that behaviors are being monitored, interventions are being implemented to prevent behaviors, and the policy regarding abuse identification, prevention and reporting is being followed. The Director of Nurses/designee will ensure that the plans of care for the affected residents will contain interventions to minimize the risk of further occurrence, and that the identified interventions have been implemented. The IDT (Interdisciplinary Team) will monitor the effectiveness of the interventions and modify them as needed. These audits were discontinued on 5/12 upon closure of the unit. The Inter-Disciplinary team will further ensure that the Policy and Procedure to Prevent Abuse is fully operationalized in the facility operation. Risk Management will be reviewed in morning stand up meeting Monday through Friday to ensure proper reporting and documentation. The IDT will also review 24/72-hour documentation during the stand-up meeting, Monday through Friday, for potential incidents meeting the definition of any form of abuse. Issues identified will be reviewed during the monthly QAPI (Quality Assessment Performance Improvement) meeting for the purpose of process improvement. F 353 Sufficient 24-hr Nursing Staff per Care Plans/Qualified and Sufficient Nursing Staff 1. All residents have the potential to be affected. 2. Facility daily staffing schedules on the secured unit were modified to include at least two (2) Certified Nursing Assistants on all shifts beginning 5/09/17. 3. DON/designee met with direct care staff and discussed issues of resident safety and staffing. In addition, the DON, Clinical Resource, Administrator and Resident Advocate met with the Ombudsman assigned to the facility on [DATE] to discuss and address these same issues. 4. In order to reduce facility dependency on Registry and have sufficient staff, the facility determined that the best alternative was to reduce census. The Interdisciplinary Team discussed this decision with the Ombudsman and determined that the best option was to close the Haven (secure unit). Residents and Resident Representatives were notified of the closure and offered alternate placement options designed to meet each resident's specific needs. All residents in secured unit were assessed for the risk of elopement on 5/10/17. Discharge planning was initiated in accordance to the preferences of the Resident Representatives and individual resident needs. Fourteen residents were discharged as a result of this effort: a. Resident #105 was discharged to an acute hospital on [DATE] where the sexual aggression could be evaluated and treated. b. Following assessment, one resident was deemed appropriate for placement to an unsecured unit within the facility. By 1700 (5:00 PM) hours on 5/11/17, all but one of the residents on the Haven had been placed in facilities of their choosing, and the last was placed on the morning of 5/12/17. c. On the morning of 5/12/17, with the last resident safely discharged , the secured unit was closed down enabling the staff on that unit to assist in the rest of the facility. d. During the afternoon of 5/12/17, the facility Resident Advocate placed calls to each of the discharged Residents Representatives to ensure that placement had gone well and that needs were being met in their new locations. All responded affirmatively and most indicated a desire to return to the facility on ce the staffing issues were resolved. 5. Registry Staff on duty were provided a facility orientation. Any new registry staff will complete this same orientation, and will be specifically in-serviced on the policy regarding abuse identification, prevention and reporting before the start of an assigned shift. Agency staff are required to review and sign the facility abuse policy prior to working the floor. 6. Additionally, to further reduce dependence on Registry staff, affiliated facilities are providing assistance with nursing staffing until the Facility is able to hire additional regular, full time staff. 7. Actual and projected nurse staffing levels were reviewed by the Clinical Resource team for oversight beginning May 10, 2017, and continuing thereafter until the Facility has been returned to a state of substantial compliance. 8. The facility has retained a recruiting resource to assist with its efforts in identifying and hiring qualified nursing candidates. 9. Clinical Resource support has been in the Facility beginning on May 9, 2016, to provide nursing support and general oversight of the facility staffing. Prior to leaving the facility on 5/16/17, the state surveyors confirmed the components, outlined above in the written plan of action, had been implemented. During the survey on 5/16/17, the surveyors confirmed the removal of the Immediate Jeopardy situation as of 5/11/17. Deficient practice with actual harm and potential for more than minimal harm remained for operationalizing facility policies and procedures for reporting and investigating abuse. Findings include: 1. Resident 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/8/17 at approximately 3:40 PM, resident 105 was observed in the hall of the secured unit. Resident 105 was observed in his wheelchair propelling himself up the hall way of the secured unit. No observations were made of facility staff in the vicinity of resident 105. Resident 105 was observed to approach resident 28 and start rubbing resident 28's right upper thigh. Resident 28 was observed in her wheelchair with her hands placed in her lap. Resident 105 was observed to tell resident 28, Oh baby, stick with me! I will take care of you! Resident 105 was then observed to grab resident 28's hand then resident 105 was observed to start rubbing resident 28's right upper thigh again. Resident 28 made no response to resident 105. During the observation, several residents were in the hallway; however, no staff were present. While resident 105 had his hand on resident 28's thigh, Certified Nursing Assistant (CNA) 8 was observed to enter the hallway, after being in a resident room, and approach resident 28. CNA 8 was observed to turn resident 28 around to assist resident 28 to the secured unit day room. No observations were made of CNA 8 stopping resident 105 from rubbing resident 28's thigh. At that time, resident 105 was observed to put his right arm around resident 71 and hold resident 71's hand with his left hand as the two residents (resident 105 and resident 71) propelled themselves toward the secured unit day room. No observations were made of CNA 8 separating resident 71 and resident 105. On 5/9/17, resident 105's medical record was reviewed. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 105 as having a score of 4 on the Brief Interview for Mental Status (BIMS). Per the CMS Resident Assessment Manual, a BIMS score of 0 to 7 represents severe impairment of mental status. Additionally, facility staff assessed that resident 105 exhibited physical behavioral symptoms such as, hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during the seven days preceding the assessment. Review of the care plan revealed a care plan, dated 9/23/15, for the identified problem of (Resident 105) has demonstrated physical behaviors r/t (related to) Dementia, Poor impulse control, hypersexuality. The goal for the identified problem was, Will not demonstrate unwanted sexual advances to others through the review date. Facility staff developed the following interventions to help resident 105 achieve the stated goal: Discuss beginning sexual deterrent medication with MD (Medical Doctor) and implement as indicated., Monitor for sexual behavior towards other residents. Redirect as needed., and Screen for UTI (Urinary Tract Infection). Review of the Progress Notes revealed the following entries: a. 3/19/2016 15:11 (3:11 PM) Nursing Note Text: Resident has been stopped by staff multiple times trying to enter female residents room. Resident redirected to day room/hallway in front of nurses station. Resident has been in view of staff all shift. UA (Urinalysis) pending at this time. WCTM (Will Continue to Monitor). b. 4/12/2016 17:46 (5:46 PM) Nursing Note Text: Behavioral RN (Registered Nurse) Note: the patient was flirtatious and observed holding hands, touching and kissing a peer in the hallway. It was clear both parties consented to this but staff distracted them by inviting them into the day room. The patient's wife became aware of the (sic) this behavior and told staff she wants staff to 'keep that woman away from him.' It was explained that because they were consenting the staff was limited in what they could do, but they would continue to distract and prompt them for boundaries. She was not able to verbalize understanding so staff ended the education. c. 5/11/2016 13:31 (1:31 PM) Nursing Note Text: the patient has a UA sent to (name of Laboratory company) on 5-10-16 related to increased flirtatiousness, pushing physicla (sic) boundaries with female peers, and a labile mood. The results came back negative for bacteria, NP (Nurse Practitioner) (name of NP) notified. d. 6/26/2016 17:41 (5:41 PM) Nursing Note Text: Resident has had increased confusion and increased [MEDICAL CONDITION]. NP notified, new order for UA with C&S (Culture and Sensitivity) if indicated. e. 6/30/2016 19:01 (7:01 PM) Nursing Note Text: The patient's [MEDICATION NAME] was changed to 150 mg (milligrams) daily after he was assessed and his behaviors of hyper-sexual and depressed features relayed to NP (name of NP). 1st dose will be tomorrow at 0800 (8:00 AM). f. 8/17/2016 17:26 (5:26 PM) Nursing Note Text: Resident found in another residents room with the other resident yelling. Staff entered room and found resident trying to exit the room and stated, 'She hit me.' Both residents were separated. No injury noted at this time. (Resident 105) was assisted to the day room where there were activities going on and the other resident remained in her room. Daughter (name of resident 105's daughter) was notified. g. 11/16/2016 19:21 (7:21 PM) Nursing Late Entry: Note Text: RESIDENT WAS GOING UP AND DONE (sic) THE HALL AND TALKING ABOUT GETTING THE FURNACE FIXED. HE KEPT GOING INTO AND ATTEMPTING TO GO INTO OTHER RESIDENT'S ROOMS, ESPECIALLY ONE IN PARTICULAR. WAS ABLE TO DEFLECT HIS ATTEMPTS MOST OF THE TIME, BUT AFTER OPENING ONE RESIDENT'S ROOM FOR THE FOURTH TIME, SHE BECAME ANGRY AND PUNCHED HIM IN THE SHOULDER, YELLING AT HIM THAT HE SHOULD GO AWAY. 'THEY'RE GONNA GET MIGHTY COLD BY SPRINGTIME.' IT HAD BEEN IMPOSSIBLE TO DISSUADE HIM THAT THE FURNACE WAS WORKING FINE AND THAT PEOPLE PREFERRED HE STAY OUT OF THEIR ROOMS. NOT QUITE FAST ENOUGH, BUT RESIDENTS WERE QUICKLY SEPARATED AND REMOVED FROM HARM. WAS FINALLY ABLE TO CONVINCE RESIDENT THAT IT WOULD BE A GOOD TIME TO LAY DOWN FOR THE NIGHT. HE WAS ANGRY AND REFUSED TO HAVE HIS VS (Vital Signs) TAKEN, BUT WAS NOT HURT IN ANY WAY. HE WENT TO SLEEP AND WAS NOT UP THE REST OF THE NIGHT. PHYSICIAN AND FAMILY NOTIFIED. h. 11/23/2016 18:10 (6:10 PM) Nursing Note Text: Resident has had increased agitation today throughout all of nursing shift. Res (resident) was combative with CNA during shower and took several attempts before getting in shower. Also verbally inappropriate with other residents in the day room with other resident after running into them with his w/c (wheelchair). NP (name of NP) notified, wants a UA collected. Passed on to NOC (night) nurse. CNA aware for need to collect. Hat placed next to toilet, will collect at next trip to restroom. i. 2/10/2017 06:19 (6:19 AM) Nursing Note Text: Res was sitting in the doorway of room [ROOM NUMBER], when the res from 313B started yelling at him to get out, that he didn't belong there. She scratched his right forearm, causing a small skin tear. It was cleansed with NS (Normal Saline) and covered with steri-strips. WCTM. j. 3/6/2017 08:28 (8:28 AM) Nursing Note Text: Last PM (night), resident was wandering in his w/c, when he opened the door of a female resident's room. She became upset and began yelling and hitting him. Resident was remove from the situation and no s/s (signs or symptoms) of injury noted. Resident was taken to his room, assisted into bed and remained there throughout the shift. WCTM. k. 3/8/2017 06:34 (6:34 AM) Nursing Note Text: Resident was found after 2 am with and small hematoma with scab in the center on the inner Right forearm of unknown origin. Res. shows no s/s pain or irritation to site and denies pain at this time. WCTM. l. 3/20/2017 14:25 Social Service Summary Late Entry: Social Service Summary: Quarterly Social Services assessment completed for (resident 105). It is noted that (resident 105) scored a 4 on his most recent BIMS test. On his most recent elopement assessment, (resident 105) scored 19. (Resident 105) is alert and oriented x1- he has fairly progressed dementia. However, he is typically in good spirits, and happy to interact with people despite not remembering who they are. He is able to make his needs known, participate in simple conversations, follow directions, and make jokes, however he is essentially unable to make new memories. His elopement risk warrants the resources of the Haven Secured Unit. It is also noted that (resident 105) scored a 2 on his most recent PQH-9 (sic) assessment. (Resident 105) is typically pleasant and easy to be around, his dementia has deteriorated some of his inhibitions, so he occasionally exhibits [MEDICAL CONDITION]. This is currently being managed with [MEDICATION NAME] 150 MG daily, and can be exacerbated when he gets a UTI. Staff report no outward signs or symptoms of hallucinations, [MEDICAL CONDITION], anxiety, or suicidal ideation. Staff and Resident Advocate will continue to monitor mood and behaviors. m. 5/7/2017 15:12 (3:12 PM) Nursing Note Text: BEHAVIORAL NOTE- PT (patient) HAS BEEN UPBEAT AND VERY VERBAL TODAY. PT WAS OBSERVED BY STAFF TRYING TO PUT HIS ARM AROUND A FEMALE PT. WHO DIDN'T WANT HIS HANDS ON HER. STAFF WENT OVER AND REMOVED PT FROM SITUATION. PT STATED 'IT WAS NONE OF YOUR BUSINESS TO GET BETWEEN US' STAFF EXPLAINED TO HIM THAT THE BEHAVIOR WAS NOT PERMITTED. NO FURTHER PROBLEMS OCCURRED DURING SHIFT. Review of facility incident reports revealed that facility staff had completed an incident report for only two incidents, 8/17/16 and 11/16/16, of resident 105 wandering into female resident rooms and being punched or hit by the female resident. No documentation could be found to show that facility staff completed an incident report on 3/19/16, 4/12/16, 2/10/17, 3/6/17, nor 5/7/17. No documentation could be found to show that facility staff were notifying Administration, the Medical Director or family of the above mentioned incidents. Resident 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/9/17 resident 71's medical record was reviewed. Review of the medical record revealed an Annual MDS assessment dated [DATE]. Facility staff assessed resident 71 as having a score of 3 on BIMS exam, indicating severe cognitive impairment. Additionally, facility staff assessed that resident 71 exhibited physical behavioral symptoms such as, hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during the seven days preceding the assessment. Review of the care plan revealed a care plan dated 4/3/17 for Potential for behavior problem r/t psychotic d/o (disorder), sexually inappropriate behaviors. The goal listed on the care plan was, Will have fewer episodes by review date. Facility staff listed the following interventions to help resident 71 achieve the stated goal: Administer medications as ordered. Monitor/document for side effects and effectiveness., Anticipate and meet needs., Approach in a calm manner., Document behaviors, and resident response to interventions., If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable., Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., Praise any indication of progress/improvement in behavior., Reward appropriate behavior as indicated. Review of the medical record revealed the following entries: a. 4/28/2016 14:29 (2:29 PM) Nursing Note Text: Res-Res #1 (Resident to Resident): The patient was struck by another resident on the left hand with a 'back-scratcher.' She was holding the hand of another male resident and it was that male's wife that struck her. The two were separated and the hand was assessed, no issues or injury was found and she denied pain to the site. Staff notified PA (Physician's Assistant) (name) and the patients emergency contact (name of resident 71's Emergency Contact). b. 1/28/2017 16:06 (4:06 PM) Nursing Note Text: Resident was in hall with her hands in another resident's pants. She gave some resistance to being separated stating that she thought it felt good to the other resident. Nurse separated residents and kept them separated. Notified (name) Daughter in law. She was surprised but had no adverse reaction. Review of incident reports revealed that facility staff completed an incident report for the 4/28/16 incident. No documentation could be found to show that facility staff completed an incident report for the 1/28/17 incident. On 5/9/17 at approximately 10:15 AM, resident 105's spouse was interviewed. Resident 105's spouse stated that she was the resident that hit resident 71 on the hand a year ago. Resident 105's spouse stated that she was living at the facility when the incident occurred but was not residing on the unit. Resident 105's spouse stated that resident 71 had, Her hands all over him and I could have killed her. Resident 105's spouse stated that the facility told her that they would keep resident 105 and resident 71 separated and keep resident 105 and resident 71 out of each other's rooms. Resident 105's spouse stated that seeing resident 105 like this was very hard for her and her children as he was not like this previously. Resident 105's spouse stated that she would hope that the facility was keeping them separated. Resident 105's spouse stated that she had refrained from visiting resident 105 for about two weeks due to the behavior with resident 71. Review of the incident report for the 4/28/16 incident revealed that facility staff had removed resident 105's spouse from the secured unit the day she had struck resident 71 and told resident 105's spouse she could not return until safety could be reestablished as violence was not tolerated. On 5/9/17 the facility's Policy/Procedure for Abuse Prevention was reviewed. The policy contained the following: Policy: It is the policy of this facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Residents must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, resident representatives, families, friends, or other individuals. Procedures: Employee Screening - . Training - . Prevention - All personnel, residents, visitors, etc. are encouraged to report incidents and grievances without the fear of retribution. Feed back regarding concerns will be given. The employees of our facility will take action to protect and prevent abuse and neglect from occurring within the facility by: - Staff has knowledge fo the individual residents' care needs. - Supervision of staff to indentify inappropriate behaviors ( i.e., derogatory language, rough handling, ignoring residens while giving care, etc.) - Assess, care plan, and monitor residents with history of aggressive behaviors, behaviors such as entering other residents' rooms, self-injurious behavior, communication disorders, totally dependent on staff. - Not employing individuals who have: (1) been found guilty of abusing or mistreating individuals; and (2) have had a finding entered into the State Nurse Aide Registry or with other licensing authorities concerning abuse, neglect, mistreatment of [REDACTED]. Indentifcation of Abuse - Identify events, such as but not limited to, suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; and to determine the direction of the investigation. 1. Bruises, skin tears and injuries of unknown source will be investigated to rule out abuse. 2. Episodes of resident to resident altercation, willful or accidental, with or without injury. 3. Occurrences, patterns, and trends will be assessed by Licensed staff and or Interdisciplinary Team to determine the direction of the investigation. Investigation - All identified events are reported to the Administrator/Designee immediately and will by thoroughly investigated. Protection - If a resident incident is reported, discovered or suspected, where the health, welfare or safety of the residents is involved, this facility will take the following steps to prevent further potential abuse while the investigation is in progress; 1. If suspected perpetrator is another resident: a. Separate the residents so they do not interact with each other until circumstances of the resported incident can be determined; b. If a room change is appropriate, advise residents' families of the change and room location; . On 5/9/17 at approximately 6:00 AM, CNA 8 was interviewed. CNA 8 was observed to be working in the unit on 5/8/17 starting at 2:00 PM. CNA 8 stated that she had worked a double shift from 2:00 PM on 5/8/17 until 6:00 AM on 5/9/17. When asked about resident 105 and his behaviors towards female residents on the unit, CNA 8 stated that resident 105, Liked the ladies! On 5/9/17 at approximately 7:00 AM, CNA 4 was interviewed regarding resident to resident altercations. CNA 4 stated that the staff would separate residents and notify the nurse. When asked about resident 105, CNA 4 stated that resident 71 keeps resident 105 busy. On 5/9/17 at 7:35 AM, CNA 9 was interviewed. CNA 9 stated that resident 105 and resident 71 liked each other and liked to hold hands. CNA 9 further stated that she only came back to the unit to help with meals. CNA 9 stated that the unit was typically staffed with one CNA for the 14 residents residing on the unit. CNA 9 stated that the unit had a second CNA only during meal times. On 5/9/17 at 6:15 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that if a resident to resident altercation or incident occurred, on the secured unit, she would write a progress note. LPN 1 stated that she did not need to fill out an incident report. LPN 1 stated that if resident 105 was observed with his arm around a female resident that she would, explain to him about the behavior because he understands. On 5/9/17 at 10:00 AM, the facility Assistant Director of Nursing (ADON) was interviewed. The ADON stated that she was working on 1/28/17, when resident 71 was observed to have her hands down resident 105's pants. The ADON stated that resident 71 was resistive to removing her hands and that resident 105 looked to be enjoying himself. The ADON stated that she had notified the former Administrator immediately regarding the incident and that she did not know if the incident had been investigated. The ADON stated that resident 105 and resident 71 were to be kept apart and that if incidents occurred between resident 105 and resident 71 the facility did not contact resident 105's spouse because those things just devastate her. On 5/8/17 an Agency nurse, who was assigned to work the secure unit, was interviewed. The Agency nurse stated that she did not know the patients back in the unit and would be unable to answer any questions regarding the residents. On 5/9/17, the facility Administrator and Interim Director of Nursing (DON) were interviewed. Both the Administrator and DON stated that all resident to resident incidents should be reported to Administration and an incident report should be completed. The DON stated that if a spouse of a resident was upset regarding sexually inappropriate behavior between two residents, the facility would move residents if needed and accommodate the wishes of the resident's spouse. Additionally, the DON stated that the incident on 1/28/17 should have been reported and investigated for consent. The DON further stated that determining consent in dementia residents could be difficult. On 5/9/17 the facility Resident Advocate (RA) was interviewed. The RA stated that she constantly had to complete training regarding abuse because the facility staff sometimes, get used to behaviors and don't report the behaviors. On 5/9/17 multiple observations were made of resident 105 wandering in the secure unit, in his wheelchair, with no staff oversight. The facility unit was observed to be left unattended from 8:55 AM until 9:06 AM. On 5/9/17 at approximately 9:10 AM, LPN 1 was observed to be administering medications to residents in the secure unit. While LPN 1 was administering medications, 15 feet away from resident 105, resident 105 was observed to attempt to enter resident room [ROOM NUMBER]. The resident residing in room [ROOM NUMBER] was observed to slam the door in resident 105's face. No observations were made of LPN 1 acknowledging the behavior or correcting the behavior. 2. Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED].

Based on interview, observation, and medical record review it was determined, for 2 of 43 sample residents, that the facility failed to ensure residents were free from abuse. Specifically, the facility did not ensure that residents, residing on the secure unit, with known hyper-sexual behaviors and severe impaired cognitive functioning were monitored at a level necessary to prevent incidents of sexual touching. The deficient practice identified for residents 71 and 105 was found to have occurred at an Immediate Jeopardy level. Resident identifiers: 28, 71, and 105 NOTICE: The Notice of Immediate Jeopardy was given verbally to the Administrator on 5/9/17 at approximately 1:30 PM. The Administrator was asked to develop an immediate plan to ensure resident safety related to abuse. PLAN: On 5/15/17 at 2:40 PM, the Administrator provided the state survey team with a written plan of action to remove the Immediate Jeopardy to residents in the facility. The written plan dated 5/11/17 revealed the following: Please accept this letter and credible allegation of the facility's abatement plan for the immediate jeopardy that was identified by the survey team on May 9, 2017. The facility believes the immediate jeopardy was fully abated on May 11, 2017 at 5:00 p.m. Re: [MEDICATION NAME] Ridge Health Care ABATEMENT PLAN The following Plan of Correction is submitted by the facility in accordance with the pertinent terms and provisions of 42 CFR Section 488 and/or related state regulations, and is intended to serve as a credible allegation of our intent to correct the practices alleged to be deficient. The Plan of Correction should not be construed or interpreted as an admission that the deficiencies alleged did, in fact, exist; rather, the facility is submitting this document in order to comply with its obligations as a provider participating in the Medicare Medicaid program(s). F 223-483.12 Residents are Free from Abuse and F226- 483.12 !bl (1)- (3) Facility must Develop and Operationalize Policies and Procedures to Prevent Abuse 1. Resident Specific: Resident #105 was immediately placed on increased monitoring on 05/09/17. Resident was initially checked q (every) 15 minute by the nursing staff, and then placed on 1:1 (one to one) supervision on 5/10/17 until discharged from the facility. Resident #28 and #71 were interviewed by a Department Manager, and reported no complaints or concerns; similarly, there were no objective signs and symptoms of fear or distress. Residents were interviewed in their room and were calm and pleasant and able to respond. A Licensed Social Worker conducted follow up assessments on 5/11/17 of Resident #28, Resident #71, and other female residents on the secured unit to assess for any signs or symptoms of psychological impact or related distress. None were noted. 2. Identification of Others: All residents had the potential of being affected by these two deficiencies. On 05/09/17, within 2 hours of notification of the issue, more than twelve (12) leaders (Directors of Nursing, Administrators, and Clinical Resources) from surrounding affiliated facility arrived to help. All residents were immediately interviewed to determine if anyone had been inappropriate with them, if they were in fear of anyone, or if they had any other concerns related to their general safety and well-being at the facility. Non-verbal residents were closely observed for facial expression of fear, anxiety or discomfort. Information received from the residents which required intervention or follow-up were reported to the Administrator for immediate investigation and response. In addition, information received which was consistent with an allegation of abuse or neglect was reported to the Department of Health as per the applicable regulations. Residents with concerns or who reported allegations consistent with abuse or neglect will receive 1:1 psychosocial support from the resident advocate. Staff will provide ongoing monitoring of their psychosocial status of affected residents. 3. Systems and Measures: Facility policy and procedure specific to abuse identification, prevention and reporting was reviewed by Clinical Resource on 05/09/17. Clinical Resources and/or designees provided education on policy and procedure for abuse identification, prevention and reporting to the Executive Director and Director of Nurses on 5/9/17. Director of Nurses and Clinical Resources provided facility and agency staff with education on behavior monitoring, interventions to prevent behaviors, and the policy on abuse identification, prevention and reporting starting on 05/09/17. Calls were made to staff not present and 1:1 training was conducted over the phone. All-Staff meetings were held on 5/10/17 and again on 5/11/17 for face-to-face training. Facility or registry staff who have not received the training and education on Abuse policies and procedures will receive training prior to their next scheduled shift. Registry staff were immediately required to go to a designated nursing station upon arrival for their shifts and read the policy and sign that they had read and understood it prior to going to their assigned unit. Further, Director of Nurses/designee will provide staff education over these same topics upon hire and annually. The abuse policy was also printed for reference on the back of the employee badges. 4. Monitoring: The Director of Nurses/designee will be responsible for ensuring that audits are completed 7 days a week on the secured unit to confirm that behaviors are being monitored, interventions are being implemented to prevent behaviors, and the policy regarding abuse identification, prevention and reporting is being followed. The Director of Nurses/designee will ensure that the plans of care for the affected residents will contain interventions to minimize the risk of further occurrence, and that the identified interventions have been implemented. The IDT (Interdisciplinary Team) will monitor the effectiveness of the interventions and modify them as needed. These audits were discontinued on 5/12 upon closure of the unit. The Inter-Disciplinary team will further ensure that the Policy and Procedure to Prevent Abuse is fully operationalized in the facility operation. Risk Management will be reviewed in morning stand up meeting Monday through Friday to ensure proper reporting and documentation. The IDT will also review 24/72-hour documentation during the stand-up meeting, Monday through Friday, for potential incidents meeting the definition of any form of abuse. Issues identified will be reviewed during the monthly QAPI (Quality Assessment Performance Improvement) meeting for the purpose of process improvement. F 353 Sufficient 24-hr Nursing Staff per Care Plans/Qualified and Sufficient Nursing Staff 1. All residents have the potential to be affected. 2. Facility daily staffing schedules on the secured unit were modified to include at least two (2) Certified Nursing Assistants on all shifts beginning 5/09/17. 3. DON/designee met with direct care staff and discussed issues of resident safety and staffing. In addition, the DON, Clinical Resource, Administrator and Resident Advocate met with the Ombudsman assigned to the facility on [DATE] to discuss and address these same issues. 4. In order to reduce facility dependency on Registry and have sufficient staff, the facility determined that the best alternative was to reduce census. The Interdisciplinary Team discussed this decision with the Ombudsman and determined that the best option was to close the Haven (secure unit). Residents and Resident Representatives were notified of the closure and offered alternate placement options designed to meet each resident's specific needs. All residents in secured unit were assessed for the risk of elopement on 5/10/17. Discharge planning was initiated in accordance to the preferences of the Resident Representatives and individual resident needs. Fourteen residents were discharged as a result of this effort: a. Resident #105 was discharged to an acute hospital on [DATE] where the sexual aggression could be evaluated and treated. b. Following assessment, one resident was deemed appropriate for placement to an unsecured unit within the facility. By 1700 (5:00 PM) hours on 5/11/17, all but one of the residents on the Haven had been placed in facilities of their choosing, and the last was placed on the morning of 5/12/17. c. On the morning of 5/12/17, with the last resident safely discharged , the secured unit was closed down enabling the staff on that unit to assist in the rest of the facility. d. During the afternoon of 5/12/17, the facility Resident Advocate placed calls to each of the discharged Residents Representatives to ensure that placement had gone well and that needs were being met in their new locations. All responded affirmatively and most indicated a desire to return to the facility on ce the staffing issues were resolved. 5. Registry Staff on duty were provided a facility orientation. Any new registry staff will complete this same orientation, and will be specifically in-serviced on the policy regarding abuse identification, prevention and reporting before the start of an assigned shift. Agency staff are required to review and sign the facility abuse policy prior to working the floor. 6. Additionally, to further reduce dependence on Registry staff, affiliated facilities are providing assistance with nursing staffing until the Facility is able to hire additional regular, full time staff. 7. Actual and projected nurse staffing levels were reviewed by the Clinical Resource team for oversight beginning May 10, 2017, and continuing thereafter until the Facility has been returned to a state of substantial compliance. 8. The facility has retained a recruiting resource to assist with its efforts in identifying and hiring qualified nursing candidates. 9. Clinical Resource support has been in the Facility beginning on May 9, 2016, to provide nursing support and general oversight of the facility staffing. Prior to leaving the facility on 5/16/17, the state surveyors confirmed the components, outlined above in the written plan of action, had been implemented. During the survey on 5/16/17, the surveyors confirmed the removal of the Immediate Jeopardy situation as of 5/11/17. Deficient practice with actual harm and potential for more than minimal harm remained for the risk of abuse. Findings include: Resident 105 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/8/17 at approximately 3:40 PM, resident 105 was observed in the hall of the secured unit. Resident 105 was observed in his wheelchair propelling himself up the hall way of the secured unit. No observations were made of facility staff in the vicinity of resident 105. Resident 105 was observed to approach resident 28 and start rubbing resident 28's right upper thigh. Resident 28 was observed, in her wheelchair, with her hands placed in her lap. Resident 105 was observed to tell resident 28, Oh baby, stick with me! I will take care of you! Resident 105 was then observed to grab resident 28's hand then resident 105 was observed to start rubbing resident 28's right upper thigh again. Resident 28 made no response to resident 105. During the observation, several residents were in the hallway; however, no staff were present. While resident 105 had his hand on resident 28's thigh, Certified Nursing Assistant (CNA) 8 was observed to enter the hallway, after being in a resident room, and approach resident 28. CNA 8 was observed to turn resident 28 around to assist resident 28 to the secured unit day room. No observations were made of CNA 8 stopping resident 105 from rubbing resident 28's thigh. At that time, resident 105 was observed to put his right arm around resident 71 and hold resident 71's hand with his left hand as the two residents (resident 105 and resident 71) propelled themselves toward the secured unit day room. No observations were made of CNA 8 separating resident 71 and resident 105. On 5/9/17, resident 105's medical record was reviewed. Review of the medical record revealed a quarterly Minimum Data Set (MDS) assessment dated [DATE]. Facility staff assessed resident 105 as having a score of 4 on the Brief Interview for Mental Status (BIMS). Per the CMS Resident Assessment Manual, a BIMS score of 0 to 7 represents severe impairment of mental status. Additionally, facility staff assessed that resident 105 exhibited physical behavioral symptoms such as, hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during the seven days preceding the assessment. Review of the care plan revealed a care plan, dated 9/23/15, for the identified problem of (Resident 105) has demonstrated physical behaviors r/t (related to) Dementia, Poor impulse control, hypersexuality. The goal for the identified problem was, Will not demonstrate unwanted sexual advances to others through the review date. Facility staff developed the following interventions to help resident 105 achieve the stated goal: Discuss beginning sexual deterrent medication with MD (Medical Doctor) and implement as indicated., Monitor for sexual behavior towards other residents. Redirect as needed., and Screen for UTI (Urinary Tract Infection). Review of the Progress Notes revealed the following entries: a. 3/19/2016 15:11 (3:11 PM) Nursing Note Text: Resident has been stopped by staff multiple times trying to enter female residents room. Resident redirected to day room/hallway in front of nurses station. Resident has been in view of staff all shift. UA (Urinalysis) pending at this time. WCTM (Will Continue to Monitor). b. 4/12/2016 17:46 (5:46 PM) Nursing Note Text: Behavioral RN (Registered Nurse) Note: the patient was flirtatious and observed holding hands, touching and kissing a peer in the hallway. It was clear both parties consented to this but staff distracted them by inviting them into the day room. The patient's wife became aware of the (sic) this behavior and told staff she wants staff to 'keep that woman away from him.' It was explained that because they were consenting the staff was limited in what they could do, but they would continue to distract and prompt them for boundaries. She was not able to verbalize understanding so staff ended the education. c. 5/11/2016 13:31 (1:31 PM) Nursing Note Text: the patient has a UA sent to (name of Laboratory company) on 5-10-16 related to increased flirtatiousness, pushing physicla (sic) boundaries with female peers, and a labile mood. The results came back negative for bacteria, NP (Nurse Practitioner) (name of NP) notified. d. 6/26/2016 17:41 (5:41 PM) Nursing Note Text: Resident has had increased confusion and increased [MEDICAL CONDITION]. NP notified, new order for UA with C&S (Culture and Sensitivity) if indicated. e. 6/30/2016 19:01 (7:01 PM) Nursing Note Text: The patient's [MEDICATION NAME] was changed to 150 mg (milligrams) daily after he was assessed and his behaviors of hyper-sexual and depressed features relayed to NP (name of NP). 1st dose will be tomorrow at 0800 (8:00 AM). f. 8/17/2016 17:26 (5:26 PM) Nursing Note Text: Resident found in another residents room with the other resident yelling. Staff entered room and found resident trying to exit the room and stated, 'She hit me.' Both residents were separated. No injury noted at this time. (Resident 105) was assisted to the day room where there were activities going on and the other resident remained in her room. Daughter (name of resident 105's daughter) was notified. g. 11/16/2016 19:21 (7:21 PM) Nursing Late Entry: Note Text: RESIDENT WAS GOING UP AND DONE (sic) THE HALL AND TALKING ABOUT GETTING THE FURNACE FIXED. HE KEPT GOING INTO AND ATTEMPTING TO GO INTO OTHER RESIDENT'S ROOMS, ESPECIALLY ONE IN PARTICULAR. WAS ABLE TO DEFLECT HIS ATTEMPTS MOST OF THE TIME, BUT AFTER OPENING ONE RESIDENT'S ROOM FOR THE FOURTH TIME, SHE BECAME ANGRY AND PUNCHED HIM IN THE SHOULDER, YELLING AT HIM THAT HE SHOULD GO AWAY. 'THEY'RE GONNA GET MIGHTY COLD BY SPRINGTIME.' IT HAD BEEN IMPOSSIBLE TO DISSUADE HIM THAT THE FURNACE WAS WORKING FINE AND THAT PEOPLE PREFERRED HE STAY OUT OF THEIR ROOMS. NOT QUITE FAST ENOUGH, BUT RESIDENTS WERE QUICKLY SEPARATED AND REMOVED FROM HARM. WAS FINALLY ABLE TO CONVINCE RESIDENT THAT IT WOULD BE A GOOD TIME TO LAY DOWN FOR THE NIGHT. HE WAS ANGRY AND REFUSED TO HAVE HIS VS (Vital Signs) TAKEN, BUT WAS NOT HURT IN ANY WAY. HE WENT TO SLEEP AND WAS NOT UP THE REST OF THE NIGHT. PHYSICIAN AND FAMILY NOTIFIED. h. 11/23/2016 18:10 (6:10 PM) Nursing Note Text: Resident has had increased agitation today throughout all of nursing shift. Res (resident) was combative with CNA during shower and took several attempts before getting in shower. Also verbally inappropriate with other residents in the day room with other resident after running into them with his w/c (wheelchair). NP (name of NP) notified, wants a UA collected. Passed on to NOC (night) nurse. CNA aware for need to collect. Hat placed next to toilet, will collect at next trip to restroom. i. 2/10/2017 06:19 (6:19 AM) Nursing Note Text: Res was sitting in the doorway of room [ROOM NUMBER], when the res from 313B started yelling at him to get out, that he didn't belong there. She scratched his right forearm, causing a small skin tear. It was cleansed with NS (Normal Saline) and covered with steri-strips. WCTM. j. 3/6/2017 08:28 (8:28 AM) Nursing Note Text: Last PM (night), resident was wandering in his w/c, when he opened the door of a female resident's room. She became upset and began yelling and hitting him. Resident was remove from the situation and no s/s (signs or symptoms) of injury noted. Resident was taken to his room, assisted into bed and remained there throughout the shift. WCTM. k. 3/8/2017 06:34 (6:34 AM) Nursing Note Text: Resident was found after 2 am with and small hematoma with scab in the center on the inner Right forearm of unknown origin. Res. shows no s/s pain or irritation to site and denies pain at this time. WCTM. l. 3/20/2017 14:25 Social Service Summary Late Entry: Social Service Summary: Quarterly Social Services assessment completed for (resident 105). It is noted that (resident 105) scored a 4 on his most recent BIMS test. On his most recent elopement assessment, (resident 105) scored 19. (Resident 105) is alert and oriented x1- he has fairly progressed dementia. However, he is typically in good spirits, and happy to interact with people despite not remembering who they are. He is able to make his needs known, participate in simple conversations, follow directions, and make jokes, however he is essentially unable to make new memories. His elopement risk warrants the resources of the Haven Secured Unit. It is also noted that (resident 105) scored a 2 on his most recent PQH-9 (sic) assessment. (Resident 105) is typically pleasant and easy to be around, his dementia has deteriorated some of his inhibitions, so he occasionally exhibits [MEDICAL CONDITION]. This is currently being managed with [MEDICATION NAME] 150 MG daily, and can be exacerbated when he gets a UTI. Staff report no outward signs or symptoms of hallucinations, [MEDICAL CONDITION], anxiety, or suicidal ideation. Staff and Resident Advocate will continue to monitor mood and behaviors. m. 5/7/2017 15:12 (3:12 PM) Nursing Note Text: BEHAVIORAL NOTE- PT (patient) HAS BEEN UPBEAT AND VERY VERBAL TODAY. PT WAS OBSERVED BY STAFF TRYING TO PUT HIS ARM AROUND A FEMALE PT. WHO DIDN'T WANT HIS HANDS ON HER. STAFF WENT OVER AND REMOVED PT FROM SITUATION. PT STATED 'IT WAS NONE OF YOUR BUSINESS TO GET BETWEEN US' STAFF EXPLAINED TO HIM THAT THE BEHAVIOR WAS NOT PERMITTED. NO FURTHER PROBLEMS OCCURRED DURING SHIFT. Review of facility incident reports revealed that facility staff had completed an incident report for only two incidents, 8/17/16 and 11/16/16, of resident 105 wandering into female resident rooms and being punched or hit by the female resident. No documentation could be found to show that facility staff completed an incident report on 3/19/16, 4/12/16, 2/10/17, 3/6/17, nor 5/7/17. No documentation could be found to show that facility staff were notifying Administration, the Medical Director or family of the above mentioned incidents. Resident 71 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/9/17 resident 71's medical record was reviewed. Review of the medical record revealed an Annual MDS assessment dated [DATE]. Facility staff assessed resident 71 as having a score of 3 on BIMS exam, indicating severe cognitive impairment. Additionally, facility staff assessed that resident 71 exhibited physical behavioral symptoms such as, hitting, kicking, pushing, scratching, grabbing, and/or abusing others sexually during the seven days preceding the assessment. Review of the care plan revealed a care plan dated 4/3/17 for Potential for behavior problem r/t psychotic d/o (disorder), sexually inappropriate behaviors. The goal listed on the care plan was, Will have fewer episodes by review date. Facility staff listed the following interventions to help resident 71 achieve the stated goal: Administer medications as ordered. Monitor/document for side effects and effectiveness., Anticipate and meet needs., Approach in a calm manner., Document behaviors, and resident response to interventions., If reasonable, discuss behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable., Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed., Praise any indication of progress/improvement in behavior., Reward appropriate behavior as indicated. Review of the medical record revealed the following entries: a. 4/28/2016 14:29 (2:29 PM) Nursing Note Text: Res-Res #1 (Resident to Resident): The patient was struck by another resident on the left hand with a 'back-scratcher.' She was holding the hand of another male resident and it was that male's wife that struck her. The two were separated and the hand was assessed, no issues or injury was found and she denied pain to the site. Staff notified PA (Physician's Assistant) (name) and the patients emergency contact (name of resident 71's Emergency Contact). b. 1/28/2017 16:06 (4:06 PM) Nursing Note Text: Resident was in hall with her hands in another resident's pants. She gave some resistance to being separated stating that she thought it felt good to the other resident. Nurse separated residents and kept them separated. Notified (name) Daughter in law. She was surprised but had no adverse reaction. Review of incident reports revealed that facility staff completed an incident report for the 4/28/16 incident. No documentation could be found to show that facility staff completed an incident report for the 1/28/17 incident. On 5/9/17 at approximately 10:15 AM, resident 105's spouse was interviewed. Resident 105's spouse stated that she was the resident that hit resident 71 on the hand a year ago. Resident 105's spouse stated that she was living at the facility when the incident occurred but was not residing on the unit. Resident 105's spouse stated that resident 71 had, Her hands all over him and I could have killed her. Resident 105's spouse stated that the facility told her that they would keep resident 105 and resident 71 separated and keep resident 105 and resident 71 out of each other's rooms. Resident 105's spouse stated that seeing resident 105 like this was very hard for her and her children as he was not like this previously. Resident 105's spouse stated that she would hope that the facility was keeping them separated. Resident 105's spouse stated that she had refrained from visiting resident 105 for about two weeks due to the behavior with resident 71. Review of the incident report for the 4/28/16 incident revealed that facility staff had removed resident 105's spouse from the secured unit the day she had struck resident 71 and told resident 105's spouse she could not return until safety could be reestablished as violence was not tolerated. On 5/9/17 at approximately 6:00 AM, CNA 8 was interviewed. CNA 8 was observed to be working in the unit on 5/8/17 starting at 2:00 PM. CNA 8 stated that she had worked a double shift from 2:00 PM on 5/8/17 until 6:00 AM on 5/9/17. When asked about resident 105 and his behaviors towards female residents on the unit, CNA 8 stated that resident 105, Liked the ladies! On 5/9/17 at approximately 7:00 AM, CNA 4 was interviewed regarding resident to resident altercations. CNA 4 stated that the staff would separate residents and notify the nurse. When asked about resident 105, CNA 4 stated that resident 71 keeps resident 105 busy. On 5/9/17 at 7:35 AM, CNA 9 was interviewed. CNA 9 stated that resident 105 and resident 71 liked each other and liked to hold hands. CNA 9 further stated that she only came back to the unit to help with meals. CNA 9 stated that the unit was typically staffed with one CNA for the 14 residents residing on the unit. CNA 9 stated that the unit had a second CNA only during meal times. On 5/9/17 at 6:15 AM, Licensed Practical Nurse (LPN) 1 was interviewed. LPN 1 stated that if a resident to resident altercation or incident occurred, on the secured unit, she would write a progress note. LPN 1 stated that she did not need to fill out an incident report. LPN 1 stated that if resident 105 was observed with his arm around a female resident that she would, explain to him about the behavior because he understands. On 5/9/17 at 10:00 AM, the facility Assistant Director of Nursing (ADON) was interviewed. The ADON stated that she was working on 1/28/17, when resident 71 was observed to have her hands down resident 105's pants. The ADON stated that resident 71 was resistive to removing her hands and that resident 105 looked to be enjoying himself. The ADON stated that she had notified the former Administrator immediately regarding the incident and that she did not know if the incident had been investigated. The ADON stated that resident 105 and resident 71 were to be kept apart and that if incidents occurred between resident 105 and resident 71 the facility did not contact resident 105's spouse because those things just devastate her. On 5/8/17 an Agency nurse, who was assigned to work the secure unit, was interviewed. The Agency nurse stated that she did not know the patients back in the unit and would be unable to answer any questions regarding the residents. On 5/9/17, the facility Administrator and Interim Director of Nursing (DON) were interviewed. Both the Administrator and DON stated that all resident to resident incidents should be reported to Administration and an incident report should be completed. The DON stated that if a spouse of a resident was upset regarding sexually inappropriate behavior between two residents, the facility would move residents if needed and accommodate the wishes of the resident's spouse. Additionally, the DON stated that the incident on 1/28/17 should have been reported and investigated for consent. The DON further stated that determining consent in dementia residents could be difficult. On 5/9/17 the facility Resident Advocate (RA) was interviewed. The RA stated that she constantly had to complete training regarding abuse because the facility staff sometimes, get used to behaviors and don't report the behaviors. On 5/9/17 multiple observations were made of resident 105 wandering in the secure unit, in his wheelchair, with no staff oversight. The facility unit was observed to be left unattended from 8:55 AM until 9:06 AM. On 5/9/17 at approximately 9:10 AM, LPN 1 was observed to be administering medications to residents in the secure unit. While LPN 1 was administering medications, 15 feet away from resident 105, resident 105 was observed to attempt to enter resident room [ROOM NUMBER]. The resident residing in room [ROOM NUMBER] was observed to slam the door in resident 105's face. No observations were made of LPN 1 acknowledging the behavior or correcting the behavior.

Based on interview and medical record review it was determined, for 1 of 43 sample residents, that the facility did not provided services as outlined in the written plan of care. Specifically, one resident who required extensive two person assistance for transfers, was assisted by a family member which resulted in a distal tibia/fibula spiral fracture. Resident identifier: 25. Findings include: Resident 25 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 5/11/17 resident 25's medical record was reviewed. A nurse's note dated 10/26/16 revealed X-ray results back from tibia and fibula 2V (two views) Portable x-ray. Findings: Bones: Nondisplaced spiral [MEDICAL CONDITION] tibial shaft extending into the metaphysis. There also appears to be a subtle [MEDICAL CONDITION] fibular shaft Impression: Nondisplaced distal tibial shaft spiral fracture An incident report dated 10/26/16 and revised 10/31/16 revealed Daughter came to nurse and said she thinks that (Resident 25) hurt or fractured her right shin last night when she and one CNA (Certified Nursing Assistant) were transferring resident into bed. Resident denied pain this morning in bed but after being up in w/c (wheel chair) reports pain right shin. Right shin has some malformation to it and is red and warm. Resident stated that she felt pain in her shin when she was standing up last night Right leg assessed, some malformation, redness, warmth noted. Resident has [DIAGNOSES REDACTED]. Impression: Nondisplaced distal tibial shaft spiral fracture. Subtle distal fibular deformity consistent with a nondisplaced fracture An x-ray report dated 10/26/16 revealed Nondisplaced distal tibial shaft spiral fracture. Subtle fibular shaft deformity consistent with a nondisplaced fracture. An Annual MDS (Minimum Data Set) assessment dated [DATE] revealed that resident 25 required extensive two person assistance for transfers. A care plan dated 10/3/16 revealed the focus problem of Has limited physical mobility r/t weakness. The goal for resident 25 was Will remain free of complications related to immobility, including contractures, thrombus formation, skin breakdown, fall related injury though the next review date. The interventions included Staff assistance with mobility, transfers, toileting, ADLs (activities of daily living) as needed. On 5/10/17 at 9:12 AM, a telephone interview was conducted with resident 25's daughter. Resident 25's daughter stated that her sister had assisted CNA 11 with the transfer to the toilet on the night of 10/25/16 because there was nobody else around to help and mom requires two people to transfer. Resident 25's daughter stated that the facility needed more staff. Resident 25's daughter stated They are short on staff and that was why my sister helped transfer mom to the toilet. On 5/11/17 at 1:45 PM, an interview was conducted with the ADON (Assistant Director of Nursing). The ADON stated that the CNA involved in the incident, no longer worked at the facility. The ADON stated that the incident should have been investigated further, that there should have been two CNAs assisting resident 25 to the toilet and thought that they had talked with the family about not participating in transfers for resident 25. The ADON stated that every CNA, upon hire, had been inserviced by the therapy department about safe transfers and that the paperwork went into the employee file. (NOTE: No documentation could be located in CNA 11's employee file of any transfer inservicing with the therapy department.) On 5/11/17 at 2:58 PM, an interview was conducted with the facility DON (Director of Nursing). The facility DON stated that the incident should have been investigated and steps taken to educate the family as to the reasons why only facility staff should transfer the residents. The DON stated that they should have gotten a statement from the CNA involved in the transfer. On 5/12/17 at 4:04 PM, a call was placed to CNA 11. (NOTE: CNA 11 was the CNA who participated in the transfer with resident 25's daughter.) CNA 11 stated that the facility was frequently short staffed and that was the reason for the daughter assisting with the transfer of resident 25 on the night of 10/25/16. CNA 11 stated that she did not remember that resident 25 had fractured her leg.

Based on interview and medical record review it was determined, for 2 of 30 sample residents, that the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Specifically, residents receiving a prescription narcotic pain medication patch experienced the loss of the patch on multiple occasions. The residents waited extended periods of time before facility staff replaced the missing patches, causing the residents to have increased pain and begin to scream out due to the increased pain. Resident identifiers: 28 and 33. Findings include: 1. Resident 28 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 resident 28's medical record was reviewed. Review of resident 28's care plan revealed the following care plan dated 8/5/13: (Resident 28) is on Pain medication Therapy r/t (related to) TBI ([MEDICAL CONDITION]), OP ([MEDICAL CONDITION]), and chronic pain. Crying is her means to communicate pain. The goal listed on the care plan was for resident 28 to be free of any discomfort or adverse side effects from pain medication through the review date. Facility staff listed the following intervention to help resident 28 achieve the stated goal: Administer medication as ordered . Review of the physician's orders [REDACTED]. Additionally, physician's orders [REDACTED]. Facility staff were to notify the DON (Director of Nursing) if patch is missing and notify MD (medical doctor) immediately for order to replace patch. Review of resident 28's Medication Administration Record [REDACTED] A. May: 1. Facility staff documented on the May 2015 MAR indicated [REDACTED]. According to documentation, resident 28 was to have a new [MEDICATION NAME] placed on 5/8/15. Facility staff documented on the May MAR indicated [REDACTED]. Review of the Progress Notes revealed an entry dated 5/8/15. Facility staff documented the following: [MEDICATION NAME] Patch 72 Hour . not given, none in stock, ordered to pharmacy. Review of the May 2015 MAR indicated [REDACTED]. It should be noted that resident 28 went three days without the prescribed [MEDICATION NAME] pain medication. No documentation could be found to show that facility staff notified the physician regarding the unavailability of the [MEDICATION NAME] on May 8, 2015. B. June: 1. Facility staff documented on the June 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 6/6/15 15:45 (3:45 PM): Resident Pain patch missing, last documented placement was on 6/4/15. Notified MD (Medical Doctor), New Order to place new pain patch today and continue Q (every) 72 hours thereafter. Resident was distressed and grimacing, pain medication administered as order via gtube (gastrostomy tube). b. 6/6/15 16:23 (4:23 PM): FentNYL (sic) Patch 72 Hour 75 MCG/HR (micrograms per hour) Apply 1 application [MEDICATION NAME] one time only for pain . apply now and q 72 hours. grimacing. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and Director of Nursing (DON), about the missing narcotic pain medication patch. 2. Facility staff documented on the June 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. According to the documentation on the June 2015 MAR, facility staff did not apply resident 28's [MEDICATION NAME] until 6/27/15. It should be noted that resident 28 went 3 days without the prescribed [MEDICATION NAME] pain medication. No documentation could be found to show that facility staff notified the physician regarding the missed dose of [MEDICATION NAME] on 6/24/15. C. July: 1. Facility staff documented on the June 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entry dated 7/1/15: . on assessment [MEDICATION NAME] was not found. According to the July 2015 MAR indicated [REDACTED]. It should be noted that resident 28 went 3 days without the prescribed [MEDICATION NAME] pain medication. No documentation could be found to show that facility staff notified the MD for an order to place a new patch after discovering that the patch was missing on 7/1/15. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. 2. Review of the Progress Notes revealed the following entry dated 7/21/15 at 9:30 AM: . [MEDICATION NAME] missing, notified DON. Review of the July 2015 MAR indicated [REDACTED]. It should be noted that facility staff waited 12 hours to apply a new patch after discovering that the patch was missing. No documentation could be found to show that facility staff notified the MD for an order to place a new patch after discovering that the patch was missing on 7/21/15. D. August: 1. Facility staff documented on the August 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entry dated 8/9/15: . Patch was replaced on 8/7/15 NOC (night) shift. No documentation could be found to explain why the patch was replaced the day before it was due. No documentation could be found to show that the MD was notified regarding the change to resident 28's scheduled application of the [MEDICATION NAME]. According to August 2015 MAR indicated [REDACTED]. It should be noted that if resident 28 had a new patch applied on 8/7/15, facility staff should have applied a new patch on 8/10/15 per physician's instructions to replace the patch every 72 hours. E. October: 1. Review of the Progress Notes revealed the following entry dated 10/21/15: [MEDICATION NAME] that is on resident's R (right) chest is dated 10/16/15. Old patch removed and New patch applied to her left deltoid. Facility staff documented on the October 2015 MAR indicated [REDACTED]. No documentation could be found to show what happened to the [MEDICATION NAME] placed on 10/19/15 or why the patch from 10/16/15 was not removed on 10/19/15 prior to the application of the new patch. F. November: 1. Facility staff documented on the November 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 11/13/15 23:27 (11:27 PM): . missing patch. b. 11/15/15 22:57 (11:57 PM): . not due replaced on 11/14/15. Review of the November 2015 MAR indicated [REDACTED]. No documentation could be found to show that facility staff applied a [MEDICATION NAME] on 11/14/15 or applied a [MEDICATION NAME] after discovering that the patch was missing on 11/13/15. It should be noted that if the patch was missing on 11/13/15 and not replaced until 11/17/15, resident 28 went five days without the prescribed [MEDICATION NAME] pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. 2. Facility staff documented on the November 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 11/20/15 05:16 (5:16 AM): patch missing at 2200 (10:00 PM) last night (11/19/15), will apply new at 0600 (6:00 AM), on left back shoulder, DON to be notified. According to November 2015 MAR indicated [REDACTED]. It should be noted that facility staff did not apply the patch at 6:00 AM on 11/20/15 as per nurse documentation. Additionally, it should be noted that according to documentation, resident 28 went approximately 14 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. 3. Facility staff documented on the November 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 11/28/15 01:35 (1:35 AM): patch is missing from about 10 pm or after (on 11/27/15). b. 11/28/15 03:32 (3:32 AM): Missing from evening shift c. 11/29/15 19:59 (7:59 PM): Patch placement will be rescheduled due to replacement on 28th. No documentation could be found to show that facility staff applied a new patch to resident 28 on 11/28/15. According to December MAR indicated [REDACTED]. It should be noted that if the patch was missing on 11/27/15, per documentation, and not replaced until 12/2/15, according to documentation, then resident 28 went five days without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. G. December: 1. Facility staff documented on the December 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 12/4/15 22:36 (10:36 PM): Patch missing. DON notified. b. 12/5/15 01:03 (1:03 AM): Patch was missing at 2200 (10:00 PM) hours. c. 12/5/15 11:21 (11:21 AM): Patch is missing. d. 12/5/15 13:45 (1:45 PM): patch went missing on previous shift, resident was moaning in pain. new patch apply to left front shoulder. DON made aware. It should be noted that previous to the placement on 12/2/15, resident 28 had gone five days without the prescribed pain medication. After staff applied the patch on 12/2/15, the patch was in place for roughly 48 hours before it went missing again. Additionally, it should be noted that resident 28 waited 15 hours for staff to apply a new patch after discovering the patch missing on 12/4/15. Resident 28 was moaning in pain prior to staff applying the new patch. No documentation could be found to show that facility staff notified the MD regarding the missing patch. 2. Facility staff documented on the December 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 12/20/15 04:09 (4:09 AM): . could not locate. b. 12/21/15 00:58 (12:58 AM): [MEDICATION NAME] unavailable at this time. According to December 2015 MAR indicated [REDACTED]. It should be noted that resident 28 went 7 days without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the physician regarding the missed dose of [MEDICATION NAME] on 12/20/15 and 12/23/15. H. January: 1. Facility staff documented on the January 2016 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entries: a. 1/27/16 22:00 (10:00 PM): Missing b. 1/28/16 7:29 (7:29 AM): Missing On 2/2/16 at 11:40 AM, the facility Administrator and DON were interviewed. The DON stated that she had been employed with the facility since November of 2015. The DON stated that the first time she had been notified of the missing patches for resident 28 was on 1/28/16. The DON stated that when facility staff notified her of the missing patch, she obtained an order for [REDACTED]. The DON stated that when staff discovered that the pain patch was missing, facility staff should have obtained an order immediately from the physician to apply a new patch. The DON stated that resident 28 should not have waited the 12 hours, 14 hours, 3 days, 5 days, or 7 days before the patch was replaced. The DON and the Administrator both stated that the missing narcotic pain patches had not been reported to them by facility staff. 2. Resident 33 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 2/2/16 resident 33's medical record was reviewed. Review of resident 33's care plan revealed the following care plan dated 07/15/13: (Resident 33) is on pain therapy for chronic generalized pain. One of the goals listed on the care plan was for resident 33 to not display behaviors of inadequate pain control through the review date. Facility staff listed the following intervention to help resident 33 achieve the stated goal: Pain medication as ordered: [MEDICATION NAME] PRN (as needed). Review of the physician's orders [REDACTED]. Additionally, there was an order dated 7/21/15 for staff to check placement of [MEDICATION NAME] Q 4 hours. Review of the Medication Administration Records from June 2015 through February 2016 revealed the following entries: A. June: 1. Facility staff documented on the June 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of the Progress Notes revealed the following entry: a. 6/29/15 21:37 (9:37 PM): Unable to find patch. According to June 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 10 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. B. July: 1. Facility staff documented on the June 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of Progress Notes revealed the following entry: a. 7/1/15 07:34 (7:34 AM): [MEDICATION NAME] not in place this morning. Resident can remove when patch is within reach. According to July 2015 MAR indicated [REDACTED]. It should be noted that resident 33's patch was discovered to be missing approximately 24 hours after being applied. Additionally, resident 33 went approximately 48 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. 2. Facility staff documented on the July 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of Progress Notes revealed the following entries: a. 7/20/15 21:58 (9:58 PM): Patch is off. b. 7/21/15 15:28 (3:28 PM): The [MEDICATION NAME] that was place on 7/21/15 was last seen by the RN (Registered Nurse) caring for the patient at roughly 1100 (11:00 AM). When her blood shugar (sic) was checked at 1520 (3:20 PM) the RN also checked her back and the patch and clear dressing was not found. Her bedding and the surrounding area was also checked with out result. c. 7/21/15 16:28 (4:28 PM): At 1555 (3:55 PM) a new patch was placed and recorded by the floor RN. Check remain every 4 hours. According to July 2015 MAR indicated [REDACTED]. It should be noted that resident 33's patch was discovered on 7/21/15 to be missing approximately 6 hours after being applied. Additionally, resident 33 went approximately 12 hours without the prescribed narcotic pain medication from the time it was discovered missing on 7/20/15 until the new patch was applied on 7/21/15. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. C. August: 1. Facility staff documented on the August 2015 MAR indicated [REDACTED]. According to documentation, resident 33 was to have a new [MEDICATION NAME] placed on 8/11/15. Facility staff documented on the August MAR indicated [REDACTED]. Review of the Progress Notes revealed an entry dated 8/11/15. Facility staff documented the following: [MEDICATION NAME] Patch 72 Hour . Drug unavailable, pharmacy notified, awaiting on signed script from MD. MD notified. Will change patch once new ones received. Review of the August 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went three days without the prescribed [MEDICATION NAME] pain medication. D. September: 1. Facility staff documented on the September 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of Progress Notes revealed the following entries: a. 9/8/15 22:15 (10:15 PM): Patch is off. b. 9/9/15 01:11 (1:11 AM): Patch is off. c. 9/9/15 03:12 (3:12 AM): Not on. d. 9/9/15 07:28 (7:28 AM): Noc nurse reports [MEDICATION NAME] was wrinkled up and came off yesterday. No patches in stock at this time. Will notify pharmacy and don. e. 9/9/15 15:43 (3:43 PM): pain patch off. f. 9/10/15 15:15 (3:15 PM): Medication was reordered from the pharmacy. g. 9/11/15 12:37 (12:37 PM): No patch. According to September 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 64 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. 2. Facility staff documented on the September 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. According to September 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 72 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the physician regarding the missed dose of [MEDICATION NAME] on 9/23/15. E. October: 1. Facility staff documented on the October 2015 MAR indicated [REDACTED]. Review of Progress Notes revealed the following entry: a. 10/4/15 23:27 (11:27 PM): No Patch in place. It should be noted that the resident 33's narcotic pain patch was discovered to be missing approximately 16 hours after being applied. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. F. November: 1. Facility staff documented on the October 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of Progress Notes revealed the following entry: a. 10/30/15 09:49 (9:49 AM): Checked patch at 0800 and found patch to be rolled up into a ball and unable to stick to skin any more. Patch was removed by RN and wasted. According to November 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 72 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the physician regarding the missed dose of [MEDICATION NAME] on 10/31/15. G. December: 1. Facility staff documented on the December 2015 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Review of Progress Notes revealed the following entries: a. 12/28/15 00:03 (12:03 AM): Patch missing. b. 12/28/15 05:17 (5:17 AM): Missing. According to December 2015 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 13 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the MD regarding the missing patch. No documentation could be found to show that facility staff notified Administration, the Facility Administrator and DON, about the missing narcotic pain medication patch. H. January: 1. Facility staff documented on the January 2016 MAR indicated [REDACTED]. According to physician's orders [REDACTED]. Facility staff documented on the January MAR indicated [REDACTED]. Review of Progress Notes revealed the following entries: a. 1/18/16 11:41 (11:41 AM): Waiting for Pharmacy. b. 1/18/16 16:51 (4:51 PM): Not Available. According to January 2016 MAR indicated [REDACTED]. It should be noted that resident 33 went approximately 72 hours without the prescribed narcotic pain medication. No documentation could be found to show that facility staff notified the physician regarding the missed dose of [MEDICATION NAME] on 1/18/16.