Every finding on record at Evergreen Post Acute

Based on observation and interview it was determined the facility failed to ensure medications and biologicals were stored in locked compartments and maintained in a safe and secured manner for 3 of 3 halls reviewed for medication storage and labeling. This placed residents at risk for unsafe medication storage. Findings include:1. On 8/3/26 at 1:22 PM a medication cart was observed to be unlocked and unattended next to the nurse's station. No staff were observed in the immediate vicinity of the medication cart. On 8/3/26 at 1:24 PM Staff 21 (Med Aide) stated he had left the medication cart unlocked and unattended. 2. On 8/5/26 at 3:39 PM a treatment cart was observed to be unlocked and unattended on the west hall. No staff were observed in the immediate vicinity of the treatment cart. On 8/5/26 at 3:49 PM Staff 22 (RN) stated she had left the treatment cart unlocked and unattended. 3. On 8/5/26 at 3:39 PM a wound cart was observed to be unlocked and unattended on the west hall. No staff were observed in the immediate vicinity of the treatment care. On 8/5/26 at 3:56 PM Staff 3 (Assistant Director of Nursing/LPN Resident Care Manager) stated she had left the wound cart unlocked an unattended. 4. On 8/3/26 from 2:41 PM until 2:55 PM, the East-Hall medication cart was observed to be unlocked. During the observation, multiple staff and residents were observed moving past the medication cart. On 8/3/26 at 2:55 PM, Staff 4 (LPN Resident Care Manager, Infection Preventionist) confirmed the East-Hall medication cart was unlocked. Staff 4 locked the medication cart, and stated medication carts were expected to be locked unless staff were present attending the medication cart. 5. On 8/6/26 from 9:24 AM until 9:48 AM, the East-Hall medication cart was observed to be unlocked, and an unopened bottle of nasal saline spray was observed on top of the medication cart. During the observation, multiple staff and residents were observed moving past the medication cart. On 8/6/26 at 9:48 AM, Staff 16 (LPN) stated the medication cart should not have been left unattended, and the bottle of saline nasal spray should be placed in a locked medication cart or room. On 8/7/26 at 10:01 AM Staff 2 (DNS) stated medication carts were expected to be locked unless attended and medication were expected to be locked up and not stored on top of the medication cart.

Based on observation, interview, and record review, it was determined the facility failed to maintain an infection prevention and control program, as evidenced by staff not performing required hand hygiene during resident care, failing to clean and store resident care equipment appropriately, and not following Enhanced Barrier Precautions (EBP) for 1 of 1 facility reviewed for infection control practices. This placed residents at risk for communicable disease transmission and infections. Findings include:The facility's 9/1/24 Hand Hygiene Facility policy indicated hand hygiene is the primary means of preventing and transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the workday. A non-inclusive list of situations that require hand hygiene includes; before and after resident contact, before and after performing an invasive procedure (e.g., fingerstick blood sampling), before and after entering transmission-based precautions areas, before and after handling peripheral vascular catheters and other invasive devices. 1.On 8/5/2026 at 12:19 PM, Staff 29 (LPN) donned a gown to enter room [ROOM NUMBER]-1, donned gloves without performing hand hygiene. Staff 29 handled the resident's alarming intravenous medication delivery pump then proceeded to perform fingerstick for blood glucose testing. Once the sample was obtained Staff 29 doffed the gown and gloves and exited the resident's room without performing hand hygiene. Staff 29 returned to the treatment cart and accessed the computer keyboard and mouse, obtained new supplies for blood glucose testing and entered room [ROOM NUMBER]-3. Staff 29 donned gloves, completed fingerstick for blood glucose testing, doffed gloves, and exited the resident's room. Staff 29 completed all of these tasks without completion of hand hygiene. On 8/5/2026 at 1:30 PM, Staff 29 (LPN) stated hand hygiene should be performed before and after any resident care provided, upon doffing PPE, leaving a resident's room, before entering a resident's room and before donning gloves. Staff 29 acknowledged he did not perform appropriate hand hygiene between tasks and multiple residents. Staff 4 (LPN Resident Care Manager) stated hand hygiene was to be performed between resident care, before and after donning and doffing PPE, and when entering and exiting a resident's room. On 8/6/2026 at 2:28 PM Staff 2 (DNS) stated all staff were expected to perform hand hygiene before and after resident contact and after removing gloves between tasks to ensure they comply with appropriate hand hygiene. Staff 2 acknowledged Staff 29 did not adhere to proper infection control practices. 2. On 8/3/26 at 2:38 PM a commode was observed in the East Hall. The commode had a bowel movement (BM) smear on the seat of the commode. On 8/3/26 at 2:39 PM, Staff 29 (CNA) confirmed there was BM smeared on the seat of the commode. Staff 29 stated commodes were expected to be cleaned and stored in another location outside of the resident's room when not in use. On 8/3/26 at 2:55 PM, Staff 4 (LPN Resident Care Manager, Infection Preventionist) stated commodes were to be cleaned appropriately and when not in use to be stored in the designated area until needed. 3. On 8/5/26 at 3:40 PM, Staff 17 (LPN) was observed providing care to a resident on enhanced barrier precautions (EBP) without wearing a gown. A dirty chux and dirty gloves were on the floor, and dirty gloves and dressing supplies were on the resident's roommate's overbed table. Staff 17 stated he had forgotten to put the gown back on after completing the dressing change. On 8/5/26 at 3:51 PM, Staff 17 stated the resident was on EBP and he should have worn a gown when changing the resident. Staff 17 stated there were no infection control issues with putting dirty chux or dirty gloves on the floor, and Staff 17 stated there was no infection control with putting dirty gloves and dressing supplies on the roommates overbed table. On 8/5/26 at 3:55 P Staff 4 (LPN Resident Care Manager, Infection Preventionist) stated staff were expected to wear a gown and gloves when providing care to a resident on EBP. Staff 4 stated dirty garbage or linen should never be placed on the floor or placed on another resident's bedside table. Staff 4 stated when changing a resident's dressing, the dirty dressing supplies and dirty linen are expected to be placed in a garbage bag.

Based on observation, interview and record review it was determined the facility failed to provide a clean and homelike environment for 1 of 1 facility reviewed for environment. This placed residents at risk for a lack of homelike environment. Findings include: 1. Observations of the facility's hallways, dining room and resident rooms from 8/3/26 through 8/7/26 between the hours of 8:00 AM and 4:30 PM found the following issues: -All of the wooden hand and foot railings in each hallway had varying sized scrapes and gouges out of the wood, large areas of discoloration where paint was worn off and areas where adhesive tape had taken off the finish. -All of the wooden doors to each resident room, offices, rehabilitation room, dining room and storage rooms had large scrapes and gouges of varying sizes out of the wood, large areas of discoloration where paint was worn off and areas where adhesive tape had taken off the finish. -The residents' community television room had three mustard-colored and four light brown vinyl chairs with rips and worn areas which exposed the inner stuffing material which was not cleanable. Multiple residents, staff and visitors were observed sitting in the chairs. The door leading from the television room to the back courtyard had large, horizontal black scrapes and gouges. -The main dining room ceiling had four approximately two foot-by-two-foot squares in the ceiling which were not painted and the far blue wall by the back windows had an approximately two foot-by-six-inch area that required painting. -An overhead, ceiling light on the south hallway had several broken and missing pieces from the light cover. -room [ROOM NUMBER] had approximately 12, one-inch brown streaks (which appeared to be blood) on the wall to the right of the resident's bed and the bottom of the closet was partially torn off. -room [ROOM NUMBER]'s wall under the window had a large, primed area which required painting. On 8/3/26 at 11:02 AM and 8/4/26 at 1:18 PM, Resident 6 in room [ROOM NUMBER] reported there were blood streaks on her/his wall which had been there for a long time. Resident 6 stated housekeepers cleaned the floors and dusted the room but never cleaned the blood streaks from the wall and she/he just wanted the wall cleaned. On 8/4/26 at 1:39 PM, Resident Council was conducted by a State Surveyor with two residents present for the meeting. Both residents reported that there were a lot of areas around the facility with unfinished painting, such as the ceiling in the dining room with multiple areas that needed to be painted after skylights were removed. The residents also stated the wooden hand and foot railings throughout the facility had scrapes and areas where the paint was coming off and they did not like to touch the hand railings. On 8/6/26 at 1:34 PM, Staff 6 (Maintenance Director), during a walk-through of the facility, stated there were many residents who used the television room and confirmed the three mustard-colored and four brown vinyl chairs were for residents' use and were torn and not cleanable, making the area unhomelike. Staff 6 reported the wooden hand and foot railings and wood doors were on my radar and needed to be repaired or replaced because they were not homelike. Staff 6 reviewed all area described above and confirmed they contributed to the environment being unhomelike. On 8/7/26 at 8:40 AM, Staff 1 stated he absolutely wanted the facility to be a finished and homelike environment. Staff 1 stated the wooden hand and foot railings were not homelike and needed to be addressed and the vinyl chairs in the residents' television room needed to be replaced. Staff 1 stated he expected the facility to be clean and homelike for the residents. 2. Resident 3 was admitted to the facility in 3/2026 with a diagnosis of PTSD (Post Traumatic Stress Disorder). The 6/25/26 Quarterly MDS revealed Resident 3 had impaired cognition and displayed verbal behaviors towards others. Resident 3's 6/3/26 care plan revealed the resident was at risk for re-living or experiencing distressing symptoms due to past wartime related traumas. On 8/3/26 at 10:47 AM Resident 3 stated she/he stated the facility was aware of her/his past traumas but did not know how to handle it. The resident stated the facility staff were often loud during shift changes and mealtimes, which caused her/him to become agitated and become aggressive towards staff. From 8/3/26 through 8/6/26 between the hours of 8:11 AM and 5:00 PM multiple observations made during mealtimes revealed staff would park the meal tray and drink carts against the wall outside Resident 3's room. During the observations, there were between three to six staff banged close the meal tray cart doors and talked to each other loudly. One of the observations was made from inside Resident 3's room. On 6/4/26 at 8:45 AM Resident 3 stated she/he was frustrated with the noise from the staff in the hallway and noise from the landscapers outside. On 8/6/26 at 8:13 AM Staff 18 (CNA) stated Resident 3 becomes agitated easily and staff must approach her/him in a calm and soft-spoken manner. Staff 18 acknowledged the hallways could be noisy and stated she had heard Resident 3 and other residents complaining about the noise in the hallways during mealtimes. On 8/6/26 at 4:25 PM Staff 16 (LPN) stated Resident 3 would become easily agitated by various triggers, including noise. On 8/7/26 at 8:14 AM Staff 3 (LPN/Resident Care Manager) and Staff 20 (Assistant DNS/LPN) acknowledged Resident 3 had concerns about the noise level and would become agitated when there were loud sounds, like meal cart door bangs. Staff 3 and Staff 20 stated the staff were told to be conscientious of their noise level in the hallways and avoid parking the meal carts outside Resident 3's door.

Based on observation, interview and record review it was determined the facility failed to ensure residents were assessed for safe self-administration of medications for 3 of 3 sampled residents (#s 4, 15 and 30) reviewed for self-administration of medications. This placed residents at risk for unsafe medication administration. Findings include: The Medication Administration/Self-Administration Policy dated 1/2023 indicated: -Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the mediations are appropriate and safe for self-administration. -If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process. 1. Resident 15 admitted to the facility in 11/2024 with diagnoses including chronic pulmonary disease and chronic kidney disease. A review of Resident 15's clinical record revealed there was no assessment for Resident 15 to self-administer medications. On 8/3/26 at 1:01 PM Resident 15 was observed in her/his room with an albuterol inhaler (quick relief of bronchospasms) and anti-fungal powder on her/his bedside table and windowsill. On 8/4/26 at 1:53 PM Resident 15 was in her/his room. The albuterol inhaler and anti-fungal powder were observed on the bedside table and windowsill. Resident 15 stated she/he used the albuterol inhaler often, as needed for her/his respiratory symptoms, and used the anti-fungal powder daily to her/his perineal area. On 8/4/26 at 1:57 PM Staff 11 (CNA) stated she had observed the inhaler and anti-fungal powder in Resident 15's room. Staff 11 stated Resident 15 used the inhaler as needed and Resident 15 reported using the anti-fungal powder daily. On 8/4/26 at 3:21 PM Staff 4 (LPN Resident Care Manager) stated he was not aware Resident 15 had an albuterol inhaler and anti-fungal powder at bedside in her/his room. Staff 4 stated Resident 15 did not have an evaluation for self-administration of either medication. Staff 4 confirmed Resident 15 had a physician order for the albuterol inhaler; however, there was no physician order for the anti-fungal powder. On 8/7/26 at 11:05 AM Staff 2 (DNS) was informed of the findings regarding Resident 15 having an albuterol inhaler and antifungal powder at bedside without an assessment for self-administration. Staff 2 confirmed residents are required to have an assessment completed prior to self-administration of medications. 2. Resident 30 was admitted to the facility in 10/2025 with diagnoses including emphysema (chronic lung disease) and respiratory failure. A review of Resident 30's clinical record revealed there was no assessment for Resident 30 to self-administer medications. On 8/5/26 at 8:54 AM Resident 30 was observed in her/his room with an albuterol inhaler (quick relief of bronchospasm) and an ipratropium/albuterol inhaler (for COPD, including emphysema) at her/his bedside. Resident 30 stated she/he used one inhaler as a rescue inhaler and the other inhaler was used as a preventative inhaler. On 8/5/26 at 9:34 AM Staff 11 (CNA) stated she had observed both inhalers in Resident 30's room. Staff 11 stated Resident 30 used both inhalers for her/his breathing. On 8/5/26 at 9:59 AM Staff 4 (LPN Resident Care Manager) stated Resident 30 did not have an evaluation for self-administration of either medication. On 8/7/26 at 11:05 AM Staff 2 (DNS) was informed of the findings regarding Resident 30 having an albuterol inhaler and an ipratropium/albuterol inhaler at bedside without an assessment for self-administration. Staff 2 confirmed residents are required to have an assessment completed prior to self-administration of medications. 3 Resident 4 was admitted to the facility in 1/2025 with diagnoses including gastric esophageal reflux disorder (GERD, a disease that caused stomach acid to flow back up into the esophagus, resulting in heartburn) and achalasia of cardia (disorder of the esophagus that makes it hard for foods and liquids to pass into the stomach). A review of Resident 4's orders revealed a 3/6/26 order for calcium carbonate (TUMS) 500 mg, give five tablets with meals three times a day for heartburn, upset stomach, or indigestion. On 8/4/26 at 2:27 PM, two medication cups were observed on Resident 4's bedside table. Each medication cup contained four nickel sized tablets. On 84/26 at 2:29 PM, Staff 7 (LPN) observed the medication cups on Resident 4's bedside table, Staff 7 stated the tablets were TUMS. Staff 7 stated Resident 4 was permitted to have five TUMS at bedside, however, they should not be left in the open where anyone could get to them. Staff 7 disposed of the TUMS. On 8/4/26 at 3:21 PM, Staff 4 (LPN Resident Care Manager, Infection Preventionist) stated medications were not expected to be left with the resident unless resident passed a medication self-administration evaluation and orders were received from the provider. Staff 4 stated Resident 4 did not have a self-administration evaluation completed for TUMS to be left at bedside. Staff 4 stated Resident 4 should not have TUMS at bedside.

Based on interview and record review it was determined the facility failed to honor a resident's preference for showers for 1 of 5 sampled residents (#46) reviewed for ADLs. This placed residents at risk for lack of autonomy and preferences. Findings include:The facility's Resident Rights Summary, undated, indicated residents had the right to a dignified existence, self-determination, and communication with and access to people and services inside and outside of the center. In addition, residents had the right to choose activities and schedules and make life choices. Resident 46 was admitted to the facility in 8/2020 with diagnoses including paraplegia (inability to move or feel the lower half of one's body) and chronic kidney disease stage 3 (moderate kidney damage). Resident 46's 8/22/20 ADL Self-Care Performance Deficit care plan indicated the resident was dependent for bathing/showering and bathing would be provided per the resident's preference. Resident 46's 5/21/26 Quarterly MDS indicated the resident had no cognitive impairment, was frequently incontinent of urine and was dependent for showering/bathing. Resident 46's 7/8/26 through 8/1/26 Bathing Task records revealed the resident received bed baths (washed while remaining in bed) on 7/11/26, 7/15/26, 7/18/26, 7/25/26, 7/29/26 and 8/1/26. On 8/3/26 at 11:37 AM and 8/4/26 at 1:10 PM, Resident 46 stated she/he requested showers but received bed baths for as long as she/he could remember. Resident 46 stated she/he spoke with Staff 4 (LPN Care Manager) several weeks ago and was told she/he could have showers if that was her/his preference. Resident 46 stated she/he wanted showers because when given bed baths, she/he was not clean enough. Resident 46 stated the reclining shower chair needed for her/him to shower was broken and needed to be repaired before she/he could have showers. On 8/5/26 at 12:33 PM, Staff 12 (CNA) reported Resident 46 liked showers and never had problems accepting a shower. Staff 12 stated she/he was unsure why Resident 46 only received bed baths. On 8/5/26 at 1:45 PM and 8/6/26 at 2:02 PM, Staff 12 (CNA) stated Resident 46 liked to take showers. Staff 12 stated the reclining shower chair used for showering Resident 46 was broken for at least the past three months, if not longer. On 8/6/26 at 10:17 AM, Staff 4 (LPN Care Manager) stated Resident 46 spoke to him about wanting showers at least three weeks ago. Staff 4 stated Resident 46 was unable to have showers until the reclining shower chair was fixed. On 8/7/26 at 8:40 AM, Staff 1 (Administrator) stated he was aware Resident 46 wanted to have showers but could not because the reclining shower chair was taking too long to get fixed. Staff 1 stated showers should be offered and provided as requested by residents and Resident 46 should be offered and given showers per her/his preference.

Based on interview and record review it was determined the facility failed to ensure residents were informed in writing of the facility's bed-hold policy and notice of transfer at the time of hospital transfer for 1 of 1 resident (#56) reviewed for hospitalizations. This placed residents and responsible parties at risk of not being informed of transfer and bed-hold policy fees. Findings include: The facility's Bed Hold Policy, dated 9/1/24, indicated upon transfer or discharge, the nursing department provided the resident and/or the resident representative a copy of the bed hold policy. Resident 56 was admitted to the facility in 5/2026 with diagnoses including acute pericarditis (swelling and irritation of the thin sac surrounding the heart) and COPD (a long-term lung disease). Resident 56's admission Profile indicated the resident was her/his own responsible party. Resident 56's health record revealed the resident was transferred to the hospital on 5/29/26. There was no evidence found in Resident 56's health record to indicate the resident was provided with the facility bed hold policy or notification of transfer at the time of discharge to the hospital. On 8/6/26 at 3:05 PM and 3:20 PM, Staff 1 (Administrator) stated when a resident was transferred to the hospital, the facility was not providing residents with a bed hold policy or a notification of transfer. Staff 1 confirmed Resident 56 was not provided with the required bed hold policy or transfer notification because they did not have a consistent system in place to notify residents or their representatives when a resident was transferred to the hospital. Staff 1 stated it was his expectation that all residents transferring to the hospital received the proper written notifications.

Based on interview and record review it was determined the facility failed to ensure residents with Serious Mental Illness (SMI) diagnoses had PASRR (pre-admission screening/resident review) level II referrals for 2 of 2 residents (#s 3 and 5) reviewed for PASRR level II screening. This placed residents at risk for unmet mental health needs. Findings include:The facility's 9/1/24 PASRR Process Policy instructed if a PASRR level II is indicated the Social Worker will ensure within a timely period that a licensed medical health professional is scheduled to evaluate. 1. Resident 5 was admitted to the facility in 5/2026 with diagnoses including schizophreniform disorder (a mental illness similar to schizophrenia), anxiety disorder, and opioid depression.The 6/5/26 admission MDS revealed Resident 5 was cognitively intact and indicated the resident had a diagnosis of schizophrenia. The 5/29/26 PASRR level 1 revealed Resident 5 had Serious Mental Illness (SMI) indicators and was exempted due to hospital discharge. The nursing facility service decision was left blank.The 6/3/26 Resident Centered Social History and Discharge Assessment revealed Resident 5 had hallucinations. On 8/3/26 at 1:05 PM Resident 5 stated she/he had not been eating her/his meals because she/he believed the food had been poisoned. On 8/6/26 at 11:41 AM Staff 5 (Social Services Director) confirmed Resident 5 had diagnoses which would indicate SMI and she had not reviewed the PASRR level I screen. Staff 5 acknowledged she had reviewed Resident 5 for a PASRR level II screening and confirmed she should have submitted a PASRR level II referral for Resident 5. 2. Resident 3 was admitted to the facility in 3/2026 with a diagnosis of PTSD (Post Traumatic Disorder) and anxiety. The 3/23/26 Resident Centered Social History and Discharge Assessment revealed Resident 3 identified multiple traumas associated with wartime experiences and had diagnoses including PTSD and anxiety. Resident 3's 6/3/26 care plan revealed the resident was at risk for re-living or experiencing distressing symptoms due to past wartime related traumas and had behavioral disturbances related to behavioral syndrome, dementia, anxiety, PTSD and mental status requiring psychotropic and antianxiety medication, and staff interventions to manage Resident 3's behaviors. Resident 63's behaviors were listed as spitting on others, yelling at staff, shouting out, and irritability. The 6/25/26 Quarterly MDS revealed Resident 3 had impaired cognition and displayed verbal behaviors towards others during the look back period. On 8/3/26 at 10:47 AM Resident 3 stated she/he stated the facility was aware of her/his past traumas but did not know how to handle it. Resident 3 acknowledged she/he had reactive behaviors to triggers such as noise levels, waking early, and being late. He said he would become angry and yell at staff when these things happened.On 8/4/26 at 8:45 AM Resident 3 was observed with a raised voice and tensed up muscles in her/his room. Resident 3 stated she/he was frustrated with the noise from the staff in the hallway and noise from the landscapers outside. On 8/5/26 at 10:14 AM Staff 21 (CNA) and 8/6/26 at 8:13 AM Staff 18, at 8:19 AM Staff 22 (CNA), and at 4:25 PM Staff 16 (LPN) stated Resident 3 had past traumas associated with the Vietnam war and was easily reactive to triggers, such as loud noises, waking early, or not doing things as Resident 3 preferred, which led to agitation and verbal aggression. On 8/6/26 at 8:11 AM Resident 3 was observed yelling at Staff 18 (CNA). Staff 18 stated Resident 3 becomes agitated easily for different reasons including noise and needing time to adjust. She stated Resident was yelling at her because she came in to deliver the breakfast tray. She said staff must approach her/him in a calm and soft-spoken manner and try to help the roommate first so Resident 3 could adjust but she/he did not adjust well that morning. On 8/6/26 at 11:41 AM Staff 5 (Social Services Director) confirmed Resident 3 had a diagnosis of PTSD and had been triggered by loud noises and disruptions when trying to sleep. Staff 5 stated she had not reviewed Resident 3's need for a PASRR level II screening but confirmed she should have due to Resident 3's diagnoses and behaviors.

Based on interview and record review it was determined the facility failed to develop a care plan for 1 of 1 sampled resident (#63) reviewed for dialysis. This placed residents at risk for lack of continuity of care. Findings include: The facility's 9/2024 Care Plan - Baseline Plan of Care Policy instructed the facility was to provide direct care givers with accurate information available to properly care for residents and a copy of the Baseline Plan of Care within 48 hours of admission.Resident 63 was admitted to the facility in 7/2026 with diagnoses including end stage renal disease.Resident 63's baseline care plan was initiated on 7/31/26 but was not completed within 48 hours of admission and was missing dietary orders, therapy services, and social services related needs. The dialysis portion was not reflective regarding Resident 63's dialysis access site or potential risks. On 8/7/26 at 8:14 AM Staff 3 (Resident Care Manager/LPN) and Staff 20 (Assistant DNS) stated the baseline care plan was to be completed within 48 hours of admission. Staff 20 confirmed Resident 63's baseline care plan was not completed within 48 hours.

Based on interview and record review it was determined the facility failed to ensure dependent residents received showers for 1 of 5 sampled residents (#38) reviewed for ADLs. This placed residents at risk for a lack of personal hygiene and loss of dignity. Findings include: The facility's Activities of Daily Living policy, undated, indicated residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Resident 38 was admitted to the facility in 10/2025 with diagnoses including stroke, amputation below the left knee and adjustment disorder (emotional and behavioral reaction to a life stressor).Resident 38's 10/22/25 ADL care plan indicated the resident required moderate to maximum assistance with bathing. Resident 38's 6/17/26 Quarterly MDS indicated the resident had no cognitive impairment, was always incontinent of bladder and bowel and had no shower during the look back period. Resident 38's 7/8/26 through 8/2/26 Bathing Task logs indicated the following:-7/8/26: no shower given due to not being the resident's scheduled shower day.-7/12/26: no shower given due to not being the resident's scheduled shower day.-7/15/26: no shower given due to not being the resident's scheduled shower day.-7/22/26: no shower given due to not being the resident's scheduled shower day.-7/23/26: shower provided. -7/26/26: not applicable. -8/2/26: no shower given due to not being the resident's scheduled shower day.A review of Resident 38's Progress Notes from 7/1/26 through 8/2/26 revealed no documentation indicating Resident 38 was provided with additional bathing opportunities if bathing was not provided. On 8/3/26 at 3:33 PM and 8/4/26 at 12:58 PM, Resident 38 stated she/he was supposed to be scheduled for showers but every time it was her/his shower day, the CNA told her/him they were too busy and could not get to her/his shower. Resident 38 stated this happened over and over again. Resident 38 stated she/he felt filthy especially in the heat. Resident 38 stated she/he used to shower every other day at home and had not been getting regular showers for the past two months. On 8/5/26 at 1:42 PM, Staff 11 (CNA) reported Resident 38 liked showers and had recently mentioned she/he had not received a shower for two months. Staff 11 stated when a resident received a shower, CNAs completed the resident's bathing task log for that day. If a resident refused a shower, they were to notify the charge nurse who would then talk to the resident. On 8/5/26 at 4:49 PM, Staff 13 (CNA) stated Resident 38 had scheduled showers, never refused showers and as far as he knew, always accepted showering. On 8/6/26 at 8:30 AM, Staff 16 (LPN) stated as far as he was aware, Resident 38 did not refuse showers. Staff 16 reviewed Resident 38's bathing task logs and confirmed, for the past month, the resident received only one shower on 7/23/26. Staff 16 reported he did not receive any verbal or written reports from CNAs that Resident 38 was refusing showers. On 8/6/26 at 10:02 AM, Staff 4 (LPN Care Manager) stated every resident was scheduled for at least two showers each week. Staff 4 reviewed Resident 38's bathing task logs and confirmed, in the past 30 days, the resident received a shower on 7/23/26. Staff 4 stated there were issues with residents missing showers and Resident 38 missed some of her/his scheduled showers. Staff 4 reported he expected Resident 38 to have more than one shower in a month. On 8/7/26 at 8:40 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated they identified issues regarding residents missing showers and improper shower documentation. Staff 1 stated he expected residents to receive showers as scheduled and Resident 38 should have received at least two showers per week.

Based on observation, interview, and record review it was determined the facility failed to assist in vision care needs for 1 of 1 sampled resident (#7) reviewed for vision. This placed residents at risk for impaired vision. Findings include:The facility's Hearing and Vision Services policy, undated, indicated the facility would ensure all residents had access to hearing and vision services and receive adaptive equipment as needed. Resident 7 was admitted to the facility in 12/2024 with diagnoses including diabetes. Resident 7's 1/8/25 Fall care plan indicated the resident was at risk for falling due to having fallen previously. Resident 7's 6/17/25 Vision Examination provided a prescription for eyeglasses and recommended the facility assist the resident to acquire glasses to reduce her/his risk for falls. It was also recommended the resident have an annual eye examination in 6/2026. Resident 7's 6/25/26 Quarterly MDS indicated the resident had no cognitive deficits, had impaired vision and did not have corrective lenses. A review of Resident 7's heath record revealed no evidence eyeglasses were ordered for the resident, or an annual vision examination was scheduled or completed in 6/2026. Observations from 8/3/26 through 8/7/26 between the hours of 8:00 AM and PM 4:00 PM revealed Resident 7 was not wearing glasses. On 8/3/26 at 11:22 AM and 8/4/26 at 12:49 PM, Resident 7 stated her/his eyesight was horrible. Resident 7 stated she/he had an eye examination completed over one year ago and was supposed to receive glasses, but nothing ever happened. Resident 7 stated she/he had difficulty seeing when watching television and doing some activities. Resident 7 stated she/he spoke with several different staff regarding eyeglasses but just gave up trying to get her/his prescription glasses. On 8/5/26 at 12:20 PM, Staff 12 (CNA) stated Resident 7 watched a lot of television but had never seen the resident wearing glasses. On 8/5/26 at 1:28 PM, Staff 11 (CNA) stated she did not see Resident 7 wearing glasses except when she/he used reading glasses to read books. Staff 11 stated she could see why Resident 7 needed glasses because she noticed the resident squinted a lot. On 8/5/26 at 2:10 PM, Staff 4 (LPN Care Manager) stated Resident 7 had an eye examination sometime last year and the facility was provided a prescription for eyeglasses. Staff 4 reported he had several rounds of communication with Staff 1 (Administrator) over the past several months and conversations with social services but Resident 7's eyeglasses fell off of my radar because he thought the resident's glasses were already ordered. On 8/5/26 at 3:46 PM, Staff 5 (Social Services) stated she was unaware Resident 7 needed eyeglasses, and she did not order eyeglasses for the resident. On 8/5/26 at 4:18 PM and 8/7/26 at 8:40 AM, Staff 1 stated he gave the green light to Staff 5 to order Resident 7's eyeglasses a while ago. Staff 1 stated he was unaware Resident 7's glasses were not ordered.

Based on observation, interview, and record review it was determined the facility failed to ensure residents were free from potential safety hazards and residents received safety devices to prevent accidents for 1 of 8 sampled residents (#16) reviewed for accidents. This placed residents at risk for injuries. Findings include:The 9/1/24 Smoking Policy indicates oxygen is not allowed in the smoking area. The policy instructs the facility to remove the cannula (a small nasal oxygen tube) and oxygen tank, allow the oxygen to dissipate, and leave the equipment at least 20 feet away. The 9/2024 Accident/Incident policy instructed the facility to initiate a plan to prevent re-occurrence at the time of the incident.1. Resident 16 was admitted to the facility in 2/2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).The 4/24/26 significant change MDS revealed the resident was cognitively intact and required oxygen use. Resident 16's 8/2/26 care plan instructed the resident was supervised for smoking and staff were to verify oxygen was removed prior to smoking. On 8/6/26 at 10:11 AM Staff 14 (CNA) was observed pushing Resident 16 in her/his wheelchair out to the smoking area. Resident 16 had a nasal canula in her/his nose, the oxygen tubing hooked over the resident's ears and looped on the wheelchair handle. The oxygen tank was not observed attached to the wheelchair at the time but had been observed in place earlier around 9:00 AM. Staff 14 was observed to light the cigarette held between Resident 16's lips.On 8/6/26 at 10:13 AM Staff 14 confirmed he had left the oxygen tubing on Resident 16 after removing the oxygen tank and lit the cigarette. Staff 14 stated he knew he was not supposed to leave the oxygen tubing on the resident, but the resident refused to let him remove it and he did not believe there was a risk leaving the oxygen tubing on since the oxygen tank had been removed.On 8/6/26 at 8:14 AM Staff 20 (Assistant DNS) and Staff 3 (LPN Resident Care Manager) stated staff were supposed to remove both the oxygen tank and the tubing when residents went out to smoke. Staff 20 stated oxygen tubing could still be at risk for explosion even when the tank was removed because oxygen remained in the tubing for a period of time.On 8/6/26 at 10:00 AM Staff 2 (DNS) and Staff 1 (Administrator) confirmed there was a risk of the oxygen igniting if any oxygen remained in the tubing and came into contact with a lit cigarette or lighter, so the staff should have removed Resident 16's oxygen tubing. 2. Resident 16 was admitted to the facility in 2/2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and anxiety disorder.The 4/24/26 significant change MDS revealed the resident was cognitively intact, required oxygen use, and was on hospice. The resident was at risk for falls due to her/his expected decline in health and use of medications which could contribute to falls. The 5/1/26 care plan revealed Resident 16 was at risk for falls and was revised on 8/2/26 to add a fall mat during bedtime.The 8/2/26 incident report revealed Resident 16 attempted to get out of bed but fell and sustained multiple injuries to her/his forehead, right cheek, and left upper arm. A fall mat was added to the resident's care plan as an intervention. Observations on 8/3/26 and 8/5/26 between 8:29 AM and 3:00 PM revealed a fall mat was not in place or in Resident 16's room while resident was in bed.On 8/4/26 8/29/26 Staff 17 (CNA) stated Resident 16 had a history of falls and did not have a fall mat in place or in her/his room. Staff 17 was not aware the resident was care planned to have a fall mat in place.On 8/5/26 at 10:38 AM Staff 23 (CNA) stated Resident 16 did not have a fall mat but the facility was working on obtaining one. Staff 23 confirmed the resident had a history of falling when she/he became agitated or anxious.On 8/5/26 at 3:59 PM Staff 25 (RN) stated Resident 16's fall mat had not arrived until 8/5/26. Staff 25 stated the facility preferred to have hospice order equipment, but acknowledged the facility had fall mats that could have been used.On 8/7/26 at 8:14 AM Staff 3 (Resident Care Manager/LPN) and Staff 20 (Assistant DNS) confirmed Resident 16 had a history of falls due to agitation, restlessness, and anxiousness. Staff 20 stated she believed a fall mat had been put in place by Staff 26 (LPN) on 8/2/26 but the fall mat could have been taken out to be cleaned during the day.On 8/7/26 at 9:19 AM Staff 26 confirmed he added a fall mat as an intervention in the care plan but did not put one in place in the resident's room. Staff 26 confirmed the fall mat was not in place when they returned to work the night shift on 8/3/26. Staff 26 acknowledged the facility had fall mats in storage, but he had not put one in place. On 8/7/26 at 9:31 AM Witness 2 (Hospice RN) stated the fall mat was not in place on 8/4/26 when she visited Resident 16.On 8/7/26 at 11:45 AM Staff 2 (DNS) stated the facility had fall mats and should have put a fall mat in place on 8/2/26 for Resident 16.

Based on observation, interview, and record review it was determined the facility failed to ensure resident respiratory equipment was maintained for 1 of 3 sampled residents (#16) reviewed for respiratory care. This placed residents at risk for increased respiratory distress. Findings include:The facility's 9/1/24 Respiratory Equipment policy instructed the facility to clean the oxygen concentrator (a machine that filters the air to produce concentrated oxygen) filter and the concentrator itself on a routine schedule. Routine maintenance and performance checks are completed per the supplier and their guidelines. The DeVilbiss(R) 5 Liter Oxygen Concentrator Instruction Guide manual instructs the user to inspect the cabinet air filter and the intake bacteria filter nightly and replace if the filter looks dirty or there is a drop in oxygen purity. The manual also instructs the user to clean the air filter weekly, and the concentrator exterior cabinet as needed (https://www.oxygenconcentratorstore.com/manuals/home/devilbiss525/OCS-Devilbiss-525-Manual.pdf).1. Resident 16 was admitted to the facility in 2/2026 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD).The 4/24/26 significant change MDS revealed the resident was cognitively intact, required oxygen use, and was on hospice. The 8/2026 physician's orders revealed an order for oxygen vial nasal cannula 1-4 liters per minute as needed to maintain oxygen saturations of 88-92% for COPD effective 4/6/26. On 8/3/26 at 3:42 PM Resident 16's DeVilbiss 525DD-331 oxygen concentrator was observed with a thick coating of dust on the outside of the concentrator exterior cabinet grate, inside the cabinet surfaces and on the filter canister. On 8/3/26 at 4:23 PM Staff 13 (CNA) confirmed Resident 16's oxygen concentrator surface and filter were dusty and stated the oxygen concentrators were cleaned by the nurses.On 8/3/26 at 4:25 PM Staff 7 (LPN) stated nurses were responsible for cleaning the oxygen concentrator filters and was usually located in the TAR (Treatment Assessment Record) weekly or monthly. Staff 7 confirmed a nurse would not have known to check the concentrator because the task was not listed in Resident 16's TAR. Staff 7 confirmed the oxygen concentrator filter, and filter cabinet had a thick coating of dust. Staff 7 was observed to wipe his index finger across the filter cabinet grate and filter and wipe off a cotton ball sized amount of dust from the surface. On 8/3/26 at 4:38 PM Staff 4 (LPN Resident Care Manager) stated Staff 6 (Maintenance Director) managed the cleaning of the oxygen concentrators once a month. Staff 6 was shown Resident 16's oxygen concentrator and confirmed there was still a coating of dust on the concentrator, filter, and filter cabinet. Staff 4 stated concentrator filters were expected to be cleaned because there was a risk of having the dust impede the flow of oxygen, which he felt could impact the resident's ability to breathe.On 8/5/26 at 11:00 AM Staff 6 stated the TELS task for quarterly oxygen concentrator checks was discontinued when he left in 9/2024 and had not been restarted since his return four months ago. He confirmed concentrators were not checked or cleaned and no documentation existed. Staff 6 stated risks of not cleaning include reduced oxygen flow, overheating, and potential bacterial growth.

Based on interview and record review, the facility failed to ensure mental health services were obtained for 1 of 3 sampled residents (#1) reviewed for behavioral health services. Findings include:Resident 1 was admitted to the facility in 2/2025 with diagnoses including major depression and suicidal ideation. Resident 1's [NAME] Psychiatric Consultant Notes dated 8/20/25 indicated she/he had last spoken to a therapist at that time. The notes indicated Resident 1 requested to discontinue services with the specific therapist. The notes indicated further therapy could be helpful for Resident 1 and the clinician recommended nursing staff and social services to assist Resident 1 with finding ongoing therapy outside the facility. There was no documented evidence in Resident 1's clinical record to indicate the facility followed up on obtaining mental health services for the resident after 8/2025. Resident 1's Care Plan dated 4/10/26 included active suicidal ideations, with interventions including to call 988, to not leave Resident 1 alone and implement one to one monitoring if Resident 1 mentioned wanting to kill herself/himself. Resident 1's care plan did not include mental health services. On 5/13/26 at 2:21 PM, Staff 10 (Social Services Director) stated she was not aware of Resident 1's Psychiatric Consultant Note to assist the resident in obtaining mental health services back in 8/2025. Staff 10 stated it was not her responsibility to follow-up on mental health notes for residents. On 5/14/26 at 12:35 PM, Staff 2 (Interim DNS) stated she was not aware of [NAME] Psychiatric Consultant notes for Resident 1 and would have expected Staff 16 (RCM) to follow up on obtaining mental health services for Resident 1.

Based on observation, interview and record review it was determined the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 sampled residents (#9) reviewed for falls. Findings include: Resident 9 admitted to the facility in 8/2025 with diagnoses including left femur fracture following a fall in previous living situation, dementia with psychotic disturbance, muscle weakness, difficulty walking, and unsteadiness on feet. A MORSE (Morse Fall Scale) Fall assessment dated [DATE] and 8/16/25 indicated Resident 9 was a high fall risk.The Occupational Therapy Evaluation and Plan dated 8/18/25 revealed Resident 9's problem solving was severely impaired and the resident required maximum assistance with transfers. The 8/22/25 admission MDS revealed Resident 9 had a BIMS score of three, which indicated the resident had severe cognitive impairment. The resident utilized a walker and wheelchair as mobility devices, required substantial to moderate assistance with transfers to and from the bed and for toileting. The resident had a history of falls with fracture.The Cognitive Loss/Dementia and Psychotropic Drug Use CAAs dated 8/22/25 indicated Resident 9 was alert, confused and forgetful at baseline, was unable to advocate for care needs, and had a history of falls at home resulting in a hip fracture. Staff were directed to complete frequent safety checks, comfort, and needs, as well as develop a care plan to decrease risks for falls. The resident was dependent on staff for all cares and that possible adverse consequences of psychotropic medication use included falls and short-term memory loss.A review of Resident 9's clinical record revealed the resident had two unwitnessed falls since admission to the facility, on 8/26/25 and 10/23/25. The second fall resulted in injury to Resident 9's head and face.According to the 9/4/25 Comprehensive Care Plan the resident was at risk for ADL/Mobility decline and required assistance related to left femur fracture, the resident was at risk for falls with or without injury related to history of falls, and the resident exhibited cognitive loss related to dementia. Interventions included assistance with locomotion, the use of a manual wheelchair and indicated the resident was dependent on assistance from staff for toileting. The care plan directed staff to use a gait belt for transfers, anticipate and meet needs promptly, fall mats on both sides of the bed, quarter bilateral enabler bars, keep call light within reach, toileting and incontinence care on rounds, upon request, and as needed, and encourage use of call light to promptly notify staff.A 10/23/25 an unwitnessed fall incident report revealed Resident 9 was found lying face down on her/his floor at the foot of her/his bed after walking unassisted. The resident was documented to have predisposing factors of impulsiveness, gait imbalance, recent room change, and non-compliance with cares. Call light within reach and footwear were not identified as being in place.Review of the 10/24/25 revised care plan showed no changes were made to the fall risk, ADL/mobility, or cognitive sections. On 11/9/25 the facility amended the care plan to include monitoring for irritability and restlessness related to depression and PTSD. None of the listed interventions reflected fall prevention. On 11/14/25 at 12:18 PM Resident 9 stated she/he did not need assistance walking in their room. Resident 9 stated she/he did not use the call light because their roommate would call staff or would go find someone. The resident was observed sitting at the edge of the bed without a call light within reach, no fall mats on either side of the resident's bed, no quarter bilateral enabler bars on the bed, or a wheelchair in the room. Observations throughout the day on 11/14/25 from 8:38 AM through 12:45 PM revealed the call light not within reach of Resident 9. The call light was observed to be stuck behind the bedside table and draped over her/his roommate's bed. On 11/14/25 at 10:37 AM and 3:15 PM Staff 30 (Agency CNA) stated they were given report during shift change from another CNA. Staff 30 stated they looked at the Kardex (a quick reference tool CNAs use to help care for residents) to know what Resident 9's care needs were. Staff 30 stated Resident 9 was independent with care but would let staff know if she/he needed assistance. Staff 30 accessed Resident 9's Kardex and confirmed Resident 9 required moderate assistance from one person with transfers and walking and should have had a wheelchair, floor mats on both sides of bed, and enabler bars attached to the bed. On 11/14/25 at 12:37 PM Staff 25 (CNA) stated Resident 9 got up on her/his own, did not ask for assistance, and, since moving rooms, was independent with walking with a walker. Staff 25 stated she did not know if Resident 9 was at risk for falls and recalled the resident had fall mats at the beginning of her/his admission but could not recall when they were removed. Staff 25 confirmed the call light was not within reach of Resident 9 and found the call light attached to the roommate's bed. On 11/14/25 at 2:47 PM Staff 31 (CNA) stated Resident 9's abilities fluctuated depending on the day, but she/he was mostly independent, if she/he needed to use the bathroom the resident went on her/his own. Resident 9 only asked for help when she/he could not do something independently.During interviews with Staff 4 (LPN-Resident Care Manager) on 11/14/25 at 10:43 AM and 2:24 PM, and 11/17/25 at 9:07 AM, Staff 4 stated Resident 9's care plan was last reviewed and updated on 11/10/25 and 11/11/25. Staff 4 confirmed the current Kardex/Care Plan was not accurate for all care needs and was not updated related to falls. Staff 4 stated she expected the care plan to be updated regularly with changes and with quarterly assessments. Staff 4 stated Resident 9 currently required hands-on assistance with transfers. Staff 4 confirmed Resident 9's care plan was not updated after the fall on 10/23/25. Staff 4 stated she expected staff to follow the care plan and to let the RCM know if the care plan needed to be updated. Staff 4 confirmed the fall mats, wheelchair, and quarter bilateral enabler bars were not removed from the care plan when they were discontinued. On 11/17/25 at 11:34 AM Staff 14 (CNA) stated they responded to calls for help from Resident 9's roommate on 10/23/25. He stated at the time of the fall Resident 9 would walk and toilet on her/his own, but staff encouraged her/him to call for assist. Staff 14 stated the resident was not impulsive, restless, or having behaviors at the time of the fall on 10/23/25. Staff 14 stated he did not recall what the Kardex stated but the expectation would have been to follow the Kardex/care plan. On 11/17/25 at 10:44 AM Staff 2 (DNS) and Staff 6 (Assistant RN Consultant) were present for an interview. Staff 2 confirmed at the time of the fall on 10/23/25 Resident 9 required moderate assist with transfers and ambulation. Staff 2 and Staff 6 confirmed the care plan was not updated after the fall with new interventions related to fall prevention. Staff 2 stated she expected staff to follow and implement the care plan. Staff 2 stated they removed the fall mats, but did not confirm when they were removed, and discussed the interventions they planned on implementing but did not change the care plan.

Based on interview and record review it was determined the facility failed to provide appropriate dosing of opioid medication for 1 of 3 sampled residents (#3) reviewed for medications. This placed residents at risk for complications related to narcotic medications. Findings include:The facility's Medication Administration Policy dated 1/2023 indicated the following: -Medications are administered in accordance with written orders. If the dose seems excessive or unrelated to the resident's current condition, the nurse calls the pharmacy or prescriber for clarification. The clarification is documented in the resident's medication record. -Prior to administration, review and confirm medication orders for each individual resident on the MAR.-If the label and MAR were different or if there was any other reason to question the dosage or directions, the prescriber's orders were to be checked for the correct dosage schedule. Resident 3 was admitted to the facility in 9/2024 with diagnoses including opioid abuse. Resident 3's 12/20/24 physician order indicated the resident was prescribed methadone (a medication used to treat opioid abuse)1gm/1ml solution: Take 20 ml of methadone once a day. A 1/10/25 Medication Risk Management investigation revealed Staff 33 (Agency LPN) opened all six prefilled bottles of Resident 3's methadone (the remainder of Resident 3's one-week supply), which resulted in the methadone needing to be destroyed. Due to the medication error, Resident 3 was sent to the methadone clinic to receive her/his 1/10/25 dose and returned to the facility with her/his replacement supply for the remainder of the week. Later that morning, Staff 33 administered a second dose of methadone to Resident 3 despite the resident telling Staff 33 she/he already received a dose of methadone earlier at the methadone clinic. Resident 3 took the second dose of methadone. Resident 3's 1/10/25 narcotic page confirmed Staff 33 signed out one dose of methadone at 11:45 AM and the resident's 1/10/25 MAR indicated Staff 33 administered methadone to Resident 3 at 11:51 AM.On 11/13/25 at 11:43 AM, Staff 9 (Former LPN Care Manager) stated Staff 33 opened Resident 3's remaining bottles of methadone, located in the resident's methadone lock box, and poured the methadone into a cup. Staff 33 came to Staff 9 questioning why there was not enough methadone to administer to Resident 3. Staff 9 stated because of the medication error, the methadone had to be destroyed, so she called the methadone clinic to explain what happened and find out what needed to be done. Staff 9 stated she was instructed to send Resident 3 to the methadone clinic so clinic staff could administer the resident's 1/10/25 dose. Staff 9 stated Resident 3 returned from the methadone clinic with her/his replacement methadone which was documented on the resident's narcotic sheet in the narcotic book. Staff 9 reported later she looked at Resident 3's narcotic sheet and noted Staff 33 provided a second dose of methadone. Staff 9 interviewed Resident 3 who confirmed she/he took a second dose of methadone because Staff 33 was insistent the resident did not receive her/his methadone yet that day. In addition, Staff 33 confirmed she administered the dose. Staff 9 stated she called the methadone clinic who then revoked our certification which resulted in Resident 3 having to go each day to have her/his methadone administered by the methadone clinic staff. On 11/13/25 at 12:28 PM, Staff 7 (Former DNS) stated Resident 3 was supposed to be administered one prefilled bottle of methadone, daily, but Staff 33 thought she was supposed to pour all of the methadone into one cup. Staff 7 stated Staff 33 went to one of my nurses who told her she was not supposed to open every bottle and because of this medication error, the methadone had to be destroyed. Staff 7 reported Resident 3 was sent to the methadone clinic to receive her/his 1/10/25 dose of methadone and was provided a second dose later in the morning by Staff 33. Staff 7 stated Staff 33 was confused about Resident 3's physician order and Staff 33 had difficulty reading the labels on the methadone bottles. Staff 7 stated the facility lost their ability for weekly take-outs so Resident 3 had to go to the methadone clinic every day to receive her/his daily methadone. On 11/14/25 at 8:19 AM, Staff 38 (Respiratory Therapist) stated on 1/10/25, he saw Staff 9, Staff 33 and Resident 3 huddled near the entrance to his office. Staff 38 stated Staff 9 and Resident 3 were upset because Staff 33 opened all of Resident 3's bottles of methadone. Resident 3 was concerned she/he would not be able to get her/his dose of methadone that day and Staff 9 promised she would take care of it. Staff 38 reported he escorted Resident 3 to the methadone clinic and watched as the resident took her/his dose of methadone. Later that day, Resident 3 was provided a second dose of methadone. Staff 38 stated he provided a breathing treatment later in the day and there was no change from her/his baseline after the resident received the second dose. On 11/14/25 at 11:38 AM, Staff 5 (RN Consultant) confirmed on 1/10/25 at 11:51 AM, Resident 3 was provided with an extra dose of methadone after her/his return from the methadone clinic. Staff 5 verified the resident was prescribed 20 ml of methadone daily. On 11/17/25 at 8:28 AM, Staff 33 stated Resident 3 had several bottles of methadone in her/his methadone lock box, but she could not read the labels on the bottles because they were smeared. Staff 33 stated she opened the bottles which she estimated to be 2 ml to 4 ml of methadone, each. Staff 33 stated when she came to the last two bottles, she realized there was not enough methadone to equal 20 ml so she asked Staff 9 what to do. Staff 9 asked Staff 33 why she opened all of Resident 3's methadone bottles. Staff 33 stated Resident 3's physician order indicated the resident was to receive 20 ml of methadone but that was wrong, the order should have been for 2 ml. Staff 33 stated Staff 9 confirmed to her, Resident 3's methadone order was for 20 ml. Staff 33 stated she and Staff 9 went to Resident 3's room to explain the situation and the resident slumped to the floor because she/he was upset. Staff 33 reported around 10:48 AM, Resident 3's new methadone was delivered to the facility and around 11:00 she went to Resident 3's room with a dose of methadone. Resident 3 stated are you sure I haven't received this already and Staff 33 answered no so Resident 3 took the dose. Staff 33 stated she was sure each bottle contained 2 ml and the physician order was wrong because it should have read 2 ml not 20 ml. Staff 33 stated she administered an extra dose of methadone to Resident 3 on 1/10/25 because staff did not communicate to her that Resident 3 went to the methadone clinic earlier in the day and received a dose at the clinic.

Based on observation, interview and record review it was determined the facility failed to provide an ongoing person-centered activity program for 3 of 4 sampled dependent residents (#s 28, 46 and 254) reviewed for activities. This placed residents at risk of a decline in psychosocial well-being and diminished quality of life. Findings include: The facility's Activity Program Policy, last revised 6/2018, indicated the following: -Activity programs were designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident. -The activities program included facility-organized group activities, independent individual activities and assisted individual activities. -The facility's activity programs were designed to encourage maximum individual participation and were geared to the individual resident's needs. -All activities were documented in the resident's medical record. 1. Resident 28 was admitted to the facility in 8/2023 with diagnoses including a brain stem stroke, severe dementia, Alzheimer's disease and dysphagia (difficulty swallowing). Resident 28's 8/28/24 Annual MDS revealed the resident had severely impaired cognition. Resident 28 liked doing things in groups of people, keeping up with the news, spending time outdoors, being around animals, listening to music and reading books/magazines and newspapers. Resident 28's Activity Care Plan, last revised 12/23/24, included giving the resident sensory supplies and helping him/her to use them and taking the resident outside when it was warm. The 1/6/25 Resident Council Meeting Minutes indicated residents wanted more in-room activities. The facility's Activity Calendar revealed the following scheduled activities: -2/10/25 10:30 AM: Clipper Cuts 2:00 PM: Farkle 3:30 PM: Stretching 4:00 PM: Charades -2/11/25 10:40 AM: Bible Study 1:30 PM: Yahtzee 3:30 PM: Ladies Group 4:30 PM: Dominoes -2/12/25 11:00 AM: Coffee Cafe 1:30 PM: Bingo 3:15 PM: Mobile Scrabble 4:00 PM: Library Cart 4:45 PM Chair Yoga -2/13/25 10:30 AM: Resident Shoppping 1:30 PM: Volleyball Thursday Therapy/Activities 2:30 PM: Chess 4:00 PM Meditation and Socialization -2/14/25 11:00 AM: Menu Planning 2:00 PM: Valentine's Prom Event 4:30 PM: Valentine's Trivia Resident 28's Activity Participation Logs from 1/10/25 through 2/10/25 indicated Resident 28 participated in a one-on-one exercise activity on 1/14/25 and was brought to group bingo on 1/29/25 with a guest. Random observations of Resident 28 conducted from 2/10/25 through 2/12/25 between the hours of 4:45 AM and 4:15 PM revealed the resident was up in her/his wheelchair for hours at a time, sitting in the living area, in front of the television. Resident 28 sat with her/his eyes closed and was not observed to watch television or look out the window. Frequently, other residents and staff were in the living area but none were observed interacting with Resident 28. On 2/11/25, the resident was seen sitting in the living area in her/his wheelchair in front of the television from 11:36 AM until the surveyor left the facility at 4:15 PM. The resident was not engaged in any activities during any observations. When the resident was not up in her/his wheelchair in the living area, the resident was in bed, positioned on her/his left side facing the wall, in a dark room with no stimulation such as music. There were no books, newpapers, magazines or sensory supplies observed in Resident 28's room. On 2/12/25 at 9:17 AM, Staff 34 (CNA) reported Resident 28 usually got up around 10:00 AM or 11:00 AM and sat in her/his wheelchair in the living area, in front of the TV all day. Staff 34 stated she never saw Resident 28 doing anything other than sitting in her/his wheelchair including no group or one-on-one activities in the resident's room or while sitting in the living area. Staff 34 stated Resident 28 did nothing all day and when the resident was in her/his bed, the room was dark and there was no stimulation such as music, occuring. On 2/18/25 at 7:49 AM, Staff 6 (Activities Director) stated she had no programs developed to provide activities to residents with dementia or residents unable to verbalize. Staff 6 reported Resident 28 was not able to engage while in group activities, such as bingo, and could not converse except to occasionally respond to yes/no questions. Staff 6 stated she had no sensory activities for Resident 28 except holding her/his hand on occasion. Staff 6 stated Resident 28 was not being provided with activities to meet her/his preferences or ability level and she/he should be getting more activities. On 2/18/25 at 10:50 AM, Staff 1 (Administrator) stated he expected the facility to have an activities program for dementia residents and residents who were non-verbal and expected residents to have a person-centered activities program. 47000 2. Resident 46 was admitted to the facility in 12/2024 with diagnoses including cognitive and communication deficit. Resident 46's 12/31/24 Baseline Care Plan indicated the resident was not alert or oriented, enjoyed to play pool and listen to music and her/his daily routine consisted of caring for her/his cat and boat. Resident 46's 1/7/25 Activity Assessment indicated the resident's activity preferences included to sail, and she/he preferred activities to occur in her/his room. Resident 46's 1/7/25 Admission MDS revealed the resident was cognitively intact and she/he preferred to listen to music, go outside when the weather was nice, be around pets and to keep up with the news. The MDS also revealed books, magazines and newspapers were not very important activity preferences for the resident. The Activities CAA indicated a care plan was to be developed in order to achieve improvement in this area. Resident 46's 1/8/25 Activity Care Plan revealed the following: -The resident's activity preferences included being around pets. -Witness 1 (Family Member) was very involved. -Ask the resident about her/his cat and sailboat. -Provide the resident with the opportunity to go outdoors and to sit by windows. -Encourage the resident to explore activities that promoted autonomy and independence with preferred activity pursuits. -Provide the resident with activity materials like books, magazines, newspapers, television, radio, arts and crafts in accordance with the resident's interests. The facility's 2/2025 Activity Calendar revealed the following activities: -2/10/25: 10:30 AM Clipper Cuts 1:30 PM Dietary Meeting 2:00 PM Farkle 3:30 PM Stretching 4:00 PM Charades -2/11/25: 10:40 AM Bible Study 1:30 PM Yatzee 3:30 PM Ladies' Group 4:30 PM Dominos -2/12/25: 11:00 Coffee Cafe 1:30 PM Bingo 3:15 PM Mobile Scrabble 4:00 PM Library Cart 4:45 PM Chair Yoga Review of Resident 46's 1/14/2025 through 2/12/2025 Activity Task Logs revealed the resident did not participate in any group activity outside of afternoon treats on 1/28/25 and her/his one-to-ones included four check ins, two family visits and one instance of conversation and reminiscing. Observations of Resident 46 from 2/10/25 through 2/12/25 between 5:27 AM to 4:03 PM revealed the resident to be in bed with her/his television on. On 2/10/25 at 3:04 PM, Witness 1 stated Resident 46 spent all day in her/his room in bed. Witness 1 stated she was never interviewed about the resident's activity preferences, which included to listen to music or a podcast, visit with her/his cat and socialize with others. Witness 1 further stated the resident did not enjoy television. On 2/11/25 at 10:59 AM, Resident 46 was observed in her/his room in bed with the television on. Resident 46 stated she/he loved to sail her/his boat, play pool and be around animals. On 2/12/25 at 9:05 AM, Staff 20 (CNA) stated Resident 46 spent most of her/his time in bed and slept a lot. Staff 20 stated the resident liked to fish but we don't have fishing stuff here so she/he could not engage in this activity interest. Staff 20 stated the resident also enjoyed to talk about her/his boat and cat but she was unaware of any additional activity interests or preferences. On 2/18/25 at 8:28 AM, Resident 46 was observed in her/his room in bed with the television on. Resident 46 stated she/he was interested to go outside and get fresh air and to receive in-room visits, and she/he loved animals and music, especially rock and roll. Resident 46 further stated she/he did not prefer to watch television but may look at it if it was on. On 2/18/25 at 7:49 AM, Staff 6 (Activities Director) stated Resident 46 slept most of the time but was always pleasant whenever she went into her/his room. Staff 6 stated she had not offered the resident an opportunity to participate in any of the activities she/he indicated were preferred on her/his Admission MDS, including to go outside, listen to music or receive a pet visit. Staff 6 stated the only activity she offered the resident was to talk about cats and boats. Staff 6 stated she did not have any idea how activity improvement as indicated in the resident's Activity CAA would be achieved and stated many of the resident's activity care plan interventions were not resident-specific but were canned. On 2/18/25 at 10:50 AM and at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (Regional Nurse Consultant) were present for an interview. Staff 1, Staff 2 and Staff 4 acknowledged the lack of activities offered for Resident 28. Staff 1 stated he expected the facility to have an activities program for residents with dementia and expected residents to have a person-centered activities program. 3. Resident 254 was admitted to the facility in 1/2025 with diagnoses including dementia. Resident 254's 1/30/25 Baseline Care Plan indicated the resident was not able to make her/his needs known, she/he liked games and her/his routine included to watch television with other residents. Resident 254's 2/6/25 Activity Assessment revealed the resident was unable to communicate what activities she/he enjoyed in the present or past and her/his preferred location for activities was anywhere in the facility. Resident 254's Activity Care Plan indicated the following: -Meaningful activities for the resident included participation in festive meals and snacks, television and visits with friends and family. -Assist the resident to-and-from activity locations as needed. -Provide one-to-one room visits for socialization if needed. The facility's 2/2025 Activity Calendar revealed the following activities: -2/10/25: 10:30 AM Clipper Cuts 1:30 PM Dietary Meeting 2:00 PM Farkle 3:30 PM Stretching 4:00 PM Charades -2/11/25: 10:40 AM Bible Study 1:30 PM Yatzee 3:30 PM Ladies' Group 4:30 PM Dominos -2/12/25: 11:00 Coffee Cafe 1:30 PM Bingo 3:15 PM Mobile Scrabble 4:00 PM Library Cart 4:45 PM Chair Yoga Review of Resident 254's 1/2025 and 2/2025 Activity Task Logs revealed the resident did not participate in a group activity and her/his one-to-ones included a check in on 1/30/25, calendar delivery on 1/31/25 and filling out menu on 2/7/25. On 2/10/25 at 10:44 AM, Resident 254 was observed in her/his room and sat in her/his wheelchair. No activity or personal items were observed in the resident's room. The televisions of the resident's roommates to both her/his right and left were on and the resident did not watch either. Resident 254 was unable to answer any questions regarding her/his activity interests or preferences at this time. On 2/10/25 at 1:47 PM, Witness 2 (Resident Representative) stated Resident 254 spent her/his day in between two beds in jail with no involvement in activities. Witness 2 stated the resident enjoyed to go outside, golf and listen to music, especially music from the 1940s. Witness 2 stated the resident enjoyed to be around people and she had repeatedly requested staff to allow her/him to participate in activities, and if she/he declined participation, it was likely on account of her/his hearing loss and difficulty with comprehension because of her/his diagnosis of dementia. Witness 2 further stated she was not interviewed about the resident's activity interests or preferences. On 2/11/25 from 10:50 AM to 12:42 PM, Resident 254 was observed in the facility's common area. The resident sat in her/his wheelchair and positioned her/his body away from the television which aired the news and a daytime talk show during this time period. The resident was not observed to watch the television or interact with other residents or staff. On 2/11/25 at 1:47 PM, Staff 27 (CNA) stated she had not seen Resident 254 participate in any activities and did not know the resident's activity interests. On 2/11/25 at 3:04 PM, Staff 28 (CNA) stated he did not know Resident 254's activity interests, the resident was confused a lot of the time and the only time he saw the resident up and in her/his wheelchair was when family visited. On 2/12/25 at 8:51 AM, and 10:52 AM, Resident 254 was observed in her/his room in bed. The televisions of the resident's roommates to both her/his right and left were on and the resident did not watch either. On 2/12/25 at 8:55 AM, Staff 13 (CNA) stated he had not seen Resident 254 participate in any activities, did not know the resident's activity interests and stated if he was curious about her/his activity interests, he would consult the resident's family as they come in enough. On 2/18/25 at 8:00 AM, Staff 6 (Activities Director) stated Resident 254's activity participation consisted primarily of meals in the dining room. Staff 6 stated she had not attempted any sensory activities with Resident 254 and the meaningful activities she included on the resident's care plan were not activity interests expressed by the resident or family but just things I saw [her/him] doing so I included them as meaningful activities. Staff 6 stated the resident had not participated in any group activities at the facility outside of Bingo on one occasion and her check in with the resident consisted of her asking the resident if there was anything [she/he] wanted to do and [she/he] said no. On 2/18/25 at 10:50 AM and at 11:08 AM Staff 1 (Administrator), Staff 2 (DNS) and Staff 4 (Regional Nurse Consultant) were present for an interview. Staff 1, Staff 2 and Staff 4 acknowledged the lack of activities offered for Resident 254. Staff 1 stated he expected the facility to have an activities program for residents with dementia and expected residents to have a person-centered activities program.

Based on observation and interview it was determined the facility failed to ensure meals served to residents in their rooms were served at palatable temperatures for 1 of 2 carts reviewed for food quality. This placed residents at risk for decreased enjoyment of food. Findings include: On 2/10/25 at 10:00 AM Resident 40 stated the food temperature for breakfast was cold if she/he wanted to eat in her/his room. On 2/10/25 at 10:10 AM Resident 24 stated breakfast was cold when she/he wanted to eat in her/his room due to it sitting out there for too long. On 2/11/25 at 8:06 AM Resident 40 had breakfast in her/his room and stated, It's cold again. On 2/11/25 at 8:08 AM Resident 24 stated breakfast was served in her/his room and the breakfast was cold. On 2/11/25 at 8:16 AM Resident 15 stated breakfast served in her/his room was cold. An observation on 2/12/25 at 7:13 AM revealed kitchen staff obtained the temperature of the scrambled eggs, which was 188 degrees Fahrenheit. On 2/12/25 at 8:22 AM staff began delivering trays. On 2/12/25 at 8:40 AM the last tray was served. On 2/12/25 at 8:42 AM a test tray was obtained by the survey team. On 2/12/25 at 8:43 AM the breakfast test tray had eggs, toast, oatmeal, juice and milk. The eggs were cold and the toast was cold and soft. During an interview on 2/18/25 at 12:01 PM, Staff 12 (Dietary Director) acknowledged resident complaints regarding cold food served in rooms and stated meals served in residents' rooms were expected to be palatably warm. During an interview on 2/18/25 at 12:25 PM, Staff 1 (Administrator) stated he was aware and acknowledged resident complaints regarding cold food being served in resident rooms.

Based on observation, interview and record review it was determined the facility failed to ensure food and beverages were labeled and stored in a manner to minimize spoilage and cross contamination for 1 of 2 unit refrigerators reviewed for sanitary conditions. This placed residents at risk for foodborne illness. Findings include: Review of the US FDA 2022 Food Code indicated the following: -Food prepared and held cold must be clearly marked with date prepared or by day which the food shall be consumed or discarded. -Food must be labeled with a use-by-date if stored for at least 24 hours. -Food could be stored up to seven days. The facility's Resident Food from Outside Source Policy, dated [DATE], indicated the following: -Refrigerated food items from an outside source was stored in a container with the date the product was received, the name of the product and the resident's name and room number. -Unlabeled and undated foods would be discarded. On [DATE] at 3:50 PM Staff 3 (Administrator in Training) and Staff 12 (Dietary Director) reviewed the residents' refrigerator which contained numerous food and beverage items. The following food and beverages were observed to be stored as follows: -meatballs in a plastic to-go container were unlabeled and undated; -pretzel bites in a plastic to-go container were unlabeled and undated; -shredded meat in a plastic to-go container was unlabeled and undated; -a container of smoked [NAME] cheese dip was unlabeled and undated; -a resident's open bag of burritos had no open date; -a container of chocolate fudge was unlabeled and undated; -a container of fruit cubes was unlabeled and undated; -a pitcher of brown liquid was unlabeled and undated; -a pitcher of purple liquid was unlabeled and dated [DATE]; -a pitcher of red liquid was unlabeled and undated; -three previously opened, one liter bottles of soda pop were unlabeled and undated. On [DATE] at 3:50 PM, Staff 3 and Staff 12 confirmed the above mentioned food and beverage items located in the residents' refrigerator were not properly labeled, dated or thrown out when expired. Staff 3 and Staff 12 stated they expected the residents' food and beverage items to be labeled and dated or discarded if the items were expired or not properly stored.

Based on observation, interview and record review it was determined the facility failed to provide physical therapy services as ordered for 4 of 4 sampled residents (#21, 154, 254 and 303) reviewed for rehabilitation services. This placed residents at risk for a decline in functional abilities and diminished quality of life. Findings include: The facility's Therapy Services Policy, last revised 7/2013, indicated therapy services were scheduled in accordance with the resident's treatment plan. 1. Resident 154 was admitted to the facility on [DATE] with diagnoses including contusion (injury caused by trauma) to the right thigh and abnormality of gait. Resident 154's 1/28/25 hospital transfer orders indicated the resident was prescribed PT to assess and treat. Resident 154's 1/30/25 Medicare PT Evaluation and Plan of Treatment indicated the resident needed PT three times a week for eight weeks. Resident 154's 1/2025 and 2/2025 Rehabilitation Service Log Matrix indicated PT assessed the resident on 1/30/25 and she/he did not receive PT treatment until 2/10/25, 11 days after her/his PT evaluation was completed. On 2/10/25 at 10:18 AM Resident 154 stated she/he was admitted to the facility two weeks ago to receive PT services so she/he could be discharged home. Resident 154 stated she/he was assessed soon after admission but, to date, she/he received no PT treatments. On 2/11/25 at 1:56 PM Staff 11 (Director of Rehabilitation) confirmed Resident 154 did not receive PT treatment per her/his treatment plan due to the facility's PT being on vacation and no PT coverage was available during that time. On 2/18/25 at 10:50 AM Staff 1 (Administrator) confirmed Resident 154 did not receive PT services due the facility not having PT coverage. 43690 2. Resident 21 was admitted to the facility in 3/2024 with diagnoses including Parkinson's disease and muscle weakness. Resident 21's 1/16/25 Physician Orders revealed PT to be provided as indicated. Resident 21's Admission MDS dated [DATE] indicated the resident had moderate cognitive impairment. On 2/10/25 at 12:32 PM, Resident 21 stated she/he was supposed to be getting more therapy than she/he was for her/his diagnosis of Parkinson's Disease. Resident 21 stated she/he had not received PT the previous week. On 2/11/25 at 11:30 AM, Staff 15 (PT) stated Resident 21 did not receive three days of PT the previous week because she was out of town and there wasn't coverage. On 2/11/25 at 11:41 AM, Staff 11 (Director of Rehabilitation) stated Resident 21 was receiving PT for functional maintenance program and contracture management. Staff 11 confirmed Resident 21 had not received therapy the week prior due to lack of PT coverage. Staff 11 stated it was his expectation that residents were seen for therapies as scheduled. On 2/11/25 at 1:07 PM, Staff 1 (Administrator) and Staff 4 (Regional Nurse Consultant) were informed of the findings of this investigation. Staff 1 stated it was his expectation that residents continuously received therapies according to the orders. 47000 3. Resident 254 was admitted to the facility in 1/2025 with diagnoses including traumatic subdural hemorrhage (a serious brain injury that occurs when blood pools beneath the brain's outermost membrane). Resident 254's 1/31/25 Physician Orders directed the resident to receive physical therapy three times weekly for four weeks. Review of Resident 254's 1/2025 and 2/2025 Physical Therapy Encounter Notes revealed the resident received physical therapy on 1/31/25. On 2/10/25 at 1:38 PM, Resident 254 was observed in the dining room accompanied by Witness 2 (Resident Representative). Witness 2 stated the resident was here for rehab but was not sure the resident received any. On 2/11/25 at 2:57 PM, Staff 11 (Director of Rehab) confirmed Resident 254 was to receive physical therapy three times weekly and had not received any physical therapy since 1/31/25. 51846 4. Resident 303 admitted to the facility in 2/2025 with diagnoses including severe chest pain due to reduced blood flow to the heart muscle. Resident 303's 2/4/25 Physician Orders revealed PT and OT to be provided as indicated. Resident 303 was evaluated on 2/5/25 by the facility to begin PT four times per week. On 2/10/25 at 10:25AM Resident 303 reported she/he had not been receiving therapy. On 2/12/25 at 1:09PM Staff 11 (Director of Rehabilitation) confirmed Resident 303 was scheduled to have physical therapy four times per week and she/he did not receive therapy. Staff 11 stated there was no physical therapist available to work with Resident 303 and there was no plan in place for coverage when therapy staff were out.

Based on observation, interview and record review it was determined the facility failed to honor a resident's preference for timing of wound care for 1 of 1 sampled resident (#42) reviewed for choices. This placed resident at risk for impaired sleep and reduced quality of life. Findings include: Resident 42 was admitted to the facility in 1/2025 with diagnoses including a stage four pressure ulcer and a non-pressure chronic ulcer with necrosis of the bone (non-healing open sore with loss of bone tissue). A review of Resident 42's physician orders indicated wound care was to be performed twice daily. A review of Resident 42's scheduled pain medication showed administration times to be at 6:00 AM, 12:00 PM, 6:00 PM, and 12:00 AM. Resident 42 also had physician orders for two other separate pain medications every three hours, as needed. On 1/28/25 Resident 42's admissions assessment noted Resident 42 to be social and looked forward to activities and it was very important for her/him to do things with groups of people. On 2/10/25 at 10:41 AM and on 2/12/25 at 1:32 PM, Resident 42 stated it was inconvenient for her/him to receive wound care at lunch time and midnight because it caused her/him to miss scheduled activities and not sleep well at night. Resident 42 stated she/he requested to have her/his scheduled wound care changed to morning and evening, but nothing was changed. On 2/12/25 at 1:16 PM Staff 13 (CNA) stated Resident 42 received her/his pain medication for wound care. On 2/12/25 Resident 42 received wound care from 2:12 PM to 2:42 PM. During an interview on 2/13/25 at 8:18 AM, Staff 30 (RCM) stated Resident 42's wound care was coordinated around the time of her/his pain medication and when nurses could do the wound care. During an interview on 2/18/25 at 11:35 AM, Staff 1 (Administrator) and Staff 2 (DNS) stated treatment times were based on residents' preferences and could be customized. Staff 1 and Staff 2 acknowledged Resident 42's preferences were not honored related to her/his wound care treatments.

Based on interview and record review it was determined the facility failed to ensure a resident was not administered a discontinued medication for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This failure resulted in the resident experiencing diaphoresis (heavy sweating), shortness of breath and diminished lung sounds which required emergency medical services and treatment at the hospital. Findings include: Resident 10 was admitted to the facility in 2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/24/20 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/18/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 4/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/22/22 5:58 PM progress note revealed Resident 10 experienced diaphoresis, shortness of breath, diminished lung sounds and was sent to the hospital on 4/22/22. A 4/29/22 hospital discharge summary revealed Resident 10 was admitted on [DATE] for respiratory failure and damaging metabolic changes (disturbance of brain functions) due to opioid intoxication. On 8/8/22 at 2:37 PM Staff 2 (DNS) confirmed Resident 10 received both medications for two and a half days until she/he was sent to the emergency room . Staff 2 stated that the error was an oversight on her part.

Based on observation, interview and record review it was determined the facility failed to monitor, assess and treat pressure ulcers for 2 of 3 residents (#s 2 and 3) reviewed for pressure ulcers. This resulted in the deterioration of Resident 2's pressure ulcer and placed residents at risk for pressure ulcers. Findings include: 1. Resident 2 admitted to the facility in 2/2018 with [DIAGNOSES REDACTED]. The 2/9/18 Admission Nursing Database form indicated Resident 2's skin condition included lower extremity pressure ulcers and a split open area to the sacral/buttocks crease. The 2/9/18 Pressure Ulcer care plan provided interventions to include frequent turning and repositioning, keep bony prominences from direct contact with one another with pillows, keep clean and dry as possible and maintain the head of the bed at the lowest degree of elevation possible. The 2/20/18 Pressure Ulcer CAA indicated Resident 2 admitted to the facility on hospice services, was bed bound and was minimally independent with position changes. The CAA further indicated skin care was provided each shift and as needed and frequent position changes were provided. The CAA indicated with staff assistance Resident 2's pressure ulcers would improve and no new skin issues would develop. A 4/18/18 hospice note indicated a new wound above the sacral (a large triangular bone at the base of the spine) area with a small 0.25 cm area hole with tunneling. A 4/25/18 Progress Noted indicated a physician order [REDACTED]. The 4/25/18 Physician order [REDACTED]. Progress Notes dated 5/24/18, 5/30/18, 5/31/18, 6/6/18, 6/7/18, 6/13/18, 6/14/18, 6/28/18 and 7/4/18 indicated Resident 2's sacral wound was treated with [MEDICATION NAME] a (topical antimicrobial). On 6/28/18 Resident 2's wound was described to have gray/green drainage and was odorous. A hospice note dated 6/14/18 indicated a Stage 3 (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. (MONTH) include undermining or tunneling) pressure ulcer on the sacrum with moderate serosanguinous (fluid) drainage. Review of Resident 2's record revealed there was no documented RN assessment of the pressure ulcer in the medical record which included evaluation of the resident's clinical condition, implementation of the care planned interventions and/or the need to revise those interventions and, it was not determined if the pressure ulcer was avoidable. Additionally, there was no documentation to indicate the 4/25/18 physician ordered treatment was provided or that ongoing wound evaluations were completed. On 7/9/18 at 12:25 pm and 2:25 pm Staff 3 (LPN) stated Resident 2 admitted to the facility with a pressure ulcer on her/his coccyx and hospice provided treatment orders to clean, pack and cover the wound with a wet to dry dressing. Staff 3 was unable to locate the treatment in Resident 2's treatment record. Staff 3 further stated ongoing wound assessments were completed and should be located in the treatment book. On 7/9/18 at 1:10 pm Staff 1 (DNS) stated ongoing wound assessments should be in the computer system and she would look to see if hospice documented the status of Resident 2's wound. Staff 1 stated she last visualized the wound a few weeks prior and thought the wound was a Stage 2 (Partial thickness loss of dermis presenting as a shallow open ulcer with a red or pink wound bed, without slough. (MONTH) also present as an intact or open/ruptured blister). Staff 1 further stated the wound was not going to heal because of the resident's poor nutrition. On 7/9/18 at 2:50 pm and 7/11/18 at 12:40 pm Staff 2 (RNCM) stated hospice wrote the current treatment orders and she observed the nurses provide the wound care. Staff 2 further stated Resident 2 did not have any other current pressure ulcers other than the one on her/his coccyx. Staff 2 stated she was unable to locate weekly wound evaluations On 7/9/18 at 3:05 pm Staff 9 (CNA) stated Resident 2 was incontinent of bowel and bladder and staff checked on her/him and provided incontinent care. Staff 9 further stated Resident 2 would refuse incontinent care and staff would re-approach the resident several times until she/he would accept the care. On 7/11/18 at 9:28 am and 12:45 pm Staff 10 (RN) stated the wound on Resident 2's bottom was open and she thought it was a Stage 4 (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes tunneling and undermining). Staff 10 further stated the wound was cleansed, packed with calcium alginate (wound dressing) and covered with a foam dressing and, she documented the wound care on the treatment record. Staff 10 stated hospice was primarily responsible for assessing Resident 2's wound. Staff 10 further stated in the past six to eight weeks the wound was treated with a saline gauze and the treatment was changed after the wound worsened. Staff 10 was unable to locate the current treatment on Resident 2's treatment record. On 7/11/18 at 10:13 am the RN surveyor observed Resident 2's wound. The wound was at the top of the coccyx (a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum), approximately 3.5 cm x 5 cm with undermining of edges present. Granulation tissue (new connective tissue) was present at the base of the wound, the surrounding tissue was pink, intact and blanchable when touched. No muscle was visible. On 7/11/18 at 12:50 pm Staff 1 stated she was unable to locate skin sheets or assessments of the wound other than documentation from hospice. Staff 1 further acknowledged the wound care orders were not on the treatment record and were not being documented. 2. Resident 3 admitted to the facility in 3/2018 with [DIAGNOSES REDACTED]. A Progress Note dated 6/11/18 indicated open areas on Resident 3's left and right buttock. The right buttock wound measured 0.7 cm x 0.9 cm and the left side buttock wound measured 1.2 cm x 0.7 cm with a depth of 0.1 cm. On 6/11/18 Skin Grid Sheets were initiated for the right and upper buttock pressure ulcers. There was no further documentation in Resident 3's medical record to indicate the wounds were evaluated again until 6/28/18 (over two weeks later). On 6/28/18 a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. (MONTH) present as an intact or open/ruptured blister) pressure ulcer 2 cm x 2 cm with no odor and a small amount of drainage was documented on the Skin Grid Sheet. The description of the wound did not indicate whether it was on the left or the right buttock. On 7/2/18 the Skin Grid Sheet indicated the right buttock pressure ulcer measured 0.3 cm x 0.2 cm x 0.2 cm and the left buttock pressure ulcer measured 0.9 cm x 0.5 cm x 0.2 cm. The wound beds were pink, the edges were smooth and no signs or symptoms of infection were noted. On 7/9/18 at 3:00 pm Staff 11 (LPN) stated she provided wound care to Resident 3's pressure ulcers earlier that morning. Staff 11 stated the left buttock pressure ulcer was resolved. On 7/11/18 at 2:30 pm Staff 4 (RNCM) stated she was unable to locate Skin Grid Sheets between 6/11/18 and 6/28/18. Staff 4 stated the licensed nurses were responsible for documenting weekly on the Skin Grid sheets.

Based on interviews and record review it was determined the facility failed to assess for pain and provide pain and antifungal medications in a timely manner for 2 of 4 sampled residents (#s 1 and 2 ) reviewed for medications. Resident 1 experienced periods of pain which limited her/his functional abilities. Findings include: 1. Resident 1 was admitted to the facility in September 2016 with [DIAGNOSES REDACTED]. The 9/29/16 local hospital discharge summary and discharge orders for the resident indicated the resident had pre-septal [MEDICAL CONDITION] from left eye to the base of her/his neck and was treated for [REDACTED]. The 9/29/16 local hospital discharge summary and physician's orders [REDACTED]. The September 2016 MAR indicated [REDACTED]. The resident's pain was assessed to be a 7 (pain scale with 1 being the least amount of pain and 10 the most severe pain). The resident was provided PRN [MEDICATION NAME]. The documentation indicated the resident was assessed at 8:46 pm, six hours after the PRN medication was provided, to be at a pain rating of 8 post medication. There was no documentation of additional approaches of pain management such as medications provided. On 10/1/16 the physician ordered 100 mg [MEDICATION NAME] every HS (hour of sleep). The 10/3/16 OT notes written at 11:04 am documented the resident had shooting pain in her/his head and nursing staff was notified. The October 2016 MAR for 10/3/16 contained no documentation PRN pain medication was provided until 7:37 pm. The 10/5/16 OT notes written at 11:12 am documented the resident had intermittent stabbing pain to the top of her/his neck and head. Functional activities were assessed to be limited and the nursing staff were notified. The October 2016 MAR for 10/5/16 contained no documentation PRN pain medication was provided until 1:21 pm when [MEDICATION NAME] was administered. The 10/5/16 PT notes written at 2:31 pm documented the resident had facial grimacing, functional activities were limited and nursing staff was informed. The October 2016 MAR for 10/5/16 contained no documentation additional PRN pain medication was provided. The 10/6/16 OT notes written at 12:38 pm documented the resident had stabbing pain on the left side of her/his head. The documentation indicated the resident was leaning over in pain about every three minutes and nursing staff was notified. The October 2016 MAR for 10/6/16 contained no documentation PRN pain medication was provided until 7:06 pm when [MEDICATION NAME] was administered. The 10/7/16 OT notes written at 9:23 am documented the resident was not able to move her/his neck without experiencing pain. The notes documented nursing staff was made aware of the resident's pain. The October 2016 MAR indicated [REDACTED]. The 10/12/16 OT notes written at 9:10 am documented the resident had intermittent stabbing like pain of the left of her/his head and nursing staff was made aware. The October 2016 MAR indicated [REDACTED]. The 10/13/16 OT notes written at 9:23 am documented the resident had shooting pain on the left side of her/his head and at times the pain was debilitating. Nursing staff was made aware of the resident's pain. The October 2016 MAR for 10/13/16 contained no documentation PRN pain medication was provided until 6:52 pm when [MEDICATION NAME] was administered. The 10/14/16 OT notes written at 2:37 pm documented the resident had shooting pain on the left side of her/his head and at times the pain was debilitating. Nursing staff was made aware of the resident's complaints of pain. The October 2016 MAR indicated [REDACTED]. The 10/15/16 OT notes written at 3:49 pm documented the resident had pain with movement of her/his head. The documentation indicated the resident continued to experience debilitating pain in her/his head with increased need for assistance due to shooting pain. The October 2016 MAR indicated [REDACTED]. There was a 10/15/16 physician's orders [REDACTED]. The October 2016 MAR indicated [REDACTED]. The 10/17/16 PT notes written at 1:39 pm documented PT made several attempts to see the resident. On the final attempt the resident was lying in bed wincing and grabbing face/head throughout session requiring increased time for all activities. The 10/17/16 OT notes written at 2:03 pm documented the resident had shooting pain in her/his head and neck. The notes indicated the nursing staff was informed. The October 2016 MAR indicated [REDACTED]. The 10/19/16 PT notes written at 10:00 am documented the resident indicated she/he had a great deal of head pain throughout the session and functional abilities were very limited. The 10/19/16 OT notes written at 2:42 pm documented the resident had pain which was debilitating in nature in limit tolerance for functional activity out of bed. The October 2016 MAR indicated [REDACTED]. The 10/20/16 PT notes written at 3:57 pm documented the resident complained of a headache throughout the session and the pain limited her/his functional activities. The October 2016 MAR indicated [REDACTED]. The 10/21/16 PT notes written at 7:46 am documented the resident had head pain and grabbed head intermittently throughout session. Pain continues to be severely limiting factor in functional mobility progress. Resident had a towel over her/his head, complained of pain in head no matter what I do, if I move at all it hurts. Resident wincing and grabbing head during conversation. The October 2016 MAR indicated [REDACTED]. On 10/21/16 Resident 1 was discharged from PT and OT. The 10/24/16 progress notes and incident investigation indicated there was a medication error. The 10/15/16 physician's orders [REDACTED]. The documentation indicated the medication order was received and transcribed as one dose order instead of ongoing. Resident 1 was discharged to the local hospital on [DATE] and was not readmitted to the facility. Interviews conducted 12/12/16 at 3:48 pm through 1/26/17 at 11:35 am revealed the following: Staff 5 (RN), Staff 6 (LPN), Staff 10 (RN), Staff 11 (LPN) stated the staff were to document when pain medications were administered and to assess if the pain medications were effective. Staff 1 (Administrator) and Staff 2 (DNS) verified the resident's pain medications were not provided as ordered and the resident's pain was not adequately assessed at times. 2. Resident 2 was admitted in November 2016 with [DIAGNOSES REDACTED]. There was an 11/3/16 physician's orders [REDACTED]. The November 2016 TAR documented the cream was not applied on the evening shift of 11/3/16 and 11/4/16 as there was no treatment nurse. There was no cream applied on the evening of 11/9/16 and 11/16/16 as the nurse ran out of time. On 11/18/16 the cream was not provided as the documentation indicated the resident was sleeping and unknown if the treatment was done on the evening shift. On 11/19/16 the medication was not available as CNA did not take the medication. On 11/23/16 and 11/24/16 the cream was not provided as the nurse was passing medications as there was no CMA in the building. Interviews conducted 12/12/16 at 3:48 pm through 1/26/17 at 11:35 am revealed the following: Staff 5 (RN), Staff 6 (LPN), Staff 10 (RN), Staff 11 (LPN) stated the staff were to document when medications were administered. The staff stated at times there were no treatment nurses available to provide treatments. Staff 6 stated if a treatment was not completed the staff were report to the next shift for the treatment to be provided. Staff 1 (Administrator) and Staff 2 (DNS) were asked to review the resident's record to determine if the medications were administered. There was no additional information provided.

Based on observation, interview and record review it was determined the facility failed to ensure professional standards were met by Staff 22 (CNA) for 1 of 4 sampled residents (#2) reviewed for incidents. Resident 2 experienced significant pain, was sent to the hospital and received sutures. Findings include: 851-063-0090 Conduct Unbecoming a Nursing Assistant A CNA, regardless of job location, responsibilities, or use of the title CNA, whose behavior fails to conform to the legal standard accepted standards of the nursing assistant profession, or whom may adversely affect the health, safety or welfare of the public, may be found guilty of conduct unbecoming a nursing assistant. Such conduct includes but is not limited to: (3) Conduct related to client safety and integrity: (a) Failing to take action to preserve or promote a person's safety based on nursing knowledge, skills, and abilities: (b) Failing to implement the plan of care developed by the registered nurse . Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gall bladder drain in place. The 4/22/16 In Room Care Plan noted the resident required two person, hoyer lift transfers. Staff 11 (LPN) documented in a 5/11/16 Progress Note that during the 5/10/16 evening shift at around 7:15 pm, a CNA reported the resident's side was hurting. Staff 11 documented Resident 2 was moaning and in extreme pain. The resident stated the drain was pulled. When asked how this occurred, the resident stated the drain was caught on the hoyer sling and pulled it out. Staff 11 assessed the resident and noticed frank blood was draining on the resident's flank (part of the abdomen), the stitches that were once intact were no longer intact and were pulled out and the tube was coming out of the site. Staff 11 placed a 4x4 dressing over the site to stop the bleeding and got pressure tape to place a pressure bandage. Another LN called the surgeon, who had the resident sent to the ER (emergency room ). 911 (emergency responders) were called at 7:26 pm and the resident left with emergency responders at 7:45 pm. Due to the placement of the pressure dressing, surgery was not required, new stitches were placed and a STAT lock was secured. A CT scan was completed to confirm placement. The resident returned to the facility at 3:45 am. The facility's correlating investigation included Staff 11(LPN) and Staff 22's (CNA) written statements regarding the incident. Staff 22 documented she entered the resident's room at around 7:30 pm and the resident wanted to be transferred to bed. The resident was in tears because of the pain and repeatedly asked for the transfer. Staff 22 left the room two or three times looking for help, both nurses were busy and she did not see anyone in the hallway. The resident was already sitting on the sling for the hoyer, she attached the sling to the hoyer and transferred the resident by herself. While lifting the resident something hit the tubing. After the resident was lying in bed Staff 22 noticed the tube was loose, but she did not observe any blood. Staff 22 located a nurse. Staff 11 documented when she interviewed Staff 22 about the incident, Staff 22 stated the incident occurred with the hoyer transfer. Staff 22 stated to Staff 11 the resident was a two person transfer, but she transferred the resident by herself. The facility determined the drain was pulled during resident handling with stitches torn. Staff 22 was counseled regarding not following the care plan. The 5/10/16 hospital records noted the resident was seen for a possible tube dislodgement. Imaging confirmed correct tube placement and the tube was stitched back into place. On 6/13/16 at 12:06 pm Resident 2 was observed sitting in her/his wheelchair, eating lunch. Regarding the 5/10/16 incident, Resident 2 stated Staff 22 (CNA) placed the hoyer sling incorrectly and when she/he was lifted up in the hoyer, the drain caught on the sling and pulled it out. Staff 22 was supposed to have another staff member with her during the transfer and was suspended because of the incident. Resident 2 stated I never had pain like that in all my life, it was a 15 out of 10. In interview on 6/16/16 at 2:20 pm Staff 22 (CNA) stated the resident was sitting in the chair, on the hoyer sling and wanted to be transferred to bed. She went out twice looking for staff and could not find anyone. The resident was in pain and crying and she transferred the resident by herself because there was no one to help. Staff 22 stated the resident was sitting on the sling for a long time prior to the transfer and may have been sitting on the tube. During the transfer Staff 22 did not hear any noise or see anything that looked different during the transfer. After transferring the resident to bed, the resident told her to get the nurse, which she did. When asked about the resident's care plan regarding transfers, Staff 22 stated she could not find the resident's care plan as the resident had recently moved to that room. When asked what she would do differently Staff 22 stated she would check the care plan in the computer or in the office maybe if there was time. Staff 22 stated she did not feel she had the time to check the care plan with this incident as the resident was crying and in pain and felt it was an emergency, I had to do what I had to do. In interview on 6/20/16 at 6:55 am Staff 11 (LPN) stated Staff 22 (CNA) reported to her Resident 2's side was hurting. The resident had a drain in place and was in an extreme amount of pain. The resident was really upset and stated Staff 22 pulled the drain out. Staff 11 assessed the drain and noticed the stitches were no longer intact. She put pressure on it due to the bleeding, had Staff 22 get a 4x4 dressing and had the other nurse call the physician. Resident 2 required two person transfers, however, Staff 22 transferred the resident by herself. Staff 11 stated there was no way the drain was pulled out before the transfer as it was flushed twice per shift, blood was coming out and the resident was in extreme pain. Refer to F323, example 1.

Based on observation, interview and record review it was determined the facility failed re-assess behaviors and follow behavior care plan interventions in a timely manner for 1 of 1 sampled residents (#5) reviewed for increased aggression and behaviors. Resident 5's aggressive behaviors escalated, which created a fearful and hostile environment for other residents in the facility. Findings include: Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/8/16 at 8:48 pm Progress Note disclosed Resident 5 was admitted to the facility with a motorized wheelchair. Staff received report the resident possibly had marijuana, which the resident denied. The resident was found to have an empty soda can with a hole it in, along with a torch. The 4/9/16 at 5:00 am Progress Note revealed Resident 5 smoked marijuana in her/his room. The 4/11/16 at 4:33 pm Progress Note disclosed Resident 5 smoked marijuana in her/his room. Later that night the resident went outside to smoke marijuana and came back in the facility with beer and was visibly intoxicated, running the wheelchair into the wall and was inappropriate with staff. The resident requested pain medication which the nurse did not administer due to being unsafe. The resident paced the halls for about an hour with the wheelchair, running into things. The 4/11/16 at 5:43 pm Progress Note documented Resident 5 became upset while waiting for physician orders [REDACTED]. When Staff 2 (DNS) reminded the resident about locking the smoking materials up, the resident became angry and very agitated. The resident was running into the front door with the motorized wheelchair. The resident left the facility, then returned at 4:40 pm with marijuana. Resident 5 continued to curse and yell at Staff 2. A LN got the marijuana from the resident and locked it up. The 4/12/16 at 3:07 am Progress Note revealed when Staff 11 (LPN) came on shift, Resident 5 cursed and yelled at Staff 2 (DNS). At dinnertime the resident yelled about the meal then went to the nurses' station and started spinning the wheelchair in a circle as fast as she/he could, in a very dangerous manner. When Staff 11 asked the resident to stop immediately due to the safety of other residents, the resident .just started laughing. Later when the resident was observed smoking marijuana in her/his room, the resident was informed she/he could not smoke in her/his room. When Staff 11 asked for the locked box of smoking materials, the resident refused. The resident eventually gave the box back but never went outside. Later the hallways got smoky again, the resident denied smoking, however, she/he had marijuana on her/his person. The resident again requested the locked box, which was provided. However, the resident refused to go off property to smoke. When the resident came back to the nurses' station she/he became sexually inappropriate with staff. The 4/12/16 at 5:50 am Progress Note disclosed Resident 5 was up all night and continued to interrupt Staff 11 (LPN) so she was unable to do her job. The resident raced the motorized wheelchair up and down the halls, spinning the wheelchair even when asked not to for safety, leaving marks on the floor throughout the building. Staff 5 observed the resident had marijuana on her/his person. The 4/12/16 Behavior Contract, which the resident signed, noted the resident was allowed one to two beers per day, had to smoke marijuana off the facility property, the smoking materials were locked up, the resident could not smoke the building or have smoking materials in her/his room and the resident was to operate the wheelchair in a safe and appropriate manner. The 4/15/16 Psychosocial Well Being and Behavior CAAS described the resident as conflictual, verbally abusive to staff and demanding. At times the resident was willing to listen and agree to compromises then turned around and broke the rules. Staff suspected the resident had a brain bleed and history of polysubstance abuse, which affected the resident's cognition. The 4/15/16 comprehensive Care Plan listed interventions including the use of a daily behavior monitor, refer the resident to community mental health PRN and engage Ombudsman/ADS worker PRN. The 4/15/16 In Room Care Plan that was updated on 6/1/16 noted Please refer to Behavior Contract .please document on behavior monitor can be verbally aggressive with staff . The resident had an order for [REDACTED]. [REDACTED].>Progress Notes dated 419/16, 4/29/16, 5/5/16 and 5/10/16 revealed the resident was observed smoking on the facility property, had smoking materials on her/his person, used the motorized wheelchair in an unsafe manner or was angry, yelling at staff. The 5/19/16 at 3:29 pm, 3:37 pm and 3:58 pm Progress Notes disclosed at 1:00 pm Resident 5 was observed knocking on a resident's door and said to the resident in that room come talk to me you snitch, then rolled the wheelchair up the hall. At 3:00 pm Resident 5 passed that same resident in the hall, calling the resident a tattle tale. Staff 4 (RNCM) told Resident 5 to stop the behavior and sent the residents in different directions. Staff 1 (Administrator) was informed, He will talk to (Resident 5). A PT reported to Staff 4 that Resident 5 was bothering another resident, making the resident feel uncomfortable, which was also reported to Staff 1 and Staff 2 (DNS.) The 5/21/16 at 9:48 pm Progress Note revealed Resident 5 was intrusive and overbearing to staff and residents. The resident yelled at a visitor, other residents and staff and was not re-directable. The resident raised her/his voice and could be heard from one end of the building to the other. The resident was observed telling another resident she/he did not like that resident, further agitated that resident. Attempts to re-direct resulted in the resident being argumentative. The 5/23/16 at 5:04 am Progress Note disclosed the resident had behavior issues during the shift related to pain medications. The resident cursed and yelled at staff and would not calm down. Staff 2 (DNS) was notified when the issues escalated to a point that other residents came out of their rooms to find out what was going on. The resident was threatening to hurt the nurse from the previous shift. About two hours later the resident went to her/his room and calmed down. The 5/24/16 at 5:00 am Progress Note revealed when Staff 11 (LPN) walked into the building for work, Resident 5 immediately started yelling and cursing. Staff 11 ignored the resident's behavior, took report and started working on the floor. The resident continued yelling and it escalated to a high point, with other residents and staff getting involved. Due to the resident's escalation with Staff 11, she had another nurse give the resident her/his medications. Staff 11 documented the incident went on for about three hours and Staff 2 (DNS) was notified. Staff 2 spoke with the resident, however, the resident didn't do anything requested by Staff 2. The 5/30/16 at 10:43 am Progress Note disclosed when Staff 11 (LPN) walked into the building for work, Resident 5 chased her down. The resident made it difficult for Staff 11 to get report from the previous shift LN and they had to move to a different location so they could be left alone for report. When the resident followed Staff 11 down to where she was working with the medication cart, she explained to the resident she/he was not allowed in that area because of issues with multiple residents. The resident became vulgar and yelled at Staff 11. When Staff 11 attempted to walk away the resident followed her. The resident was gone for awhile, then was found in Resident 8 and 9's room. When Resident 5 left the room, Residents 8 and 9 were shaken up. Staff 11 continued with the medication pass and Resident 5 came down to her and started screaming about her/his pain medication. The resident was informed she/he could not receive the medication due to recently smoking marijuana. The resident screamed extremely loud and cursed at Staff 11. At the same time three other residents came out of their rooms because they were sick of (Resident 5) talking and screaming like this and they stated they had it! Staff 11 had CNAs get in-between the residents so no fights broke out. The residents refused to go to their rooms because they felt the employees were unsafe. 911 was called by multiple employees and some residents that felt unsafe also called from their rooms Some residents were traumatized from the incident and came out crying to see what was going on because they were scared. Staff 11 had CNAs provide support to the residents and residents went back to their rooms. Resident 5's wheelchair was locked as she/he was darting the wheelchair at them and trying to hit us. Everyone left the situation to see if they could calm the resident down, however, the resident continued to scream and curse. The police arrived and spoke with the resident. The resident fell asleep, then woke up at around 3:00 am and started smoking marijuana in her/his room. All of the resident's smoking materials were confiscated at that time. Staff 1 (Administrator) was notified multiple times and came to the facility in the morning to deal with the issue. The Behavior Care Plan was updated on 5/30/16, which directed the resident to not make verbal or hand gestures that were vulgar or sexual in nature and to not harass any resident. On 6/1/16 the contract was updated and the resident was directed to not go in any other resident rooms and a staff member was to be with the resident when she/he was up in the wheelchair, out of her/his room. The 5/31/16 at 2:20 pm and 4:08 pm Progress Notes documented the resident's case manager and community mental health were contacted regarding the resident's behaviors. Appointments were set for dates in 6/2016. The 5/2016 and 6/2016 Behavior Monitoring Logs listed multiple interventions including engaging the family to assist PRN. There were no documented entries on the logs. On 6/3/16 - 6/5/16, 6/7/16, 6/8/16 and 6/12/16 Resident 5 continued to exhibit behaviors of non-compliance regarding smoking materials, smoking on facility property or yelling. The 6/14/16 at 7:28 am Progress Note disclosed when Resident 5 went down by Resident 8 and 9's room, where she/he was not allowed, Residents 8 and 9 started yelling. When Resident 5 was asked to go back to her/his room, she/he used vulgar language, refused to leave, raised her/his voice even louder and started threatening Staff 11 (LPN). Resident 6 and her/his roommate were very scared and called 911. Staff 11 notified Staff 2 (DNS), however, Resident 5 refused to speak to Staff 2. The resident's language worsened and she/he continued to stay in that hallway. Residents 8 & 9 were hysterical and staff phoned 911. The resident's one to one staff member came back from lunch and placed the resident back in bed. The police showed up and spoke with Residents 5, 8 and 9 to help calm them down. Later at around 2:00 am the resident requested a PRN sleeping medication and narcotics. The resident did not have orders for sleeping medication and it was too early for the narcotic medication. The resident again started yelling and being vulgar. Staff 11 called Staff 2 and while on the phone, the resident showed up at the nurses' station. Resident 5 spoke with Staff 2, then threw the phone across the desk. There was no documentation the resident's family was contacted in 5/2016 or 6/2016 when the resident exhibited behaviors. There was no documented evidence the case manager or community mental health was contacted regarding the resident's escalating behaviors in 5/2016 until after the 5/29/16 incident. There was no documented evidence the Ombudsman was contacted per the care plan nor was there a re-assessment of the resident's escalating behaviors. On 6/14/16 at 3:40 pm Resident 5 was observed in a motorized wheelchair at the nurses' station, requesting her/his smoking materials. The LN gave the resident the locked box, which was stored at the nurses' station. The resident kept moving items around in the box and removing/replacing items in the box until she/he left the facility. On 6/20/16 at 10:49 am Resident 5 was observed up in the wheelchair, at the nurses' station. The resident was calm, with no aggressive behaviors noted. Staff were not consistently at the nurses' station while the resident was there. At 10:58 am the resident moved to the TV lounge area and attempted to interact with two residents. There was no one to one staff member present. In interview on 6/20/16 at 10:18 am Resident 10 stated on 5/29/16 while she/he was at the nurse's station,Resident 5 came to the nurses' station, yelling. Resident 10 stated she/he told Resident 5 to calm down and stop yelling, however, the resident continued. There were other residents, including herself/himself that were sitting between Staff 11 (LPN) and Resident 5 but nothing stopped Resident 5. Two residents were crying because they were scared. At some point Resident 5 went back to her/his room and the police came. Resident 10 stated Resident 5 .pushes every button you have in your body .You don't know what is going to happen next. In interview on 6/20/16 at 10:32 am Resident 7 stated Resident 5 went in and out of residents' rooms. On one occasion Resident 5 went out to smoke marijuana then came in the facility and wanted medication. Staff 11 (LPN) told Resident 5 she/he had to wait four hours. Resident 5 got upset with Staff 11 and degraded her. Resident 7 stated Resident 5 almost got hurt that night. In interview on 6/20/16 at 11:02 am Resident 9 stated staff informed her/him to scream if Resident 5 came by her/his room. After an incident between Resident 5 and Resident 9's roommate, Resident 8, there were two incidents when Resident 5 was by their door and would not leave. Resident 5 screamed for staff assistance and staff escorted the resident from the area. Resident 9 stated she/he did not feel safe and was scared. In interview on 6/20/16 at 11:09 am Resident 8 was observed in bed, with the bed approximately two feet away from the window. Resident 8 stated she/he was scared of Resident 5, who knew she/he could not come in Resident 8's room. However, Resident 5 showed up outside the doorway, attempting to talk to her/him. Resident 5 was also outside the window to Resident 8's room, waving and yelling her/his name. In interview on 6/20/16 at 11:27 am Resident 6 stated there was an incident of Resident 5 yelling at Staff 4 (RNCM) and Staff 11 (LPN), which occurred the night before the big incident. During the big incident, Resident 5 chased Staff 11 down the hall, calling Staff 11 names and screaming. Staff 11 asked Resident 6 to call 911, which she/he did. Resident 6 stated I am paralyzed so if (Resident 5) came in here I would have no way to defend myself. In interview on 6/14/16 at 1:00 pm, Staff 2 (DNS) stated Resident 5 was re-directable until the 5/29/16 incident when the police were involved. Staff 2 stated she called the resident's family on one occasion soon after admission and there were other times the family member was contacted. Staff 2 did not provide any additional documentation of staff contacting family per the behavior care plan. In interview on 6/14/16 at 4:10 pm Staff 6 (CNA) stated on 5/29/16 Resident 5 became upset about her/his medications, cursed and did not want to listen or do anything staff requested. Other residents were present and ready to fight Resident 5 and staff intervened to keep the residents from fighting. The situation was resolved with police involvement. Staff 6 stated Resident 5 scared other residents in the facility and had a motorized wheelchair, which she/he used in a threatening manner towards others. In interview on 6/14/16 at 4:28 pm Staff 20 (CNA) stated it was hard to diffuse the situation when Resident 5 was denied pain medication after consuming alcohol or marijuana. Resident 5 followed Staff 11 (LPN) while in her/his motorized wheelchair, trying to look at the computer while Staff 11 gave other residents their medications. Staff 11 told Resident 5 it was not appropriate for her/him to look at other residents' information and Resident 5 responded with screaming and cursing. Re-directing the resident did not work. On 5/29/16 Resident 5 was outside smoking marijuana between 7:30 pm and 8:00 pm, then wanted pain medication. When it was not given to her/him, Resident 5 started screaming at Staff 11. Other residents came out into the hallway and told Resident 5 to listen to Staff 11. Resident 5 started to go forward at the other residents with the motorized wheelchair, so Staff 6 (CNA) locked the wheelchair so it would only go up and down, while they waited for the police. The residents in the hallway were angry, residents in rooms were scared and one resident called the police. In interview on 6/16/16 at 8:38 am Staff 16 (SSD) stated Resident 5 was a challenge since admission to the facility. Regarding managing the resident's behaviors since admission, the facility tried to use behavior contracts which did not work. When asked why there was no referral to community mental health until after the 5/29/16 incident, Staff 16 stated she was on vacation for two and a half weeks in May 2016. Staff 16 acknowledged the community mental health referral was not completed timely. Staff 16 stated the resident was disruptive to the entire milieu of the facility and behaviors were related to the resident's consumption of substances. Staff 16 stated she was aware there was no documentation on the behavior monitors, including interventions attempted. Calling family when the resident escalated may have helped staff with the behaviors. In interview on 6/16/16 at 11:52 am Staff 13 (RN) stated Residents 8 & 9 exhibited increased agitation and anxiety related to Resident 5. If they heard Resident 5's voice in the hallway they screamed. In interview on 6/17/16 at 5:30 am Staff 18 (CNA) stated there was no way to re-direct Resident 5 when she/he exhibited behaviors. In interview on 6/17/16 at 1:00 pm Staff 10 (RN) stated Resident 5 followed her around while she passed medications to other residents and wanted to see the computer showing other residents' MARs. Staff 10 told Resident 5 she/he could not look at other residents' information, however, she/he continued to follow Staff 10 around until she/he became tired. The resident made scenes in the hallway, arguing with staff. Most of the time it was hard to re-direct the resident. Staff 10 stated she was aware one of the interventions included calling the resident's family but she did not call the family member. Staff 10 stated Resident 5's behaviors affected all the residents as she/he yelled in the hallway. Staff told Resident 5 she/he could not be near Residents 8 & 9's room, however, Resident 5 continued to go by the room and they screamed for help. Resident 5 liked to go into other residents' room and those residents didn't like it. In interview on 6/20/16 at 6:30 am Staff 4 (RNCM) stated she had no additional information regarding the timeliness of the mental health referral as that was usually done by Staff 16 (SSD). Staff 4 stated when the resident's behavior escalated staff should have called the resident's family once they tried everything else. Staff 4 stated some residents want to deck Resident 5, others were fearful. In interview on 6//20/16 at 6:55 am Staff 11 (LPN) stated anything set Resident 5 off. The resident followed her into residents' rooms. Resident 5 felt she/he could go into other residents' rooms, even if the residents did not want her/him there. The resident could not be re-directed once she/he escalated, screaming and cursing. The behaviors occurred since the resident's admission and she did not call the resident's family at the time of the behaviors. Staff 11 described the 5/29/16 incident as it was like a small riot. Three residents wanted to harm Resident 5 because they were tired of her/his behaviors. She placed CNAs between the residents to keep people from being harmed, called the Administrator and different residents and staff called the police. Staff 11 stated some residents were extremely fearful and others were angry. After the incident the resident was placed on one to one supervision from 2:00 pm until 10:00 pm, when the resident went to bed. However, after that plan was implemented, another incident occurred when the resident got up after 10:00 pm and she had to call the police. In interview on 6/20/16 at 11:43 pm Staff 1 (Administrator) stated when Resident 5 exhibited behaviors prior to the 5/29/16 incident, he and Staff 2 (DNS) talked with the resident. Staff 1 stated re-direction was effective, depending on who the staff member was and they discussed with staff on how to de-escalate the situations. When asked about the behavioral contract intervention directing staff to be with Resident 5 when up in the wheelchair/out of her/his room, Staff 1 stated the resident was placed on one to one supervision during the evening shift. Resident 5 got up late and there were more staff, including department head staff to monitor the resident during the day shift. After 10:00 pm the resident was in bed. When asked about the 6/14/16 incident that occurred after 10:00 pm, Staff 1 stated he was not aware of the incident. In subsequent interview with Staff 1 (Administrator) on 6/21/16 at 11:58 am, Staff 1 stated the facility changed the one to one supervision to include department head staff providing one to one during the day shift and if the resident got up after 10:00 pm, a CNA would be pulled to provide one to one care.

Based on observation, interview and record review it was determined the facility failed to follow care planned interventions, re-assess smoking and the use of an motorized wheelchair for 2 of 4 sampled residents (#s 2 and 5) reviewed for incidents. Resident 2 experienced significant pain, was sent to the hospital and received sutures. Findings include: 1. Resident 2 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident had a gall bladder drain in place. The 4/22/16 In Room Care Plan noted the resident required two person, hoyer lift transfers. Staff 11 (LPN) documented in a 5/11/16 Progress Note that during the 5/10/16 evening shift at around 7:15 pm, a CNA reported the resident's side was hurting. Staff 11 documented Resident 2 was moaning and in extreme pain. The resident stated the drain was pulled. When asked how this occurred, the resident stated the drain was caught on the hoyer sling and pulled it out. Staff 11 assessed the resident and noticed frank blood was draining on the resident's flank (part of the abdomen), the stitches that were once intact were no longer intact and were pulled out and the tube was coming out of the site. Staff 11 placed a 4x4 dressing over the site to stop the bleeding and got pressure tape to place a pressure bandage. Another LN called the surgeon, who had the resident sent to the ER (emergency room ). 911 (emergency responders) were called at 7:26 pm and the resident left with emergency responders at 7:45 pm. Due to the placement of the pressure dressing, surgery was not required, new stitches were placed and a STAT lock was secured. A CT scan was completed to confirm placement. The resident returned to the facility at 3:45 am. The facility's correlating investigation included Staff 11 (LPN) and Staff 22's (CNA) written statements regarding the incident. Staff 22 documented she entered the resident's room at around 7:30 pm and the resident wanted to be transferred to bed. The resident was in tears because of the pain and repeatedly asked for the transfer. Staff 22 left the room two or three times looking for help, both nurses were busy and she did not see anyone in the hallway. The resident was already sitting on the sling for the hoyer, she attached the sling to the hoyer and transferred the resident by herself. While lifting the resident something hit the tubing. After the resident was lying in bed Staff 22 noticed the tube was loose, but she did not observe any blood. Staff 22 located a nurse. Staff 11 documented when she interviewed Staff 22 about the incident, Staff 22 stated the incident occurred with the hoyer transfer. Staff 22 stated to Staff 11 the resident was a two person transfer, but she transferred the resident by herself. The facility determined the drain was pulled during resident handling with stitches torn. Staff 22 was counseled regarding not following the care plan. The 5/10/16 hospital records noted the resident was seen for a possible tube dislodgement. Imaging confirmed correct tube placement and the tube was stitched back into place. On 6/13/16 at 12:06 pm Resident 2 was observed sitting in her/his wheelchair, eating lunch. Regarding the 5/10/16 incident, Resident 2 stated Staff 22 (CNA) placed the hoyer sling incorrectly and when she/he was lifted up in the hoyer, the drain caught on the sling and pulled it out. Staff 22 was supposed to have another staff member with her during the transfer and was suspended because of the incident. Resident 2 stated I never had pain like that in all my life, it was a 15 out of 10. In interview on 6/16/16 at 2:20 pm Staff 22 (CNA) stated the resident was sitting in the chair, on the hoyer sling and wanted to be transferred to bed. She went out twice looking for staff and could not find anyone. The resident was in pain and crying and she transferred the resident by herself because there was no one to help. Staff 22 stated the resident was sitting on the sling for a long time prior to the transfer and may have been sitting on the tube. During the transfer Staff 22 did not hear any noise or see anything that looked different during the transfer. After transferring the resident to bed, the resident told her to get the nurse, which she did. When asked about the resident's care plan regarding transfers, Staff 22 stated she could not find the resident's care plan as the resident had recently moved to that room. When asked what she would do differently Staff 22 stated she would check the care plan in the computer or in the office maybe if there was time. Staff 22 stated she did not feel she had the time to check the care plan with this incident as the resident was crying and in pain and felt it was an emergency, I had to do what I had to do. In interview on 6/20/16 at 6:55 am Staff 11 (LPN) stated Staff 22 (CNA) reported to her Resident 2's side was hurting. The resident had a drain in place and was in an extreme amount of pain. The resident was really upset and stated Staff 22 pulled the drain out. Staff 11 assessed the drain and noticed the stitches were no longer intact. She put pressure on it due to the bleeding, had Staff 22 get a 4x4 dressing and had the other nurse call the physician. Resident 2 required two person transfers, however, Staff 22 transferred the resident by herself. Staff 11 stated there was no way the drain was pulled out before the transfer as it was flushed twice per shift, blood was coming out and the resident was in extreme pain. 2. The facility's 3/2015 Smoking Policy and Procedure noted an established set of criteria was used to evaluate safety risks and residents who did not meet the established criteria for independence would be provided assistance during a supervised smoking activity. No smoking or use of smoking materials will be allowed on the grounds, including parking lots . except for the designated smoking areas. Resident 5 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 4/8/16 at 8:48 pm Progress Note disclosed Resident 5 was admitted to the facility with a motorized wheelchair. Staff received report the resident possibly had marijuana, which the resident denied. The resident was found to have an empty soda can with a hole it in, along with a torch. The resident was reminded per the policy and for safety reasons she/he was not allowed to have flammables. Resident 5's admission smoking assessment noted the resident was independent with smoking. The resident knew how the smoking materials were stored and exhibited the proper storage of smoking materials, but did not have a history free of smoking related incidents. The resident acknowledged that no smoking materials were shared with other residents. The undated admission In Room Care Plan directed staff to notify the LN if the resident smelled of alcohol or marijuana. The resident was a recreational marijuana user and had a lock box for storage of smoking materials. The 4/9/16 at 5:00 am and 5:57 pm Progress Notes revealed Resident 5 was smoking marijuana in her/his room, using the soda can with a hole in it. Staff removed the soda can and lighter. The smoking policy was given and explained to the resident, who acknowledged understanding. The 4/11/16 at 4:33 am and 5:43 pm Progress Notes disclosed at the start of shift staff smelled marijuana in the hallway. Staff 11 (LPN) went into the resident's room, where she/he was smoking marijuana. It was explained again she/he cannot smoke in her/his room and needed to leave the premises to smoke marijuana. The resident denied she/he was smoking and a burning joint fell on the floor. Later that night the resident had a visitor and they went outside to smoke marijuana. The resident came back in with a beer and was visibly intoxicated, slurring words, running the wheelchair into the wall and was inappropriate with staff. The resident requested pain medication and was upset when the staff member held the medication due to being unsafe. The resident paced the halls for about an hour with the wheelchair running into things. The resident refused to get into bed and passed out in the wheelchair. Later in the day the resident once again became agitated, running into the front door with the wheelchair. The 4/12/16 at 3:07 am Progress Note revealed at dinnertime the resident came to the nurses' station and started spinning the wheelchair in a circle as fast as she/he could, in a very dangerous manner. Staff 11 (LPN) asked the resident to stop immediately due to other residents using canes, walkers, other wheelchairs and were weak with walking. Resident 5 .just started laughing. Later in the shift the resident got the locked box of smoking materials and borrowed a lighter. The resident was reminded to leave the facility and sign out. Shortly afterwards the hallways smelled of marijuana and Staff 11 went to the resident's room and the resident was smoking. The resident refused to return the locked box and stated she/he would return it when finished. The resident later gave the box back, but never went outside. The hallways got smoky again, the resident denied smoking and had a small container full of marijuana which she/he was using in her/his room. The 4/12/16 at 5:50 am Progress Note documented the resident raced the motorized wheelchair up and down the halls, spinning the wheelchair, leaving marks on the floor throughout the building. Staff 11 (LPN) found a marijuana cigarette the resident had on her/his lap and marijuana in the shirt pocket. The resident refused to give the smoking materials to Staff 11. On 4/12/16 a Behavior Contract was developed and was signed by the resident, which directed the resident to only smoke marijuana off the facility property, to never smoke in the building, never have smoking materials in her/his room and to drive the motorized wheelchair in a safe/appropriate manner. The 4/13/16 at 2:20 pm Progress Note documented a staff member observed the resident in the wheelchair, sitting in the middle of the road, in front of the facility. The staff member told the resident she/he should move to the side so as to not get hit by a car. The resident stated I'll be fine. The resident continued to exhibit behaviors including keeping smoking materials on her/his person on 4/13/16 and 4/14/16. The 4/19/16 at 2:20 pm Progress Note disclosed Staff 2 (DNS) spoke with the resident regarding use of marijuana in the facility and on the property. The resident was reminded if she/he wanted to continue to stay in the facility, the resident must follow the policy. The resident was seen riding the wheelchair in the hall very fast and almost tipping the wheelchair. Staff 2 reminded the resident to slow down for her/his and other residents' safety. The resident went into another resident's room with marijuana on her/his lap. Staff 2 reminded Resident 5 she/he could not take the marijuana into other residents' rooms and needed to go outside once items were retrieved from the locked box. The resident continued to exhibit behaviors including keeping smoking materials on her/his person, refusing to smoke off property or operating the wheelchair in an unsafe manner on 4/20/16, 5/2/16, 5/5/16, 5/10/16, 6/3/16, 6/5/16 and 6/7/16. The Behavior Contract was updated on 6/1/16 with new interventions, including a staff member being with the resident when the resident was up in the wheelchair, out of the room. The 6/8/16 at 7:09 pm Progress Note revealed at 1:00 pm Staff 2 (DNS) smelled marijuana when walking past the resident's room. The resident had marijuana in her/his hand with the lid off of the container. Staff 2 reminded the resident the smoking materials needed to be locked in the box. The resident spilled it on the floor and again the resident was reminded to not open it in the building because of the smell. The resident agreed and took it to the nurses' station. Staff 2 documented there were multiple reports from staff of the resident asking what kind of car they drove. The resident was observed out in the road in the wheelchair. The resident placed the wheelchair in front of the cars purposefully and refused to move. Staff 2 explained to the resident she/he needed to stay on the side of the road unless crossing the road. The resident continued to exhibit behaviors including keeping smoking materials on her/his person, refusing to smoke off property or operating the wheelchair in an unsafe manner on 6/12/16, 6/14/16 and 6/16/16. At the time of the survey, there was no documented re-assessments of the resident's ability to smoke independently, nor the unsafe use of the wheelchair, including how the resident operated the wheelchair after consuming either marijuana or alcohol. On 6/13/16 at 4:05 pm the resident's locked box of smoking materials was observed stored in a room at the nurses' station. On 6/14/16 at 3:40 pm Resident 5 was observed in the motorized wheelchair at the nurses' station, requesting her/his smoking materials. The LN gave the resident the locked box, which was stored at the nurses' station. The resident kept moving items around in the box and removing/replacing items in the box until she/he left the facility. In interviews on 6/13/16 at 4:09 pm and 6/14/16 at 1:00 pm Staff 2 (DNS) stated the established criteria noted in their policy referred to the areas addressed in the smoking assessment. Resident 5 was assessed as an independent smoker because she/he could open the locked box, take it outside, go off campus and light the marijuana cigarette herself/himself. When asked if the resident's ability to smoke was re-assessed after the incidents of smoking on the grounds or the resident's room, Staff 2 stated a re-assessment was not done and the resident was still assessed as independent. Staff have counseled the resident and in an effort to control the resident's behaviors staff allowed the resident to continue with the marijuana and updated the behavioral contract. The lack of a documented assessment of the resident's ability to use the wheelchair when under the influence or exhibiting increased behaviors was discussed. Staff 2 stated the resident's behaviors and smoking marijuana occurred in the evening, when therapy was not available. No assessment of the resident's continued use of wheelchair when under the influence of alcohol or marijuana was provided. In interviews on 6/14/16 at 12:36 pm and 3:30 pm Staff 23 (PT) stated when Resident 5 was admitted to the facility, she/he had problems with substance use and operating the motorized wheelchair, however, there was no assessment of the resident's abilities to operate the wheelchair when under the influence. After smoking marijuana Staff 23 observed the resident as being impaired, trying to go through the front door without opening the door and listing the wheelchair to the side, grazing the wall then correcting herself/himself. Staff 23 stated he observed the resident riding the wheelchair in the middle of the street on at least three or four occasions, with the last time being a couple of weeks ago. Staff 23 stated when the resident was not under the influence, she/he had good safety awareness with the wheelchair, however, after consuming marijuana the resident was different in both attitude and the ability to use the wheelchair. In interview on 6/14/16 at 4:10 pm Staff 6 (CNA) stated he smelled marijuana in the halls when the resident was in her/his room. The resident stashed her/his contraband. The resident also consumed alcohol, going out of the facility once or twice a day. Staff 6 stated after the resident drank alcohol she/he was more loose with the wheelchair, like a drunken driver, speeding up and down the hall and doing tricks with the wheelchair. In interview on 6/16/16 at 11:30 am Staff 14 (RN) stated he observed Resident 5 smoking on the facility grounds and received reports Resident 5 shared the marijuana with other residents. In interview on 6/16/16 at 12:19 pm Staff 12 (LPN) stated she observed Resident 5 with smoking materials on her/his person and smoking on the property. The resident had incidents of unsafe wheelchair use, evidence by going fast and sitting in the wheelchair in the middle of the driveway, in front of cars. The resident acted like she/he was moving away, then did not move. On one occasion the resident parked in front of her car and would not move. Staff 12 called Staff 2 (DNS) for help and eventually the resident moved out of the way. In interview on 6/17/16 at 5:30 am Staff 18 (CNA) stated when the resident was first admitted to the facility, she/he smoked in her/his room. The resident had staff open the window, however, they could still smell the marijuana. The resident smoked on the facility property and it was difficult for the resident to follow the rules to return the smoking materials. In interview on 6/17/16 at 1:00 pm Staff 10 (RN) stated she observed Resident 5 smoking in her/his room on one occasion and she confiscated the smoking materials. Staff 10 stated it was hard to get the smoking materials from the resident, it took a lot of asking. It could take an hour to convince the resident to turn in the smoking materials, then an hour later she/he had it again. In interview on 6/20/16 at 6:30 am Staff 4 (RNCM) stated there was no re-assessment of the resident's smoking and asked if a re-assessment was required. In interview on 6/20/16 at 6:55 am Staff 11 (LPN) stated the resident smoked on the facility property and she has caught the resident smoking in her/his room on multiple occasions, which was documented in the progress notes. The resident refused to put the smoking materials back in the locked box when in the building. When under the influence the resident drove the wheelchair really fast, careless, did circles around her while she was passing medications and ran into multiple things, including the back of other residents' wheelchairs and people. In interview on 6/20/16 at 11:43 am Staff 1 (Administrator) stated if the resident was smoking in an unsafe manner, she/he could not smoke independently and should be re-assessed. Regarding the use of the wheelchair when under the influence, Staff 1 stated if the resident could not maneuver the wheelchair in a safe manner, she/he should not use the chair.

Based on interview and record review it was determined the facility failed to follow a physician's order for administration of medication for 1 of 3 sampled residents (#1) reviewed for medication administration. This placed residents at risk for hospitalization due to incorrect medication administration. Findings include: Resident 1 was admitted in 12/2014 with [DIAGNOSES REDACTED]. Resident 1's 7/2015 MAR and doctor's orders directed staff to administer [MEDICATION NAME] (an anti-anxiety medication), calcium, [MEDICATION NAME], tums, [MEDICATION NAME] (diabetic medication), [MEDICATION NAME] (a hypertensive medication), [MEDICATION NAME] (a medication to decrease cholesterol), multivitamin, fish oil and xyprexa (an antipsychotic medication) in the morning. According to the resident's medical record on 7/31/15 Resident 1 received [MEDICATION NAME], apap (a pain medication), calcium [MEDICATION NAME], senna, Vitamin D3, letrozole ([MEDICAL CONDITION] medication), [MEDICATION NAME], and [MEDICATION NAME] (an anti-depressant) in the morning at approximately 8:45 am. The medications were administered by a student nurse. A nursing note dated 7/31/15 indicated a student nurse administered the wrong morning medications for Resident 1 at 8:45 am. The student nurse reported to the charge nurse another resident's medications were accidentally given to Resident 1. The charge nurse called the physician who directed the facility to send the resident to the hospital. Resident 1's hospital notes dated 7/31/15 and 8/1/15 indicated the resident was administered the wrong medications at the facility on the morning of 7/31/15. Emergency Services transported the resident who was given [MEDICATION NAME] at approximately 9:45 am despite not having respiratory depression. The resident had normal vital signs at 10:11 am when seen in the emergency department. The hospital doctor contacted poison control who recommended 12 hour monitoring. Resident 1 was admitted to the hospital and returned to the facility on [DATE]. In an interview on 10/7/15 at 10:33 am, Resident 1 stated the wrong medications had been given to her/him on 7/31/15 and she/he felt out of it. Then the resident was sent to the hospital by her/his doctor. In an interview on 10/8/15 at 11:35 am, Staff 1, LPN, stated she was the charge nurse on duty on 7/31/15. She further stated Resident 1 was given another resident's medications by a student nurse on the morning of 7/31/15. She called the doctor who stated the long acting [MEDICATION NAME] would make the resident sleepy. The doctor instructed the nurse to send the resident out to the hospital for monitoring.