Every finding on record at Coronado Healthcare Center

Based on observation, clinical record review, interviews, facility documentation, and policy, the facility failed to ensure wound care treatments were provided according to professional standards of practice and provider orders for one resident (#4) out of three sampled residents. The universe was 165. This deficient practice placed residents at risk for infection. Findings include:Resident #4 was admitted on [DATE], with diagnoses including third-degree burns of the left forearm and buttock, muscle weakness, and dysphagia.A Skin Check Assessment form dated July 9, 2026, revealed that skin issues were evaluated and locations were identified as follows:Left gluteus: Pressure ulcer measuring 3.4 cm (centimeters) length x 3.5 cm width x 0.1 cm depth. Dressings included antimicrobial and dry dressings with a treatment frequency of daily.Left inner forearm: Identified as other skin issue present on admission; however, there was no evidence of measurements or treatment provided.Right outer forearm: Identified skin issue (burn) measuring 28 cm length x 7.5 cm width x 0.1 cm depth. Treatment consisted of A&D ointment and Xeroform applied daily.A care plan dated July 10, 2026, revealed the following focus areas:Risk for infection related to wound care. Interventions included monitoring and documenting vital signs as ordered in the clinical chart.Presence of, or potential for, pressure ulcer development related to impaired cognition and burns of the left forearm, left wrist, and buttock. Interventions included administering treatments as ordered and monitoring for effectiveness.A skin check progress note dated July 10, 2026, indicated that the initial skin assessment was completed. Resident #4 had a pressure ulcer on the left gluteus measuring 3.4 cm length x 3.5 cm width x 0.1 cm depth, treated with antimicrobial and dry dressings. The assessment also identified a burn on the right outer forearm measuring 28 cm length x 7.5 cm width x 0.1 cm depth, with ordered treatment of A&D ointment and Xeroform.While the note documented a burn wound from the left forearm to the palm of the left hand with pink moist tissue and serous drainage, it failed to include wound measurements or specified treatments for the left arm/hand burn.A review of the current active physician orders revealed the following orders:Left buttock: Clean with wound cleanser, apply silver sulfadiazine, and cover with a dry dressing every day shift; start date July 11, 2026.Left forearm: Clean with wound cleanser, apply A&D ointment and Xeroform, and cover with a dry dressing every day shift; start date July 11, 2026.Further review of physician orders showed no evidence of treatment orders for the right outer forearm burn identified on the July 09, 2026, skin assessment.A review of the Treatment Administration Record (TAR) for July 2026 showed no evidence that the left buttock and left forearm received wound treatments as ordered on July 11, 2026 and July 14, 2026Progress notes dated July 11, 2026 and July 14, 2026, contained no evidence that wound treatments were provided for the left buttock or left forearm as ordered.Clinical record review confirmed Resident #4 was present in the facility and had no outside appointments on July 11 or July 14, 2026.A Medicare 5 day Minimum Data Set (MDS) assessment dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The assessment noted the resident had third-degree skin burns, with interventions including nonsurgical dressings, ointments, and medications.During an interview conducted on on July 17, 2026, at 11:08 a.m., a Licensed Practical Nurse (LPN, Staff #156) stated the facility's process for wound care requires a skin assessment upon admission, followed by provider notification and obtaining treatment orders. Upon reviewing the clinical record, the LPN confirmed the resident had active orders from July 11, 2026, for the left buttock (silver sulfadiazine) and left forearm (A&D/Xeroform). The LPN further acknowledged that the TAR for July 2026 showed no evidence that these treatments were provided on July 14, 2026, and stated that the failure to provide treatment increases the resident's risk for infection.During an interview conducted on July 17, 2026, at 11:53 a.m., a second Licensed Practical Nurse (LPN, Staff #78) stated the wound care process involved reviewing orders, gathering supplies, following infection control protocols, and documenting in the MAR/TAR post-treatment. The LPN reviewed Resident #4's clinical record and confirmed active orders existed for the left buttock and left forearm. The LPN stated there was no evidence the treatments were performed on July 14, 2026, could not explain the omission, and noted the risk of infection resulting from the failure to follow orders.During an interview conducted on July 17, 2026, at 2:08 p.m., the Director of Nursing (DON, Staff #228) stated that the facility process is to monitor, assess, and treat according to physician orders. The DON confirmed the resident's diagnoses and the active orders for the left buttock and forearm. After reviewing the July 2026 TAR, the DON stated that the treatments were not performed or documented on July 14, 2026. The DON further noted that the failure to perform treatments as ordered results in a risk of infection and that missing documentation constitutes a documentation error.A facility policy titled, Administration of Medications and Fluids, Intravenous, reviewed on August, 2025, revealed that medications must be administered in accordance with the written orders of the attending physician. The policy further revealed that all current drugs and dosage schedules must be recorded on the resident electronic medication administration record (eMAR).

Based on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to update and revise care plans for two residents (Residents #21 and #56). The deficient practice can result in inaccurate monitoring of a resident's medical conditions and care, which are necessary to achieve the resident's health and well-being goals. The universe was 180. Findings Includes: Regarding Resident #21: Resident #21 was admitted to the facility on [DATE], with diagnoses of multiple sclerosis, bipolar disorder, anxiety disorder, and cognitive communication deficit. The Minimum Data Set (MDS) dated [DATE], revealed the resident had limited range of motion in the lower extremities and was dependent on staff for toileting hygiene, bathing, upper and lower body dressing, putting on and taking off footwear, and personal hygiene. The MDS dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. On September 16, 2024, a complaint was filed with the State Agency (SA) regarding Resident #21. The complainant stated the resident had telephoned 911 and requested a brief change, and noted the resident had a history of this. However, review of the care plan dated January 5, 2022, with revisions, did not include the resident behavior of calling 911 for brief change. An interview was conducted on January 28, 2026, at 12:46 PM with Certified Nursing Assistant (CNA, staff #159). She stated resident #21 experiences anxiety and sundowning every evening. When the resident requires assistance, she thinks she has pressed her call button but has actually pressed the remote for the bed controls. So, in a panic she dials 911. The CNA stated this is a behavior that the Resident had and that brief changes are completed frequently. An interview was conducted on January 28, 2026, at 1:51 PM with the acting Director of Nursing (DON, staff #105). She stated residents exhibiting behaviors are always documented in the care plan. Otherwise, clinical staff would not know what the behaviors are. An interview was conducted on January 28, 2026, at 2:42 PM with CNA (staff #250). She stated resident #21 has a behavior of calling 911 for brief changes, however because of the resident's confusion she forgets the staff were just in the room and completed a brief change. When the resident does call 911, the operator will call the facility and check with the clinical staff to ensure if the resident requires emergency services. Regarding Resident #56: Resident #56 was admitted on [DATE], with the diagnosis that included epilepsy, unspecified, not intractable, without status epilepticus; traumatic brain compression with herniation, subsequent encounter, alcohol abuse, in remission; alcoholic cirrhosis of liver without ascites; thrombocytopenia, unspecified, essential (primary) hypertension; unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, unspecified; unspecified mood [affective] disorder; major depressive disorder, single episode, moderate; anddepression, unspecified. A care plan focus with the initiation date of June 3, 2023, revealed that Resident #56 had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI (traumatic brain injury), and to wear a helmet out of bed. There was no evidence in Resident #56's care plan that indicate that Resident #56 refused to utilize the helmet, or that the usage of the helmet was to be discontinued. An active order entry dated June 6, 2023, revealed that Resident #56 was to wear a helmet when out of bed; the entry further revealed that the type of order was a standard treatment (TAR). A physician's progress note dated January 9, 2026, revealed that Resident #56 is to utilize a helmet out of bed. A quarterly therapy screen progress note dated January 13, 2026, revealed no indication of Resident #56's refusal to apply the helmet out of bed, or the discontinuance of the utilization of the helmet out of bed. A quarterly MDS (minimum data set) assessment dated [DATE], revealed that Resident #56 had a BIMS (brief interview of mental status) score of 10, indicating moderate cognitive impairment and a higher likelihood of requiring assistance with daily activities. The assessment also revealed that, within the last 7 days before the completion of the assessment, Resident #56 did not exhibit behaviors of rejection of care that are necessary to achieve the resident's goals for health and well-being. A physician's progress note dated January 19, 2025, revealed that Resident #56 is to utilize a helmet out of bed, and that Resident #56 refuses to. There is no evidence that the helmet usage for Resident #56 had been discontinued. On January 27, 2026, at 9:00 AM, an observation of Resident #56 was made during the initial interview conducted on survey day one, where Resident #56 had been standing in their room, out of bed, without a helmet on. A helmet had been located on a night stand located against the wall of the head of the bed. The same wall had also been observed with a sign that stated 'HELMET ON AT ALL TIMES OUT OF BED'. During this observation, Resident #56 stated that the staff had helped him put the helmet on in the past. Following this interview and initial observation, a nurse walked into Resident #56's room to administer medications at approximately 9:31 AM. It was observed that this nurse did not assist the Resident with the application of the helmet. At 9:38 AM, Resident #56 was observed walking out of his room without a helmet applied to his head. On January 28, 2026, at 10:21 AM, Resident #56 is observed in the activities room with no helmet applied to his head. Another observation on January 28, 2026, at 12:07 PM, where Resident #56 is observed getting up from his seat in the dining room following the completion of their meal, to walk around the room, and then walked out of the dining room. Following this observation, an interview was conducted with Resident #56. During this interview, Resident #56 shared the extent of their traumatic brain injury and stated that he would need to be careful with his ambulation due to the possibility of re-injury. Resident #56 stated that he was aware of the signage on the wall located at the end of their bed, and that he had staff assist him with the application of the helmet when he need it. On January 29, 2026, at 10:31 AM, Resident #56 is observed walking out of the dining room without a helmet applied to his head. An interview was conducted on January 29, 2026, at 10:31 AM, with an LPN (licensed practical nurse/Staff #203), who stated that they have provided care to Resident #56, and stated that Resident #56 has a history of seizures, that he has seizure medications been administered, and that he has had seizures while at the facility. Staff #203 reviewed the medical record of Resident #56, and stated that they had been unsure as to why Resident #56 required helmet usage when out of bed, and had not seen Resident #56 wear the helmet during her time working on the hall Resident #56 resided on. Staff #203 stated that with Resident #56's history of seizures and TBI, Resident #56 had the risk of re-injury if he did not wear his helmet as ordered. At this time of the interview, an observation was made of Resident #56's room with Staff #203, which identified the signage to wear the helmet when out of bed, located on the wall at the end of Resident #56's bed, and the helmet located on the nightstand under the signage, against the wall that the signage is located on. Staff #203 stated that they would need to review the chart of Resident #56 for further assessment of helmet usage. An interview was conducted on January 29, 2026, at 10:57 AM, with a CNA (certified nursing assistant/Staff # 9), who stated that they have provided care to Resident #56 before, and, that Resident #56 used to wear it more frequently when they first arrived to the facility, however, was unable to determine why Resident #56 stopped wearing it, and why the resident should have been wearing it. A secondary interview with Staff #203 was conducted at 1:40 PM, with an additional staff member (charge nurse/Staff #121) during an observation of Resident #56's room, where the signage located on the wall at the end of the bed of Resident #56 was no longer located. Staff #121 stated that they were unsure why the signage was taken down and that if helmet usage were to be discontinued, that would be at the discretion of therapy, and then the signage would be removed. Following the observation of Resident #56's room, Staff #203 once again stated that they were unsure that Resident #56 had a helmet to be worn and that the Resident's risk of not wearing an ordered helmet would be further head injury and seizures. Staff #203 also stated that if a resident should refuse treatment, such as a helmet, that is to be documented on the MAR/TAR (medication administration record/treatment administration record), and to ensure the charge nurse is aware of the refusal. Staff #203 stated that the facility expects to ensure documentation of refusals is documented in a resident's chart, and that residents do have the right to refusal of treatment, and to provide re-education on the treatment intervention and the risk of not completing the ordered treatment. Regarding Resident #56, Staff #203 could not locate the treatment on the MAR/TAR and stated that the appliance, such as a helmet, would be a treatment that would be documented on a MAR/TAR. Staff #203 also stated that they were unaware of the signage located in Resident #56's room, and that Resident #203 had been ordered to utilize a helmet out of bed. Staff #203 stated that if the documentation regarding the refusal of treatment is not accurate and documented within the health records, it poses the risk that the care plan team would not be able to adequately update Resident #56's care plan as necessary to achieve the resident's goals for health and well-being. A secondary interview was conducted with Staff #9 at 1:56 PM, who stated that they were aware of the signage in Resident #56's room, but had expressed uncertainty regarding when the signage had been originally put up on the wall in Resident #56's room. Staff #9 also stated that she had assumed that therapy discharged the order due to the resident no longer wearing the helmet. Staff #9 also stated that they had not been informed of the helmet usage, and had not been informed if the helmet usage had been discontinued. Staff #9 also stated that they have never assisted Resident #56 with putting on the helmet or with further education on why he should wear the helmet, due to not being told to do so. Staff #9 stated that the risk of not applying an ordered helmet and not documenting any usage, refusals, or if it had been discontinued can put a resident at further risk for additional injuries, the possibility of an inadequate healing process, the lack of protection to the resident's head, and the lack of communication of a resident's care. An interview was conducted on January 30, 2026, at 11:41 AM, with the director of rehabilitation services (Staff #213), who stated that the facility's expectations regarding physical appliances, including helmets, is that the facility's therapy services are trained individuals to assess, and provide additional training to the residents and the floor staff regarding the usage of the physical appliances. Staff #213 stated that each resident undergoes an assessment for proper and adequate usage of appliances, and ensures the appliances can be put on and taken off. Staff #213 also stated that any caretaker can apply on a helmet for a resident, and receives training from therapy services when a helmet has been ordered for a resident. Regarding Resident #56, Staff #213 stated that therapy services did work with the resident at some point during their stay. Staff #213 reviewed the medical records of Resident #56 and stated that Resident #56 underwent assessment and education regarding his helmet during his occupational therapy session. Staff #213 stated that Resident #56 underwent therapy for active range of motion of the right shoulder, full shower routine, strength, fine motor skills, and upper extremities. Staff #213 also stated that a part of his occupational therapy services included being able to put on and take off a helmet, and stated that there had been modifications to his ordered helmet to allow easier accessibility to put on and take off. Staff #213 stated that Resident #56 had been discharged from therapy services, with the expectation to continue the usage of the helmet out of bed, and to have floor staff queue Resident #56 to get ready for the day, and to utilize the helmet. Staff #213 also stated that Resident #56 had been in a unit that required constant supervision, and the ability to cue the resident for helmet usage should not have been an issue. Staff #213 also stated that floor staff would have been able to apply the helmet back on for the resident if observed off. Staff #213 had also stated that should a physical appliance be discontinued from a resident's care, it would be documented in a resident's chart, and if the helmet had been discontinued from Resident #56's care and services, it was not evident in Resident #56's charts. Staff #213 further stated that the risk of not utilizing an ordered helmet can put a resident at risk for further injury, as well as worsening medical conditions. Staff #213 also stated that the risk of inadequate documentation of a resident's treatment implementation, or documentation of a discontinued physical appliance such as a helmet, can provide inaccurate documentation of the current status of a resident's care, and inaccurate care planning. An interview was conducted on January 30, 2026, at 12:20 PM, with the interim DON (Director of Nursing/Staff #122), who stated that the facility is expected to follow the physician's orders as written by the provider. Staff #122 also stated that care plans are to be updated quarterly and as needed to provide patient-specific care. Staff #122 also stated that documentation of the completion of orders and care plan interventions should be done according to the facility's system in place to ensure that staff are able to paint a picture of the care a resident is to receive. Staff #122 also stated that should a resident refuse care and services, staff is expected to document the refusal of the care, update the resident's care plan regarding the refusal of treatment, and ensure the providers are aware of the refusal for necessary changes to care. Regarding Resident #56, Staff #212 reviewed the care plan for Resident #56 and stated that there had been a note within the care plan that stated that Resident #56 refused to utilize their care plan. However, the reviewed care plan retrieved from Resident #56's electronic health record on January 28, 2026, did not include the note that the resident refused to utilize the helmet. Both care plans were reviewed side by side by Staff #212, and she stated that she was unsure what had happened with the documentation discrepancy. Staff #212 stated that the floor staff had access to view and review Resident #56's electronic health record and care plan regarding the usage of the helmet out of bed. Staff #212 also stated that the documentation of the helmet should have been determined by the facility, and, to include the refusal of the usage of the helmet, so that the provider is aware of the refusal. Staff #212 also stated that if a sign were in place in the resident room, the expectation of staff would have been to educate and encourage Resident #56 with cues to wear the helmet and to document any refusals. A policy titled 'Comprehensive Person-Centered Care Planning', last revised in April of 2024, revealed that in the event a resident refused certain services posing a risk to the resident's health and safety, the comprehensive care plan will identify care or service declined, the associated risks; and the interdisciplinary team's efforts to educate the resident and the resident representative and any alternate means to address the risks. A policy titled 'Documenting and Charting', last reviewed in July of 2024, revealed that it is the policy of the facility to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. The policy also revealed that it is the policy of the facility to provide the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.

Based on observations, facility documentation, staff and resident interviews, and the facility policy and procedures, the facility failed to provide an ongoing program of activities designed to meet the interest and the physical, mental, and psychological well-being of one resident (Resident #15). The sample was three residents and the universe is 191 residents. The deficient practice could result in a decline in physical, mental, and social skills. Findings include: Resident #15 was admitted to the facility on [DATE] with diagnoses that include, Chronic Obstructive Pulmonary Disorder (COPD), unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, bipolar disorder, and anxiety. Review of the comprehensive care plan initiated on August 5, 2021 revealed a focus indicating Resident #15 participates in activities with assistance such as bingo and ice cream social. Interventions include invite to scheduled activities, provide activities calendar monthly, and establish and record a prior level of activity involvement and interests by talking with resident, caregivers, and family on admission and as needed. Further review of the care plan revealed a focus for elopement risk/wanderer related to impaired safety awareness, dementia, and anxiety. Interventions include providing structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. Further review of the care plan revealed a focus for psychotropic medications use related to bipolar disorder with psychotic features. Interventions include, non-pharmalogical interventions (NPI) done: back rub, redirection, speak to/approach in a calm manner, reposition, provide a quiet environment, and take to activities. Review of the most recent quarterly minimum data set (MDS) dated [DATE] revealed Resident #15 had a brief interview for mental status (BIMS) score of 9, indicating a moderate cognitive impairment. Additionally, Resident #15 had a score of 13 on the Resident Mood Interview indicating Resident #15 was moderately depressed and reported sometimes feeling socially isolated. Further review of the MDS revealed Resident #15 required maximum assistance with toileting, bathing, and transfers to and from the wheelchair. Further review of the MDS revealed Resident #15 to be taking scheduled antipsychotic and psychotropic medications with clinical indication. Review of the social activity task log for the dates of December 29, 2025 through January 29, 2026 which included activities such as; bingo, games, T.V., snack socials, story time, exercise, and smoking, revealed two days out of thirty days marked for activity participation. An observation was conducted on January 28, 2026 at 10:08am of Resident #15 located outside of his room in the hallway with no observed staff nearby. Resident #15 was observed to be in his wheelchair at this time. Residents were observed in the common area of the secured unit with one staff present. The television was playing a movie at a loud volume and several residents were staring at the wall. An observation was conducted on January 28, 2026 at 2:35pm. Resident #15 was not observed to be in the common area of the secured unit where the scheduled ice cream social was to be held. At the observed time, no activities were being held. An observation was conducted on January 29, 2026 at 9:42am. Eight residents were observed in the common area while two staff members were observed in the secluded nursing desk conversing with each other. The television was on however, no staff interaction, structured activities, or resident socialization were observed. On January 29, 2026 at 10:32 am., Resident #15 was observed in bed with covers drawn, and lights off. An interview was conducted on January 30, 2026, at 9:58 a.m. with the Activity Director (Staff #279). Staff #279 stated that she currently only has one staff member, a Certified Nursing Assistant (CNA) who is on light duty, working on Mondays, Tuesdays, and Wednesdays. Staff #279 further stated that there is no activities staff on the weekends and that CNAs are expected to hold activities on the weekends. Staff #279 stated that she brings over residents from the secured unit whom she knows will not try to elope or wander, and that CNAs on the secured unit will play games with residents who cannot attend scheduled activities. Staff #279 stated that the CNAs will set up games for residents on the secured unit and will sometimes stay through their lunch to assist. When asked, Staff #279 stated that she does not have enough staff to hold the activities she wants to do. She further stated that if she had a full-time assistant, she could prioritize providing one-on-one activities and indicated that residents' social skills and behaviors would improve greatly. Staff #279 also stated that the few minutes she is able to sit with residents is not enough. Staff #279 stated that activity participation is documented in Point of Care (POC) and that she was recently told by a previous Director of Nursing that she must also keep paper documentation of participation. Staff #279 stated that she did not document, and was not trained to document, when a resident refused, was out of the building, or when activities were not applicable.Review of the paper activity participation logs for December 2025 and January 2026 which were provided by Staff #279 revealed Resident #15 was not documented to be in attendance for the month of January 2026. Resident #15 activity participation was documented once for the month of December 2025.Review of the December 2025 and January 2026 activity calendars for both the secured unit and non-secured unit revealed the only activities scheduled are a mix of bingo, coffee social, woodworking, table games, and open activities. Activity calendars for both the secured and non-secured units revealed that the scheduled activities were identical for both units and did not reflect individualized or unit specific programming for residents on the secured unit. An observation was made on January 30, 2026, at 10:57 am in the secured unit common area. Two CNAs entered the room at 11:17 a.m. and did not interact with any residents. They sat in the small area designated for nursing staff. One resident was observed sitting in the corner of the room yelling, and the television was on however, no residents were observed engaging with the television or participating in any activity.An interview was conducted on January 30, 2026, at 11:20 am with two CNAs (Staff #114 and Staff #28). Staff #114 stated that there is no set time for activities in the secured unit and that CNAs provide activities if they have time. Staff #28 stated that they still have their own work to do, which is providing resident care. Staff #114 stated that they do not document the activities they do and that they do them on their own time so the residents have something to do.Review of the policy titled Delivery of Activity Services last revised in July 2007 and last reviewed in February 2024 revealed, should a resident be considered medically or mentally incompetent, or physically unable to participate in such programs, an entry will be made in the resident's medical record (chart) stating fully the reason(s) for the restriction(s). Such an entry will be signed and dated by the person recording such data. Further review of the policy revealed, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.

Based on a review of the clinical record, staff interviews, and a review of policies and procedures, the facility failed to ensure that the physician's orders were implemented per professional standards for one resident (Resident #56). The deficient practice can result in inaccurate monitoring of a resident's medical conditions and care, which are necessary to achieve the resident's health and well-being goals. The universe was 180. Findings include:Resident #56 was admitted on [DATE], with the diagnosis that included epilepsy, unspecified, not intractable, without status epilepticus; traumatic brain compression with herniation, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety; anxiety disorder, unspecified; unspecified mood [affective] disorder and major depressive disorder.A care plan focus with the initiation date of June 3, 2023, revealed that Resident #56 had an activities of daily living self-care performance deficit related to activity intolerance, fatigue, confusion, and TBI (traumatic brain injury), and to wear a helmet out of bed. There was no evidence in Resident #56's care plan that indicated that Resident #56 refused to utilize the helmet or that the usage of the helmet was to be discontinued.An active order entry dated June 6, 2023, revealed that Resident #56 was to wear a helmet when out of bed; the entry further revealed that the type of order was a standard treatment (TAR).A physician's progress note dated January 9, 2026, revealed that Resident #56 is to utilize a helmet out of bed.A quarterly therapy screen progress note dated January 13, 2026, revealed no indication of Resident #56's refusal to apply the helmet out of bed, or the discontinuance of the utilization of the helmet out of bed.A quarterly MDS (minimum data set) assessment dated [DATE], revealed that Resident #56 had a BIMS (brief interview of mental status) score of 10, indicating moderate cognitive impairment and a higher likelihood of requiring assistance with daily activities. The assessment also revealed that, within the last 7 days before the completion of the assessment, Resident #56 did not exhibit behaviors of rejection of care that are necessary to achieve the resident's goals for health and well-being.A physician's progress note dated January 19, 2025, revealed that Resident #56 is to utilize a helmet out of bed, and that Resident #56 refuses to. There is no evidence that the helmet usage for Resident #56 had been discontinued.On January 27, 2026, at 9:00 AM, an observation of Resident #56 was made during the initial interview conducted on survey day one, where Resident #56 had been standing in their room, out of bed, without a helmet on. A helmet had been located on a night stand located against the wall of the head of the bed. The same wall had also been observed with a sign that stated 'HELMET ON AT ALL TIMES OUT OF BED'. During this observation, Resident #56 stated that the staff had helped him put the helmet on in the past.Following this interview and initial observation, a nurse walked into Resident #56's room to administer medications at approximately 9:31 AM. It was observed that this nurse did not assist the Resident with the application of the helmet. At 9:38 AM, Resident #56 was observed walking out of his room without a helmet applied to his head.On January 28, 2026, at 10:21 AM, Resident #56 is observed in the activities room with no helmet applied to their head.Another observation on January 28, 2026, at 12:07 PM, where Resident #56 is observed getting up from his seat in the dining room following the completion of their meal, to walk around the room, and then walked out of the dining room. Following this observation, an interview was conducted with Resident #56. During this interview, Resident #56 shared the extent of their traumatic brain injury and stated that they would need to be careful with their ambulation due to the possibility of re-injury. Resident #56 stated that he was aware of the signage on the wall located at the end of their bed, and that he had staff assist them with the application of the helmet when needed.On January 29, 2026, at 10:31 AM, Resident #56 is observed walking out of the dining room without a helmet applied to his head.Review of medical record lacked evidence that the physician-order to wear helmet when out of bed was implemented, and lacked documentation of resident refusal.An interview was conducted on January 29, 2026, at 10:31 AM, with an LPN (licensed practical nurse/Staff #203), who stated that they have provided care to Resident #56, and stated that Resident #56 has a history of seizures, that he has seizure medications been administered, and that he has had seizures while at the facility. Staff #203 reviewed the medical record of Resident #56, and stated that they had been unsure as to why Resident #56 required helmet usage when out of bed, and had not seen Resident #56 wear the helmet during her time working on the hall Resident #56 resided on. Staff #203 stated that with Resident #56's history of seizures and TBI, Resident #56 had the risk of re-injury if he did not wear his helmet as ordered. At this time of the interview, an observation was made of Resident #56's room with Staff #203, which identified the signage to wear the helmet when out of bed, located on the wall at the end of Resident #56's bed, and the helmet located on the nightstand under the signage, against the wall that the signage is located on. Staff #203 stated that they would need to review the chart of Resident #56 for further assessment of helmet usage.An interview was conducted on January 29, 2026, at 10:57 AM, with a CNA (certified nursing assistant/Staff # 9), who stated that they have provided care to Resident #56 before, and, that Resident #56 used to wear it more frequently when they first arrived to the facility, however, was unable to determine why Resident #56 stopped wearing it, and why the resident should have been wearing it.A secondary interview with Staff #203 was conducted at 1:40 PM, with an additional staff member (charge nurse/Staff #121) during an observation of Resident #56's room, where the signage located on the wall at the end of the bed of Resident #56 was no longer located. Staff #121 stated that they were unsure why the signage was taken down and that if helmet usage were to be discontinued, that would be at the discretion of therapy, and then the signage would be removed. Following the observation of Resident #56's room, Staff #203 once again stated that they were unsure that Resident #56 had a helmet to be worn and that the Resident's risk of not wearing an ordered helmet would be further head injury and seizures. Staff #203 also stated that if a resident should refuse treatment, such as a helmet, that is to be documented on the MAR/TAR (medication administration record/treatment administration record), and to ensure the charge nurse is aware of the refusal. Staff #203 stated that the facility expects to ensure documentation of refusals is documented in a resident's chart, and that residents do have the right to refusal of treatment, and to provide re-education on the treatment intervention and the risk of not completing the ordered treatment. Regarding Resident #56, Staff #203 could not locate the treatment on the MAR/TAR and stated that the appliance, such as a helmet, would be a treatment that would be documented on a MAR/TAR. Staff #203 also stated that they were unaware of the signage located in Resident #56's room, and that Resident #203 had been ordered to utilize a helmet out of bed. Staff #203 stated that if the documentation regarding the refusal of treatment is not accurate and documented within the health records, it poses the risk that the care plan team would not be able to adequately update Resident #56's care plan as necessary to achieve the resident's goals for health and well-being.A secondary interview was conducted with Staff #9 at 1:56 PM, who stated that they were aware of the signage in Resident #56's room, but had expressed uncertainty regarding when the signage had been originally put up on the wall in Resident #56's room. Staff #9 also stated that she had assumed that therapy discontinued the order due to the resident no longer wearing the helmet. Staff #9 also stated that they had not been informed of the helmet usage, and had not been informed if the usage of the helmet had been discontinued. Staff #9 stated that the risk of not applying an ordered helmet and not documenting any usage, refusals, or discharges can put a resident at further risk for additional injuries, the possibility of an inadequate healing process, the lack of protection to the resident's head, and the lack of communication of a resident's care.An interview was conducted on January 30, 2026, at 11:41 AM, with the director of rehabilitation services (Staff #213), who stated that the facility's expectations regarding physical appliances, including helmets, is that the facility's therapy services are trained individuals to assess, and provide additional training to the residents and the floor staff regarding the usage of the physical appliances. Staff #213 stated that each resident undergoes an assessment for proper and adequate usage of appliances, and ensures the appliances can be put on and taken off. Staff #213 also stated that any caretaker can apply on a helmet for a resident, and receives training from therapy services when a helmet has been ordered for a resident. Regarding Resident #56, Staff #213 stated that therapy services did work with the resident at some point during their stay. Staff #213 reviewed the medical records of Resident #56 and stated that Resident #56 underwent assessment and education regarding his helmet during his occupational therapy session. Staff #213 stated that Resident #56 underwent therapy for active range of motion of the right shoulder, full shower routine, strength, fine motor skills, and upper extremities. Staff #213 also stated that a part of his occupational therapy services included being able to put on and take off a helmet, and stated that there had been modifications to his ordered helmet to allow easier accessibility to put on and take off. Staff #213 stated that Resident #56 had been discharged from therapy services, with the expectation to continue the usage of the helmet out of bed, and to have floor staff queue Resident #56 to get ready for the day, and to utilize the helmet. Staff #213 also stated that Resident #56 had been in a unit that required constant supervision, and the ability to cue the resident for helmet usage should not have been an issue. Staff #213 also stated that floor staff would have been able to apply the helmet back on for the resident if observed off. Staff #213 reviewed the orders of Resident #56 and stated that the order states to wear the helmet out of bed, which indicates that if the resident's head is not supported, such as out of bed, or sitting at the side of his bed, the helmet should be on. Staff #213 also stated that it's the responsibility of the nursing staff to ensure this is being done, and that it should be documented on the MAR/TAR, expressed uncertainty of reach administration record that staff are to utilize, as that is the responsibility of the nursing staff. Staff #213 had also stated that should a physical appliance be discontinued from a resident's care, it would be documented in a resident's chart, and if the helmet had been discontinued from Resident #56's care and services, it was not evident in Resident #56's charts. Staff #213 further stated that the risk of not utilizing an ordered helmet can put a resident at risk for further injury, as well as worsening medical conditions. Staff #213 also stated that the risk of inadequate documentation of a resident's treatment implementation, or documentation of a discontinued physical appliance such as a helmet, can provide inaccurate documentation of the current status of a resident's care, and inaccurate care planning.An interview was conducted on January 30, 2026, at 12:20 PM, with the interim DON (Director of Nursing/Staff #122), who stated that the facility is expected to follow the physician's orders as written by the provider. Staff #122 also stated that care plans are to be updated quarterly and as needed to provide patient-specific care. Staff #122 also stated that documentation of the completion of orders and care plan interventions should be done according to the facility's system in place to ensure that staff are able to paint a picture of the care a resident is to receive. Staff #122 also stated that should a resident refuse care and services, staff is expected to document the refusal of the care, update the resident's care plan regarding the refusal of treatment, and ensure the providers are aware of the refusal for necessary changes to care. Regarding Resident #56, Staff #212 reviewed the medical records and confirmed that Resident #56 had an active order to utilize his helmet out of bed, and had also stated that the order had not been discontinued, indicating that the order is active, and if there had been a discussion for a discontinuance. Staff #212 stated that the expectation was to have the order discontinued on the resident's electronic health record if that had been the discussion to do so. Staff #212 then stated that whether or not the Resident #56 is wearing the helmet or not wearing the helmet, the lack of an accurate order in place did not depict if an order should be in place or not, and the overall care of the resident is being completed. Staff #212 also stated that the documentation of the helmet should have been determined by the facility, and, to include the refusal of the usage of the helmet, so that the provider is aware of the refusal. Staff #212 also stated that if a sign were in place in the resident room, the expectation of staff would have been to educate and encourage Resident #56 with cues to wear the helmet and to document any refusals.A policy titled 'Documenting and Charting', last reviewed in July of 2024, revealed that it is the policy of the facility to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care. The policy also revealed that it is the policy of the facility to provide the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident.A policy titled 'Physicians Orders', last reviewed in August of 2025, revealed that it is the policy of the facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. The policy also revealed that medication, treatment or related procedure orders are transcribed in the eMAR and eTAR accordingly.

Based on staff interviews, observations, and review of facility policies and procedures ,the facility failed to ensure food was stored within appropriate guidelines. The deficient practice could increase the risk for foodborne illness. The facility census was 191 and the survey sample size was thirty-five.During the initial kitchen observation conducted on January 27, 2026 at 8:21am, food debris was noted in the dry storage area, under the bottom shelf. It appeared to dry, crumblike items. The dietary manager #42 also observed the debris and stated that it could possibly draw vermin to the area. He also stated that their procedure is that dishwashing staff are responsible for sweeping and mopping all floors after every meal, including this dry storage area.During this same initial tour, the refrigerator was observed and the following items noted: one individual plastic cup of applesauce with a loosened snap-on type lid that was open approximately 1/4 inch, exposing it to air. Three sheet cakes were found in the back of the refrigerator on separate shelves. These cakes were uncovered, exposed to air, and undated. Also observed were undated tubes of ground beef in their original packaging, and one open block of cheese, exposed to air and undated.In this initial observation, three sheet trays of uncovered burger patties were seen in the freezer. There were a total of ninety patties in single layers with a sheet of wax paper between trays, all exposed to air. The dietary manager #42 stated they were being removed from the freezer for resident lunches on this date. One opened and undated bag of frozen egg rolls were also seen exposed to air. Staff #42 stated that these practices could allow foodborne illness potential.When the door of the ice machine was lifted, debris particles were seen on the rubber rims. These particles appeared gray and wet. The dietary manager #42 stated this area need cleaning.During a second kitchen observation on January 28, 2026 at 9:10am, the unit refrigerators were examined. On the 500 wing, spilled liquid appearing similar to yogurt was noted on the bottom shelf. Staff #42 also observed the spill and stated that his staff come daily at 2pm to clean all unit refrigerators.After observing the tray line on January 28, 2026, the last unit tray cart was followed. The test tray temperatures were measured by staff #42. The chicken [NAME] measured 120 degrees. the mixed vegetables read 115 degrees, but an accurate reading was not achieved on this food item as it was impossible to maintain a discrete pile for the thermometer to enter. the baked bread pudding measured 120 degrees.On January 29, 2026 at 1:20pm, dietary manager #42 stated that sweeping and mopping are done after lunch and at night (the kitchen closes at 8pm). They do not clean after breakfast due to how busy they are at that time. Staff #42 also stated that he is responsible for overseeing that these tasks are completed.The facility's Resident/Personal Food Storage policy was reviewed and stated: Food storage areas shall be clean at all times.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident's (#30) rights were honored with notification of changes of condition to the resident's legal guardian. The deficient practice could result in a legal guardian not being aware of a resident's condition, and unable to participate in medical decision-making on behalf of the resident. -Findings include: Resident #30 was re-admitted to the facility on [DATE], with diagnoses that included acute on chronic congestive heart failure, chronic obstructive pulmonary disease, type 2 diabetes mellitus, chronic kidney disease, unspecified dementia, and dysphagia. A Letter and Acceptance of Permanent Guardianship, provided to the State Agency, dated April 25, 2024, revealed Resident #30 was appointed a permanent legal guardian by the court. An Advance Directive Statement dated June 25, 2024, revealed verbal consent from the resident's Public Fiduciary for the resident's care directives. An admission minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, indicating severely impaired cognition. A patient profile banner in the resident's electronic medical record revealed Resident #30 has a legal guardian, with a phone contact. A care plan dated June 25, 2024, revealed the resident is at risk for impaired cognitive function / dementia or impaired thought processes. There was no evidence of any intervention to include communication with the resident's legal guardian. A Case Manager note dated June 26, 2024, revealed case management followed up with a call to the resident's emergency contact, and they informed the name of the Public Fiduciary. An additional Case Manager note dated June 26, 2024, revealed the Public Fiduciary called back and the resident lives at a memory care unit. An eMAR-Medication Administration Note dated June 28, 2024, revealed a change of condition for elevated INR, hold coumadin for 48 hours, and repeat INR. The note stated Provider notified. Responsible party notified: Resident #30, does not want anyone else notified. There was no evidence of notification to the resident's legal guardian. A Nursing note dated June 29, 2024, revealed the resident's blood glucose was uncontrolled and noted to be 560 at 3:00 PM. The provider was notified of concerns, and new order was noted. There was no evidence of notification to the resident's legal guardian. An eMAR-Medication Administration Note dated June 30, 2024, revealed a change of condition for dose increase of Glargine for uncontrolled blood glucose. The note stated Provider notified. Responsible party notified: Resident #30. There was no evidence of notification to the resident's legal guardian. A Social Service Summary, dated July 3, 2024, revealed Resident #30 admitted from the hospital and was there for skilled services. The note state There is no discharge date at this time. Case manager will follow up with the resident regarding discharge plans. There was no evidence of notification to the resident's legal guardian. An eMAR-Medication Administration Note dated July 4, 2024, revealed a change of condition for chest x-ray for diagnosis of congestive heart failure. The note stated Provider notified. Responsible party notified was Resident #30. There was no evidence of notification to the resident's legal guardian. An additional eMAR-Medication Administration Note dated July 4, 2024, revealed a change of condition for increased dose of Lasix for edema. The note stated Provider notified. Responsible party notified: Resident #30. There was no evidence of notification to the resident's legal guardian. A Nursing note dated July 5, 2025, revealed a new verbal order received from the provider to schedule paracentesis for diagnosis of ascites. There was no evidence of notification to the resident's legal guardian. A Care Conference note dated July 10, 2024, revealed the Interdisciplinary Team (IDT) held a Care Conference for Resident #30 on Juy 9, 2024. There was no evidence of communication to the resident's legal guardian. A Case Manager note dated July 10, 2024, revealed case management spoke with the resident's Public Fiduciary, letting her know Notice of Medical Non-Coverage (NOMNC) was issued, and the resident will return back to the memory care unit. An interview was conducted with a registered nurse (RN / Staff #16) on June 4, 2025, at 11:19 AM, who stated if a resident has a legal guardian, nursing communication occurs with both the legal guardian and the resident, and nurses obtain a resident's legal consents with the legal guardian. Staff #16 stated if a resident has a change of condition, the legal guardian would be notified. An interview was conducted with a licensed practical nurse (LPN / Staff #28) on June 4, 2025, at 11:28 AM. Staff #28 stated if there is a change of condition with a resident, the nurse would call the legal guardian to let them know about changes with the resident. Staff #28 stated that even if the resident requested that the nurse not contact anyone, the nurse would still contact the legal guardian anyway. An interview was conducted with the Social Services Supervisor (Staff #91) on June 4, 2024, at 11:42 AM. Staff #91 stated that a legal guardian, is an individual appointed by court, that is responsible for a resident, and they would make decisions for the resident. Staff #91 stated that nursing staff would communicate with both the resident and the legal guardian regarding medical changes of condition and decision-making. Staff #91 stated that even if a resident did not want their legal guardian notified, the guardian is appointed by the court, so staff would be obligated to communicate with the guardian, and that they have to be informed of what is going on with the resident. An interview was conducted with the Director of Nursing (DON / Staff #35) on June 4, 2025, at 12:58 PM. The DON stated that there are different levels of legal guardianship, so he would have to see documentation to see what the specific guardianship entails. The DON stated that sometimes the facility does not know if a resident has a legal guardian. Additionally, the DON stated that if the facility was aware that the resident has a court appointed legal guardian, then communication and consent for treatment should occur with the legal guardian, and that if the resident has a change of condition, then both the resident and legal guardian should be notified. Review of the facility policy titled Resident Rights, reviewed May 2022, revealed it is the policy of this facility that all resident rights be followed per state and federal guidelines. The Resident has the right to be fully informed in advance about care and treatment, and, unless adjudicated incompetent or otherwise found incapacitated under state law, participate in planning medical treatment, to be fully informed in a language he or she understands of his or her medical condition, to refuse medical treatment, to Nursing Center compliance with the terms of a written directive concerning medical care signed by Resident (i.e. Durable Power of Attorney for Health Care, Living Will, etc.) that complies with applicable state law, and to be informed of any significant change in the Resident's condition, or need to alter treatment significantly. Review of the policy titled Advance Directive Documentation, revised November 2016, revealed a conservator the person appointed by a court with the legal power and duty of taking care of and managing the property and/or personal affairs of another person who is considered incapable of administering his/her own affairs. Decision-making capacity is the ability to make choices that reflect an understanding and appreciation of the nature and consequences of one's actions. A person is presumed to have a capacity to make health care decisions unless the attending physician determines that the person is incapacitated or a court rules that the person is incompetent. A surrogate decision-maker is an individual who participates in health care decision-making on behalf of an incapacitated person. This individual may be formally appointed by the Durable Power of Attorney for Health Care or by a court in a conservatorship or guardianship proceeding. The admission Coordinator, or Social Service Director, shall provide the resident or responsible agent information regarding the right to formulate an advance directive, inquire whether he/she has completed an Advance Directive, and document in the resident's health record. If a resident is not capable of independent decision making inform the surrogate decision maker to document his/her desire to initiate an advance directive and his/her knowledge that this decision is in the resident's best interest or is to comply with resident's known desires, when this need arises.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure one resident (#10) was provided care regarding wound care treatments. -Findings include: Resident #10 was re-admitted to the facility on [DATE], with diagnoses that included acute respiratory failure with hypoxia, methicillin resistant staphylococcus aureus infection, bacteremia, acute and subacute infective endocarditis, type 2 diabetes mellitus with foot ulcer, and congestive heart failure. A significant change minimum data set (MDS) assessment dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. Section M revealed the resident had 4 unstageable pressure ulcers present on admission or reentry, and additionally diabetic foot ulcer(s) present. The assessment revealed the resident was receiving pressure ulcer/injury care and application of dressings to the feet. A care plan dated April 8, 2025, revealed the resident has actual impairment in skin integrity / pressure injury development: pressure injury (PI) right heel, PI left distal heel, PI left proximal heel, and PI sacrum. Interventions included to administer treatments as ordered and monitor for effectiveness, educate resident, family / caregivers as to causes of skin breakdown; including: transfer / positioning requirements; importance of taking care during ambulating / mobility, good nutrition and frequent repositioning, and weekly head to toe skin at risk assessment. A physician order dated April 9, 2025, indicated to cleanse sacrum with wound cleanser, apply Silver Sulfadiazine Cream 1 % to sacrum topically, and cover with dry dressing, every day shift. A physician order dated April 9, 2025, indicated to apply betadine topically to right 3rd toe, every day shift. Four physician orders dated April 9, 2025, and discontinued April 15, 2025, indicated to apply betadine moist gauze and cover with dry dressing, every day shift, to 4 wound locations: left lateral mid foot, left distal heel, left proximal heel, and right lateral mid foot. Five physician orders dated April 16, 2025, indicated to apply MeSalt and cover with dry dressing, every day shift, to 5 wound locations: left lateral mid foot, left distal heel, left proximal heel, right lateral mid foot, and right lateral heel. A Skin Evaluation- PRN/Weekly assessment dated [DATE], revealed Resident #10 had sacral ulceration, and open ulceration to the left lateral mid foot, left distal heel, left proximal heel, right lateral heel, right lateral foot, and a missing toe nail to the right 3rd toe with dry crusted blood. A Skin Pressure Ulcer Weekly assessment dated [DATE], revealed the following unstageable pressure ulcers: 1.) Right heel, lateral (length x width): 6.8 x 5.0 centimeters (cm), depth: unable to determine (UTD) 2.) Left heel, distal: 2.0 x 2.0, depth: UTD 3.) Left heel, proximal: 1.0 x 1.0, depth: UTD 4.) Sacrum: 2.5 x 4.0, depth: UTD A Skin Ulcer Non-Pressure Weekly assessment dated [DATE], revealed the following wounds: 1.) Diabetic ulcer, left lateral mid foot: 0.5 x 0.4, depth: UTD 2.) Diabetic ulcer, right lateral mid foot: 1.0 x 2.0, depth: UTD 3.) Right 3rd toe, toe nail came off for unknown reason: 0.8 x 0.8, depth: UTD A Skin Pressure Ulcer Weekly assessment dated [DATE], revealed the following unstageable pressure ulcers: 1.) Right heel, lateral: 1.2 x 1.0, depth: UTD 2.) Left heel, distal: 2.0 x 2.0, depth: UTD 3.) Left heel, proximal: 3.0 x 2.5, depth: UTD 4.) Sacrum: 2.6 x 4.0, depth: UTD A Skin Ulcer Non-Pressure Weekly assessment dated [DATE], revealed the following wounds: 1.) Diabetic ulcer, left lateral mid foot: 2.5 x 1.5, depth: UTD 2.) Diabetic ulcer, right lateral mid foot: 1.0 x 2.0, depth: UTD 3.) Right 3rd toe, toe nail came off for unknown reason: 0.8 x 0.8, depth: UTD An Interdisciplinary Team Skin Review - Weekly Update, dated April 16, 2025, revealed the following interventions are monitored to maximize resident outcomes to further enhance the wound healing process: treatment per physician orders, medication / mineral / vitamin supplements, and pressure redistributing devices. The resident's response to treatment plan revealed the resident readmits with ongoing pressure injuries to bilateral heels and returns with new pressure injury to the sacrum, low air loss mattress put in place, utilizing heel protectors when in bed, and utilizing a waffle cushion to the wheelchair. There was no evidence of addressing the resident's missed wound care treatments. An Interdisciplinary Team Skin Review - Weekly Update, dated April 22, 2025, revealed the same response to treatment: readmits with ongoing pressure injuries to bilateral heels and returns with new pressure injury to the sacrum, low air loss mattress put in place, utilizing heel protectors when in bed, and utilizing a waffle cushion to the wheelchair. There was no evidence of addressing the resident's missed wound care treatments. The Medication and Treatment Administration Record (MAR / TAR) for April 2025, revealed no evidence that Resident #10 received any wound care treatments on April 10, 2025. Additionally, the MAR / TAR revealed 2; Hold/See Nurse Notes for all wound care orders for the following dates in April 2024: 11, 13, 14, 16, 17, 19, 21, 23, 24, 26. Review of the clinical record revealed the following nurse notes regarding the wound treatments that were not administered: -April 11: resident not in room or surrounding area -April 13: not in room, several attempt between 11:00 and 2:00 -April 14: not in room or on unit, unable to change dressing -April 16: refused dressing change -April 17: not in room or on unit, unable to change dressing -April 19: refused at this time -April 21: attempted to see resident x 2, not in room or surrounding -April 23: not in room or on unit -April 24: refused treatment, wanting to sleep -April 26: no evidence of a note Additionally, there was no evidence of follow-through to re-attempt treatment at a later time, or to coordinate with the resident an alternate time, or to communicate to the following shift to attempt to provide wound care. An interview was conducted with a registered nurse (RN / Staff #16) on June 4, 2025, at 11:19 AM, who stated if a resident is unavailable for treatment, staff would find the resident see where they are at. If the resident was not in their room, or anywhere else that staff looked, the nurse would then notify managers and determine the last time the resident was seen, and that would be urgent to locate a missing resident. Staff #16 stated if the resident were at dialysis, staff would give the treatment when the resident returns. Additionally, Staff #16 stated if a resident were in their wheelchair, smoking, or visiting with family, and preferred the treatment not at that particular time, then staff would return to see if it is a better time later. Staff #16 stated if a nurse did not return later to give an ordered wound treatment, the result could be infection or worsening of symptoms, because of the missed treatment. Staff #16 stated her understanding of neglect is residents not getting their needs met. An interview was conducted with a licensed practical nurse (LPN / Staff #28) on June 4, 2025, at 11:28 AM. Staff #28 stated if a nurse noticed a resident were not in their room and they had a treatment due, the nurse would check in common areas and all other places such as activities, the bathroom, patios, other resident rooms, and therapy gym. If the resident could not be located, that would be an urgent situation, and then the nurse would announce the resident as missing, and staff would search until that resident were located. Staff #28 stated if a resident were due a wound care treatment, and the resident was busy doing something they wanted to do, and the resident stated not right now, then the nurse would come back later and reschedule it with the resident. Staff #28 stated that if a resident were not given ordered medication or treatment over time, that would be neglect. An interview was conducted with the Director of Nursing (DON / Staff #35) on June 4, 2024, at 12:28 PM. The DON stated that neglect could be withholding services and care, locking a resident in a room, or not allowing the resident things they need. The DON stated the expectation for nurses is to follow physician orders, and if there is a change, to notify the physician for guidance. The DON stated if a resident is unavailable for treatment, the nurse would hold the treatment and wait for resident and/or find the resident. The DON stated if the resident was up in their wheelchair or smoking or visiting with family and the resident said not right now for a treatment, the nurse should then ask when a better time would be, and try to follow up at least one more time. If a resident were due a treatment and could not be located, the DON stated the nurse would look for the resident, and have other staff assist in looking for the resident, and that the facility has an elopement procedure if residents are missing. The interview with the DON continued, and the clinical record was reviewed for Resident #10. The DON stated that the 2 coded on the MAR / TAR indicates to see the nurse's notes. The DON stated that no wound care treatment was provided on April 10, 2025, and no notes specifying the reason. The DON stated that there was no evidence that the wound care treatments were followed-up to attempt later on April 11, 13, 14, 16, 17, 19, 21, 23, or 24, 2025. The DON stated that there was no evidence of the nurse following-up or to educate the resident, and that he would expect that the nurse would follow-up on what the determination was and then have the follow-through. The DON stated that esident #10 was choosing to make himself unavailable for wound treatments that the nurses were trying to provide. The DON also stated that he was not aware of a scheduled time that the resident should have been in his room for wound treatments. Review of the policy titled Abuse: Prevention of and Prohibition Against, revised October 2023, revealed 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. Neglect is the failure of the facility, its employees, or service providers, to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy titled Wound Management, revised February 2021, revealed it is the policy of this facility that a resident having pressure ulcers receives necessary treatment and services to promote healing, prevent infection, and prevent new, avoidable sores from developing. Once a wound has been identified, assessed, and documented, nursing shall administer treatment to each affected area as per the Physician's order. All wound or skin treatments should be documented in the resident's clinical record at the time they are administered. In order to prevent the development of skin breakdown or prevent existing pressure ulcers from worsening, nursing staff shall monitor impact of interventions and modify interventions as appropriate based on any identified changes in condition and review and / or re-evaluate existing treatment regimen in connection with the resident's clinical presentation, to include current interventions and care plan considerations, if any wound is non-healing or not showing signs of improvement after a given time or any time a wound is worsening. Review of the policy titled Physician Orders, revised May 2021, revealed it is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Medication, treatment, or related procedure orders are transcribed in the medical record accordingly. Review of the policy titled Documentation and Charting, reviewed July 2022, revealed it is the policy of the facility to provide a complete account of the resident's care, treatment, response to the care, signs, symptoms, etc., as well as the progress of the resident's care, guidance to the physician in prescribing appropriate medications and treatments, the facility, as well as other interested parties, with a tool for measuring the quality of care provided to the resident, nursing service personnel with a record of the physical and mental status of the resident, the elements of quality medical nursing care, and a legal record that protects the resident, physician, nurse and the facility.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#4) was provided treatment and services according to professional standards regarding following a physician order regarding care of an intravenous (IV) site. The deficient practice could lead to infection of an IV site. -Findings Include: Resident #4 was admitted to the facility May 7, 2025, with diagnoses that included staphylococcal arthritis of right hand, methicillin susceptible staphylococcus aureus infection, cellulitis of right upper limb, and cutaneous abscess of right hand. A physician order dated May 7, 2025, indicated for central line and midline care: change all central line, PICC, and midline transparent dressings per sterile technique upon admission, every 7 days, and as needed for wet, loose, or soiled. If site is not visible for assessment, change dressing every 48 hours. Change injection caps to each lumen upon admission, every 7 days and after blood draws only if not able to clear line The Medication Administration Record (MAR) for May 2025 revealed the order to change the central line / PICC / midline transparent dressing was checked off as completed by a Registered Nurse (RN / Staff #29) on May 12, 2025. An observation was conducted on May 16, 2025, at 10:09 AM. Resident #4 was lying in bed with an IV treatment administered through an IV line in the resident's left arm. There was a transparent dressing present on the IV site, secured by tape, with a date marked on the dressing of 5/4 with initials. An interview was conducted at this time with an RN (Staff #29). Staff #29 stated that the date on the dressing was May 4, 2025, and that a nurse would not be able to remove or change the dressing without removing the part of the dressing that was initialed and dated. Staff #29 also stated that the dressing was from the discharging hospital. An interview was conducted with the Assistant Director of Nursing (ADON / Staff #41) on May 16, 2025, at approximately 1:15 PM. The ADON stated that the facility ensures IV sites are kept clean and free from infection by following physician orders, and that the order for central line care indicates to change the transparent dressing every 7 days and as needed. The ADON stated that if the orders were not followed then the risk to a resident could be infection of the IV site. The ADON reviewed Resident #4's MAR for May 2025, and stated that record indicated that the nurse had changed the transparent IV dressing on May 12, 2025. Review of the facility policy titled Nursing Clinical: Physician Orders, revised May 2021, revealed it is the policy of the facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs. It is the policy of this facility to accurately implement orders in addition to medication orders (treatment, procedures) only upon the written order of a person duly licensed and authorized to do so in accordance with the resident's plan of care. Medication, treatment or related procedure orders are transcribed in the eMAR (electronic Medication Administration Record) accordingly.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure infection control policies were followed for one resident (#4) regarding Enhanced Barrier Precautions (EBP). The deficient practice could lead to the spread of infection. -Findings Include: Resident #4 was admitted to the facility May 7, 2025, with diagnoses that included staphylococcal arthritis of right hand, methicillin susceptible staphylococcus aureus infection, cellulitis of right upper limb, and cutaneous abscess of right hand. A physician order dated May 8, 2025, indicated for enhanced barrier precautions: personal protective equipment (PPE) required for high resident contact care activities, with an indication of wounds and a central line. An additional physician order dated May 8, 2025, indicated for ceftriaxone sodium injection solution reconstituted 2 gm (Ceftriaxone Sodium), to use 2 grams intravenously one time a day. An observation was conducted on May 16, 2025, at 10:09 AM. Resident #4 was lying in bed with an IV treatment administered through a central line in the resident's left arm. A Registered Nurse (RN / Staff #29) entered the room, only donned gloves and did not don a gown, disconnected the IV line, wiped the hub with an alcohol wipe, and flushed the IV line. An interview was conducted with the Assistant Director of Nursing (ADON / Staff #41) on May 16, 2025, at approximately 1:15 PM. The ADON stated that EBP are applied when giving direct patient care for residents who have a central line, indwelling urinary catheter, wounds, and other specific care. The ADON stated that EBP require staff to don a gown and gloves to prevent the spread of infection. Additionally, the ADON stated that staff know which residents to apply EBP, because there is a physician order for it. Review of the facility policy titled IPCP Standard and Transmission-Based Precautions: Infection Control, revised October 2023, Enhanced Barrier Protection (EBP}: expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for indirect transfer of multi drug resistant organisms (MDROs) to staff hands and clothing then indirectly transferred to residents or from resident-to-resident (e.g., residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs). Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include: i. Dressing ii. Bathing/showering iii. Transferring iv. Providing hygiene v. Changing linens vi. Changing briefs or assisting with toileting vii. Device care or use: central vascular line (including hemodialysis catheters), indwelling urinary catheter, feeding tube, tracheostomy/ventilator viii. Wound care: any skin opening requiring a dressing.

Based on clinical record review and review of facility documentation, policy and procedure, the facility failed to protect the residents' rights (#49, #216 and #175) to be free from abuse by another resident (#161 and #216) and by a visitor. The deficient practice could result in further resident abuse. Findings include: Regarding resident #49 and resident #161 -Resident #49 (alleged victim) was admitted to facility on June 16, 2019 with diagnoses of history of psychotic disturbance, mood disturbance, anxiety, anoxic brain damage, adult failure to thrive and depression. Review of the clinical record revealed that resident #49 had a BIMS (Brief Interview for Mental Status) score of 3 indicating the resident had severe cognitive impairment; and that, the resident had wandering behaviors. -Resident #161 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses of history of encephalopathy, type II diabetes, homelessness and muscle weakness. Review of the clinical record revealed that resident #161 had a BIMS score of 3 indicating the resident had severe cognitive impairment. Both residents #49 and #161 reside in the secured behavioral unit. The facility report dated May 25, 2023 included that on May 18, 2023 that resident #161 made contact with resident #49. Per the documentation, on the evening of May 18, 2023, a certified nurse assistant (CNA/staff #165) saw resident #49 was in the hallway with another resident's (#161) wheelchair; and, had a small amount of blood on her face. It also included that the CNA did not witness any contact between the residents; and that, resident #49 entered the room and used the wheelchair of resident #161. Continued review of the facility report revealed that resident #161 was seen by the nurse to be scooting on the floor yelling, she took my wheelchair. Per the documentation, resident #161 reported that she made contact with the nose of resident #49 because resident #49 took his chair. Further, the facility report included that this was an isolated event; and that, this incident resulted in a facial bruise for resident #49. An interview with a licensed practical nurse (LPN/staff #201) was conducted on March 25, 2024 at 3:08 p.m. The LPN stated that during common area times, staff give activities such as games or playing cards to and continuously monitored the residents. The LPN said that there were 25 residents in the unit; and that, resident #49 can get very loud and resident #161 can get very intrusive. The LPN said that at the time of the incident, she recalled that residents #49 and #161 were separated from each other. The LPN said that the kinds of abuse included physical, emotional, neglect, financial and sexual; and that, when a resident to resident altercation occurs, the involved residents are separated from each other, assessed for injuries, the incident is reported to the Administrator and DON (director of nursing) immediately and investigated. Further, the LPN stated that residents are then placed on one on one monitoring, the physician and psychiatric physician; and that, the psychiatric physician may come in for an as needed evaluation of the residents involved. Regarding resident #175 and a visitor Resident #175 was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), type II diabetes, unspecified psychosis and anxiety disorder. A progress note dated October 12, 2022 at 11:28 a.m. revealed that a staff witnessed the resident's visitor was hitting the back of the head of resident #175; and that, resident #175 sustained a small opening on the back of his head. Another progress note dated October 12, 2022 at 12:13 p.m. included that a CNA reported that the resident was having an argument in his room with his visitor. Per the documentation, the social services manager was requested to help deescalate the situation and ask visitor to leave; and that, when the social services manager entered the resident's room, the visitor was standing in the doorway and was demanding for her purse back from the resident. The documentation also included that the CNA reported that the visitor used her large black purse to hit the back of the head of resident #175 who then took purse away from the visitor and was holding onto it until support arrived. The documentation also included that resident #175 had blood on the back of his head; and that, the resident reported that the visitor does this all the time. The facility 5-day report dated October 19, 2022 included that in the morning of October 12, 2022, resident #175 and his visitor was having a discussion as the visitor was exiting the facility. The operation manager overheard the visitor say I will not as the visitor was leaving; and resident #175 was walking a distance away behind the visitor. Per the documentation, the visitor came back a short time later; and resident #175 and the visitor were having a verbal discussion in the resident's room. The CNA overheard the discussion being louder in volume and as the CNA was entering the resident room, the CNA saw the visitor swing her purse at the resident. The documentation also included that the CNA asked assistance from the licensed practical nurse (LPN who positioned herself between the resident and the visitor; and that, the social services director also entered the room and spoke with resident #175 who returned the purse of the visitor who then left the facility and was told that she would not be permitted to return to the facility. Further review of the report revealed that the resident sustained a cut on the back of his head due to this incident. The facility concluded that this was an isolated event between resident #175 and his visitor, no pattern identified and the facility acted promptly. Regarding resident #216 and resident #223 -Resident #223 (alleged victim) was admitted on [DATE] with diagnoses of Huntington's disease, dementia, traumatic brain injury and major depressive disorder. The clinical record revealed resident had a BIMS score of 8 indicating the resident had moderate cognitive impairment. -Resident #216 (alleged perpetrator) was admitted to the facility on [DATE] with diagoses of alcohol polyneuropathy, schizoaffective disorder, bipolar disorder and traumatic brain injury. The clinical record revealed resident had a BIMS score of 13 indicating the resident had intact cognition. The facility report dated April 26, 2022 revealed that in the morning of April 20, 2022, a CNA saw resident #216 had a closed hand contact with the back of resident #223. Per the documentation, the CNA immediately gave verbal direction to stop and move away from each other; and that, the CNA was able to place herself in between residents #216 and #223. The documentation included that resident #116 reported that he asked for a cigarette while on the smoking patio from resident #223 who threw the box of cigarettes in the direction of resident #216. It also included that resident #216 reported that resident #223 was swinging his arms around which made resident #216 feel threatened. The documentation also included that resident #216 stated he went to leave the patio and was pushing the wheelchair of resident #223 from behind while resident #223 was swinging his arms around. Further, the documentation included that resident #216 reported that he made contact with Resident #223; and, resident #223 reported that resident #216 hit him but did not elaborate or provide any details. Continued review of the facility report revealed that this was an isolated event between residents #216 and #223. In an interview with a CNA (staff #161) conducted on March 14, 2024 at 2:43 a.m., the CNA stated that abuse can be physical, verbal, financial and emotional; and that, if abuse happens, she will immediately report the incident to the administrator who will then suspend the staff involved in the allegation. An interview with another LPN (staff #110) was conducted on March 21, 2024 at 3:26 p.m. The LPN stated that when a resident report that a staff abused them, she will contact the abuse coordinator within two hour and the administrator may decide to send the staff home. The LPN also stated that if a resident to resident altercation occurs, staff will separate and re-direct residents involved and staff will then call and report the incident to the administrator. Further, the LPN said that staff also do room changes and check residents regularly to avoid altercations. During an interview with another LPN (staff #81) conducted on March 21, 2024 at 3:34 p.m., the LPN stated that abuse happens between residents, staff will separate both residents from each other. The LPN also said that when a staff is accused of abuse, the involved staff will be taken off shift pending the facility's investigation. Further, the LPN said that abuse allegations are reported to the Administrator immediately. Review of facility's policy on Abuse included that it is their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation; and that, abuse is willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting in physical harm, pain or mental anguish. Willful, as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided to one resident (#184) to prevent elopement. The deficient practice could result in injury or harm to the resident. Findings include: Resident #184 was admitted to the facility on [DATE] with diagnoses of meningitis, sepsis, subperiosteal abscess of mastoid in left ear, pneumonia due to pseudomonas, chronic viral hepatitis C and transient ischemic attack. The initial admission record dated June 10, 2022 included the resident was alert but was not oriented to time, place and person; and, was not able to follow simple commands. The documentation also included that the resident was ambulatory and had no wandering behaviors The care plan dated June 10, 2022 included the resident was at risk for impaired cognitive function/dementia or impaired thought process related to dementia. Interventions included to give step by step instructions one at a time as needed to support cognitive function, keep routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. Another care plan dated June 10, 2022 revealed that per the resident's public fiduciary, the resident will remain in the facility with LTC (long term care) services. Interventions included to establish a pre-discharge plan with the resident, family/caregivers, evaluate progress and revise plan as needed. The care plan dated June 23, 2022 included the resident was at risk for a communication problem. Intervention included to anticipate and meet the resident needs. The MDS (Minimum Data Set) note dated September 8, 2022 revealed the resident was alert and oriented x2, was able to make needs known, was independent with transfers and ADLs (activities of daily living) and required set up assistance. The elopement evaluation dated September 10, 2022 included that the resident had a score of 3 indicating low risk for elopement. Per the documentation, the resident was alert and oriented, had no history of elopement in the last 6 months, was not making statements about a desire to leave the facility and had no wandering behavior. The nursing progress note dated November 27, 2022 included that the front door alarm was set off around 7:00 p.m.; and that, a head count was completed and resident #184 was not in his room. Per the documentation, the smoking patio on Palm and South unit was checked; and, a nurse on south unit reported she saw a person walking down 19th Avenue that fit the description of resident #184. Further, the documentation included that an incident report was made. A late entry social services note dated November 28, 2022 included that social services received a voicemail message from the local police department regarding the resident's missing person report. The social services note dated November 29, 2022 revealed that staff spoke with the resident's public fiduciary regarding resident's choice to leave AMA (against medical advice). An interview was conducted on March 14, 2024 at 1:49 p.m. with the Director of Nursing (DON/staff #159) who stated that when a resident is not found, the protocol was to search the building, until the resident was found. The DON stated that if staff could not find the resident, the facility will call the police and place a missing person report. In another interview with the DON conducted on March 14, 2024 at 2:14 p.m., the DON stated that there was no self-report with investigative documentation and witness statements for this incident. During a telephone interview with the resident's public fiduciary conducted on March 14, 2024 at 2:18 p.m., the public fiduciary stated she had full guardianship on resident #184 on August 8, 2022; and that, she did not allow the resident or gave consent for the resident to leave the facility. The public fiduciary further stated that the facility called her to let her know that resident #184 exited through the fire exit door; and that, staff followed the resident but could not catch up to him. Further, the public fiduciary stated that the resident refused to come back. An attempt to conduct a phone interview with the social services staff (#229) was conducted on March 14, 2024 at 2:27 p.m. but was unsuccessful as staff #229 did not answer or return the call.

Based on clinical record review, facility documentation, staff interviews, and policy the facility failed to ensure that one resident (#1) was free from sexual abuse. The deficient practice has the potential for further abuse resulting in harm to residents. Findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included metabolic encephalopathy, neurosyphilis, cerebral edema, rhabdomyolysis, anxiety disorder, bipolar disorder, and cognitive communication deficit. Review of the MDS (Minimum Data Set) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. In a psychiatric evaluation dated 1/4/2024, the Nurse Practitioner stated that resident #1 had Lack of insight concerning matters of self .Please note, due to the patient's lack of insight and impaired memory, patient has no capacity to make her own medical decisions and her [family member], who has the MPOA [Medical Power of Attorney], makes decisions for her. Review of the progress note from 1/21/2024 and 1/22/2024 revealed documentation that resident #1 was increasingly expressing a desire for sexual activity and asked staff if they wanted to see her nipples. The note stated resident #1 was place on a 1:1 for increased monitoring and help redirect the resident's behavior and comments; and, that the psychiatric provider was notified. Review of the facility's investigation report noted an interview with a Certified Nursing Assistant (CNA/staff# 52). The CNA (#52) reported that on the evening of 1/21/2024, she saw resident #1 bent over with resident #2 standing behind her. Both residents had their pants and briefs pulled down. The staff separated residents and reported what she saw to the a nurse (staff #34). Review of a surveillance video footage from 1/21/2024 of the hallway outside resident #1's bedroom showed resident #1 and resident #2 enter resident #1's room at 8:27 p.m. Then at 8:28 p.m. a CNA (staff #52) entered resident #1's room and leave the room seconds later while resident #1 and resident #2 remained together inside the room. The CNA walked to the nurse's station with her back to the room and several seconds later resident #1 and resident #2 stepped out into the hallway. Review of the physician order dated 1/23/24 revealed an order for a one on one (1:1) staff supervision due to increased statements of expressing her sexuality and redirection; an order for a change in condition protocols to be completed every shift for 3 days. Changes in condition were identified as increased statements of expressing her sexuality and sexual desires and Start Sertraline, Depakote, and Melatonin. The physician also ordered for 250 milligram (mg) of Depakote tablet every 12 hours dated 1/23/2024 and 50 mg Sertraline one time a day dated 1/24/2024. Review of a care plan initiated on 1/23/2024 for behavior problem of expressing sexual desires related to metabolic encephalopathy and cognitive communication deficit revealed a goal of having fewer episodes by review date of 03/20/2024. Interventions included 1:1 for redirecting sexual comments and administer medications as ordered. A progress note dated 1/23/2024 at 10:46 a.m., stated that nursing staff spoke with resident #1's MPOA about the increase in sexual behaviors and that the resident now had a 1:1 with her to ensure the safety of her and other patients in the facility. A progress note dated 1/24/2024 revealed resident received new medications after staff spoke with resident's psychiatric provider and received new orders. A Preadmission Screening and Resident Review (PASRR) screening was completed for resident #1 on 1/24/2024 and a referral for Level II determination for mental illness was recommended. In an interview with Resident #1's MPOA on 1/25/2024, he stated he did not consent for resident #1 to engage in any sexual relationship and did not believe it was appropriate for her at all. -Resident #2 was admitted on [DATE] and discharged on [DATE]. Review of an MDS assessment dated [DATE] revealed a BIMS score of 9 indicating moderate cognitive impairment. A telephone interview was conducted on 1/25/2024 with resident #2 and he seemed hesitant answering questions about the incident and confused. Resident #2 stated he did not remember resident #1, and that he did not have a sexual relationship with any one at the facility. -Resident #3 admitted to the facility on [DATE] and discharged against medical advice (AMA) on 1/20/2024. Review of the MDS assessment dated [DATE] revealed resident #3 had a BIMS score of 15 indicating no cognitive impairment. A telephone interview was conducted with resident #3 on 1/25/2024. Resident #3 stated he never said a word to resident #1 but also stated that they have hugged and that he has been in her room and spent time with her on the smoking patio. He explained that soon after their hug he left the facility AMA for personal reasons. He expressed he felt resident #1 was in the wrong place and was worried for her because people might take advantage of her. Without being prompted, resident #3 stated several times that he was not a dirty old man and that people get lonely. He explained they were just friends. An interview was conducted on 1/25/2024 at 1:25 p.m. with resident #1. During the interview, resident #1 was observed drooling without any attempt of wiping it. Resident #1 stated she did not know when or why she was assigned a 1:1 staff. Resident #1 denied sexual contact with any residents during her stay in the facility and that she felt safe. During the interview, the 1:1 staff was present. An interview was conducted on 1/25/2024 wtih a CNA (staff #71) and she stated as a 1:1 staff her responsibility was to redirect resident #1's sexual behaviors. She also stated that resident #1 was alert and oriented at baseline. In a telephone interview with a Licensed Practical Nurse (LPN, staff #34) conducted on 1/25/2024 at 12:00 p.m., he stated that resident #1 was not fully lucid. He stated that her baseline was she knew where she was but had a mentality of a child and did not understand the consequences of her actions. Further, he stated that sexual abuse was not limited to actual sexual intercourse but any sexual advances from one person to another person would need to be reported immediately. Staff #34 explained that he did not witness any sexual contacts between resident #1 and another male resident from a different unit; however, he had seen the two residents earlier in the shift in front of the resident's room and suspected something might happen. He stated a CNA had reported to him that she witnessed resident #1 bent over with the other resident behind her. Staff #34 explained that he reported the incident to the administrator and had stated it was not an assault because they saw it as mutual. He stated he felt resident #1 was able to consent. Further, he stated resident #1 cannot make decisions but like a child wants things, she is allowed to want something. He said that penetration probably did occur because there was not enough time before staff intervened and that other resident was very advanced in age. In an interview conducted with an MDS nurse (Staff #6) on 1/25/2024 at 2:37 p.m., she stated that she completed resident #1's BIMS again after the incident on 1/21/2024 occured, a directive she received from the DON, and the resident scored a 12. During an interview with the psychiatric nurse practitioner on 1/25/2024, he stated resident #1 is alert and oriented x 2 (who she is and where she is). He stated she does not have insight. He further stated she does not know what happened to her or why she is in the facility; she cannot make medical decision; and, had no insight. He stated he will refer to her parent who is her MPOA for all decision making. He stated resident #1 did not have the insight to know that sexual intercourse could lead to her getting pregnant. He stated he recommended to the facility that they provide her with a pregnancy test, but he is not sure if they did so or not. He then stated that resident #1 was the aggressor in sexual situations and felt she can consent. An interview was conducted on 1/25/2024 at 1:31 p.m. with a CNA (Staff #15). The CNA stated that resident #1 is not alert or oriented at baseline. She does not consistently make activity of daily living decisions. She stated Resident #1 did not make decisions on when she got up or what she wore. As an example, she stated resident #1 was not able to make decisions for what she wanted for lunch. In an interview with a nurse (staff #3) on 1/25/2024 at 1:35 p.m. she stated that the 1:1 staff is for the increased sexuality and interaction with other patients. She added the 1:1 kept her safe and kept her mind occupied. Her baseline was alert and oriented x 2. She can say when her birthday was, but her decision making is impaired. Staff #3 also stated resident #1 made impulsive decisions, but cannot understand consequences. She stated she was not on shift during the incidents, but to her knowledge, resident #1 has not had sexual contact with any other residents. An interview was conducted with the Director of Nursing (DON/staff #22) on 1/25/2024 at 3:00 p.m. and he stated that the facility did not have a policy on when, how, and by whom the determination of capacity to consent to a sexual relationship were made or documented. He stated if residents wanted to engage in sexual relations, then they have a conversation with the DON and Social Services about awareness of what they are asking for. As part of protecting resident rights they would then help provide privacy or what was needed to facilitate resident doing what they wanted. The DON stated that in regards to resident #1, he was notified on Sunday, 1/21/2024 of the sexual contact between resident #1 and another male resident. He stated that after speaking with staff #34, the nurse assigned to resident #1 that shift, he made the decision to place resident #1 on a 1:1 until everything could be looked at. He further stated that additional details came to light when Adult Protective Services (APS) came in to investigate on Tuesday 1/23/2024, which included the allegation that the resident was not oriented and was being sexually touched by other residents. He stated the event was not reportable on 1/21/2024, and he did not need to report until the details of possible assault from APS were shared. He stated resident #1 was placed on the 1:1 on 1/21/2024 because his concern at the time was someone was approaching resident #1. They later determined that resident #1 was possibly the aggressor. The DON stated he was familiar with resident #1 prior to the incident and spoke with her MPOA multiple times. He stated she can make decisions, for example, what she wanted to eat, if she wanted to call a specific family member, and when she does not want something. He stated he is used to her being alert and oriented x 2 as a baseline. He stated he noted big improvements since resident #1's admission. He explained, in the beginning, she constantly asked the same questions and not know what was happening from minute to minute. Further, he described her mind as child-like intially, but in gathering information this past week, he no longer agreed with that assessment. Review of the facility's policy titled, Freedom From Abuse, Neglect, Exploitation reviewed on 10/2023 revealed, It is the policy of this Facility to protect its residents from abuse, neglect, exploitation and misappropriation of resident property.

Based on clinical record review, facility documentation, staff interviews, and policy the facility failed to ensure that an allegation of sexual abuse for one resident (#1) were reported timely to the State Agency. This deficiency practice could result in the appropriate State agencies not being notified of allegations of abuse as required. Review of the facility's investigation report noted an interview with a Certified Nursing Assistant (CNA/staff #52). The CNA (#52) reported that on the evening of 1/21/2024, she saw resident #1 bent over with resident #2 standing behind her. Both residents had their pants and briefs pulled down. The staff separated residents and reported what she saw to a nurse (staff #34). Review of a surveillance video footage from 1/21/2024 of the hallway outside resident #1's bedroom showed resident #1 and resident #2 enter resident #1's room at 8:27 p.m. Then at 8:28 p.m. CNA (staff #52) entered resident #1's room and leave the room seconds later while resident #1 and resident #2 remained together inside the room. The CNA walked to the nurse's station with her back to the room and several seconds later resident #1 and resident #2 stepped out into the hallway. In a telephone interview conducted on 1/25/2024 at 12:00 p.m. with Licensed Practical Nurse (LPN, staff #34), he stated a CNA had reported to him that she witnessed resident #1 bent over with the other resident behind her. Staff #24 explained that he reported the incident to the administrator and had stated it was not an assault because they saw it as mutual. An interview was conducted with the Director of Nursing (DON/staff #22) on 1/25/2024 at 3:00 p.m. The DON stated that he was notified on Sunday 1/21/2024 of the sexual contact between resident #1 and another male resident. He stated that after speaking with staff #34, the nurse assigned to resident #1 during that shift, he made the decision to place resident #1 on a 1:1 until everything could be looked at. The DON stated that additional details came to light when Adult Protective Services (APS) came in to investigate on Tuesday 1/23/2024, which included the allegation that the resident was not oriented and was being sexually touched by other residents. He stated the event was not reportable on 1/21/2024, and he did not need to report until the details of possible assault from APS were shared. He stated resident #1 was placed on the 1:1 on 1/21/2024 because his concern at the time was someone was approaching resident #1. They later determined that resident #1 was possibly the aggressor. The facility did not report the incident to the State agency until 1/23/23 at 3:49 p.m. Review of the facility's policy titled, Freedom From Abuse, Neglect, Exploitation reviewed on 10/2023 revealed, Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, staff interviews, and review of the facility policy and procedures, the facility failed to ensure one resident (#465) was free from abuse of another. The deficient practice could result on resident being physically and psychosocially harmed by other residents. Finding includes: Resident #465 was admitted to the facility on [DATE] with diagnosis included metabolic encephalopathy, acute respiratory failure with hypoxia, Chronic Obstructive Pulmonary Disease (COPD), protein-calorie malnutrition, dysphagia, benign prostatic hyperplasia without lower urinary tract symptoms, Hypertension (HTN). Resident #465 is alert and oriented with BIMS score of 13. Resident #464 was admitted to the facility on [DATE] with diagnosis included rhabdomyolysis, unspecified convulsions, heart failure, chronic viral hepatitis C, adjustment disorder with mixed anxiety and depressed mood, mood disorder, insomnia, other stimulant abuse, opioid abuse. Resident #464 is alert and oriented with BIMS score of 14. Review of an 5 Day Report revealed that Resident #465 was interviewed by the Operations Manager (staff # 177) and he stated that Resident #464 became upset with Resident #465 being in his room. Resident #465 further stated that Resident #464 kicked at him, contacting his right forearm causing a skin tear. Resident #465 was moved from room [ROOM NUMBER] A and relocated to 507 B, and full body check was completed. Review of the 5 Day Report revealed that Resident #464 stated to a Licensed Practical Nurse (LPN, staff# 205) that I told Resident #465 that I was going to kick his ass. When asked why he was upset, Resident #464 did not provide a reason. Facility further reached out to the crisis response team due to Resident #464 behaviors. Review of Resident #465 in a progress note on November 8, 2021 by the Behavioral staff revealed that Resident was just lying in his bed when Resident #464 came over to his bed and started kicking him then he hit him on his arm causing it to bleed. Review of Resident #464 in a progress note on November 7, 2021 from the Behavioral staff revealed that resident confirmed to staff that Yes, I told Resident #465 that I was going to kick his ass so I went up to him and hit and kicked him. An Interview was conducted with Certified Nursing Assistant (CNA, staff # 156) on November 7, 2021 she stated that she heard a commotion from room [ROOM NUMBER] and responded immediately. She noted Resident #464 by Resident #465 bed and he was informed by Resident #465 that Resident #464 kicked him. During an interview conducted on December 20, 2023 at 11:05 AM with the Operations Manager (staff #177), she stated that she does not remember about the incident. She further stated that if criteria is present then it should be substantiated. During an interview conducted with Director of Nursing (DON, staff #11) on December 21, 2023 at 2:35 PM, she stated that facility will file a report within 2 hours whether the injury is serious or non-serious to the State Agency. Review of the facility policy Abuse Prevention of and Prohibition Against revised 11/2017 stated that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facility failed to ensure that one resident (# 613) had a reconciliation of post-discharge medications according to professional standards. The deficient practice could result in unsafe discharges for residents. Findings include: Resident # 613 was admitted into the facility on [DATE] with diagnoses that included rhabdomyolysis, dementia, acute respiratory failure with hypoxia, and chronic obstructive pulmonary artery disease. A discharge Minimum Data Set (MDS) assessment revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident was moderately cognitively impaired. Clinical record review revealed that resident # 613 had a planned discharge on May 21, 2021. Discharge documentation electronically signed by staff # 203 on May 21, 2021 revealed that the resident had improved sufficiently, and no longer needed the services of the facility. Discharge progress notes electronically signed by staff # 203 revealed resident required assistance with activities of daily living, and supervision - oversight, encouragement or cueing. Clinical record review revealed that resident # 613 was to be discharged with all her current medications on hand. The following physician medication orders were actively being administered and were listed on the discharge report: - Zoloft tablet, 25 milligrams by mouth, one time a day for depression - Amlodipine besylate tablet, 5 milligrams, 1 tablet by mouth one time a day for hypertension - Docusate sodium tablet 100 milligrams, 1 tablet by mouth one time a day for bowel care - Acetaminophen tablet 650 milligrams, 1 tablet by mouth every 6 hours as needed for pain - Calcium carbonate tablet chewable 500 milligrams, 1 chewable tablet by mouth every 6 hours as needed for dyspepsia The May 2021 medication administration record (MAR) report revealed staff # 203 administered the Zoloft, Amlodipine, and Docusate on the day of discharge. Photographs of nine medication blister packs, taken by daughter May 2021, revealed resident # 613 was discharged with blister pack of Amlodipine 5 milligram, however was also given eight other medication blister packs belonging to three different residents # 614, # 615, # 616. The photographs revealed that three out of eight medication blister packs were not empty; including 2 blister packs of Diltiazem 360 milligram extended release containing at least 8 and 5 capsules each, and 1 pack of Atorvastatin 40 milligram containing at least 8 tablets. Resident # 614 was admitted into the facility on [DATE] and discharged on [DATE]. Review of the May 2021 MAR revealed actively administered to resident # 614: - Cardizem long acting tablet extended release, 24 hour 360 milligrams (Diltiazem hydrochloride extended release coated beads) give 1 tablet by mouth one time a day for hypertension, hold for heart rate below 60 - Clonidine hydrochloride tablet 0.2 milligram, give 1 tablet by mouth one time a day for hypertension - Levetiracetam tablet 1000 milligrams, give 1 tablet by mouth two times a day for seizures - Lisinopril tablet 40 milligrams, give 1 tablet by mouth one time a day for hypertension - Atorvastatin calcium tablet 20 milligrams, give 1 tablet by mouth at bedtime for hyperlipidemia Staff # 203 administered Cardizem, Clonidine, Levetiracetam, and Lisinopril to resident # 614 on May 21, 2021. Staff # 205 administered Atorvastatin to resident # 614 on May 21, 2021. Resident # 615 was admitted into the facility on [DATE] and discharged on [DATE]. Review of the May 2021 MAR revealed actively administered to resident # 615: Atorvastatin calcium tablet 40 milligrams, give 1 tablet by mouth at bedtime for hyperlipidemia. Staff # 206 administered Atorvastatin to resident # 615 on May 21, 2021. Resident # 616 was admitted into the facility on [DATE] and discharged on [DATE]. Review of the May 2021 MAR revealed actively administered to resident # 616: Apixaban tablet 5 milligrams, give 5 milligrams by mouth every 12 hours for atrial fibrillation. Staff # 203 administered Apixaban to resident # 616 on May 21, 2021. During an interview via phone on December 19, 2023 at 03:00 PM with the daughter of resident # 613 reaffirmed that resident # 613 had been discharged with medications that were not for her mother stating that medication blister packages were labeled with other resident's names. The medication blister packs that were given to resident # 613: 1. Amlodipine besylate tablet, 5 milligrams, 1 tablet by mouth one time a day for hypertension 2. Cardizem long acting tablet extended release, 24 hour 360 milligrams (Diltiazem hydrochloride extended release coated beads) give 1 tablet by mouth one time a day for hypertension, hold for heart rate below 60 - containing at least 8 capsules 3. Cardizem long acting tablet extended release, 24 hour 360 milligrams (Diltiazem hydrochloride extended release coated beads) give 1 tablet by mouth one time a day for hypertension, hold for heart rate below 60 - containing at least 5 capsules 4. Clonidine hydrochloride tablet 0.2 milligram, give 1 tablet by mouth one time a day for hypertension 5. Levetiracetam tablet 1000 milligrams, give 1 tablet by mouth two times a day for seizures 6. Lisinopril tablet 40 milligrams, give 1 tablet by mouth one time a day for hypertension 7. Atorvastatin calcium tablet 20 milligrams, give 1 tablet by mouth at bedtime for hyperlipidemia 8. Atorvastatin calcium tablet 40 milligrams, give 1 tablet by mouth at bedtime for hyperlipidemia 9. Apixaban tablet 5 milligrams, give 5 milligrams by mouth every 12 hours for atrial fibrillation An interview was conducted on December 19, 2023 at 1:22 PM with Registered Nurse (RN/Staff # 45) who stated that they learn which residents will be discharged from their case managers. Staff # 45 stated the process for residents who are able to take their medications home involves physically printing out a medication sheet which they can use to grab the medications that are given to the residents. Staff # 45 states that the discharge nurse is the one responsible to verify that the medications handed to the resident or family match the discharge summary. Staff # 45 stated that if a resident is given Cardizem and does not require it can cause the heart rate to drop. An interview was conducted on December 20, 2023 at 8:29 AM with the Operations Manager (Staff # 177) who stated that nurses handle the actual discharge and provide documents regarding any records. Staff # 177 stated that medication reconciliation is done by the nurses which go through the reconciliation list, however interdisciplinary team will complete individualized section of the discharge form. An interview was conducted on December 20, 2023 at 8:40 AM with the Director of Nursing (DON/Staff # 11).The DON stated that as member of the interdisciplinary team he works with other staff during the discharge process. DON stated there is always a potential risk that a resident could be discharged with inappropriate medication because it is a full manual process. DON stated that the floor nurses don't really document anything, they print-out the orders and go with resident to sign-off on discharge paperwork. At 10:00 AM DON stated that the facility was notified that a resident had been discharged with medications belonging to other residents days after. DON stated the facility had implemented an education on this stating, I will find documents to find reports we did about this occurrence. At approximately 12:16 PM DON provided a written letter and dated May 25, 2021 by DON which revealed the following: The facility was notified that a resident was discharged to a group home with another residents' medications. Facility will implement and establish a system to evaluate medications on discharge to ensure right medication go with the discharging resident. Licensed nurses will in-serviced by DNS or designee about discharge process, ensuring right medications are prepared and given to residents on discharge as well as reviewing discharge paperwork with residents with proper documentation. DON stated that discharging a resident with other resident's medications did not meet his expectations. Review of the facility's Nursing Services Policy and Procedure titled, Admission, Transfer and Discharge Rights: Discharge Summary (revised 11/2016) revealed that, When the facility anticipates a resident's discharge, the discharge summary shall include, but not limited to, the following: b. A final summary of the resident's status to include a description of the resident's: xiv. Medications. Additionally, A reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter).

Based on record clinical review, staff interviews, facility documentation, policy and procedures, the facility failed to ensure one resident (#170) was free from unnecessary medication. The deficient practice could result in resident developing complications such as overdose. Findings include: Resident #170 was admitted on [DATE] with diagnoses that included cervical disc degeneration and hypertension. The inventory of personal items record was dated February 17, 2023 and included one hospital gown and one pair of hospital socks. There were no other items written in the list. The list was signed by two staff and the date on the list was incomplete. Review of the Initial Admission Record dated February 17, 2023 and signed by a registered nurse (RN/staff #160) revealed the resident did not want to self-administer medication. It also stated that if a resident wants to self-administer medication an IDT (interdisciplinary team) determination evaluation will be triggered. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 11 indicating the resident had moderately impaired cognition. A nursing progress note dated February 18, 2023 at 7:06 a.m. revealed the resident was found during the a.m. medication pass becoming unresponsive. Per the documentation, another nurse was immediately brought to the room to stay with the resident, while Narcan (opioid antagonist) and a concentrator was brought into the room. The supervisor brought in the intramuscular (IM) Narcan, which was administered and oxygen (O2) per nasal cannula (NC) at 3-4 liters to stabilize O2 saturation. According to the documentation, the resident became responsive and 911 was called. It also included that the paramedics showed up and after trying to keep the resident stable, the paramedics decided to transfer the patient to the hospital. The Nursing Home to Hospital Transfer form dated February 18, 2023 revealed an altered mental status as the reason for transfer. Review of hospital documentation dated February 20, 2023 revealed that the resident was an [AGE] year-old male who presented at the emergency department with a potential overdose. Per the documentation, the resident's history was limited; but that, resident got into his own supply of medication including morphine (narcotic opioid), metoprolol (antihypertensive) and Lisinopril (antihypertensive) at his care home and that it was unclear how much he took. It also included that EMS (emergency medical services) reported the resident was alert and oriented x2 at baseline; however, this was inconsistent with chart review from recent hospitalization . The documentation included that EMS gave 0.4 of intranasal Narcan and 2 mg of IR (immediate release) Narcan. Further, the documentation included that a complete health patient information (HPI) was unable to be obtained because of the resident's altered mental status. According to the documentation, family reported that resident's home medications were not secured at the facility; and that, the resident had access to them while there. An interview was conducted on March 8, 2023 with a registered nurse (RN/staff #209) who stated that she completed the Initial Admission Record for the resident #170. The RN stated that medication self-administration was one of the questions on the Initial Admission Record; but this did not matter because the facility does not allow residents to self-administer medication. She also stated she does not use the admission record when she was asking the resident the questions on the form; and that, she creates a cheat sheet to include the main points and writes the answers on the same piece of paper. However, the RN stated that her cheat sheet does not include the question regarding medication self-administration. She stated that she would not necessarily ask if the resident has medications because the resident usually brings it to her attention; and, if a resident told her that he had medications, she would collect and store the medications so she does not double dose the resident. The RN also stated that the certified nursing assistants (CNAs) go through the resident's belongings to complete an inventory list and this may be done before or after she completes the Initial Admission Record. An interview was conducted with a licensed practical nurse, (LPN/staff #180) on March 8, 2023 at 12:52 p.m. Regarding resident #170, the LPN stated the resident was newly admitted at the facility at the time of the incident. She stated that the incident occurred during the morning med pass when she calling the name of the resident who was not saying anything. She stated the resident was still breathing and she went to get another nurse to stay with the resident while she went get Narcan. She stated that she gave him the Narcan because she saw some bottles of medication on the bed and one of the bottles was morphine. The LPN said the Narcan made him conscious; however, the resident was not able to respond to his name. The LPN said that 911 arrived and gave the resident more Narcan, but the resident was still not responding to his name. According to the LPN, she was watching the entire events from the bedroom door; and that, her assessment was that the resident overdosed on a medication. The LPN also said that resident #170 was already admitted at the facility, so she does not know how the resident obtain the medication and may have brought it from the hospital. She stated that usually when a resident is admitted , the CNA checks the resident's vitals and belongings. She stated that while completing the inventory list, she would check the resident's belongings and ask the resident if they had any medications form home. On March 8, 2023 at 1:12 p.m., an interview was conducted with the Director of Nursing (DON/staff #127) who stated that the RN (staff #209) completed the Initial Admission Record when the resident was admitted . The DON said it was not his expectation that the nurse had the admission record with her when going over the questions with the resident. During the interview, the DON reviewed the inventory list for resident #170 and stated that the resident had a gown and a pair of socks. The DON said that it was the responsibility of the CNA to take the resident's vitals and complete the inventory list when a resident is admitted . However, the DON was not able to identify the CNA's signature on the inventory list. He stated that the first signature was that of an LPN (staff#43) who has the responsibility to double check the inventory list. The DON stated that it was not his expectation that the staff would ask if the resident has medications with him because the admission guide provided to a resident on admission; however, he stated that it was his expectation that the two staff went over the bullet point regarding medication not being allowed or illegal drugs. The DON said that it was reported that staff was administering morning medications and found the resident unresponsive. He stated he did not investigate, so he was not aware of what type of medications were found with the resident. The DON stated the hospital emailed him and reported that the resident had gotten into his own medications and had taken them. He said that the hospital also reported that the resident's family did not secure the medications. During the interview, the DON reviewed the facility entry logs and stated that there was no record of anyone visiting the resident; so, he does not know how the resident got the medications. The DON further stated that the facility and 911 gave the resident Narcan for a potential overdose of opioid. The facility's policy on Self-Administration of Medications, revised in May 2007 included that the resident/resident representative are instructed at time of admission that outside medication or medication from home, over the counter or prescription, are restricted from the facility. nursing will be responsible for monitoring self-administered doses in the resident's medication administration record (MAR). The facility policy on Medication Administration included that it is their policy that medications shall be administered as prescribed by the attending physician. It also included that medications must be administered in accordance with the written orders of the attending physician.

Based on clinical record review, staff interviews, facility documentation, policy and procedure and the State Agency (SA) database, the facility failed to implement their abuse policy by failing to ensure an allegation of abuse was reported to the State Survey Agency and APS (Adult Protective Services) within the required timeframe for one resident (#1). The deficient practice could result in abuse not reported and investigated on. Findings include: Resident #1 was admitted on [DATE] with diagnosis of sepsis, acute respiratory failure, chronic obstructive pulmonary disease and unspecified dementia. A behavior note dated January 6, 2023 included that at around 8:30 p.m., the resident called 911 stating the skin tears on his arm were caused by staff assaulting him and wanted to file a police report. Despite documentation of resident making an allegation of abuse, there was no evidence found that this allegation was reported to the SA and the APS as required. A review of the SA database for January 6, 2023 did not reveal any notifications from the facility of an allegation of abuse from staff towards resident #1. During a telephone interview conducted with a licensed practical nurse (LPN/staff #11) on January 10, 2023 at 11:12 a.m., the LPN stated that the resident called 911 and informed her that the staff had assaulted the resident resulting in the scratches on the resident's arms. The LPN stated she did not tell of report the incident to her supervisor until the next day. An interview was conducted with the Director of Nursing (DON/staff #7) on January 10, 2023 at 11:28 a.m. The DON stated the expectation was for staff to report any allegations of abuse to the supervisor or abuse coordinator immediately. Regarding resident #1, the DON stated he was not aware that the resident reported that he was assaulted by staff; and that, the allegation was not reported to the SA and APS. In an interview with the Executive Director (ED/staff #20) conducted on January 10, 2023 at 11:44 a.m., the ED stated he was the abuse coordinator for the facility; however, he was not made aware of any allegation made by resident #1. Further, the ED said that there were no notifications made to APS or the SA. A facility policy on Abuse: Prevention of and Prohibition Against revised in October 2022, revealed that it was their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also included that the facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, staff interviews, facility documentation, policy and procedure and the State Agency (SA) database, the facility failed to ensure an allegation of abuse was reported to the State Survey Agency and APS (Adult Protective Services) within the required timeframe for one resident (#1). The deficient practice could result in abuse not reported and investigated on. Findings include: Resident #1 was admitted on [DATE] with diagnosis of sepsis, acute respiratory failure, chronic obstructive pulmonary disease and unspecified dementia. A psychiatric note dated January 5, 2023 included resident #1 was alert and oriented x 4 with good insight, had some intermittent episodes of anxiety with intermittent episodes of noncompliance. Per the documentation, the resident had the mental capacity to make his own medical decisions. A behavior note dated January 6, 2023 included that at around 8:30 p.m., the resident called 911 stating the skin tears on his arm were caused by staff assaulting him and wanted to file a police report. According to the documentation, when the officers arrived the resident was told the officers were going to watch the cameras, open an investigation and if the resident was not being honest the resident could get in trouble for making a false report to law enforcement. Per the note, the resident then denied the claims and declined filing a report. Despite documentation of resident making an allegation of abuse, there was no evidence found that this allegation was reported to the SA and the APS as required. A review of the SA database for January 6, 2023 did not reveal any notifications from the facility of an allegation of abuse from staff towards resident #1. During a telephone interview conducted with a licensed practical nurse (LPN/staff #11) on January 10, 2023 at 11:12 a.m., the LPN stated that the resident called 911 and informed her that the staff had assaulted the resident resulting in the scratches on the resident's arms. The LPN stated she and a certified nursing assistant (CNA) helped the resident; and that, she did not investigate the allegation nor did she remove any staff members at the time of the incident. Staff #11 stated the resident was questioned by law enforcement about the incident; and that, the resident changed his statement after talking to the officer. Further, staff #11 stated she did not tell of report the incident to her supervisor until the next day. An interview was conducted with the Director of Nursing (DON/staff #7) on January 10, 2023 at 11:28 a.m. The DON stated the expectation was for staff to report any allegations of abuse to the supervisor or abuse coordinator immediately. Regarding resident #1, the DON stated he was not aware that the resident reported that he was assaulted by staff; and that, the allegation was not reported to the SA and APS. In an interview with the Executive Director (ED/staff #20) conducted on January 10, 2023 at 11:44 a.m., the ED stated he was the abuse coordinator for the facility; however, he was not made aware of any allegation made by resident #1. Further, the ED said that there were no notifications made to APS or the SA. A facility policy on Abuse: Prevention of and Prohibition Against revised in October 2022, revealed that it was their policy that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be from abuse, neglect, misappropriation of resident property, and exploitation. Residents also have the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. The policy also included that the facility staff with knowledge of an actual or potential violation of this policy must report the violation to his or her supervisor or the facility administrator immediately. All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the administrator. Allegations of abuse, neglect, misappropriation of resident property, or exploitation will be reported outside the Facility and to the appropriate State or Federal agencies in the applicable timeframes, as per this policy and applicable regulations.

Based on clinical record review, observation, staff interview, and policy review, the facility failed to ensure that one resident's (#52) care plan for pain was followed. The deficient practice could result in residents care plans not being implemented. Findings include: Resident #52 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 03/05/2021 revealed the resident was on as needed pain medication for the left lower extremity [CONDITION(S)] with abscess. The goals included the resident will verbalize adequate relief of pain. One of the interventions was that the resident would be administered [MEDICATION(S)] medication as per orders. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview of Mental Status (BIMS), indicating the resident had no cognitive impairment. The MDS assessment also revealed the resident experienced pain almost constantly. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . During an observation conducted on 04/29/2021 at 12:24 PM, resident #52 was observed telling the nurse that she was in pain and wanted an Oxycodone. The resident was observed walking away saying the nurse could not give her anything. An interview was conducted with the Licensed Practical Nurse (LPN/staff #172) on 04/29/2021 at 12:29 PM. The LPN stated the resident's physician cut her off of narcotics two weeks ago and the pharmacy will not send anymore. Staff #172 stated that she could not give the resident any Tylenol or [MEDICATION(S)] because there was no order for Tylenol or [MEDICATION(S)]. The LPN further stated that neither the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with the Director of Nursing (DON/staff #139) on 04/30/2021 at 08:13 AM. The DON stated Oxycodone should have been discontinued and an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #139 stated the orders and the plan of care should have been updated with new orders. In an interview conducted with a Registered Nurse RN/staff #170) on 04/30/2021 at 08:21 AM, the RN stated that she was aware the resident was not allowed to have Oxycodone even though there is an active order for Oxycodone. The RN further stated the care plan could not be followed because there was a lack of clarification. The facility's policy on pain management reviewed 09/2020 stated the facility assist each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by developing and implementing a plan, using pharmacological and/or non-pharmacological interventions to manage the pain.

Based on clinical record review, observation, resident and staff interviews, and policy review, the facility failed to ensure two of six sampled residents (#63 and #52) were provided pain management services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for residents. Findings include: Resident #63 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the care plan initiated on March 14, 2021 revealed the resident was prescribed an opioid for pain management, with potential for adverse outcomes from opioid use. The goal was that the resident would be free of adverse reactions related to opioid use. The interventions were to administer opioid as prescribed and provide education to the resident on the potential risks, adverse outcomes, complications, and medication interactions associated with opioid use including death. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. The MDS assessment included the resident had almost constant pain, the pain made it hard to sleep at night, and the resident's day-to-day activities were limited because of pain. A nursing progress note dated April 6, 2021 included the resident requested the physician increase the pain medication dosage. The note also included new orders for the pain clinic referral were received. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . However, further review of the clinical record did not reveal any additional information or documentation regarding the referral to the pain clinic. An interview was conducted with the resident on April 26, 2021 at 01:11 p.m. The resident stated that she wanted the pain medication changed to something else because the [MEDICATION(S)] was not working. The resident stated that the facility was going to send her to a pain management appointment. The resident also stated that she had not heard anything else about the appointment being set up. In an interview conducted on April 28, 2021 at 01:24 p.m. with a unit manager/Licensed Practical Nurse (LPN/staff #177), the LPN stated that regarding an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted on April 28, 2021 at 1:50 p.m. with a Medical Records assistant (staff #10) and the Medical Records Director (staff #121). Staff #10 stated that the referral for resident #63 had not been sent to the pain clinic because the order did not include a diagnosis. Staff #10 stated that on April 6, 2021, she notified the nurse that wrote the order via Tiger text message, that a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Staff #10 stated that appointments for outside providers should be scheduled within a day or two of receipt of the order. Staff #121 stated the referral had not been sent and no appointment had been made. Staff #121 stated that they should have followed up with the nurse when there was no response to the text message requesting additional information. On April 28, 2021 at 2:17 p.m., an interview was conducted with the Director of Nursing (DON/staff #139). The DON stated that the order for an outside referral would be entered into the electronic record and the nurse would notify the Medical Records Department who would send the referral to the outside provider and schedule the appointment. The DON stated the referral should be sent within 72 hours or so. Staff #139 stated that if Medical Records needed additional information for the referral, they would communicate it in the daily meeting or by Tiger text to the nurse, nurse manager and potentially to him. Staff #139 stated that he would hope Medical Records would follow up with the nurse if they had not heard anything back from the nurse within 24 to 48 hours. He stated that any clinician could obtain the needed information for Medical Records and that it did not need to be the specific nurse that wrote the order. The DON stated that his expectations were not met regarding the pain clinic referral dated April 6, 2021 not being sent to the outside provider. Review of the facility's policy for outside referrals revealed if the facility does not employ a qualified professional to furnish a specific service ordered by the physician, the facility will make necessary arrangements for services to be furnished to the resident by a person or agency outside the facility. The primary physician will order the consult or outside referral, the facility will arrange and schedule the appointment with considerations or the resident's insurance and availability of the service in the area, and the facility will notify the responsible party once appointment is arranged. In the event the facility is unable to schedule the appointment in a timely manner, the responsible party will be informed and the ordering physician be notified so that follow up action can be taken accordingly. Review of the facility's policy for pain management included it is the policy of this facility to provide an environment and programs that assist each resident to attain or maintain the resident's highest practicable physical, mental and psychosocial wellbeing. Consult the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures. -Resident #52 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a physician discharge summary from the Burn Clinic dated 03/05/2021 at 9:33 AM revealed the resident could have Oxycodone for severe pain and/or 30 minutes prior to dressing changes and to wean the resident off Oxycodone as the pain improves. The summary also revealed to alternate between Tylenol and/or [MEDICATION(S)] every 4-6 hours for mild to moderate pain. Review of the clinical record revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan dated 03/05/2021 revealed the resident was on as needed pain medication for the left lower extremity [CONDITION(S)] with abscess. The goals included the resident will verbalize adequate relief of pain. One of the interventions was that the resident would be administered [MEDICATION(S)] medication as per orders. Review of the admission MDS assessment dated [DATE] revealed the resident scored a 15 on the BIMS, indicating the resident had no cognitive impairment. The MDS assessment also revealed the resident experienced pain almost constantly. Review of the physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . A nurse progress note dated 4/22/2021 at 01:38 PM revealed the resident was currently taking Tylenol and alternating with [MEDICATION(S)] with some relief. Review of the Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . An interview was conducted with resident #52 on 04/29/21 at 12:21 PM. The resident stated that her pain level was 8. The resident stated that she stopped asking for pain medication a few weeks ago because the nurse refused to give her any. During an observation conducted on 04/29/21 at 12:24 PM, resident #52 was observed telling the nurse that she was in pain and wanted an Oxycodone. The resident was observed walking away without any medication. The resident stated that the nurse said she could not give her any. An interview was conducted with the LPN (staff #172) on 04/29/2021 at 12:29 PM. The LPN stated the resident's physician cut her off of narcotics two weeks ago and the pharmacy will not send anymore. Staff #172 stated the system had not been updated and so she could not give the resident any pain medication. Staff #172 also stated that she has not given the resident any Tylenol or [MEDICATION(S)] because she does not have an order for [MEDICAL RECORD OR PHYSICIAN ORDER] An interview was conducted with the DON (staff #139) on 04/30/21 at 08:13 AM. The DON stated the plan was to wean the resident off of Oxycodone and start Tylenol for pain management. The DON stated the physician did not specifically give a verbal order to do this, and there was no order written to discontinue Oxycodone. The DON said that this was an oversight, and that the nurse should have called the physician for verification and addressed the resident's pain. The DON stated the nursing note stating the resident was currently taking Tylenol alternating with [MEDICATION(S)] was incorrect and was typed as what the nurse believed at the time. An interview was conducted with a Registered Nurse (RN/staff #170) on 04/30/21 at 08:34 AM. Staff #170 stated that she was aware the resident was not to be given Oxycodone anymore. The RN stated that it was wrong the resident was not given Oxycodone when there was an active order for it. The RN stated the physician should have been called to clarify his intentions with orders. The facility's policy on pain management reviewed 09/2020 stated residents are provided and receive the care and services needed according to established practice guidelines. Resident pain is assessed and managed by an interdisciplinary team who work together to achieve the highest practicable outcome. The facility assists each resident with pain to maintain or achieve the highest practicable level of well-being and functioning by developing and implementing a plan, using pharmacological and/or non-pharmacological interventions to manage the pain. The policy also stated to consult the physician for additional interventions if pain is not relieved by currently ordered treatment modalities and comfort measures.

Based on closed clinical review, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure one resident (#1) was free from neglect by failing to provide supervision and care needed to address his mental and psychosocial needs, which resulted in harm and ultimately death. Past non-compliance was identified and cited. The deficient practice could lead to residents not being provided with services necessary to meet their mental and psychosocial needs. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PASSR (Pre-Admission Screening and Resident Review) Level 1 screening dated [DATE] included the resident had a serious mental illness [DIAGNOSES REDACTED]. It also included the resident did not require level II screening. The cognition care plan dated [DATE] included the resident was at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included medications as ordered and to monitor/document/report to the physician any changes in cognitive function. The physician admission progress note dated [DATE] included the resident was alert and oriented x 3 with past medical history of [REDACTED]. Assessment included psychiatric disorder. The Admission Minimum Data Set (MDS) assessment dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. It also revealed the resident was feeling down, depressed, or hopeless and had thoughts that he would be better off dead or of hurting himself in some way nearly all the time for 12 to 14 days. The assessment included no hallucinations or delusions and had a [DIAGNOSES REDACTED]. The care plan dated [DATE] included the resident had potential for mood and psychosocial well-being problem related to recent admission. Interventions included medications as ordered, allowing time to answer questions, verbalizing feelings, perceptions and fears, and behavioral health consult as needed. A physician progress notes [REDACTED]. Assessment included psychiatric disorder. According to the documentation, the resident had a very advance psychiatric disease and needed a psychiatric evaluation. The care plan on antidepressant medication with initiation date of [DATE] included the resident had depression as evidenced by ineffective sleep. The goal was the resident will show decreased episodes of sad moods. Interventions included monitoring/documenting/reporting to the physician as needed ongoing signs and symptoms of depression unaltered by antidepressant meds such as sadness irritability, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative moods/comments and concern with body functions. A physician late entry progress note dated [DATE] stated the resident said he has [MEDICAL CONDITION] every day. The physician states the resident had a psychiatric disorder and needed a psychiatric evaluation. A physician progress notes [REDACTED]. Despite documentation of the need for psychiatric evaluation, the clinical record revealed the resident was not seen by a psychiatrist from [DATE] through February 26, 2020. Review of a psychiatric progress note dated February 27, 2020, revealed the resident reported he was depressed, lonely, had chronic pain and isolated himself in his room. The note included the resident was alert and oriented x 3, was sad/depressed, had no abnormal thought content, had no suicidal ideation, had poor insight, impaired judgment and poor impulse control. Per the documentation, the resident was screened for suicide risk factors that included the following: -Prior, current and history medically serious attempt; -Sleep problems; -Hopelessness, panic or significant anxiety; -Actively making death arrangements; -Social isolation; and, -Family member committing suicide. Continued review of the note revealed a suicide prevention plan of someone living with the resident. Assessment included [MEDICAL CONDITION] and [MEDICAL CONDITION]. Impression revealed the resident was adjusting to milieu with some complaint of depression and chronic pain. The plan included adding [MEDICATION NAME] (antidepressant) 20 mg (milligrams) and contacting and coordinating with an outside provider. However, review of the clinical record revealed no evidence the resident was referred, evaluated and treated by an outside provider. Review of the Physician order [REDACTED]. -[MEDICATION NAME] (antidepressant) 10 mg give 1 capsule by mouth at bedtime for depression as evidenced by ineffective sleep. NPI included 1:1/reassurance, redirection/removal from environment, repositioning for comfort, offering food/fluid, adjusting temperature and aromatherapy (Start date of [DATE]) ; -Monitor hours of sleep [MEDICATION NAME] every night shift (Start date of [DATE]) ; -[MEDICATION NAME] 10 mg give 2 capsules by mouth at bedtime for depression as evidenced by ineffective sleep. NPI included 1:1/reassurance, redirection/removal from environment, repositioning for comfort, offering food/fluid, adjusting temperature and aromatherapy. This order had a start date of February 5, 2020.; -Duloxetine (antidepressant) 20 mg give 1 capsule by mouth two times a day for [MEDICAL CONDITION] as evidenced by sad mood. NPI (Non-pharmacological interventions) included reassurance, redirection or removal from environment, repositioning for comfort, offering food/fluid, adjusting temperature, and aromatherapy. This order had a start date of February 27, 2020; and, -(AD) Anti-depressant target behavior: sad mood. Monitor episodes of targeted behavior every shift. This order had a start date of February 27, 2020. According to the documentation in the MAR (medication administration record), these medications were administered as ordered from February 1 and [DATE]. Continued review of the MAR indicated [REDACTED]. Review of the clinical record revealed the resident had exhibited episodes of delusions from [DATE] through 8, 2020. Further review of the MAR for [DATE] revealed the resident was monitored for a sad mood from [DATE] through [DATE]. The MAR indicated [REDACTED] -1 episode on the day shift on [DATE]; -1 episode on the night shift on [DATE]; and -1 episode on the night shift on [DATE]. Continued review of the MAR indicated [REDACTED]. Review of the Kardex Report dated [DATE], revealed an instruction to monitor, document, and report to the physician as needed ongoing signs and symptoms of depression unaltered by antidepressant meds that included being sad, irritable, [MEDICAL CONDITION], negative moods/comments and agitation. Review of a late entry nursing progress note dated [DATE] revealed that at 9:20 p.m., a Certified Nursing Assistant (CNA/staff #173) found the resident's leg sticking out of the closet with the call-light cord wrapped around his neck on one end and the other end tied to the bar in the closet. According to the documentation, the resident's airway was obstructed by pressure from the cord which was cut by the two nurses who assisted and lowered the resident on the floor. The note also included the resident was warm, without pulse or respiration, with fixed and dilated pupils. The documentation included CPR (cardiopulmonary resuscitation) was immediately initiated and continued until the paramedics arrived and the resident was transferred to the hospital. Per the documentation, the administrator, Director of Nursing and the physician were notified. The discharge MDS assessment dated [DATE] included the resident had an unplanned discharge to acute hospital on [DATE]. Further review of the clinical record revealed no documentation the resident exhibited any sad behaviors prior to [DATE]. According to the documentation in the nurse progress note dated [DATE] the physician (#208) and the covering nurse practitioner (NP/ staff #209) were notified about the incident on [DATE]. A review of the Certificate of Death revealed the resident expired on [DATE]. The immediate cause of death was hanging and the manner of death was suicide. Review of the facility's 5-day written report dated [DATE] revealed that on [DATE] after breakfast, a certified nursing assistant (CNA/staff #66) found resident #1 in bed with the call-light cord wrapped loosely around his neck. Staff #66 called for the Assistant Director of Nursing (ADON/staff #211), who went to his room to assess him. The resident told staff #211 he was in significant pain and requested for [MEDICATION NAME] (narcotic). Staff #211 informed the physician (staff #208) of the incident and an order for [REDACTED].#211 instructed staff (CNAs) to check on the resident every 15 minutes. The Social Services Director (staff #206) assessed the resident who reported he was in severe back pain from [MEDICAL CONDITION], did not want to live in pain, but did not have a plan to harm himself. Staff #206 instructed the CNAs to keep an eye on the resident and staff #206 informed the physician (#208) and the psychiatric Nurse Practitioner (NP/staff #207). The investigation included that on [DATE] at approximately 3:00 p.m. Social Services Manager (staff #206) met with the resident who was noted to be agitated, complaining of back pain, made a comment that he did not want to live like this but did not have a plan. According to the documentation, staff #206 did not believe resident #1 presented a danger to himself. It also included she informed the physician (staff #208) and the psychiatric NP (staff #207) and instructed staff to conduct 15-minute checks. Review of the investigation also revealed multiple staff were aware and informed of the resident's complaint of difficulty dealing with pain and statements about harming self earlier on [DATE]. The documentation also included the resident was placed on every 15- and 30-minute checks, an assessment was done by the Social Services Manager (staff #206) after the incident and the physician and the psychiatric NP were notified. However, there was no evidence found in clinical record the physician (staff #208) and the psychiatric NP (staff #207) were notified of the first incident on [DATE]. Despite documentation of staff awareness and knowledge of the first incident that occurred earlier on [DATE], the clinical record revealed no documentation on the details of the first incident, the assessment that was conducted by the Social Services Manager (staff #206) and the interventions put in place such as 15- and/or 30-minute minutes checks as written in the investigation. Continued review of the investigation revealed that at the change of the shift, all on-coming staff were informed of the resident's statements and behavior, were told to continue room checks and to monitor the resident and report any observed changes in behavior. Per the documentation the resident did not complain of pain or make additional statements consistent with self-harm throughout the afternoon and evening on [DATE]. The report revealed the following events had occurred: -At 8:18 p.m., a Registered Nurse (RN/staff #210) gave the resident his medications; -At 8:50 p.m., staff #210 checked the resident and found him resting with no signs or symptoms of distress. The documentation included that during this time, CNAs continued to perform frequent checks on the resident; and observations were changed to 30-minute checks in response to resident's decreased complaints of pain and return to his baseline behavior.; -At approximately 9:15 p.m., a CNA (staff #68) went to check on the resident, but the resident was not in bed or the bathroom. Staff #68 informed another CNA (staff #173) the resident could not be found. Staff #173 went back to the room at approximately 9:20 p.m. to look for the resident and found the resident's leg protruding from the closet. Staff #173 looked inside the closet and found the resident with the call-light cord wrapped around his neck. The documentation also included staff #173 called for help and the nursing staff released the call-light cord from his neck, performed CPR and called 911. EMS arrived, took over resuscitation efforts and were able to obtain a pulse. The resident was then transferred to the hospital. Review of the facility's Corrective Action Plan documentation revealed that following this incident, staff were educated on pain management, identifying signs and symptoms of depression, suicidal precautions, management of suicidal behaviors, behavior change in condition and reporting pain, behaviors and verbalization of self-harm to the physician. It also included that the MDS nurse, social worker and unit managers received in-service training on the protocol to follow when a resident is noted to have a PHQ-9 (Patient Health Questionnaire-9) score of 5 or more. The documentation also included daily review of progress notes to ensure appropriate concerns have been reported; weekly and monthly random audits on staff knowledge of reporting and communicating protocols for depression and suicide risks; and, weekly audits of residents and their pain management. Further, the plan included new admissions were reviewed for PHQ-9 score of 5 and above were referred for psychiatric evaluation. An interview was conducted on [DATE] at 3:05 p.m. with a licensed practical nurse (LPN/staff #26), who stated if a resident was acting odd, she would assess the resident for danger, send the CNA to get help, and contact the physician. She said if a resident tried to harm self, she will not leave the resident alone, would have a CNA sit with the resident and will document the incident in a progress note. The LPN stated it is a facility's policy that staff notify the supervisor and the physician. Attempts were made on [DATE] at 4:01 p.m. and on [DATE] at 9:32 a.m. to conduct a phone interview with the ADON (staff #211) who was no longer working at the facility. However, attempts were unsuccessful and staff #211 never returned the call. An interview was conducted with CNA (staff #61) on [DATE] at 10:02 a.m. Staff #61 stated during the day shift on [DATE], the resident kept asking to have the call-light right next to him. She said the resident told her that he wanted to go, he was in a lot of pain, he wanted to hang himself and he could not stand the pain. She said she was concerned the resident would harm himself because the resident was different that day. She said the resident mentioned pain before but had never made statements about harming himself. She said the resident did not answer and just laughed when she asked him how he was going to hang himself. The CNA stated she reported this and the statements the resident made to the ADON (staff #211). She said the resident was placed on an every 15-minute checks; and that the call-light cord remained connected to the wall. She further stated this incident was the first attempt the resident made to harm himself on [DATE]. An interview was conducted on [DATE] at 10:30 a.m. with another CNA (staff #66), who stated that she worked the day shift on [DATE] from 6:30 a.m. to 2:30 p.m. Staff #66 stated that after breakfast she checked on the resident because his call-light was on. She said she found the call-light cord was no longer connected to the wall and was loosely wrapped around the resident's neck. She asked the resident why the cord was around his neck but she could not remember the resident's answer. She said she thought the resident was trying to harm himself so she removed the cord, placed it on the other side of the bed, stayed with the resident, and called for and informed another CNA and the nurse what had happened. She stated the nurse instructed them to conduct 15-minute checks to keep the resident safe. She said 15-minute checks are documented in the electronic record but that she did not document the 15-minute check she conducted on the resident on that day. She further stated she does not remember whether the call-light cord was removed from the room after the incident. However, she said that it should have been removed because she was worried the resident would do it again. An interview was conducted on [DATE] at 10:59 a.m. with the Social Services Manager (staff #155), who stated she was not the social services manager at the time of the incident. She said she would have assessed the resident to identify the concerns immediately following the first incident when the resident was found with the call-light cord wrapped loosely around his neck and verbalized that he was in pain and did not want to live with pain. She said she would have removed anything that could be used by the resident for self harm including the call light cord; contacted the police and Crisis team; and assigned a one-to-one staff to supervise the resident or implement 15-minute checks until the Crisis team arrived. A review of the clinical record was conducted with staff #155. She stated she was unable to find the progress notes and/or the assessment completed by the previous Social Services Manager (staff #206) after the first incident and there were no other notes found in related to the first incident that occurred earlier on [DATE]. A phone interview was conducted on [DATE] at 1:14 p.m. with the Social Services Assistant (#205), who stated the resident was aggressive and always cried out he was in pain. She said the resident showed signs of depression, such as not wanting to bathe. She further stated if a resident is suicidal, she will notify her supervisor, seek outside services, such as Adult Protective Services, and look for a more appropriate placement for the resident. An interview was conducted on [DATE] at 1:27 p.m. with a CNA (staff #196), who stated she was assigned to the resident during the day shift on [DATE] and the resident's behavior that day was totally out of character. Staff #196 stated the resident told her he did not want to be in this world anymore and begged her to shoot him. She said the resident was agitated and struggling with pain. She reported his comments to the ADON (staff #211) and the resident was placed on 15-minute checks. A phone interview with the Social Services Manager (staff #206) was conducted on [DATE] at 2:39 p.m. Staff #206 said she was told the resident wanted to speak with her and she was not aware of the incident and statements made by the resident. She said that if she was, she would have seen the resident sooner. She said the resident reported he was suicidal, but did not have a plan. She said staff were directed to do 15-minute checks on the resident because there wasn't enough staff for a one-to-one. Further, she stated she did not contact the physician or the psychiatric NP because it was the responsibility of the nurse to contact the physician if the nurse deemed it necessary. Staff #206 also said it was the nurse who was responsible in deciding if the resident needed to be sent out for evaluation that day. She stated she would have documented her notes about her assessment in the electronic record. In an interview conducted with another CNA (staff #173) on [DATE] at 3:25 p.m., she said she said the resident was having a bad day and was acting weird that day; and another CNA told her the resident had the call-light cord around his neck. She said that during her shift, the resident's call-light was in his room and was hooked to the wall and the resident was checked every 15 minutes. She said staff are supposed to document the checks made on the 15-Minute Checks form; however, she did not document the checks conducted on [DATE]. She said she told the nurse each time she checked the resident and thought the nurse documented it. An LPN (staff #35) joined in the interview and stated staff must initial the 15-Minute Checks form every 15 minutes and sign it at least once during their shift. During a phone interview conducted with the physician (staff #208) on [DATE] at 8:42 a.m., he stated he received a call from the facility on [DATE] and was informed the patient was in pain. However, he said he was not informed the resident was found with the call-light cord around the neck that morning and that the resident was making statements about harming self. He said he was on vacation and instructed staff to contact the on-call Nurse Practitioner (NP/staff #209) to address the resident's pain. He stated if he had known about the call-light being wrapped around the resident's neck along with the comments about self-harm, he would have gotten the psychiatrist involved. He said if a resident had a plan, he would have instructed the staff to transfer the resident to the emergency room . He further stated he did not know anything about the resident's behavior or statements until he was contacted by the Administrator after the resident had committed suicide. A phone interview with an RN (staff #210) was conducted on [DATE] at 9:38 a.m. Staff #210 stated she worked the night shift on [DATE] and was not told the resident was found with the call-light cord around the neck and/or had verbalized wanting to do self-harm that morning. She stated the resident did not speak to her and it was odd that on that evening the resident seemed almost happy. In a phone interview with the psychiatric NP (staff #207) conducted on [DATE] at 9:43 a.m., she stated she was not informed of the resident's behavior and statements that day. She said she was informed by the facility the next day following the resident transfer to the hospital. An interview was conducted on [DATE] at 11:20 a.m. with the Director of Nursing (staff #150). He stated he left a message on the physician's (staff #208) voicemail on [DATE] at 11:15 p.m. He said he informed the psychiatric NP (staff #209) on [DATE] about the resident's suicide; and, staff #209 was not aware of the resident's behaviors that occurred on [DATE]. He said he did not find any order for pain medication dated [DATE]. He stated the staff should have called the physician back after the assessment was completed by the Social Services Manager (staff #206) and the Medical Director should have been informed about the resident's behaviors and statements. He said in this situation he would have assigned a one-to-one to the resident and removed anything that could be used to harm the resident including the call light. Another phone interview was conducted with the NP (staff #209) on [DATE] at 2:40 p.m. Staff #209 stated she was not aware nor informed the resident was found with the call light wrapped around the neck and had complaints of pain earlier on [DATE]. She said she was informed of the situation only after the resident had committed suicide. She further stated that if she was informed of the incident, she would have called the Medical Director and a Crisis Team to help the resident. The facility's policy on Prevention of and Prohibition Against Abuse, included that each resident has the right to be free from abuse and neglect. It also included the facility will provide oversight and monitoring to ensure that its staff, who are agents of the facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse and neglect. The policy defined neglect as the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Continued review of the policy included the facility will take action to protect and prevent neglect from occurring by: -Identifying, correcting and intervening in situations in which neglect is more likely to occur, to include validating that the facility has deployed the correct number of competent staffs on each shift to meet the needs of the residents -Assuring that residents are free from neglect by having the structures and processes to provide needed care and services to all residents, which include but not limited to the completion of a facility assessment to determine what resources are necessary to care for its residents competently; and, -Identifying, assessing, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect The facility's policy on Management of Suicidal Behavior, stated that it is their policy to attempt to assess resident's self-injury/suicide potential and to intervene with suicide precautions in order to prevent suicide attempts and/or self-injuries among residents. The policy included a purpose to prevent self-harm among residents. The Attending Physician is notified immediately of the resident's change of condition. Suicide precautions are in effect for no more than twenty-four (24) hours without being renewed. The Charge Nurse is responsible for removing all dangerous articles from the resident's possession. (e.g., glass objects, shoelaces, razors and blades, nail clippers or files, metal eating utensils, cords, belts, or excel linen). These items are considered contraband and are maintained by the nursing department. Suicidal residents are not allowed to use these articles unless nursing staff believes it is safe, and only with constant and ample supervision. Further review of the policy revealed that the resident's exact Suicide Precaution restriction is listed at the nurse's station. Following each suicide assessment, the resident is placed on 15-minute watches and more restrictive measures including line of sight supervision, continuous observation or 1:1 supervision. The facility's policy on Reporting Change of Condition revealed that any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. If unable to contact the physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. The responsible party will be notified that there has been a change in the resident's condition and what steps are being taken. The facility's Services to Carry Out ADL (Activities of Daily Living) policy included the residents are given appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of resident in accordance with a written plan of care.

Based on clinical review, facility documentation, staff interviews, policy and procedures, the facility failed to ensure one resident (#1) with a known suicidal ideation was provided with the treatment and services to attain his highest practicable mental and psychosocial well-being. Past non-compliance was identified and cited. The deficient practice resulted in self-harm and ultimately death of the resident. Findings include: Resident #1 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The PASSR (Pre-Admission Screening and Resident Review) Level 1 screening dated [DATE] included the resident had a serious mental illness [DIAGNOSES REDACTED]. It also included the resident did not require level II screening. The cognition care plan dated [DATE] included the resident was at risk for impaired cognitive function/dementia or impaired thought processes. Interventions included medications as ordered and to monitor/document/report to the physician any changes in cognitive function. A nursing note dated [DATE] included the resident was in withdrawal. Per the documentation, the resident continued to request to be left on the bed pan throughout the shift. However, the documentation did not include the resident was in withdrawal for. The physician admission progress note dated [DATE] included the resident was alert and oriented x 3 with past medical history of [REDACTED]. It also included the resident complained of pain. Assessments included psychiatric disorder, [MEDICAL CONDITION] and severe L4 (lumbar-4)/L5 disease. The Admission Minimum Data Set (MDS) dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. The mood score was 17 indicating the resident had a moderately severe depression. The assessment also included the resident had no hallucinations, delusions or behaviors. Active [DIAGNOSES REDACTED]. The CAA (Care Area Assessment) triggered the following areas for care planning: mood, behavior, psychosocial well-being. A physician progress notes [REDACTED]. According to the documentation, the resident did not want to talk with or let the physician examine him unless the nurse changed him. Assessments included severe L4/L5 disease, [MEDICAL CONDITION], dementia and psychiatric disorder. The care plan dated [DATE] included the resident had potential for mood and psychosocial well-being problem related to recent admission. Interventions included medications as ordered, allowing time to answer questions, verbalizing feelings, perceptions and fears, and behavioral health consult as needed. The physician progress notes [REDACTED]. The nursing note dated [DATE] included resident refused showers and bed bath three times and gave no reason for the refusal. A physician progress notes [REDACTED]. Assessment included psychiatric disorder. According to the documentation, the resident had a very advance psychiatric disease and needed a psychiatric evaluation. The pharmacy medication report dated [DATE] revealed the resident's medication were reviewed and there were no recommendations made. Review of the physician progress notes [REDACTED]. A nursing note dated [DATE] included resident refused showers three times and did not inform staff why he was declining. The physician order [REDACTED]. The antidepressant care plan dated of [DATE] included resident had depression as evidenced by ineffective sleep. Goal was the resident will show decreased episodes of sad moods. Interventions included monitoring/documenting/reporting to the physician as needed ongoing signs and symptoms of depression unaltered by antidepressant meds such as sadness irritability, anger, never satisfied, crying, shame, worthlessness, guilt, [MEDICAL CONDITION], negative moods/comments and concern with body functions. A nursing note dated [DATE] included resident refused showers three times and did not inform staff why he was declining. Review of the physician progress notes [REDACTED]. The MAR (medication administration record) revealed the resident slept for 7 hours per day from February 1 through 5. Review of the clinical record revealed that on February 5, 2020, the previous order for Nortriptylline 10 mg was changed from one capsule to two capsules by mouth at bedtime for depression as evidenced by ineffective sleep. A nursing note dated February 14, 2020 included resident refused showers three times and did not provide the reason for declining. The pharmacy medication report dated February 14, 2020 revealed the resident's medication were reviewed and there were no recommendations made. The physician progress notes [REDACTED]. Despite documentation the resident needed psychiatric evaluation and had exhibited behaviors of not wanting to talk, not maintaining good hygiene and refusing showers, there was no evidence the resident was seen by a psychiatrist from [DATE] through February 26, 2020. Review of a psychiatric progress note dated February 27, 2020, revealed the resident reported he was depressed, lonely, had chronic pain and isolated himself in his room. Examination included the resident was alert and oriented x 3, sad/depressed, had no abnormal thought content, had no suicidal ideation, had poor insight, impaired judgment and poor impulse control. Per the documentation, the resident was screened for suicide risk factors that included the following: -Prior, current and history medically serious attempt of suicide; -Sleep problems; -Hopelessness, panic or significant anxiety; -Actively making death arrangements; -Social isolation; and, -Family member committing suicide. Continued review of the note revealed a suicide prevention plan documented as someone living with the resident. Assessment included [MEDICAL CONDITION] and [MEDICAL CONDITION]. The impression revealed the resident was adjusting to his condition or setting with some complaint of depression and chronic pain. Plan included adding [MEDICATION NAME] (antidepressant) 20 mg (milligrams) and contacting and coordinating with an outside provider. A physician order [REDACTED]. Despite documentation of a care plan intervention to monitor, document and report to the physician signs and symptoms of depression such as sadness, [MEDICAL CONDITION] and negative moods/comments and concern with body functions, the clinical record revealed no evidence the resident was monitored for these behaviors from [DATE] through February 27, 2020. A physician order [REDACTED]. The orders for Duloxetine and monitoring of behaviors were transcribed onto the MAR (medication administration record) from February 27 through [DATE] and were administered as ordered. The pharmacy medication report dated [DATE] revealed the resident's medication were reviewed and there were no recommendations made. According to the documentation in the MAR (medication administration record) from [DATE] through [DATE], the resident was monitored for a target behavior of sad mood. The documentation also included the resident had following number of episodes of sad mood on the following dates and shifts: -1 episode on the day shift on [DATE]; -1 episode on the night shift on [DATE]; and -1 episode on the night shift on [DATE]. Review of the clinical record revealed the resident did not exhibited any episodes of sad mood from [DATE] through 15. Review of the Kardex Report dated [DATE], revealed a instruction to monitor, document, report to MD as needed ongoing signs and symptoms of depression unaltered by antidepressant meds that included the following: being sad, irritable, [MEDICAL CONDITION], negative moods/comments and agitation. Review of a nursing late entry progress note dated [DATE] revealed that at 9:20 p.m., a CNA found the resident's leg sticking out of the closet with the call-light cord wrapped around his neck on one end and the other end tied to the bar in the closet. According to the documentation, the resident's airway was obstructed by pressure from the cord which was cut by the two nurses who assisted and lowered the resident on the floor. It also included the resident was warm, without pulse or respiration, with pupils fixed and dilated. The documentation included CPR (cardiopulmonary resuscitation) was immediately initiated and continued until the paramedics arrived and resident was transferred to the hospital. Per the documentation, the administrator, Director of Nursing (DON) and the physician were notified. The discharge MDS assessment dated [DATE] included the resident had an unplanned discharge to acute hospital on [DATE]. A review of the Certificate of Death revealed the resident expired on [DATE]. The immediate cause of death was hanging and the manner of death was suicide. Review of the facility's 5-day written report dated [DATE] revealed that on [DATE] after breakfast, a certified nursing assistant (CNA/staff #66) found resident #1 in bed with the call-light cord wrapped loosely around his neck. Staff #66 called for the Assistant Director of Nursing (ADON/staff #211), who went to his room to assess him. The resident told staff #211 he was in significant pain and requested for [MEDICATION NAME] (narcotic). Staff #211 informed the physician (staff #208) of the incident and an order for [REDACTED].#211 instructed staff (CNAs) to check on the resident every 15 minutes. The Social Services Director (staff #206) assessed the resident who reported he was in severe back pain from [MEDICAL CONDITION], did not want to live in pain, but did not have a plan to harm himself. Staff #206 instructed the CNAs to keep an eye on the resident and staff #206 informed the physician (#208) and the psychiatric Nurse Practitioner (NP/staff #207). The investigation included that on [DATE] at approximately 3:00 p.m. Social Services Manager (staff #206) met with the resident who was noted to be agitated, complaining of back pain, made a comment that he did not want to live like this but did not have a plan. According to the documentation, staff #206 did not believe resident #1 presented a danger to himself. It also included she informed physician (staff #208) and the psychiatric NP (staff #207) and instructed staff to conduct 15-minute checks. Review of the investigation also revealed multiple staff were aware and informed of the resident's complaint of difficulty dealing with pain and statements about harming self earlier on [DATE]. The documentation also included the resident was placed on every 15- and 30-minute checks, an assessment was done by the Social Services Manager (staff #206) after the incident and the physician and the psychiatric NP were notified. However, there was no evidence found in clinical record the physician (staff #208) and the psychiatric NP (staff #207) were notified of the first incident on [DATE]. Despite documentations of staff awareness and knowledge of the first incident that occurred earlier on [DATE], the clinical record revealed no documentation on the details of the first incident, the assessment that was conducted by the Social Services Manager (staff #206) and the interventions put in place such as 15- and/or 30-minute checks as written in the investigation. Continued review of the report revealed that at the change of the shift, all on-coming staff were informed of the resident's statements and behavior, were told to continue room checks and to monitor the resident and report any observed changes in behavior. Per the documentation the resident did not complain of pain or make additional statements consistent with self-harm throughout the afternoon and evening on [DATE]. The report revealed the following events had occurred: -At 8:18 p.m., a Registered Nurse (RN/staff #210) gave the resident his medications; -At 8:50 p.m., staff #210 checked the resident and found him resting with no signs or symptoms of distress. The documentation included that during this time, CNAs continued to perform frequent checks on the resident; and observations were changed to 30-minute checks in response to resident's decreased complaints of pain and return to his baseline behavior.; -At approximately 9:15 p.m., a CNA (staff #68) went to check on the resident, but the resident was not in bed or the bathroom. Staff #68 informed another CNA (staff #173) the resident could not be found. Staff #173 went back to the room at approximately 9:20 p.m. to look for the resident and found the resident's leg protruding from the closet. Staff #173 looked inside the closet and found the resident with the call-light cord wrapped around his neck. The documentation also included staff #173 called for help and the nursing staff released the call-light cord from his neck, performed CPR and called 911. EMS arrived, took over resuscitation efforts and were able to obtain a pulse. The resident was then transferred to the hospital. Review of the facility's Corrective Action Plan documentation revealed that following this incident, staff were educated on pain management, identifying signs and symptoms of depression, suicidal precautions, management of suicidal behaviors, behavior change in condition and reporting pain, behaviors and verbalization of self-harm to the physician. It also included that the MDS nurse, social worker and unit managers received in-service training on the protocol to follow when a resident is noted to have a PHQ-9 (patient Health Questionnaire-9) score of 5 or more. The documentation also included daily review of progress notes to ensure appropriate concerns have been reported; weekly and monthly random audits on staff knowledge of reporting and communicating protocols for depression and suicide risks; and, weekly audits of residents and their pain management. Further, the plan included new admissions were reviewed for PHQ-9 score of 5 and above were referred for psychiatric evaluation. An interview was conducted on [DATE] at 3:05 p.m. with a licensed practical nurse (LPN/staff #26), who stated if a resident was acting odd, she would assess the resident for danger, send the CNA to get help, and contact the physician. She said if a resident tried to harm self, she will not leave the resident alone, would have a CNA sit with the resident and will document the incident in a progress note. The LPN stated it is their policy that staff notify the supervisor and the physician. Attempts were made on [DATE] at 4:01 p.m. and on [DATE] at 9:32 a.m. to conduct a phone interview with the ADON (staff #211) who was no longer working at the facility. However, attempts were unsuccessful and staff #211 never returned the call. An interview was conducted with CNA (staff #61) on [DATE] at 10:02 a.m. Staff #61 stated during the day shift on [DATE], the resident kept asking to have the call-light right next to him. She said the resident told her that he wanted to go, he was in a lot of pain, he wanted to hang himself and he could not stand the pain. She said she was concerned the resident would harm himself because the resident was different that day. She said the resident mentioned pain before but had never made statements about harming self. She said the resident did not answer and just laughed when she asked him how he was going to hang himself. The CNA stated she reported this and the statements the resident made to the ADON (staff #211). She said the resident was placed on an every 15-minute checks; and that the call-light cord remained connected to the wall. She further stated this incident was the first attempt the resident made to harm himself on [DATE]. An interview was conducted on [DATE] at 10:30 a.m. with another CNA (staff #66), who stated that she worked the day shift on [DATE] from 6:30 a.m. to 2:30 p.m. Staff #66 stated that after breakfast she checked on the resident because his call-light was on. She said she found the call-light cord was no longer connected to the wall and was loosely wrapped around the resident's neck. She asked the resident why the cord was around his neck but she could not remember the resident's answer. She said she thought the resident was trying to harm himself so she removed the cord, placed it on the other side of the bed, stayed with the resident, and called for and informed another CNA and the nurse what had happened. She stated the nurse instructed them to conduct 15-minute checks to keep the resident safe. She said 15-minute checks are documented in the electronic record but that she did not document the 15-minute check she conducted on the resident on that day. She further stated she does not remember whether the call-light cord was removed from the room after the incident. However, she said that it should have been removed because she was worried the resident would do it again. An interview was conducted on [DATE] at 10:59 a.m. with the Social Services Manager (staff #155), who stated she was not the social services manager at the time of the incident. She said she would have assessed the resident to identify the concerns immediately following the first incident when the resident was found with the call-light cord wrapped loosely around his neck and verbalized that he was in pain and did not want to live with pain. She said she would have removed anything that could be used by the resident for self harm including the call light cord; contacted the police and Crisis team; and assigned a one-to-one staff to supervise the resident or implement 15-minute checks until the Crisis team arrived. A review of the clinical record was conducted with staff #155. She stated she was unable to find the progress notes and/or the assessment completed by the previous Social Services Manager (staff #206) after the first incident and there were no other notes found in related to the first incident that occurred earlier on [DATE]. A phone interview was conducted on [DATE] at 1:14 p.m. with the Social Services Assistant (#205), who stated the resident was aggressive and always cried out he was in pain. She said the resident showed signs of depression, such as not wanting to bathe. She further stated if a resident is suicidal, she will notify her supervisor, seek outside services, such as Adult Protective Services, and look for a more appropriate placement for the resident. An interview was conducted on [DATE] at 1:27 p.m. with a CNA (staff #196), who stated she was assigned to the resident during the day shift on [DATE] and the resident's behavior that day was totally out of character. Staff #196 stated the resident told her he did not want to be in this world anymore and begged her to shoot him. She said the resident was agitated and struggling with pain. She reported his comments to the ADON (staff #211) and the resident was placed on 15-minute checks. A phone interview with the Social Services Manager (staff #206) was conducted on [DATE] at 2:39 p.m. Staff #206 said she was told the resident wanted to speak with her and she was not aware of the incident and statements made by the resident. She said that if she was, she would have seen the resident sooner. She said the resident reported he was suicidal, but did not have a plan. She said staff were directed to do 15-minute checks on the resident because there wasn't enough staff for a one-to-one. Further, she stated she did not contact the physician or the psychiatric NP because it was the responsibility of the nurse to contact the physician if the nurse deemed it necessary. Staff #206 also said it was the nurse who was responsible in deciding if the resident needed to be sent out for evaluation that day. She stated she would have documented her notes about her assessment in the electronic record. In an interview conducted with CNA (staff #173) on [DATE] at 3:25 p.m. , she said the resident was having a bad day and was acting weird on the day of the incident. She said another CNA told her the resident was found the call-light cord around his neck during the shift. She said that during her shift, the resident's call-light was in his room and was hooked up to the wall. She said the CNAs checked the resident every 15 minutes and were supposed to document the checks on the 15-Minute Checks form. However, she did not document the checks conducted and/or use the form on [DATE]. She said she told the nurse each time she checked the resident and thought the nurse documented it. A licensed practical nurse (LPN/staff #35) joined in the interview and said staff must initial the 15-Minute Checks form every 15 minutes and sign it at least once during their shift. During a phone interview conducted with the physician (staff #208) on [DATE] at 8:42 a.m., he stated he received a call from the facility on [DATE] and was informed the patient was in pain. However, he said he was not informed the resident was found with the call-light cord around the neck that morning and that the resident was making statements about harming self. He said he was on vacation and instructed staff to contact the on-call Nurse Practitioner (NP/staff #209) to address the resident's pain. He stated if he had known about the call-light being wrapped around the resident's neck along with the comments about self-harm, he would have gotten the psychiatrist involved. He said if a resident had a plan, he would have instructed the staff to transfer the resident to the emergency room . He further stated he did not know anything about the resident's behavior or statements until he was contacted by the Administrator after the resident had committed suicide. A phone interview with an RN (staff #210) was conducted on [DATE] at 9:38 a.m. Staff #210 stated she worked the night shift on [DATE] and was not told the resident was found with the call-light cord around the neck and/or had verbalized wanting to do self-harm that morning. She stated the resident did not speak to her and it was odd that on that evening the resident seemed almost happy. In a phone interview with the psychiatric NP (staff #207) conducted on [DATE] at 9:43 a.m., she stated she was not informed of the resident's behavior and statements that day. She said she was informed by the facility the next day following the resident transfer to the hospital. An interview was conducted on [DATE] at 11:20 a.m. with the Director of Nursing (staff #150). He stated he left a message on the physician's (staff #208) voicemail on [DATE] at 11:15 p.m. He said he informed the psychiatric NP (staff #209) on [DATE] about the resident's suicide; and, staff #209 was not aware of the resident's behaviors that occurred on [DATE]. He said he did not find any order for pain medication dated [DATE]. He stated the staff should have called the physician back after the assessment was completed by the Social Services Manager (staff #206) and the Medical Director should have been informed about the resident's behaviors and statements. He said in this situation he would have assigned a one-to-one to the resident and removed anything that could be used to harm the resident including the call light. Another phone interview was conducted with the NP (staff #209) on [DATE] at 2:40 p.m. Staff #209 stated she was not aware nor informed the resident was found with the call light wrapped around the neck and had complaints of pain earlier on [DATE]. She said she was informed of the situation only after the resident had committed suicide. She further stated that if she was informed of the incident, she would have called the Medical Director and a Crisis Team to help the resident. The policy on Management of Suicidal Behavior, stated that it is a policy to attempt to assess resident's self-injury/suicide potential and to intervene with suicide precautions in order to prevent suicide attempts and/or self-injuries among residents. The policy included a purpose to prevent self-harm among residents. The Attending Physician is notified immediately of the resident's change of condition. Suicide precautions are in effect for no more than twenty-four (24) hours without being renewed. The Charge Nurse is responsible for removing all dangerous articles from the resident's possession. (e.g., glass objects, shoelaces, razors and blades, nail clippers or files, metal eating utensils, cords, belts, or excel linen). These items are considered contrband and are maintained by the nursing department. Suicidal residents are not allowed to use these articles unless nursing staff believes it is safe, and only with constant and ample supervision. Further review of the policy revealed that the resident's exact Suicide Precaution restriction is listed at the nurse's station. Following each suicide assessment, the resident is placed on 15 minute watches and more restrictive measures including line of sight supervision, continuous observation or 1:1 supervision. The facility policy, Change of Condition Reporting, stated any sudden or serious change in a resident's condition manifested by a marked change in physical or mental behavior will be communicated to the physician with a request for physician visit promptly and/or acute care evaluation. The licensed nurse in charge will notify the physician. If unable to contact the physician or alternate physician timely, notify Medical Director for follow-up to change in resident condition. The responsilble party will be notified that there has been a change in the resident;'s condition and what steps are being taken. The Services to Carry Out ADL (Activities of Daily Living) policy included the residents are given appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being of resident in accordance with a written plan of care.

Based on closed record review, staff interviews, facility documentation, and policy review, the facility failed to ensure one resident (#1) was free from neglect. Findings include: Resident #1 was admitted to the facility on (MONTH) 27, (YEAR), with [DIAGNOSES REDACTED]. The initial admission record dated (MONTH) 27, (YEAR), included that the resident was alert and oriented to time, place, and person and had clear speech and was able to follow simple commands. A physician's note dated (MONTH) 27, (YEAR), revealed the resident was alert and oriented x 3. The note also included the resident had an abnormal CT (computed tomography) scan of the pancreatic head. The plan was for the resident to follow up with a [MEDICATION NAME] for possible EUS (endoscopic ultrasound). The IDT (interdisciplinary team) - Care Plan Review note dated (MONTH) 1, (YEAR), revealed the resident was not feeling well and had nausea and vomiting. The admission MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), included a BIMS (Brief Interview for Mental Status) score of 15 which indicated the resident was cognitively intact. Review of the physician's orders [REDACTED]. A physician's note dated (MONTH) 21, (YEAR), revealed the resident continued to be nauseated and that the resident's heart rate was tacky at 104 Review of the physician's note dated (MONTH) 23, (YEAR), revealed the resident was scheduled for a [MEDICATION NAME] follow-up visit on (MONTH) 24, (YEAR) regarding the possible pancreatic mass. The facility's documentation revealed an appointment with the [MEDICATION NAME] was scheduled for (MONTH) 24, (YEAR) at 2:30 p.m. Review of the MAR (medication administration record) dated (MONTH) (YEAR), revealed that on (MONTH) 24, the medication pass at 4:00 p.m., 5:00 p.m., 8:00 p.m., 10:00 p.m., and 11:00 p.m. were marked by day shift (staff #143) and second shift (staff #91) nurses with a number 8 which is a code for absent from facility. Review of the clinical record did not reveal any evidence that staff attempted to locate the resident, and no evidence that the physician, family, DON (Director of Nursing), the ED (Executive Director), nor the police were notified that resident did not return to the facility from the appointment. Review of the facility's report dated (MONTH) 30, (YEAR), revealed the following events that occurred on (MONTH) 24, (YEAR) (day of the GI appointment) and (MONTH) 25, (YEAR): -At approximately 1:30 p.m., the resident was transported by a transport service to her GI appointment. -At approximately 2:40 p.m., the GI office called and spoke with the medical records assistant (staff #46) to inform the facility that they did not have the resident's medical record. The GI office requested for the medical records and transport service information to be faxed to their office. -At around 4:00 p.m., the day shift nurse (staff #143) received a phone call from the GI office and was told that the resident was at the wrong physician's office. The GI office also asked staff #143 to call transportation to pick up the resident. Staff #143 made a call for transport but had called the wrong transport company. Per the documentation, staff #143 became busy and did not call the transport company again but reported to the oncoming second shift nurse (staff #91) that the resident was out at an appointment. The documentation also included that staff #143 did not let any staff know of the possible transport issue at that time. - Further review of the facility's investigation revealed, the information received by the facility from the hospital included that emergency personnel responded to the GI office on (MONTH) 24, (YEAR) at 7:04 p.m. after receiving a call from a concerned citizen. -During the facility's interview (no specified date/time of interview) conducted with the oncoming second shift nurse (staff #91), she confirmed that staff #143 told her that the resident remained out of the building. Per the documentation, staff #91 reported this information to her night supervisor (staff #72) but did not include what time it was reported to the supervisor. -The facility's investigation included an interview (no specified date/time of interview) conducted with the night supervisor (staff #72). She stated that she remembered staff #91 reporting to her that the resident was out of the facility. Per the documentation, staff #72 called the physician's office. The physician's answering service answered but was unable to assist her with information regarding the resident. Also included was that staff #72 did not think of calling the DON or the ED because she assumed the resident was taken to the hospital from the appointment. -On (MONTH) 25, (YEAR) at approximately 10:00 a.m., the weekend nurse supervisor (staff #208) reported to the ED (staff #218) that the facility was notified by the hospital that the resident was admitted . Review of the hospital ER (emergency room ) record revealed the patient was seen by provider on (MONTH) 24, (YEAR) at 7:34 p.m. The chief complaint was that the resident was found at the physician's office unresponsive. The History of Present Illness included the resident (named as a(NAME)Doe) was found minimally responsive by paramedics in her wheelchair outside of the physician's office. Per the documentation, the resident was initially responding to pain and was moaning unintelligible words with her eyes open. In route to the hospital, the resident became increasingly less responsive with a pulse oximetry reading of 50% oxygen saturation, and appeared apneic as they were unloading her from the ambulance. An oral airway was placed and the resident was bagged on her way to the ER. However, upon arrival to the ER, the resident was completely unresponsive. The assessment included hypoxic [MEDICAL CONDITION], oliguric kidney failure, [MEDICAL CONDITION], and profound dehydration. An interview was conducted with the executive director of the transport company that transported the resident to the appointment on (MONTH) 31, (YEAR) at 9:35 a.m. She stated that the resident was picked up from the facility on (MONTH) 24, (YEAR) at 1:39 p.m. and arrived at the physician's office at 2:28 p.m. During an interview conducted with the medical records assistant (staff #46) on (MONTH) 31, (YEAR) at 10:20 a.m., she stated that on (MONTH) 24, (YEAR) at approximately 1:30 p.m., she saw the resident's transportation packet at the nurse station. She stated that the resident had already left for the appointment. She stated that the doctor's office requested that she fax the resident's medical records and transportation information to them and that she faxed the information. Staff #46 stated that the transportation information is usually sent with the resident, so that the physician's office can call the transportation service after the appointment. An interview was conducted with the night supervisor (staff #72) on (MONTH) 31, (YEAR) at 11:47 a.m. Staff #72 stated that at the beginning of her night shift (12 midnight) on (MONTH) 24, (YEAR), she received a verbal list of 5 resident names (which included resident #1) who were still out of the facility and had not come back from either [MEDICAL TREATMENT] or a physician's appointment. She stated that the shift was overwhelming and that she had to call the police three times that night for different issues. She stated none of the reports were regarding resident #1 not returning from an appointment. The night supervisor stated that around 4:10 a.m. on (MONTH) 25, (YEAR), the resident's night nurse (she could not recall the nurse's name) reported that the resident never returned from an appointment. She later retracted the time to 2:30 a.m. instead of 4:10 a.m. Staff #72 stated that she then called the physician's office and got the answering service who was not helpful. She stated that she instructed the nurse to follow-up with the social worker later that day regarding the status of the resident. Staff #72 stated that she did not inform the DON or the ED because she heard during her shift that there were several residents who were transferred to the hospital from an appointment and she thought resident #1 was one of them. She also stated that never called the hospital or the police. During an interview conducted with the day shift (6:00 a.m. - 6:00 p.m.) nurse (staff #143) on (MONTH) 31, (YEAR) at 11:43 a.m., she stated that she was on shift when the resident had an appointment to see the GI physician on (MONTH) 24, (YEAR). She stated that at approximately 3:00 p.m. or 3:30 p.m. on (MONTH) 24, (YEAR), she received a call from the GI office stating they called transportation services but that transport was not there to pick up the resident. She stated she called the transport company but was told that they were not the one who transported the resident to the appointment and that they did not have the resident scheduled for pick up. Staff #143 stated her plan was to call another transport service, but that she got busy with two discharges. She stated by the time she finished with the discharges, it was time for shift change. She stated she reported to the oncoming second shift nurse that the resident was still out of the facility and that there were issues with transportation. On (MONTH) 31, (YEAR) at 2:55 p.m., an interview was conducted with a certified nurse assistant (CNA/staff #28) who worked from 6:30 a.m. to 10:30 p.m. on (MONTH) 24, (YEAR). She stated that the resident eats in her room and that when she was passing the meal trays at 5:00 p.m., the resident was not in her room and she could not locate her. She stated that she reported to the nurse that she could not locate the resident. She stated after the nurses changed shift between 7:00 p.m. and 8:00 p.m., she was doing her rounds and was unable to find the resident. She stated she reported this to the second shift nurse, and that the second shift nurse was also asking her where the resident was. She stated that between 9:00 p.m. and 10:30 p.m., just prior to the end of her shift, she made another round and was still unable to locate the resident. Staff #28 stated she report this to the second shift nurse again. An interview with another CNA (staff #128) was conducted on (MONTH) 31, (YEAR) at 3:10 p.m. She stated that she worked the evening shift from 2:30 p.m. through 10:30 p.m. on (MONTH) 24, (YEAR). She remembered there were a lot of things going on that day. She stated she was conducting random checks up and down the hall throughout her shift. Staff #128 stated she noticed the resident's privacy curtains were closed and that she had not seen the resident. She stated that she started looking for the resident and was told that the resident had an appointment. She stated that around 8:00 p.m. on (MONTH) 24, (YEAR), she still did not see the resident and was not sure whether she reported this to the nurse. Staff #128 also stated that she did not make a big deal out of this because based on her experience; residents who do not return from an appointment were probably sent out to the hospital. However, she stated that she did not know whether the resident was sent to the hospital or not. During an interview conducted with the second shift (6:00 p.m. - 6:00 a.m.) nurse (staff #91) on (MONTH) 1, (YEAR) at 7:36 a.m., she stated that at the beginning of her shift on (MONTH) 24, (YEAR), she received a report from staff #143 that the resident was out on an appointment. She stated that she was never told that the resident had transportation issues. She also stated that it was not reported to her during her shift that the resident had not returned from the appointment. Staff #91 stated that between 9:00 p.m. and 10:00 p.m., she reported to the nurse supervisor that the resident did not return from the appointment. During an interview conducted with the DON (staff #219) on (MONTH) 1, (YEAR) at 8:19 a.m., she stated that she was never notified that the resident had not returned from the appointment until (MONTH) 29, (YEAR). She stated that she was told the resident went out for an appointment and ended up in the hospital where the resident passed away. The DON stated that when an alert and oriented resident does not come back from an appointment, nurses are to call the physician office, the transport service, and notify the resident's family. She stated that it is expected that the nurses will try to find and locate the resident. She also stated that if these measures are implemented and the resident is still unable to be located, it will be assumed that the resident left AMA (against medical advice). The DON stated the nurses are aware of the residents who have appointments, because the schedule is posted at the nurse station. She stated the nurses are responsible to follow-up on a resident who has not returned from an appointment. An interview was conducted with the ED (staff #218) on (MONTH) 1, (YEAR) at 8:40 a.m. She stated that she received a call from the weekend supervisor (staff #208) on (MONTH) 25, (YEAR) at around 10:00 a.m. informing her that the hospital physician had notified her, that the resident was at the hospital. She stated that she conducted phone interviews with the involved staff (#143, #91 and #72) and that none of these staff provided her with specific times of events. The ED also stated that the night supervisor (staff #72) did not report the incident to her or the DON. An interview was conducted with the weekend nurse supervisor (staff #208) on (MONTH) 1, (YEAR) at 9:00 a.m. She stated that at the beginning of her 6:00 a.m. - 6:00 p.m. shift on (MONTH) 25, (YEAR), she did not receive any report from any of the nurses that worked prior to her shift that the resident was missing and had not returned from an appointment. She stated that at around 10:00 a.m., during the stand-up meeting, she was notified by the receptionist (staff #43) that the resident was at the hospital. She stated that she received a report from someone (she could not recall the name) that when the physician's office closed at 4:30 p.m. on (MONTH) 24, (YEAR), the resident was left outside the building waiting for transportation. Staff #208 stated that if she receives a report that a resident is missing or has not returned from an appointment, she will call the physician, transport service, and the emergency contact. She also stated that if the resident is unable to be located, she will call her immediate supervisor, the DON/ED, and the police. During an interview conducted with the receptionist (staff #43) on (MONTH) 1, (YEAR) at 9:16 a.m., she stated that she received a call from the physician's office late afternoon on (MONTH) 24, (YEAR), to inform them that they had called transportation and that the transport service had not arrived and that the resident needed transportation. The receptionist stated that the unit clerk who was responsible for appointment/transportation scheduling was not available so she transferred the call to medical records. She stated that on (MONTH) 25, (YEAR), she reported to the weekend nurse supervisor (staff #208) that the hospital had called to inform them that the resident was admitted to the ICU (intensive care unit). The facility's policy regarding Transportation to Specialty Appointment included that the facility will assist residents in arranging transportation to/from diagnostic appointments when necessary. It also included that a member of the medical records will remain in the facility until all patients out on specialty appointments have returned to facility and are accounted for. By 6:00 p.m. every weekday, medical records and nursing staff of each unit will account for all patients. Continued review of the policy revealed that in the event a patient does not return to the facility prior to 6:00 p.m., the DON or ED, family/emergency contact, physician, the transportation company, and the physician's office will be called for additional information. It also included that a missing person report will be filed if after calling these offices and contacts, the resident is still not accounted for. The policy also included that if after 6:00 p.m. the nursing supervisor receives information regarding a resident not in the building, the DON and/or the ED will be notified as soon as possible and the police will be contacted.