Every finding on record at Fiesta Park Wellness & Rehabilitation

Based on record review and interviews, the facility failed to provide adequate oversight of nursing students in accordance with professional standards of practice for 1 (R #1) of 1 (R #1) resident reviewed, which resulted in a nursing student providing R #1 a meal tray despite R #1 having an active nothing by mouth (NPO) dietary order. If staff serve food to a resident with an NPO order, then the resident is at risk for aspiration, choking, respiratory distress, and other preventable adverse outcomes. The findings are: A. Record review of the facility's nursing student educational agreement, dated 02/01/24, revealed the following: The student responsibilities include following the facility's administrative policies, procedures, rules, and regulations, and providing services to the facility's patients under the direct supervision of a faculty member provided by the college or a facility provided preceptor. The facility's responsibilities include retaining ultimate responsibility for patient care and services, providing orientation for faculty and students, accepting a mutually agreed upon number of students enrolled in the program, and providing those students with a supervised clinical experience. B. Record review of R #1's Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 06/06/26, revealed R #1 was admitted to the facility on [DATE] from the hospital. The MDS revealed R #1 had a Brief Interview of Mental Status (BIMS; a screening for cognitive impairment) score of 11, moderate cognitive impairment. The MDS revealed diagnoses including: Aspiration pneumonia (infection and inflammation of the lung caused by aspiration). Acute respiratory failure with hypoxia (when the lungs cannot adequately exchange oxygen and carbon dioxide, resulting in low levels of oxygen in the blood). Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease). Percutaneous endoscopic gastrostomy (PEG; a type of G-tube) dependence. C. Record review of R #1's comprehensive care plan, initiated 06/03/26, revealed R #1 required tube feeding related to dysphagia. The care plan directed staff to discuss tube feeding with the resident and family, monitor nutritional and hydration status, and obtain Registered Dietitian (RD) evaluations and recommendations for tube feeding as needed. D. Record review of R #1's physician orders revealed: An order, dated 06/03/26, for a nothing by mouth (NPO) diet. An order, dated 06/03/26, for continuous enteral feeding (the continuous administration of liquid nutrition through a feeding tube using a feeding pump). An order, dated 06/04/26, for continuous enteral feeding. E. Record review of R #1's nursing progress notes, dated 06/07/26, revealed the facility contacted the on-call provider regarding R #1, who was on an NPO diet and was mistakenly provided a breakfast tray. Staff documented R #1 experienced chest congestion and had an oxygen saturation (the amount of oxygen in the blood) of 87 percent (%; normal range is 95 to 100%). The resident's oxygen saturation improved with oxygen delivered at 2 liters per minute (LPM) through a nasal cannula (a small, flexible tube that delivers oxygen to the nose through soft prongs). The provider ordered a chest Xray and planned to reassess R #1. F. Record review of R #1's Change in Condition (CIC) Situation, Background, Assessment, Recommendation evaluation (SBAR; a concise, standardized method for communicating important information about a patient or situation to ensure clarity and prompt action), dated 06/07/26, revealed R #1's oxygen saturation was 86% without supplemental oxygen and on room air. R #1 experienced abnormal lung sounds, including rales (crackles; abnormal, discontinuous lung sounds heard primarily during inhalation, often indicating fluid or mucus in the airways), rhonchi (low-pitched, continuous lung sounds caused by air moving through mucus or other obstructions in the larger airways, often resembling snoring or gurgling), and wheezing. G. Record review of R #1's CIC-SBAR, dated 06/08/26, revealed R #1 was unresponsive and with congested lung sounds. The facility provider recommended R #1 be transferred to the emergency room. H. Record review of R #1's hospital documentation, dated 06/08/26, revealed R #1 presented to the emergency room with shortness of breath and an increased need for oxygen use. R #1's chest x-ray revealed a concern for aspiration (the inhalation of foreign material, such as food, liquid, or gastric contents, into the airways or lungs) or multifocal pneumonia (lung infection characterized by multiple areas of inflammation or infection occurring in different regions or lobes of the lungs). I. Record review of the facility incident report, dated 06/10/26, revealed a Nursing Student (NS) #1 provided R #1 with a regular breakfast tray on 06/06/26. The incident report stated R #1 consumed some bacon and eggs before staff identified the error and removed the meal tray. J. On 06/16/26 at 11:00 AM, during an interview, the Certified Nursing Assistant (CNA) #1 stated NS #1 assisted with meal tray delivery on 06/06/26. CNA #1 stated he instructed NS #1 to deliver the meal tray to room [ROOM NUMBER] but NS #1 delivered the meal tray to room [ROOM NUMBER], where R #1 resided. CNA #1 stated he later observed R #1 with a breakfast tray and immediately notified the Licensed Practical Nurse (LPN) #1. The CNA #1 stated R #1 had consumed portions of bacon and eggs before the tray from the resident. K. On 06/16/26 at 12:44 PM, during an interview, the Nursing Student Instructor (NSI) stated she supervised six first-level nursing students during their clinical rotation at the facility. The NSI stated the students received training through classroom instruction and simulation laboratories before participating in clinical rotations. She stated her role was to provide clinical instruction. The NSI stated she provided an orientation to the unit on the first day of clinicals and reviewed expectations, including meal tray delivery procedures. NSI stated nursing students were expected to verify each resident's identity, including the resident's name and room number, before delivering meal trays. The NSI stated students received education regarding diet orders, NPO status, and dietary restrictions. She stated residents' dietary restrictions, and NPO dietary orders were not routinely reviewed during the facility clinical orientation. The NSI stated students generally received information only for residents assigned to them. She stated if a student entered another resident's room, the student might not know that resident's dietary restrictions. The NSI stated she supervised six students, was present on the unit during meal tray delivery, and was not physically present with each student while meal trays were delivered. She stated students were working on both sides of the unit while she remained in a central location. The NSI stated she was informed of the incident involving R #1 immediately after it occurred. The NSI stated neither she nor her students received a facility-specific orientation before beginning the clinical rotation. L. On 06/16/26 at 2:52 PM, during an interview, LPN #1 stated CNA #1 informed him of the incident involving R #1 shortly after the meal trays was delivered. The LPN #1 stated he immediately went to R #1's room and removed the meal tray from R #1. The LPN #1 stated he informed the resident he could not continue eating the food, because he was not allowed to eat food. M. On 06/17/26 at 9:03 AM, during an interview, Nursing Student (NS) #1 stated she was assisting with meal tray delivery on 06/06/26. NS #1 stated Certified Nursing Assistant (CNA) #1 directed her to deliver a meal tray to a resident room. NS #1 stated she did not verify the meal tray ticket, the resident's identity, or the resident's diet order before delivering the meal. NS #1 stated she received education in nursing school regarding diet orders, NPO status, and verifying resident identification before providing care. NS #1 stated she was assisting the CNA with meal tray delivery and entered the room based on the CNA's directions. NS #1 stated she noticed the resident had a feeding tube but did not view it as a concern because some residents with feeding tubes are permitted oral intake. NS #1 stated she later learned R #1 had a NPO dietary order and should not have received food. NS #1 stated the clinical instructor was present on the unit but was not physically present with each student during meal tray delivery. NS #1 stated students worked under the supervision of the clinical instructor and could ask the instructor questions during the clinical rotation. NS #1 stated the facility did not provide an orientation regarding residents' diet orders, NPO status, code status, or facility-specific procedures before students participated in resident care. N. On 06/17/26 at 12:54 PM, during an interview, the Medical Director (MD) stated residents who are fed food while on an NPO diet are at risk for choking and aspiration. The MD stated aspiration may occur without being directly observed, and symptoms may develop later. O. On 06/17/26 at 1:30 PM, during an interview, the Director of Nursing (DON) stated NS #1 was not assigned to R #1 and would not have known R #1 had a nothing by mouth (NPO) dietary order. The DON stated the Nursing Student Instructor (NSI) was responsible for supervising the nursing students during clinical rotations. The DON stated the resident had been discharged to the hospital. P. On 06/17/26 at 2:15 PM, during an interview, the Administrator (ADM) stated his expectation was for the instructor to supervise nursing students while in the facility. The Administrator stated he would not consider a CNA to be a qualified licensed professional, and CNA #1 should not have directed NS #1 to provide meal trays to residents. Based on record review and interviews, an Immediate Jeopardy (IJ) was identified. The facility ADM was notified in person on 06/17/26 at 6:42 pm. The facility took corrective action by providing an acceptable Plan of Removal (POR). The POR was approved on 06/18/26 at 3:17 pm. Corrective action for affected resident: The resident involved in the incident was immediately assessed and monitored following identification of the meal delivery error on 06/06/26. The provider was notified, and appropriate clinical interventions were initiated on 06/06/26. The resident was transferred to the hospital on [DATE] when a change of condition was identified and remains under hospital care. An immediate audit was completed on 06/06/26 for all residents with provider orders for NPO status to verify dietary orders, meal service processes, and resident identifiers. No additional residents were identified as having received food contrary to provider orders. Resident Identification Procedures: On 06/13/26, nursing students and current licensed nursing staff received education regarding resident identification procedures. Follow-up reinforcement education was provided to licensed nursing staff on 06/17/26. Education included: Verifying resident identity prior to providing care, services, or meal delivery. Confirming that services and meal trays are provided to the intended resident. Verifying that the resident's name and room number match the information listed on the tray card prior to meal delivery. Seeking assistance from the nursing instructor or licensed nursing staff whenever questions arise regarding resident identification. Nursing Student Responsibilities and Supervision Expectations: On 06/13/26, nursing students and current licensed nursing staff received education regarding nursing student responsibilities and supervision expectations. Follow-up reinforcement education was provided to licensed nursing staff on 06/17/26. Education included: Nursing students are supervised by their assigned nursing instructor while participating in clinical experiences within the facility. Nursing students are expected to follow facility policies and procedures while providing resident services. Nursing students must communicate questions or concerns to their nursing instructor and supervising nurse. Nursing students may not perform resident care activities without supervision by their nursing instructor. Immediate Escalation and Notification Expectations: Beginning on 06/17/26, nursing students and current licensed nursing staff will receive education regarding immediate escalation and notification expectations prior to working the floor. Education included: Reporting concerns immediately to the nursing instructor and licensed nursing staff. Immediate nursing assessment when a resident receives services inconsistent with physician orders. Completion of facility incident reporting requirements. Notification of the attending provider, Director of Nursing, Administrator, resident representative, and other appropriate parties as indicated. Following facility reporting and notification procedures for significant clinical events. Oversight of Nursing Students: Effective 06/17/26, the facility implemented additional oversight measures for nursing students participating in clinical experiences. The nursing instructor will receive education regarding facility policies, resident identification procedures, incident reporting requirements, supervision expectations, and escalation processes. Education included the nursing instructor's responsibility to provide direct supervision of nursing students, review facility expectations with assigned students, communicate with facility nursing staff regarding student assignments, and immediately address concerns related to resident safety, prior to each new rotation. Nursing students will remain under the supervision of their assigned nursing instructor during clinical activities. Prior to each clinical experience, the nursing instructor will review facility expectations with assigned students. At the beginning of each clinical day, the nursing instructor will communicate with the charge nurse or designee regarding student assignments and resident care activities. Facility nursing leadership or designee will conduct observational rounds during student clinical experiences to verify compliance with resident identification procedures and supervision expectations. Any concerns identified during observations will be addressed immediately through intervention and re-education as appropriate. The Director of Nursing or designee will monitor compliance with these processes to ensure ongoing resident safety. Implementation of the POR was verified onsite on 06/18/26, and the IJ was removed on 06/18/26 at 4:45 pm. The scope and severity were reduced from a J to a D. Implementation of the POR was verified by the following: On 06/18/26 at 3:00 PM, during an interview, the Assistant Director of Nursing (ADON) #2 stated the facility nursing management was recently educated regarding their responsibility for oversight and supervision of nursing students while in the facility. ADON #2 stated nursing students were required to be with facility staff or their nursing instructor while participating in clinical activities. ADON #2 stated nursing management would be more hands-on with the oversight of nursing students moving forward. ADON #2 stated the level of student participation depended on the student's clinical level, and the nursing students currently attending the facility were to observe and learn unless otherwise directed by facility management. ADON #2 stated nursing students would not be permitted to pass meal trays. ADON #2 stated staff received education regarding meal tray delivery procedures and the requirement that nursing students were not to participate in tray pass activities. On 06/18/26 at 3:18 PM, during an interview, LPN #7 stated the facility staff were expected to verify the correct resident, correct room, correct diet, and resident allergies before delivering a meal tray. LPN #7 stated this verification process applied to both room trays and meals served in the dining room. LPN #7 stated staff recently received education on meal tray verification procedures. LPN #7 stated if a resident received the wrong diet, then staff must immediately remove the tray, determine whether the resident consumed any portion of the meal, notify nursing management and the physician, and follow all physician orders. LPN #7 stated staff would initiate a CIC following such an event. LPN #7 stated if staff observed a nursing student performing activities outside the facility policy, then staff must immediately stop the activity and intervene. On 06/18/26 at 3:20 PM, during an interview, ADON #3 stated LPNs serving as nursing supervisors were responsible for the oversight of the building and ensuring staff followed the facility policies and procedures. ADON #3 stated Nursing Supervisors received education regarding the oversight and supervision of nursing students. ADON #3 stated the same expectations applied to nursing instructors supervising the nursing students while in the facility. ADON #3 stated nursing students were expected to observe and learn while in the facility and were not expected to independently perform tasks. ADON #3 stated the facility nursing management now participated in the oversight of nursing students throughout the building. ADON #3 stated the facility nursing management observed the nursing students during meal service and monitored student activities during all meals. On 06/18/26 at 3:25 PM, during an interview, LPN #6 stated staff received education regarding meal tray delivery procedures. LPN #6 stated staff were educated on the processes to verify the correct resident, correct diet, and compare the meal tray ticket to the resident before delivering a meal tray. LPN #6 stated staff should open the meal trays and verify if the contents match the diet order identified on the meal ticket. LPN #6 stated staff must follow this verification process for all meal trays, including trays delivered to resident rooms and meals served in the dining room. LPN #6 stated if a resident received an incorrect diet, then staff must immediately notify nursing management, complete an incident report, monitor the resident for changes in condition, and follow all physician orders and recommendations. LPN #6 stated nursing students were not permitted to provide resident care independently. LPN #6 stated if staff observe a nursing student performing tasks outside the scope of their permitted role, then staff must stop the activity immediately, educate the student, and notify the nursing instructor. On 06/18/26 at 3:27 PM, during an interview, LPN #8 stated staff received retraining on meal tray delivery procedures. LPN #8 stated staff were instructed to verify that the dietary ticket matches the food on the tray and to ensure the correct meal was delivered to the correct resident and room. LPN #8 stated the same verification process applied to residents receiving meals in their rooms and those dining in the dining room. LPN #8 stated if a resident received an incorrect diet, then staff must immediately notify nursing management and the provider. Staff must assess the residents to ensure the residents were not experiencing negative effects. LPN #8 stated staff would initiate a CIC if the residents experienced any negative effects from the incident. LPN #8 stated the nursing students were generally present to observe and learn but did not independently provide resident care. LPN #8 stated the nursing student instructors made rounds throughout the facility and checked on students during clinical activities. LPN #8 stated nursing students typically observed residents and completed assigned learning activities, but they were not expected to independently provide care or pass meal trays. On 06/18/26 at 3:39 PM, during an interview, LPN #1 stated he worked at the facility for approximately four years and served in his current position for approximately one year. LPN #1 stated he received education from the DON and ADONs regarding nursing student supervision. LPN #1 stated nursing students were not permitted to perform tasks independently and the nursing facility was expected to provide oversight while students were in the facility. LPN #1 stated the nursing students were generally expected to observe, shadow staff, and learn through observation. LPN #1 stated he recently received additional education that nursing students were not to perform tasks independently and should seek clarification from nursing management when questions arose. The facility staff were expected to notify nursing management when an incident occurred. On 06/18/26 at 3:46 PM, during an interview, CNA #1 stated staff were expected to verify meal trays to ensure residents received the correct meals and diets. CNA #1 stated if he observed a resident receiving the wrong diet, then he would immediately notify the nurse and report the concern. CNA #1 stated the nursing students were generally present to observe and learn and were not expected to provide resident care independently. On 06/18/26 at 3:50 PM, during an interview, CNA #3 stated she worked at the facility since October 2025. The CNA #3 stated the facility staff were expected to verify meal trays and meal tickets before delivering meals to residents. CNA #3 stated the facility staff verified the resident's diet order and identity and ensured the resident was authorized to receive the meal. CNA #3 stated the meal tray verification process applied throughout the facility, including resident rooms and the dining room. CNA # 3 stated the nursing students were generally present to observe and learn and did not assist with meal service. CNA #3 stated she did not allow nursing students to pass meal trays because they may not be familiar with residents or their diet requirements. CNA #3 stated the nursing instructors directed students to observe and not to perform tasks independently. On 06/18/26 at 4:06 PM, during an interview, CNA #4 stated staff assisted with meal service by preparing trays, filling beverages, and ensuring condiments were provided as appropriate. CNA #4 stated the facility staff were expected to verify the correct resident received the correct meal tray and diet prior to meal service. CNA #4 stated if staff identified a resident receiving the wrong tray, then they should remove the tray immediately. CNA #4 stated the facility staff were expected to notify the nurse when a resident received an incorrect meal tray. CNA #4 stated the nursing students followed the direction of their nursing instructor and were present to observe facility operations.

Based on record review and interviews, the facility failed to ensure a resident was free from abuse for 1 (R #2) of 1 (R #2) resident, when a facility Certified Nursing Assistant (CNA) engaged in unwanted physical contact with the resident and ate food from the resident's meal tray. This deficient practice resulted in R #2 experiencing fear, anxiety, tearfulness, sleep disturbance, emotional distress, and concern regarding retaliation. The findings are:A. Record review of R #2's Minimum Data Set (MDS; a standardized assessment used to evaluate a resident's clinical status and care needs) discharge assessment, dated 06/14/26, revealed:R #2 was admitted to the facility on [DATE] with the diagnoses of a displaced fracture of the lower end of the left femur (the large bone extending from the hip to the knee), impaired mobility, and weakness. R #2 had a Brief Interview for Mental Status (BIMS; a standardized cognitive screening assessment) score of 15, indicating the resident was cognitively intact.R #2 utilized a wheelchair for mobility.R #2 required assistance with transfers. B. Record review of R #2's nursing progress notes, dated 06/05/26, revealed R #2 appeared very concerned. The resident reported CNA #5 entered her room after dinner and appeared to be unbalanced, leaning, hovering over her, and moving side to side. R #2 reported CNA #5 touched her shoulder, rubbed it, and moved his hand down her arm. She stated she felt uncomfortable and scared during the interaction. R #2 stated CNA #5 grabbed her meal tray, took a bite from her hamburger, and left the room. R #2 stated she did not want CNA #5 to care for her anymore. R #2 stated CNA #5 smelled of alcohol and marijuana. C. Record review of R #2's nursing progress notes, dated 06/10/26, revealed R #2 approached the nursing station and requested to speak with the Director of Nursing (DON). R #2 was tearful and stated she did not sleep well since the incident involving CNA #5. The facility offered R #2 a referral to the facility's psychological provider and notified the DON. D. Record review of R #2's Patient Health Questionnaire (PHQ-9; a nine-item self-administered tool used to screen, assess, and monitor the severity of depression in adults), dated 06/10/26, revealed R #2 reported feeling down, depressed, or hopeless; difficulty falling asleep, staying asleep, or sleeping too much; and difficulty concentrating on things, such as reading the newspaper or watching television. E. On 06/15/26 at 1:09 PM, during an interview, R # 2 stated CNA #5 entered her room on 06/05/26 during the evening shift and appeared unsteady, stumbled, and was not speaking normally. R #2 stated CNA #5 approached her meal tray, asked if she was finished with her hamburger, picked it up, took a large bite, and placed it back on her meal tray. R #2 stated CNA #5 began rubbing her arm and back in a sexual manner. She stated she pulled away from him quickly. She stated she felt violated, stunned, terrible, and trapped in her room while he was touching her. R #2 stated she wanted to run and get away, but she could not because she used a wheelchair. F. On 06/17/26 at 8:54 AM, during an interview, Licensed Practical Nurse (LPN) #9 stated R #2 reported CNA #5 acted strangely, swaying, and appeared unable to stand upright. LPN #9 stated R #2 reported CNA #5 took a bite from her hamburger and ran his hand down her arm. LPN #9 stated R #2 reported the CNA's behavior made her uncomfortable. LPN #9 stated she immediately notified Assistant Director of Nursing (ADON) #1. She stated another CNA was assigned to remain with R #2 while staff located CNA #5 and removed him from resident care duties. LPN #9 stated R #2 reported the contact made her feel uncomfortable and unsafe in the facility. G. On 06/17/26 at 10:00 AM, during an interview, ADON #1 stated R #2 initially appeared hesitant to discuss the incident because she was concerned about retaliation. ADON #1 stated R #2 believed CNA #5 was under the influence of an unknown substance and was not acting appropriately. He stated R #2 told him CNA #5 ate part of her hamburger and touched her arm in a sexual manner. ADON #1 stated R#2 was anxious and worried during their conversation. ADON #1 stated the facility staff searched the facility for approximately one hour before locating CNA #5 inside a locked restroom at the front of the building. He stated CNA #5 lay on the floor, unresponsive, snoring, with vomit around his mouth and on the floor. ADON #1 stated the facility called emergency medical services and law enforcement. ADON #1 stated he detected the odor of alcohol on CNA #5, and the CNA #5 admitted later to ingesting an unknown substance. H. On 06/17/26 at 2:00 PM, during an interview, the Administrator stated he was aware of the situation that occurred on 06/05/26 between R #2 and CNA #5. He stated it was his expectation the facility staff would not give any resident an unwanted touch or eat any portion of a resident's food.

Based on record review and interview, the facility failed to submit the required incident summary report for multiple days to the State Agency (SA) for 1 (R #1) of 1 (R #1) resident. If the facility does not submit the incident summary to the State Agency without delay, then the State Agency cannot appropriately triage (review) the allegation for further investigation. The findings are: A. Record review of the facility's abuse prevention program policy, revised 10/24/22, revealed the facility will promptly and thoroughly investigate all reports of abuse, mistreatment, neglect, injuries of unknown origin, or criminal acts. The policy states that staff must report allegations of abuse or neglect that do not result in serious bodily injury no later than 24 hours after forming the suspicion. B. Record review of R #1's face sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses:Aspiration pneumonia (pneumonia caused by inhaling something other than air into the lungs).Respiratory failure (when the lungs can't supply enough oxygen or clear enough carbon dioxide to keep the body working).Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease).Percutaneous endoscopic gastrostomy dependence (PEG; a type of g-tube). C. Record review of the facility incident report, dated 06/10/26 at 9:15 pm, revealed that on 06/06/26, a Nursing Student (NS) #1 provided R #1 with a regular breakfast tray despite physician orders for an NPO status. The incident report stated R #1 consumed portions of bacon and eggs before the error was identified and the tray was removed. R #1 became unresponsive and was discharged to the emergency room (ER) on 06/08/26. D. On 06/17/26 at 2:15 PM, during an interview, the Administrator stated he first became aware of the incident involving R #1 on 06/10/26 during the facility's morning meeting. He stated it was his expectation that R #1's incident should have been reported to the State Agency on 06/06/26, when it occurred but the incident report was not submitted until 06/10/26.

Based on record review and interviews, the facility failed to ensure a resident was free from neglect for 1 (R #131) of 1 (R #131) resident, when:The facility van driver failed to completely secure R #131's wheelchair in the van prior to transport.The facility van driver failed to contact emergency medical services (EMS) after the resident sustained a fall with injury during transport to an appointment. If the facility fails to properly secure residents in the transport van and contact EMS providers after a resident experiences a fall with injury, then residents are at risk for delayed treatment or worsening injury. The findings are:A. Record review of the facility's Vehicle Safety Program Policy, undated, revealed the policy directed authorized employees to operate company vehicles in a safe manner and ensure all occupants used seatbelts prior to moving the vehicle. The policy directed staff to ensure all wheelchairs were tied down securely before moving the vehicle. The policy directed staff to check for injuries and call Police/EMS, if needed in the event of an accident. B. Record review of R #131's face sheet revealed R #131 was admitted into the facility on [DATE] with the following diagnoses:Muscle weakness (reduction in the power exerted by muscles),Difficulty walking,Renal dialysis (the process of removing extra fluid and waste products from the blood when the kidneys cannot function properly). C. Record review of R #131's incident report, dated 03/02/26, revealed on 02/28/26 at approximately 1:00 PM during transport to a dialysis appointment, R #131's wheelchair tipped backward in the transport van when the van accelerated, but the staff was unsure if R #131 hit her head. Staff encouraged R #131 to go to the emergency room (ER), but she declined. R #131 later agreed to go to the ER and returned to the facility without any new diagnoses. On 03/01/26, R #131 developed bruising to her right foot and stated it was from the fall on 02/28/26. D. Record review of the facility's five-day follow-up report (a written report submitted to the State Agency within five working days following an alleged violation or incident, and it details the investigation findings and actions taken), dated 03/09/26, revealed the following:The facility van driver stated he secured the back straps to R #131's wheelchair, and he thought he secured the front straps. He went back inside the facility to give the receptionist a receipt. When he returned to the van, he drove off with R #131, and he did not realize he forgot to secure the front straps of R #131's wheelchair. Most of the transport was uneventful. As they neared the dialysis clinic, the driver stopped at a stop light. When the light turned green, the driver began to accelerate, and R #131 rolled backwards in her wheelchair. The facility van driver stated he pulled over as soon as possible. Once the van was pulled over, the driver assessed R #131. The facility van driver determined R #131 did not have any injuries and moved her. The facility van driver stated he was a nurse technician [medical care provider who give basic medical care to patients under the supervision of a Registered Nurse]. He secured all R #131's wheelchair straps and proceeded to take R #131 to her dialysis appointment. Once at dialysis, R #131 became upset, and the facility van driver reported the incident to his Supervisor.The facility van driver's Supervisor stated they viewed the van video, and it took the facility van driver approximately 30 seconds to pull over after R #131's wheelchair fell backwards. The Supervisor stated the facility expectation was the facility van driver should have secured all four of R #131's wheelchair straps prior to transport, and the van driver should have called 911 immediately after R #131 fell backwards.R #131 stated the facility van driver locked in the back wheels of her wheelchair, but he did not secure the front wheels prior to transport. The resident stated she experienced pain to her neck and shoulders after she hit her head when the van accelerated. R #131 stated she told the van driver to call an ambulance, but he did not take her. She told the van driver to not move her, but he did anyway. R #131 stated she told the van driver to call for an ambulance multiple times, but he did not. She stated the van driver only mentioned his anxiety. R #131 stated she was scared and asked the dialysis staff to send her to the hospital. R #131 stated she experienced whiplash (neck injury caused by the head suddenly snapping forward and backward. It often causes neck pain and stiffness) and a bruised foot.During the investigation, the facility van driver was suspended, and R #131 was diagnosed with a broken toe.In conclusion, R #131 experienced a fall in the facility van after staff did not properly secure the resident, which caused her to experience whiplash and a broken toe. The facility van driver was terminated, but the facility did not believe abuse or neglect occurred. E. On 04/16/26 at 9:39 AM, during an interview, R #131 stated the facility van driver did not secure the front of her wheelchair prior to transport. She stated her wheelchair tipped backwards, and she fell to the floor of the van. R #131 stated she experienced immediate pain in her neck and back. R #131 stated she told the driver multiple times to call an ambulance, but the facility van driver did not call 911. R #131 stated she remained on the floor of the van for approximately five to seven minutes before the driver attempted to lift her. R #131 stated the driver continued the transport to the dialysis center, and he did not seek emergency medical care for her. R #131 stated dialysis staff later arranged an ambulance transport to the hospital. The resident stated she rated her pain at the time of the incident as a 10 out of 10 (a pain level of 10 out of 10 means the worst possible pain) and continued to experience pain in her neck, back, and foot. The resident stated the dialysis center monitored R #131 and then called 911 for transport to the hospital. The resident stated she was still in pain after she finished her treatment. F. On 04/16/26 at 10:38 AM, during an interview, the Administrator stated the facility van driver failed to properly secure the resident in the wheelchair. The Administrator stated the driver should have double-checked the restraints before leaving the facility. The Administrator stated staff did not properly secure R #131 during transport. G. On 04/20/26 at 2:22 PM, during an interview, the Director of Nursing (DON) stated they determined the facility van driver failed to secure the resident's wheelchair during transport, and the resident's wheelchair tipped over. The DON stated R #131 sustained a fractured fifth metatarsal (the long bone connected to the little toe of the foot). H. On 04/30/26 at 5:14 PM, during an interview, the facility van driver stated R #131 urged him to leave the facility quickly because he was running late for her appointment. He stated he secured the resident in the vehicle, departed for dialysis, and became distracted. The facility van driver stated approximately five minutes before arriving at dialysis, while driving uphill on a slight incline and accelerating, the resident's wheelchair tipped backward, and the resident fell backward. The driver stated he pulled over, assessed the resident, and noted she remained conscious and responsive. He stated the resident requested to continue to dialysis rather than call 911. The driver stated he transported the resident to the dialysis clinic, and he informed staff of the incident. The facility van driver stated facility staff later advised him that he should have called emergency medical services for the resident. The driver stated the resident did not request an ambulance.

Based on observation and interview, the facility failed to ensure the outdoor trash dumpster was covered to minimize odors and prevent pests or rodents. If staff fail to keep outdoor trash bins closed, the environment may become unsanitary, increasing the risk of pest infestation and disease transmission to residents.The finding are:A. On 04/14/26 at 2:14 PM, during an observation, an outside trash dumpster had its' lid left open, exposing waste material to the environment. B. On 04/20/26 at 9:47 AM, during an observation, an outside trash dumpster was unattended and had its' lid left open, making waste material accessible to the environment. C. On 04/20/26 at 9:50 AM, during an interview, the Dietary Manager (DM) stated the outside dumpster should remain closed when not in use. He stated leaving the dumpster open could attract pests.

Based on interviews and record reviews, the facility failed to properly complete consent forms for 5 (R #3, R #12, R #13, R #74, and R #129) of 5 (R #3, R #12, R #13, R #74, and R #129) residents, when: Vaccination consent forms were not signed by residents or resident representatives for R #12, R #74, and R #129.Psychotropic medication (medication used to treat mental health conditions) consent forms were not signed by residents or resident representatives for R #3 and R #13. This deficient practice is likely to result in residents and/or their representatives not being consulted and informed of the risks and benefits of medications and treatments being provided to them. The findings are: Vaccination Consents: R #12: A. Record review of R #12's face sheet revealed R #12 was admitted into the facility on [DATE]. B. Record review of R #12's vaccination consent forms, undated, revealed the form was incomplete and without information present in the signature, date, and time sections indicating vaccination consent was not obtained for R #12. Further review revealed the provider notification of vaccination refusal section was also incomplete. R #74: C. Record review of R #74's face sheet revealed R #74 was admitted into the facility on [DATE]. D. Record review of R #74's vaccination consent forms, undated, revealed the form was incomplete and without information present in the signature, date, and time sections indicating vaccination consent was not obtained for R #74. Further review revealed the provider notification of vaccination refusal section was also incomplete. R #129: E. Record review of R #129's face sheet revealed R #129 was admitted into the facility on [DATE]. F. Record review of R #129's vaccination consent forms, undated, revealed the form was incomplete and without information present in the signature, date, and time sections indicating vaccination consent was not obtained for R #129. Further review revealed the provider notification of vaccination refusal section was also incomplete. G. On 04/16/26 at 2:05 PM, during an interview, the Director of Nursing (DON) stated the vaccination consent forms were mostly obtained verbally by the facility nursing staff, but the resident or representative name should be typed in the box if not signed in person. The DON stated the consent forms for R #12, #74, and #129 were incomplete and should have been completed. H. On 04/17/26 at 1:10 PM, during an interview, the Assistant Director of Nursing (ADON) and Infection Preventionist (IP), stated the signature line of the vaccination consent form must be completed for the consent form to be considered valid. Psychotropic Consents: R #3: I. Record review of R #3's face sheet revealed R #3 was admitted into the facility on [DATE], with an initial admission date of 11/03/22. J. Record review of R #3's physician orders, dated 10/23/25, revealed the following medication orders: TraZoDone HCl (antidepressant) Oral Tablet 50 mg (milligrams): Give one tablet by mouth one time a day at bedtime for depression. Sertraline HCl (antidepressant and antianxiety) Oral Tablet: Give 50 mg by mouth one time a day for Depression/Anxiety. K. Record review of R #3's psychotropic medication consents, dated 10/27/26, revealed documentation indicated consent was obtained in person/written; however, the consent form lacked the signature of the resident or their Power of Attorney (POA; legal authorization for a designated person to make decisions about another person's property, finances, or medical care) for the following medications: Sertraline Trazadone R #13: L. Record review of R #13 face sheet revealed he was admitted to the facility on [DATE] with the following diagnosis: Depression M. Record review of R #13's psychotropic medication consents, dated 03/23/26, revealed the following: Bupropion (antidepressant medication): Documentation indicated consent was obtained in person/written; however, the consent form lacked the signature of the resident or their POA. N. Record review of R #13's physician orders, dated 03/23/26, revealed the following: Bupropion: Oral Tablet Extended Release 12 Hour 100 mg to be administered by mouth. O. On 04/16/26 at 2:05 PM, during an interview, the DON stated the consent forms are mostly obtained verbally, but the resident or representative name should be typed in the box if not signed in person. The DON stated the consent forms for R #3 and #13 were incomplete and should have been completed. P. On 04/17/26 at 1:10 PM, during an interview, the ADON stated the consent form did not require a handwritten signature and a typed name was acceptable. She the signature line of the psychotropic medication consent form must be completed for the consent form to be considered valid.

Based on record review and interviews, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) was accurate for 2 (R #4 and R #7) of 2 (R #4 and R #7) residents reviewed for MDS accuracy, when: R #4's MDS indicated she had clear speech when she was non-verbal (a person that does not speak). The facility staff did not complete R #7's mood assessment section of the MDS.This deficient practice is likely to result in a failure to provide adequate care and treatment of residents' needs.The findings are: R #4: A. Record review of R #4's face sheet revealed an admission date of 11/21/2023 and the following diagnoses: Dementia (a group of conditions characterized by impairment of at least two brain functions, such as memory loss and judgment), Cognitive impairment (a decline in cognitive function), Dysphagia (difficulty or discomfort in swallowing, as a symptom of disease), Muscle wasting and atrophy (a decrease in muscle mass and strength). B. Record review of R #4's Comprehensive MDS, dated [DATE], revealed R #4 has clear speech. C. Record review of R #4's Quarterly MDS, dated [DATE], revealed R #4 has clear speech. D. Record review of R #4's nursing progress notes revealed the following: Dated 01/21/26, R #4 is non-verbal and unable to answer questions as per her baseline (the starting point of an individual's physical, mental, and emotional health, used as a reference to track changes, monitor progress, and guide preventive or therapeutic care). Dated 02/13/26, R #4 is non-verbal. Dated 04/15/26 R #4 is non-verbal and unable to answer questions as per her baseline. E. On 04/14/26 at 9:37 AM, during an interview, Certified Nursing Assistant (CNA) #4 stated R #4 is non-verbal. F. On 04/14/26 at 9:50 AM, during an interview, Licensed Practical Nurse (LPN) #4 stated R #4 is non-verbal. G. On 04/20/26 at 9:21 AM, during an interview, the MDS Coordinator stated R #4's MDS dated [DATE] and 02/25/2026 were documented incorrectly. She stated R #4 was non-verbal, but each MDS indicated R #34 had clear speech. The MDS Coordinator stated it is her expectation that each MDS should be completed and accurate. She stated if the MDS is not completed accurately, miscommunication in caring for the resident can occur. R #7: H. Record review of R #7's face sheet revealed R #7 was originally admitted into the facility on [DATE]. I. Record review of R #7's re-entry MDS, dated [DATE], revealed R #7's mood and mood interview was not completed by the facility staff. J. On 04/20/26 at 10:30 AM, during an interview, the MDS Coordinator stated R #7 was not assessed for mood on the MDS dated [DATE] and should have been. She stated it was the responsibility of Social Services Department to complete the Mood assessment, and it is the responsibility of the MDS Department to ensure R #7's MDS was completed. K. On 04/20/26 at 2:24 PM, during an interview, the Director of Nursing (DON) stated the Social Services Department is responsible for completing mood assessments. The DON stated R #7's MDS mood assessment, dated 03/20/26, should have been completed but it was not. L. On 04/20/26 at 3:15 PM, during an interview, the Administrator (ADM) stated R #7's MDS mood assessment, dated 03/20/26, should have been completed.

Based on record review and interviews, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 1 (R #11) of 1 (R #11) residents reviewed for baseline care plans, when: R #11's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include foley catheter (a thin, sterile tube inserted into the bladder to drain urine) use with interventions. If the facility fails to develop and implement an adequate baseline care plan within 48 hours of admission for residents, then staff may lack necessary guidance to provide appropriate care which could lead to an adverse event (undesirable experience, preventable or non-preventable, that causes harm to a resident due to medical care or lack of medical care). The findings are:A. Record review of R #11's face sheet revealed R #11 was admitted into the facility on [DATE] with the following diagnoses: Urinary tract infection (UTI; an infection in any part of the urinary system, which includes the kidneys, ureters, bladder, and urethra),Retention of urine (a condition that occurs when a person is unable to empty their bladder, either partially or completely). B. Record review of R #11's admission Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff), dated 03/28/26, revealed R #11 was admitted with a foley catheter. C. Record review of R #11's March 2026 treatment administration record (TAR) revealed the following:Foley catheter care every shift.R #11 required the use of a Foley catheter due to chronic urinary tract infections. D. Record review R #11's baseline care plan, dated 03/26/26, revealed foley catheter use was not included in R #11's baseline care plan. E. On 04/17/26 at 11:00 am, during an interview, Certified Nurse Aide (CNA) #8 stated R #11 used a foley catheter when he was admitted into the facility. F. On 04/20/26 at 2:22 pm, during an interview, the Director of Nursing (DON) stated R #11 had a foley catheter in place during the resident's stay, but R #11's foley catheter use was not included in his baseline care plan and should have been.

Based on observations and interviews, the facility failed to ensure the proper storage and security of medications located in the medication carts, when: The 200-unit narcotic (controlled medication used for the management of pain) box located in a medication cart was left unlocked. Medications were pre-poured (the practice of preparing and pouring medications in advance of their scheduled administration time, which carries significant risks) prior to administration and left in the medication cart located in the 400-unit. A medication tablet was left out of the packaging and on the floor in the 200-unit. This deficient practice is likely to increase the risk of unauthorized access to medications, medication diversion, contamination, and administration of medications to the wrong resident. The findings are: Medication Cart Narcotic Box: A. On 04/15/26 at 1:46 PM, during an observation, the narcotic box located in one of the two medication carts in the 200-unit behind the nurse's station was found to be unlocked and could be easily opened, allowing access to the narcotic medications stored inside. B. On 04/15/26 at 1:47 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated the narcotic box located in the medication carts should always be locked. She stated the narcotic box is not locking properly and that was reported to the pharmacy on 04/13/26. She stated if the narcotic box is not properly locked, anyone could easily open and take medications which do not belong to them. She stated there could be several potential adverse outcomes for whoever consumed the medications. C. On 04/15/26 at 1:56 PM, during an interview, the Director of Nursing (DON) stated the narcotic box should be secured behind two locks at all times when not in use. She stated she was informed of the narcotic box not locking on 04/14/26. She stated the narcotics should have been moved to another medication cart because they were unable to be stored securely in their current location. Pre-Poured Medications: D. On 04/15/26 at 8:00 AM, during an observation, Certified Medication Aide (CMA) #1 was observed removing three lidocaine patches (a local anesthetic that prevents pain by blocking the signals at the nerve endings in the skin) from the packaging, dating and initialing each lidocaine patch, and then placed each prepared lidocaine patch in the medication cart for future use. E. On 04/16/26 at 7:59 AM, during and observation, CMA #2 was observed preparing medications for a resident, and then realized he needed to obtain a nutritional shake from the refrigerator. CMA #2 placed the prepared medication in the top drawer of the medication cart, locked the cart, and then left the cart to obtain the nutritional shake. F. On 04/15/26 at 8:16 AM, during an interview, CMA #1 stated medications should not be pre-poured or prepared in advanced prior to medication administration. G. On 04/16/26 at 8:01 AM, during an interview, CMA #2 stated pre-poured medications should not be placed in medication carts. If they have prepared medications and need to obtain another or other supplies, they are to give the medications they have prepared to the resident and then obtain the missing item. H. On 04/20/26 at 2:25 PM, during an interview, the Director of Nursing (DON) stated it is her expectation medications are not pre-poured, and if a staff member needs to step away from cart to obtain other medications, the medications should be taken with the staff member and not placed in the medication cart while the staff member is away. Medication on the Floor: I. On 04/13/26 at 1:01 PM, during an observation, a small round peach-colored oral tablet with the imprint H1 was lying on the floor in the 200-unit between rooms #215 and #216. The medication was on the ground next to the wall by the baseboard, and facility staff was not present. The medication cart was observed down the hall near the nursing station. J. On 04/13/26 at 1:10 PM, during an interview, the Assistant Director of Nursing (ADON) stated she was unsure what type of medication was left on the floor, but the medication tablet should not have been left on the floor. K. On 04/13/26 at 1:31 PM, during an interview, the DON stated she did not know how the medication tablet was left on the floor. She stated she was unsure what the medication was for and initially thought it may have been for blood pressure; however, she could not confirm. She stated the medication tablet should not have been left on the floor and that it was her expectation that medications remain secured at all times.

Based on record review and interview, the facility failed to ensure care plan interventions were implemented for 1 (R #5) of 1 (R #5) resident reviewed for falls. If the facility does not ensure care plan interventions for falls are implemented, then residents are at risk for continued falls and potential injury.The findings are:A. Record review of R #5's face sheet revealed R #5 was originally admitted into the facility on [DATE]. B. Record review of R #5's nursing progress notes revealed the following: R #5 had a Change in Condition (CIC; a comprehensive re-evaluation of physical, mental, or psychosocial status that occurs when baseline functioning is altered or indicates a new, ongoing risk) assessment completed for a fall on 04/07/26.R #5 had a CIC assessment completed for a fall on 04/09/26. C. Record review of R #5's Care Plan, dated 04/10/26, revealed the following:R #5 was at risk for falls related to generalized weakness and impaired mobility.Dated 04/07/26, new fall interventions were added to R #5's care plan stating R #5 was re-educated to be patient and wait for staff to assist her on and off the toilet, and she was supplied with non-slip socks for her feet.Dated 04/10/26, new fall interventions were added to R #5's care plan stating R #5 was educated to call for assistance when transferring, and while in her orthopedic boot (a removable medical device used to stabilize, protect, and support the foot and ankle during recovery from injuries or surgery). D. On 04/16/26 at 2:12 pm, during an interview, Certified Nursing Assistant (CNA) #3 stated she had worked with R #5 and was aware of R #5's falls. CNA #3 stated R #5 did not have any fall precautions (interventions designed to reduce injury risk by addressing resident-specific factors and environmental hazards) in place to prevent her from falling. E. On 04/16/26 at 3:14 pm, during an interview, Licensed Practical Nurse (LPN) #3 stated R #5 did not have any fall precautions and reported there were not any new interventions implemented following R #5's prior falls on 04/07/26 and 04/09/26. LPN #3 stated management (the Administrator, Director of Nursing, and nursing supervisors) are responsible for updating the resident care plans, and informing the nursing staff of new interventions added to the care plan to be implemented. LPN #3 stated the facility nursing staff relies on management to communicate any changes made to a resident's care plan. F. On 04/20/26 at 3:00 pm, during an interview, the Director of Nursing (DON) stated R #5's fall interventions included the use of non-skid footwear, the use of call light assistance, and instruction for R #5 to wait for staff before transferring. The DON stated that after each fall, she added new fall interventions to R #5's care plan. The DON stated she expects the facility nursing staff that are caring for R #5 to be aware of each fall intervention and implement each intervention to prevent R #5 from experiencing falls.

Based on observations, record review, and interviews, the facility failed to ensure staff revised the care plan for 1 (R #74) of 1 (R #74) resident reviewed, when:Facility staff failed to update R #74's plan of care to include R #74's use of a Hoyer lift (equipment used to safely transfer residents with limited mobility) for transfers. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated. The findings are: A. Record review of R #74's face sheet revealed admission date of 12/30/2025 with the following diagnoses: Spinal stenosis (narrowing of the space surrounding the spinal cord causing pressure and pain), Muscle weakness (reduction in the power exerted by muscles), Need for assistance with personal care and activities of daily living (ADL; activities related to personal care such as bathing, showering, dressing, walking, toileting, and eating). B. Record review of R #74's care plan, dated 12/30/2025, revealed R #74's Hoyer lift use was not included in her care plan. C. On 04/14/2026 at 10:40 AM, during an observation, Certified Nursing Assistants (CNAs) #5 and #6 were observed using a Hoyer lift to transfer R #74 from her bed to her wheelchair. D. On 04/14/2026 at 10:49 AM, during an interview, R #74 stated the facility nursing staff use a Hoyer lift to transfer her in and out of bed. R #74 stated following a recent infection, she became significantly weakened and required increased assistance, including the use of a Hoyer lift for transfers. E. On 04/16/2026 at 3:31 PM, during an interview, Licensed Practical Nurse (LPN) #3 stated R #74 requires two-person assistance when transferring. LPN #3 stated the resident uses a Hoyer lift for transfers. F. On 04/17/2026 at 2:21 PM, during an interview, the Director of Nursing (DON) stated it is her expectation all residents who utilize a Hoyer lift are care planned accordingly to their care needs. The DON stated if a resident's care plan does not reflect the required care, resident care information can be miscommunicated. The DON stated R #74's use of a Hoyer lift for transfers should have been care planned but was not.

Based on record review and interview, the facility failed to provide quality care that meets professional standards for 1 (R #25) of 1 (R #25) resident reviewed, when staff failed to: Update R #25's physician orders to reflect a new dialysis (a medical treatment which filters waste and excess fluid from the blood) schedule. This deficient practice is likely to result in residents not maintaining their optimal health as planned by their medical provider. The findings are:A. Record review of R #25's face sheet revealed R #25 was admitted into the facility on [DATE] with the following diagnosis: End stage renal disease (ESRD; chronic irreversible kidney failure) B. Record review of R #25's active physician orders, dated 12/22/25, revealed R #25's dialysis is scheduled for Monday, Wednesday, and Friday at 6:00 am. C. Record review of R #25's care plan, dated 12/22/25, revealed R #25's days of dialysis treatment is Monday, Wednesday, and Friday at 6:00am. D. On 04/14/26 at 10:00 am, during an interview, R #25 stated he goes to Dialysis on Tuesday, Thursday, and Saturday at 11:45 am. E. On 04/20/26 at 2:22 pm, during an interview, the Director of Nursing (DON) stated R #25's dialysis schedule has changed, and R #25's physician orders and care plan should have been updated to reflect the new dialysis schedule.

Based on observation, record review, and interviews, the facility failed to maintain a safe and sanitary environment to prevent the transmission of infectious agents and communicable diseases for 1 (R #10) of 3 (R #10, #52, and #62) residents, when the facility: Failed to prevent a urinary catheter (a thin, flexible tube which drains urine from the bladder) bag and tubing from touching the floor.These deficient practices have the potential to expose staff and other residents to infectious diseases. The findings are: A. Record review of R #10's face sheet revealed R #10 was admitted into the facility on [DATE]. B. Record review of R #10's care plan, dated 04/13/26, revealed R #10 used a foley catheter (a thin, sterile tube inserted into the bladder to drain urine) due to Neurogenic bladder (a condition in which nerve damage or neurological disorders disrupt the normal communication between the brain, spinal cord, and bladder, leading to loss of bladder control). C. On 04/15/26 at 11:23 AM, during an observation, R #10 was observed sitting in her wheelchair while being pushed to activities by a facility staff member. R #10's urinary catheter bag was dragging on the floor as she was pushed in her wheelchair. D. On 04/20/26 at 8:22 AM, during an interview, Licensed Practical Nurse (LPN) #2 stated a resident's urinary catheter bag should be secured below the level of the bladder. She stated the urinary catheter bags should not be allowed to touch or drag on the ground, as it presents a risk of infection for the residents. E. On 04/20/26 at 2:24 PM, during an interview, the Director of Nursing (DON) stated her expectation is resident's urinary catheter bags are to be secured below the bladder and should not be dragging or laying on the floor. She stated there is a risk the bag could open and present the risk of infection to the residents.

Based on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASARR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) out of 9 (R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11) residents reviewed for PASARR accuracy. This deficient practice has the potential to result in the facility not providing the services needed for residents who are identified in the screening process as needing additional care and services. The findings are: R #2:A. Record review of R #2's Face Sheet revealed the following: admission date of 09/02/25,Diagnosis of major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). B. Record review of R #2's PASARR Level 1 Screening, dated 09/02/25, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #3:C. Record review of R #3's Face Sheet revealed the following: admission date of 10/07/25,Diagnosis of major depressive disorder. D. Record review of R #3's PASARR Level 1 Screening, dated 10/06/25, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #5:E. Record review of R# 5's Face Sheet revealed the following: admission date of 09/26/23,Diagnosis of anxiety disorder (feelings of fear or apprehension). F. Record review of R #5's PASARR Level 1 Screening, dated 09/26/23, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #6:G. Record review of R #6's Face Sheet revealed the following: admission date of 02/04/26,Diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). H. Record review of R #6's PASARR Level 1 Screening, dated 02/04/26, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #7:I. Record review of R #7's Face Sheet revealed the following: admission date of 10/05/21,Diagnosis of major depressive disorder.J. Record review of R #7's PASARR Level 1 Screening, dated 02/04/26, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #8:K. Record review of R #8's Face Sheet revealed the following: admission date of 01/28/26,Diagnosis of depression. L. Record review of R #8's PASARR Level 1 Screening, dated 01/28/26, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #9: M. Record review of R #9's Face Sheet revealed the following: admission date of 02/02/24,Diagnosis of anxiety. N. Record review of R #9's PASARR Level 1 Screening, dated 01/28/26, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #10:O. Record review of R #10's Face Sheet revealed the following: admission date of 02/02/24,Diagnosis of anxiety. P. Record review of R #10's PASARR Level 1 Screening, dated 09/03/24, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.R #11:Q. Record review of R #11's Face Sheet revealed the following: admission date of 08/06/24,Diagnosis of Major Depressive Disorder.R. Record review of R #11's PASARR Level 1 Screening, dated 08/06/24, revealed staff documented the resident did not have diagnoses such as schizophrenia (severe mental disorder that affects how a person thinks, feels, and behaves, often leading to hallucinations, delusions, and disorganized thinking), or disorders of mood, panic, anxiety, personality, psychotic, depression, and substance related.S. On 02/19/26 at 3:07 pm during an interview, the Social Services Director (SSD) stated the facility did not have a systematic process in place to review incoming PASARRs as part of the PASARR screening process for admissions. The SSD stated she was recently informed by the facility that reviewing resident PASARRs was the responsibility of her department. She stated PASARRs were not reviewed for accuracy. The SSD stated if residents are not properly screened, residents who require additional support and services may not receive the appropriate level of care. The SSD confirmed the PASARRs for R #2, R #3, R #5, R #6, R #7, R #8, R #9, R #10, and R #11 were not accurate, and she stated they should be.

Based on record review, observation, and interviews, the facility failed to maintain a safe environment for all residents in the 200-unit when staff failed to ensure the facility oxygen (O2) storage room was secured to prevent unauthorized access. This deficient practice has the potential to lead to residents experiencing avoidable accidents.The findings are: A. Record review of the facilities Oxygen Administration Policy, dated 06/2020, revealed the following: Oxygen cylinders are to be secured in a cylinder cart or bracket at all times, Oxygen stored in clean, dry locations. B. On 02/18/26 at 1:59 pm, observation of the facility's 200-unit oxygen room revealed the following: The oxygen storage room keypad door lock was without power and nonoperational. The keypad screen remained blank and did not activate when touched. Further observation revealed occupants in the area could open the oxygen storage room door without entering an access code. Oxygen cylinders (portable medical oxygen tanks) sat on the floor and were not stored in the designated oxygen cylinder rack. C. On 02/18/26 at 2:17 pm during an interview, the Central Supply Manger (CSM) stated all oxygen equipment, including portable oxygen tanks, must be stored in the proper storage areas for safety. The CSM stated if oxygen tanks are not properly stored, then it could create a hazard. D. On 02/19/26 at 1:00 PM during an interview, the Administrator stated the oxygen storage room should remain locked at all times when not in use. The Administrator stated she was not aware the keypad door lock was not functioning, and the door could be opened without entering a code. The Administrator stated she expected the oxygen storage room door to remain locked at all times.

Based on record review and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #2) of 1 (R #2) resident reviewed for MDS accuracy. This deficient practice could result in failure to provide adequate care and treatment of the resident's needs. The findings are:A. Record review of R #2's face sheet revealed R #2 was admitted into the facility on [DATE] with the following diagnoses: Guillain-Barre syndrome (a rare condition where the body's immune system attacks the nerves),Epilepsy (a long-term brain disorder that causes repeated, unprovoked seizures due to abnormal electrical activity in the brain),Depression (a mood disorder that causes a persistent feeling of sadness and loss of interest).R #2 was discharged to the hospital on [DATE]. B. Record review of R #2's Change in Condition (CIC) form, dated 10/16/25, revealed R #2 was unable to transfer out of bed and sent to the hospital. C. Record review of R # 2's Progress Note, dated 10/16/25, revealed R #2 was transported via ambulance to the hospital.D. Record review of R # 2's Discharge MDS, dated [DATE], revealed staff did not document a discharge destination. E. On 02/20/26 at 3:33 PM during an interview, the Director of Nursing (DON) stated R #2 was scheduled to discharge from the facility on 10/16/25. She stated R #2 experienced abdominal pain and was sent to the hospital for an evaluation. F. On 02/20/26 at 3:58 PM during an interview, the MDS Coordinator (MDSC) stated she was responsible for completing R #2's MDS assessments. She stated R #2's MDS, dated [DATE], was inaccurate because R #2's discharge destination was left blank. The MDSC stated R #2 was discharged to the hospital. The MDSC stated it was her expectation all MDS assessments be coded accurately.

Based on observation and interview, the facility failed to ensure residents where give prior notice and equal accommodations during a remodeling project for 4 (R #1, #2, #3, and #4) out of 4 residents. These deficient practices could result in residents feeling as if they were unimportant, restricted, did not have freedom to make their own choices, and did not have privacy. The findings are: A. On 01/15/26 at 1:15 pm, observation revealed the 400 hallway was under renovation. Multiple resident rooms did not have furniture or flooring, and construction workers were present laying flooring in the empty rooms. Residents were present in the 400 hallway and some resided in rooms 423, 424, 425, and 426. B. On 01/15/26 at 12:50 pm, during an interview, R #4 stated staff kicked me out of my room yesterday, and he had to sit in his wheelchair from 7:40 am to 6:00 pm. He stated the staff did not give him any notice, and they just told me to get out. The resident stated the facility made him leave his room so they could remove the carpet and replace it with flooring. R #4 stated he did not have access to his own bathroom or any of his belongings when he had to leave his room. He stated he did not have anywhere to lay down if he wanted, and he sat in his wheelchair all day. He stated that was uncomfortable for him. C. On 01/15/26 at 1:30 pm observation revealed R #1, R #2, and R #3 were in a resident room together. R #2 and R #3 sat in wheelchairs, and R #1 lay in a hospital bed without railings. D. On 01/15/26 at 1:30 pm during an interview, R #1 stated she was moved out of her room without notice, from a bariatric bed with rails to a standard hospital bed without rails. She stated she asked staff how long she would be out of her room, but the staff did not tell her how long it would be. She stated the staff told her the facility needed to replace the flooring. R #1 stated staff did not inform her how they would assist her with restroom assistance, since she required equipment located back in her assigned room. She stated she was worried about when it was time for her to have a bowel movement. R #1 stated she used a bariatric bed, but the bed she was moved to was smaller and did not have rails. She stated that made her a little nervous, and she hoped she would not be in the smaller bed too long. E. On 01/15/26 at 1:35 pm during an interview, R #2 stated she was removed from her room the previous day at 8:00 am, and she was not allowed to return until after 7:00 pm. She stated she was not given prior notice before she had to leave her room. She stated staff walked in and told her she had to leave her room for the day. She stated she was exhausted, and she did not have a place to nap during the construction of her room. R #2 stated she was in her wheelchair all day while she waited for access to her room, and she saw other residents who slept on the couches in the common areas while they were removed from their rooms as well. F. On 01/15/26 at 1:36 pm during an interview, R # 3 stated she was moved out of her room without notice, due to the flooring being replaced in her room. She stated staff did not tell her when she would be permitted to return or where she could use the restroom with her wheelchair privately. G. On 01/15/26 at 2:31 pm during an interview the Administrator stated the facility replaced the flooring throughout the facility. She stated the 400 hallway was the last area to complete. She stated she did not receive any complaints from Residents during the construction. The Administrator did not state whether residents were given notice or options before they were told to leave their rooms for the day.

Based on observations, interviews, and record review, the facility failed to maintain a safe and comfortable environment for all residents and occupants during a remodeling project when staff failed to:- Maintain proper ventilation of construction flooring adhesive odors.- Maintain the means of egress (a continuous and unobstructed way of travel from any point in the building or structure to a public way) throughout the facility. If staff fail to maintain a safe environment, then the residents could find themselves in an emergency situation which could endanger their health and safety. The findings are:Construction Adhesive Fumes A. Record review of the facility's Safety Plan for the floor renovation project, dated 09/16/2025, revealed the following: - The resident units affected were Gila, [NAME], and Pecos. - Potential issues included unpleasant odors due to the materials in use. - Staff were instructed to contain the aerosol dust/debris with ventilation as needed, close doors where applicable to provide barriers, and remove patient activity and exposure in areas being worked on as allowable. B. On 01/15/26 at 1:10 pm, observation revealed the following:- Multiple five gallon buckets of industrial flooring adhesive were present in the 400 hallway and uncovered. Three buckets of flooring adhesive sat in an electrical closet with the door open. One bucket of flooring adhesive sat on a table in the hallway, and another sat on the floor. The buckets contained some adhesive on the side and bottom of buckets. Further observation revealed residents moved throughout the units around the open buckets of flooring adhesive.- Resident room (RR) 427 had flooring adhesive on the floor, and the door was open. A construction worker laid flooring over the adhesive. The worker wore a face mask. Further observations revealed there was a strong odor from the adhesive throughout the 400 hallway. The windows in RR 427 were not open, and the exit door at the end of the hallway was not open. The hallway did not have any fans present. Residents were present on the hallway in RR 423, 424, 425, and 426, and the doors to residents' rooms were open. C. Record review of the manufacturer's instructions for the flooring adhesive revealed first aid instructions for inhalation. The instructions stated supply fresh oxygen, call for a doctor, and in case of unconsciousness, place in side position for transportation. D. On 01/15/26 at 1:30 pm during an interview with R #1, #2, #3, and a visitor, the visitor stated she could smell the flooring adhesive when she came onto the unit. She stated the odor was unpleasant and strong, and she could smell it through her face mask. The visitor stated closing the resident's room door would help protect them from the unpleasant odor. R #3 stated she could not smell the odor, because she had difficulty smelling anything. She stated to odor was concerning for her, because she had asthma. E. Record review of the flooring adhesive's Material Safety Data Sheet (MSDS, a product identification and hazards information sheet) revealed the following: - If inhaled, move to fresh air in case of accidental inhalation of vapors or decomposition products.- In case of skin contact, wash off with soap and water. Get medical attention if irritation develops and persists.- In case of eye contact, flush eyes with water at least 15 minutes. Get medical attention if eye irritation develops or persists.- If swallowed, if conscious, drink plenty of water. Never give anything by mouth to an unconscious person. Consult a physician if necessary.- Accidental release measures. Methods and materials for containment and clean up: Ventilate the area.- Handling and storage. Local/Total ventilation: Use only with adequate ventilation. Advice on safe handling: Use only with adequate ventilation/personal protection. Keep container closed when not in use. Conditions for safe storage: Keep container tightly closed in a dry and well-ventilated place.- Exposure controls/personal protection. Personal protective equipment, respiratory protection: Use respiratory protection unless adequate risk management measures (exhaust/ventilation) were provided or exposure assessment demonstrates that exposures are within recommended exposure guidelines. Organic vapor type. Skin and body protection: Skin should be washed after contact. Protective measures: Avoid contact with skin. Hygiene measures: Avoid contact with skin, eyes, and clothing.- Toxicological information (the harmful effects of substances on living organisms): No data available for acute toxicity, skin corrosion/irritation, serious eye damage/eye irritation, respiratory or skin sensitization.- The NFPA 704 sign (a standardized symbol with four colored quadrants indicating specific dangers to health, flammability, instability, and special hazards): health hazard 1, slight. F. On 01/15/26 at 2:30 pm during an interview with the Plant Operations Manager (POM) and the Administrator, the Administrator stated she did not think the residents were at risk from inhalation of the adhesive's vapors, and she did not receive any complaints throughout the facility's floor renovations. The Administrator stated she and the POM reviewed the manufacturer's instructions for the flooring adhesive, and she did not think the occupants of the building were at risk of adverse effects from the flooring adhesive odors. The POM stated the hallway did have mechanical ventilation, and they thought the mechanical ventilation would be sufficient to contain the odors during the remodeling project. He stated the [NAME] and Pecos Unit exit doors should be opened for ventilation if the residents were uncomfortable. Means of Egress G. Record review of National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, revealed the means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. (7.1.10, 7.1.10.1) H. On 01/15/26 at 12:24 pm observation revealed the 400 hallway was under renovation, and residents lived on the hallway. Further observation revealed the means of egress from the residents' rooms to the public way (a street, alley, or other similar parcel of land essentially open to the outside air deeded, dedicated, or otherwise permanently appropriated to the public for public use) was blocked by two trash cans, four beds, one armchair, three tables, one chair, three 4-gallon buckets, one industrial tile cutter, and piled boxes of wood flooring strips. Observations also revealed residents moved in their wheelchairs around the items in the hallways.- The means of egress, located in the Utility hallway, was blocked by three boxes containing wheelchairs, a plastic crate, and two cardboard boxes. - The means of egress, located in the kitchen dock hallway, was blocked by a 6-foot- tall food tray cart, a box of disinfectant cleaner bottles, a broom, and five cardboard boxes. Further observation revealed the means of egress from double exit doors was blocked by a wood pallet and a cardboard box. - The means of egress, located in the Administration wing, was blocked by eight vacuums, two chairs, three tables, five cardboard boxes, a housekeeping cart, an industrial floor cleaning machine, a hoyer lift (equipment used to move residents who have limited mobility), a 6 foot (ft.) by 3 ft. wooden cabinet, a mobile standing scale with handrails, a hospital bed, a wheelchair, a bedside rolling table, a 5-ft. tall kitchen appliance, a 3-ft. tall storage bag with an air mattress, a motorized wheelchair, an industrial floor cleaning machine, a rolling walker, a black rolling plastic cart with a plastic box on top, and stacked cardboard boxes. Further observation revealed the emergency exit door was blocked by an oxygen cylinder, an industrial printer, a computer processing unit, two desk printers, and cardboard boxes. - The means of egress door from the Administration wing was blocked by a vacuum, a gallon jug of cleaning liquid, an industrial roll of baseboard materials, two dustpans, a broom, a cardboard box, and a rolled floor mat. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], was blocked by a utility cart which was not in use. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], was blocked by a treatment car which was not in use. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], was blocked by a treatment cart and mattress which was not in use. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], was contained a wheelchair which encroached into the means of egress through the double exit doors.- The means of egress, located in the hallway outside resident room [ROOM NUMBER], was blocked by a medication cart which was not in use. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], was blocked by a three tier service cart which was not in use. - The means of egress, located in the hallway outside resident room [ROOM NUMBER], contained a three tier cart which was not in use. I. On 01/15/26 at 12 :50 pm during an interview, R #4 stated staff told him to leave his room on 01/14/26 from 7:40 am to 6:00 pm. He stated the facility made him leave his room so they could remove the carpet and replace it with flooring. R #4 stated the items in the 400 hallway were there when he had to get out of his room. He stated staff moved the items out of the hallway and then brought them back again. He stated it had been like that for a while. J. On 01/15/26 at 2:31 pm during an interview, with the Plant Operations Manager (POM) and the Administrator, the Administrator stated the Maintenance Department was responsible to maintain the facility according to the Life Safety Code. She stated the facility was replacing all of the flooring in the building, and the 400 hallway was the last part of the building to complete. The POM stated the means of egress should be maintained throughout the remodeling/renovation period. He stated facility staff should remove items stored within the means of egress.

Based on record review and interview the facility failed to complete an initial skin assessment for 1 (R #1) of 3 (R #1, #2 and #3) residents reviewed for skin assessments, during the initial admission. If the facility fails to complete a skin assessments then facility is unable to provide proper care and treatment for the residents. The findings are: A. Record review of the State Agency complaint received on 05/13/25 stated that R #1 had been discharged AMA (against medical advice) from facility on 05/12/25 for physical abuse by facility staff and had been transported by [name of transport service] to [name of local hospital] at 6:00 pm with bruising, swollen genitals and penile bleeding along with various bruising on the body. B. Record review of R #1's facesheet revealed R #1 was admitted on [DATE]. C. On 05/14/25 at 11:17 am during a telephone interview with R #1's daughter, she stated that she believed her father was physically abused by the facility staff due to the amount of bruising present when she took R #1 out of the facility AMA (05/12/25). She further stated that R #1 had recently had a procedure at local hospital to have a de-fibulator implant (implanted to help monitor heart activity, delivers electrical shock to reset the heart to a normal rhythm) prior to admission to facility. Daughter stated that after taking her father home and seeing the extensive bruising she called an ambulance to transport R #1 to [name of local hospital] he was admitted and remains hospitalized (05/16/25). D. On 05/13/25 upon record review of R #1's medical chart a skin assessment was not available for review. E. On 05/15/25 at 10:57 am during an interview, the Director of Nursing (DON) stated that an initial skin assessments are completed upon admission by the admitting nurse, upon review of R #1's medical chart the DON did not observe that a skin assessment had been completed by the admitting nurse and should have been done. F. On 05/15/25 at 2:43 pm during an interview with Licensed Practical Nurse (LPN) #1, he stated that he had not completed a skin assessment upon admission because the resident (R #1) was fatigued and extremely tired and he was attempting to complete paperwork with the family and the unit was very busy that night. LPN #1 further stated that he did not remove R #1's clothing to check his body for any bruising or surgical sites. LPN did notice that R #1 had tugged on his foley catheter (a thin flexible tube inserted into the bladder to drain urine) and the tip of the penis did have some excoriation (wearing away of the skin, resulting in a raw, irritated lesion). LPN #1 did not recall if he had let anyone know that he had not completed the skin check and he did not document any of his initial assessments as he should have, therefore it did not trigger on the system for another nurse to know that it had not been done. LPN #1 stated that he did not know reason for admission he had glanced at paperwork, but did not have time to read it extensively.

Based on record review and interview, the facility failed to ensure medical records were updated with necessary documents and are accurate for 1 (R #4) of 1 (R #4) resident reviewed, when the facility failed to update and upload hospital discharge orders into the electronic medical record (EMR). This deficient practice is likely to result in residents not receiving accurate care and having an inaccurate medical record. The findings are: A. Record review of R #4's face sheet revealed she was admitted on [DATE]. B. On 05/14/25 at 10:23 AM, during an interview with R #4, she stated that intravenous (IV) antibiotics had been discontinued earlier than her hospital discharge orders indicated. She explained that the antibiotics should have continued for four weeks after her hospital discharge. C. On 05/15/25 at 10:28 AM, during an interview with the Nurse Practitioner (NP) #1, she stated that R #4 had been on IV antibiotics for a severe infection. She noted that R #4's hospital discharge orders dated 03/25/25 clearly stated that the IV antibiotics should continue until 04/25/25. She further explained that the facility had discontinued the antibiotics on 04/01/25 and did not restart them until she re-ordered them on 04/11/25. D. On 05/15/25 at 1:24 PM, during an interview with Licensed Practical Nurse (LPN) #2, he stated that he had received incomplete hospital discharge orders for R #4's admission. He explained that the orders for the IV antibiotics were not included in the discharge orders he had been given. LPN #2 further stated that he contacted the facility liaison to obtain updated discharge orders orders for R #4. He was emailed the updated discharge orders for R #4 on 03/25/25 which were then used for R #4's admission. The discharge orders were reviewed with NP #2 and entered into the EMR with. E. Record review of R #4's EMR revealed discharge orders dated 03/20/25. No updated discharge orders were available for state agency's review. F. On 05/15/25 at 2:25 PM, during an interview, the Director of Nursing stated that the discharge documents uploaded into the EMR were the original discharge orders sent by the hospital case manager. She further explained that, after researching and reviewing the message thread between the admissions nurse and facility liaisons, it was revealed that updated discharge orders had been emailed directly to LPN #2, the admitting nurse for R #4. LPN #2 was able to provide the updated orders to the Director of Nursing, who stated that they should have been uploaded into R #4's EMR but were not.

Based on observation, record review and interview, the facility failed to ensure that one (R #1) of 3 (R #,d+[DATE]) residents reviewed for elopement (an unauthorized departure of a patient from an around-the-clock care setting) were free from accidents/hazards by not accurately assessing R #1 for risk and not providing adequate supervision by not: 1. Accurately assess R #1 for elopement risk upon admission from an acute care facility for worsening neurocognitive decline and confusion, paranoid delusions, and attempts to leave the acute care facility; 2. Reassess R #1 for elopement risk after exhibiting increased wandering behavior and actual wandering into facility parking lot on [DATE]; 3. Notify appropriate facility staff and administration of R #1's elopement attempt on [DATE]; 4. Implement interventions and supervision to prevent reoccurrence of elopement for R #1 after an attempted elopement on [DATE]; and 5. Prevent R #1 from eloping from the facility on [DATE]. This deficient practice likely resulted in R #1 eloping from the facility on [DATE] at approximately 1:22 pm out of the main entrance of the facility passed facility staff. R #1 was found in an [NAME] (dry river bed) outside of the facility, more than 3 hours later at 5:29 pm with no pulse or signs of life. Resuscitation efforts were unsuccessful by facility staff, and the resident was pronounced deceased at the scene by emergency medical personnel. The findings are: A. Record review of R #1's Hospital Documents revealed the following: 1. [DATE]- Reason for consultation: Pt [patient] is a 81 y.o. [year old] M [male] with progressively worsening neurocognitive decline over the past year, now admitted after being brought here by his family for safety concerns, recent falls at home. On my exam pt having delusions, paranoid, perseverative. Gets confused and tries to leave so placed a sitter order. Needs a psych [psychiatric] eval (evaluation), also to eval for decisionality (decision making capacity). 2. [DATE]- Patient has neither understanding or appreciation of his hospitalization . He has a notable memory deficit, currently believing that his son and POA [Power Of Attorney], [Name of R #1's son] is 17 and in high school, and his late siblings are still alive. He lacks capacity for medical decision and has an active POA. 3. [DATE]- Upon review of PCP [Primary Care Physician] notes, [Name of R #1] has been experiencing memory loss since last year, has undergone workup and has been referred to the memory clinic. Appt [appointment] [DATE]. 4. [DATE]- Pt tolerates mobility in room with good standing balance at sink. Due to recent falls and reports of pt having difficulty caring for himself at this time, OT [Occupational Therapy] recs [recommends] are for SNF [Skilled Nursing Facility] to address functional deficits and consider ,d+[DATE] supervision in living arrangement. 5. [DATE]- Patient admitted [DATE] for safety concern after falls occurring at home. There was also a concern for not eating adequately at home per family (loss of ,d+[DATE] pounds per VS [vital signs] record). 1 instance of PRN [as needed] given for agitation/attempting to leave hospital shortly after admission, given Ativan, was sedated afterwards [ .]. 6. [DATE]- When asked how he is doing this morning he [R #1] says 'I'm not sure how to respond to that question, everyone is treating me like I'm a criminal.' States that he is upset that he is unable to 'leave freely' and urges me to look up his background, stating he does not have any criminal hx [history] but that 'someone must have said something because they're holding me here.' Says he [R #1] notices 'people looking at me sideways.' Unable to say if he is having auditory or visual hallucinations. 7. [DATE]- Patient will be discharged from the inpatient medicine service with the following discharge diagnosis(es) that were present on admission; Dementia (Alzheimer's v. Microvascular v. Lewy body). Recommend the following as outpatient: Long-term care facility. B. Record review of R #1's Face Sheet revealed R #1 was admitted into the facility on [DATE] with the following diagnoses: 1. SPINAL STENOSIS, CERVICAL REGION (narrowing of the spinal canal) 2. ANEMIA, UNSPECIFIED (Deficiency of healthy red blood cells in blood) 3. VITAMIN D DEFICIENCY, UNSPECIFIED 4. HYPERLIPIDEMIA, UNSPECIFIED ( abnormally elevated levels of any or all lipids or lipoproteins in the blood) 5. UNSPECIFIED DEMENTIA (a group of symptoms affecting memory, thinking and social abilities), UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY 6. GENERALIZED ANXIETY DISORDER 7. INSOMNIA (common sleep disorder that can make it hard to fall asleep, hard to stay asleep, or cause you to wake up too early and not be able to get back to sleep), UNSPECIFIED 8. OTHER CHRONIC PAIN 9. ESSENTIAL (PRIMARY) HYPERTENSION (high blood pressure) 10. UNSPECIFIED ASTHMA (a condition in which your airways narrow and swell and may produce extra mucus), UNCOMPLICATED 11. PAIN IN RIGHT HIP 12. MUSCLE WEAKNESS (GENERALIZED) 13. BENIGN PROSTATIC HYPERPLASIA (the flow of urine is blocked due to the enlargement of prostate gland) WITH LOWER URINARY TRACT SYMPTOMS 14. REPEATED FALLS 15. ALTERED MENTAL STATUS, UNSPECIFIED 16. COGNITIVE COMMUNICATION DEFICIT 17. ADULT FAILURE TO THRIVE 18. BODY MASS INDEX [BMI] 20XXX,d+[DATE].9, ADULT 19. NEED FOR ASSISTANCE WITH PERSONAL CARE 20. PERSONAL HISTORY OF COLONIC POLYPS (a small clump of cells that forms on the lining of the colon) C. Record review of R #1's Elopement Risk Evaluation dated [DATE] revealed R #1 was considered a Moderate Risk for facility elopement due to patient is cognitively impaired and ambulates or propels self. Patient may go outdoors on occasion but makes no attempt to leave grounds. Imminent Risk criteria was documented as No for Patient ambulates and propels self, and/or wanders. Patient has intentionally or unintentionally attempted to leave the community. There were no other Elopement Risk Evaluations completed for R #1. D. Record review of R #1's Care Plan dated [DATE] revealed, Focus: Resident is at risk for elopement related to Elopement Evaluation Risk score. Interventions: Discuss and educate resident/family risks of elopement and additional risk reduction strategies, and engage resident in activities of choice. Care Plan also identified that R #1 had history of falls. E. Record review of R #1's Nursing Progress Notes dated [DATE] at 7:24 pm revealed, Today at approximately 1415 [2:15 pm] [Name of R #1] was reported missing. Immediate CODE PINK [missing person notification] was called via intercom and all staff immediately began looking for resident. Multiple staff searched around the building and down through the baseball park and down to the balloon fiesta park. Multiple staff got into their vehicles and began to search. [R #1's] Daughter was contacted by primary nurse to notify her of father missing. Police were contacted at around 1425 [2:25 pm] to report [Name of R #1] missing. [R #1's] Daughter was again contacted by Administrator at approximately 1634 [4:34 pm]. [R #1's] Daughter reported everything and everywhere she was looking. Medical Director notified resident missing at 1725 [5:25 pm] and updated on all efforts being made to locate pt [patient]. At approximately 1729 [5:29 pm] liaison contacted this writer stating that [R #1's] son had contacted her and found pt [R #1] in ditch ([NAME]) about 1 mile from building. This writer, ADON [Assistant Director of Nursing], UM [Unit Manager], Transport Supervisor, headed to the area. Pt [R #1] was discovered on ground in ditch assessed and no signs of life present, no pulse at this time. CPR (Cardiopulmonary Resuscitation) started immediately at 1737 [5:37 pm] by nurse. CPR continued until EMT (Emergency Medical Technicians) arrived on scene and assessed. Police arrived on scene at approximately 1749 [5:49 pm]. EMT's about 10 minutes after 1st officer arrived. EMT assessed and gave immediate orders to stop CPR as pt [R #1] was deceased . Police on scene got all information from everyone on scene and asked that we leave the site at this time [ .]. F. On [DATE] at 3:15 pm during a video observation, R #1 was observed walking out the front entrance of the facility on [DATE] at 1:22 pm. The facility Receptionist (REC) #1 and two visitors were seen at the front entrance. Facility Receptionist did not attempt to re-direct R #1. G. On [DATE] at 3:45 pm during an interview with the REC #1, she stated, I did not see him [R #1] walk by [on [DATE] at 1:22 pm]. I knew who he [R #1] was by pictures. He [R #1] got here on the weekend and I wasn't here to familiarize myself with him. I did not see him [R #1] leave the building. I was on the phone and I had 4 people standing in front of me. I just saw a picture of him. REC #1 confirmed she was not aware of R #1 exiting the front entrance on [DATE] at 1:22 pm because she was helping people in the front lobby. REC #1 also confirmed she was busy at the front desk and does not see everyone leave the building. H. On [DATE] at 11:29 am during an interview with the Clinical Intake Coordinator (CIC), he stated, I know they [facility] don't have a locked unit or they don't have a memory care area focus. If there was a concern that he [R #1] was a wanderer or elopement risk, I would have said no [to R #1 admitting into the current facility]. I. On [DATE] at 12:13 pm during an interview with Licensed Practical Nurse (LPN) #1, he stated, We were told he [R #1] was a moderate risk from prior situations. The conversation I had with him [R #1] was pretty on queue. He [R #1] didn't want to take his medications and I was asking him about that. It seemed like a pretty normal conversation. We're [facility] obviously not a lock down unit and we wouldn't be able to handle a high risk [elopement resident]. It appeared he [R #1] was doing okay in the beginning and it didn't seem like he would take off. We do an elopement risk assessment on admission. If they're [resident's an imminent elopement risk], we would do one to one care until we find a different facility appropriate for that. J. On [DATE] at 12:29 pm during an interview with Certified Nursing Assistant (CNA) #1, she stated, He [R #1] was walking towards [Name of 200 unit] after 8 am [on [DATE]] and the nurse brought him back. I spoke to him [R #1] in the morning [[DATE]] when I took his [R #1's] vitals and he was in bed. When I took him breakfast, he was sitting in bed. He [R #1] didn't want it [breakfast] and I offered him other things but he didn't want it. I gave him [R #1] his lunch tray and he didn't refuse it. He [R #1] was leaving his room at the time [the last time CNA #1 saw him on [DATE]]. He [R #1] didn't mention anything to me [about leaving the facility]. I knew he [R #1] walked around [the facility] a lot and was very mobile. I only saw him [R #1] leave his room door after me [on [DATE]] because I had to give a shower and when I came out [from giving a resident a shower], that's when everyone was looking for him [R #1]. It was about 1:10 pm to 1:15 pm [on [DATE]] when I think he [R #1] walked out [of his room]. K. On [DATE] at 1:17 pm during an interview with the Director of Nursing (DON), she stated, I was in the office and [Name of LPN #1] came to the office around 2:15 pm [on [DATE]] and they said they couldn't find [Name of R #1]. I asked if they started searching and they said yes. I called a Code Pink. I asked for all staff at the nurses station to assist. We had his [R #1's] face sheet printed. [Name of CNA #1] said she had given him [R #1] his lunch tray and went back to get it a few minutes before he walked out. He [R #1] hadn't eaten his lunch. He said he didn't want lunch. After ,d+[DATE] minutes from when I last saw him at lunch, they [LPN #1 and CNA #1] came in and said he [R #1] was gone. I got the keys to my car and we drove around [looking for R #1]. We left the parking lot and went by the baseball fields. We turned into the [nearby] parking lot and searched in there. We started driving towards his [R #1] home. We went by his [R #1's] house and knocked on the door, but nobody came and we turned back around. We were out [looking for R #1 for] ,d+[DATE] hours. At 5:29 pm, [Name of facility staff member] texted me and said they found him [R #1] a mile from the building in an [NAME]. [Name of Wound Care Registered Nurse (WCRN)] had already started CPR on him [R #1] immediately. We continued CPR and they called 911 and the police showed up. We started CPR at [around] 5:37 pm. We continued CPR between the three of us and the cops got there and the EMT's (Emergency Medical Technicians) got there and they said they needed to stop [CPR], and he [R #1] was clearly gone [dead]. DON reported that R #1 had visible skin tears on his arms and dirt on his face when he was found face down in the [NAME]. The DON stated it looked like he had fallen. [Name of R #1] was a moderate risk [for elopement]. He [R #1] knew he had a room here and yes he had some dementia. He [R #1] knew he was at the facility for therapy. He [R #1] wasn't asking how to get out or where to get out. This patient [R #1] was doing jumping [NAME] in his room when he was admitted . The family wanted him [R #1] to get stronger in therapy and they would look at placement here or somewhere else. He [R #1] was accepted [to the facility] because they removed the one to one [observation at the hospital] prior [to being admitted into the facility]. When they brought him here [on [DATE]], they [facility staff] said he [R #1] was pleasant and nice, I heard nothing through the weekend [about R #1 wandering and attempting to elope]. [When R #1 was found] he clearly had fallen and had skin tears on his arms and dirt on his face. DON confirmed they were aware that R #1 was on a one-to-one at the hospital prior to his admission. L. On [DATE] at 1:08 pm during an interview with LPN #2, she stated that on [DATE], He [R #1] was around [Name of 200 unit] and he asked if I could show him where his room is. He [R #1] pulled a paper out of his pocket and showed me his room number and I took him. He [R #1] said 'oh yeah this is my room'. He [R #1] didn't say anything that he actively wanted to leave. [Name of CNA #1] saw me take him back and I know she was taking care of him. M. On [DATE] at 10:22 am during an interview with R #1's son, he stated, I work nights and I had a really loud knocking on my window by my mom and she said my father [R #1] was missing [on [DATE]]. It was about 4:30 pm [on [DATE]]. They [facility] contacted my sister at 2:30 pm [on [DATE]] and said he [R #1] was missing. As we were driving out from the [NAME] on the east side [near the facility], I saw my father face down in the dirt. We flipped around and ran up to him. I was yelling 'Dad! Dad!' I could tell he [R #1] was deceased already and he was bloating and purple. It was terrible. I called them [facility] back and said I found him and told them he's dead. I called 911 and it took like 17 minutes [for the EMT's to arrive]. They [EMT's] showed up and did not resuscitate him [R #1]. My father [R #1] left the faciity on that Saturday [[DATE]] and they [facility staff] found him in the parking lot. My sister witnessed it [R #1's elopement attempt on [DATE]] and they brought him inside. At the [Name of Local Hospital], they [hospital staff] checked on him [R #1] constantly and his bed had an alarm. He [R #1] was calling my sister mom and it was obvious he had dementia, so we took him to the [Name of Local Hospital on [DATE]] because he was out of it that day. N. On [DATE] at 10:38 am during an interview with R #1's Daughter, she stated, That Saturday [[DATE]] morning when I arrived [to the facility], it was around 9 [am] and I look up and see my dad right there [in the parking lot]. They [facility staff] were trying to talk him [R #1] back, going into the facility. A male nurse shows up and talks him [R #1] into going back to the facility. [Name of Director of Rehab (DOR)] came in [to R #1's room]. I said [to the DOR], 'did you know that he [R #1] tried to leave this morning?' She [DOR] said she would inform the doctor, those were her [DOR] words. She [DOR] said, 'Do they [facility] know how advanced [in cognitive decline] he [R #1] is?' He [R #1] tried to leave that Saturday [[DATE]] morning. When I went to the nurses station [to tell staff about R #1's elopement attempt on [DATE]], everyone was gone. [On [DATE]] It was 2:34 pm [when the facility called to inform her that R #1 was missing] and it was a nurse named [Name of LPN #1]. He [LPN #1] said we tried to call your brother, so we're calling you next, but your dad [R #1] is missing. My family and I were in separate cars looking for him [R #1]. O. On [DATE] at 10:55 am during an interview with the Director of Rehab (DOR) confirmed that R #1's daughter spoke with her on Saturday [[DATE]] and she stated, She [R #1's daughter] was not specific to what day [R #1 attempted to elope prior to [DATE]]. What I remember the conversation was, she [R #1's daughter] said, 'He [R #1] followed me out [of the facility].' I wasn't sure if it happened the Friday [[DATE]] or Saturday [[DATE]]. She [R #1's daughter] was worried he [R #1] might wander. I told nursing that he [R #1] was confused and they were aware and when everything happened on Monday [[DATE]], they [staff] all said they are aware. I didn't specifically say wandering [to nursing staff]. She [R #1's daughter] wasn't specific about the time frame [when R #1 attempted to elope on [DATE]] and I assumed it was the day before. DOR confirmed she did not specifically tell nursing staff R #1 was confused or attempted to elope, it was only in passing. P. On [DATE] at 11:20 am, the DOR returned and stated, At the time [[DATE]], she [R #1's daughter] said he [R #1] might wander and I'm not clear on the timeline. I said if that's [R #1 wandering in and out of the facility] a concern, we [facility] don't provide that level of care. I told her we can't do one to one's [observations] here. It [R #1's daughters concern for R #1's safety] didn't come across as [R #1 being in] imminent danger. I didn't know he [R #1] was so mobile. He [R #1] just sat in a wheelchair and didn't say he wanted to leave [the facility]. I didn't have that knowledge about the mobility. Yes, we all knew he [R #1] was confused, but I didn't say he was a wander risk. I heard he [R #1] tried to get out of the hospital too [before admitting to the facility] and I wasn't aware of it. I didn't know there was a history of wandering [for R #1]. She [R #1's daughter] said he [R #1] tried to follow her out to the parking lot [on [DATE]]. I thought it [R #1 following R #1's daughter into the parking lot] was some prior incident. I told them [R #1's family] that this [facility] might not be the best place for him. I told her [R #1's daughter] if she has concerns [about R #1 eloping], this might not be the best place for him. Q. On [DATE] at 11:54 am during an interview with LPN #3, he stated, Nobody came to me and told me he was in the parking lot [on [DATE]]. Saturday [[DATE]], he [R #1] was kind of wandering around the building, he [R #1] said he wanted to go to church and it was a lot of reorienting [R #1] that day. He [R #1] wasn't exit seeking. Sunday [[DATE]], he [R #1] was really calm. I would go in and check on him. I would encourage him [R #1] to eat. For the most part, he [R #1] stayed in his room. I actually got him in the elopement book (entered all information and picture of R #1 in a book maintained for any residents that are at risk for elopement). I notified my manager [Name of Weekend Manager (WM) about R #1's increased facility wandering on [DATE]]. I believe I notified her [WM] and I put him [R #1] in the elopement book. He [R #1] was a moderate [elopement] risk due to his dementia and when he said he wanted to go to church, I asked where the elopement book was and that was the extent to it. LPN #3 confirmed R #1 had increased wandering throughout the facility on [DATE] and he had to redirect R #1 several times. R. On [DATE] at 12:22 pm during an interview with the Weekend Manager (WM), she stated, He [R #1] was a moderate elopement risk and he was ambulatory. I was never told that he was wandering [throughout the facility on [DATE]] besides his room. I would have had to call [Name of DON and Administrator (ADM)] immediately [to notify them of R #1's increased wandering]. I work on the weekends. If anybody [residents] would have been out [of the facility], I would have to call them [DON and ADM] immediately. I knew dementia was a diagnoses [for R #1], but that's because I looked at the chart. I was just told of the moderate elopement risks and he [R #1] was ambulatory. I never heard anyone complain about him [R #1] or say anything. WM confirmed she was not informed of R #1's increased wandering on [DATE]. S. On [DATE] at 12:49 pm during an interview with CNA #2, she stated, I know he [R #1] was going towards [Name of 200 unit] and I would redirect him to go to his room and he would stay. He [R #1] was moderate [elopement risk]. I feel like he [R #1] had some dementia because he was confused. I told the nurse and the person up front [Name of Receptionist #2] and we were on the look out for him [R #1 eloping]. It was just one time during the morning [on [DATE] when R #1 was wandering to the 200 unit]. T. On [DATE] at 1:03 pm during an interview with the Administrator (ADM), she stated, What was communicated to me is she [DOR] had a conversation with the daughter on Saturday [[DATE]] and he [R #1] was an elopement risk. She [DOR] had a conversation [with R #1's daughter] that we [facility] don't do one to one [observations]. The [R #1's] daughter said, 'he [R #1] followed me out to the car', but didn't say when and that wasn't communicated to me by [Name of DOR]. I talked to [Name of LPN #3] and he mentioned that he [R #1] was wanting to go to church and I was under the impression it was a one time occurrence. It [R #1's facility wandering] wasn't anything that was abnormal. [Name of LPN #3] said he [R #1] was going to church and was redirecting him [R #1]. He [R #1] was already in the elopement book and we weren't constantly redirecting him. We would expect them to let the nurse know [if family takes resident out of facility]. ADM confirmed R #1 would have had his elopement risk assessment changed to high risk if the nursing staff would have notified her or the Director of Nursing (DON) that R #1 eloped on [DATE] into the parking lot and was brought back into the facility. U. On [DATE] at 1:38 pm during an interview with Receptionist (REC) #2, she stated that she was working on Saturday, [DATE], I do know that he [R #1] was a new admission on Friday [[DATE]]. The [front] desk is kind of busy. I don't have a recollection [if R #1 left the faciity on the morning of [DATE] and was brought in by staff] and if he [R #1] did [leave the facility]. I was busy helping people at the desk. We have an elopement book and if they [resident's] are a [elopement] risk, they'll be in there. I don't recall that [R #1 leaving the facility on [DATE]], there could have been people going in and out. When I'm at the desk, I try to be aware but if I have visitors, I'm helping them screen [into the facility]. These deficient practices resulted in Immediate Jeopardy being identified on [DATE]. The facility Administrator was first notified of the Immediate Jeopardy on [DATE] at 1:29 pm. Implementation of the Plan of Removal was validated on [DATE] onsite through observation and interview. The Plan of Removal Included: 1. On [DATE] center staff to receive immediate re-education regarding assessing new residents for elopement upon admission, elopement prevention, notification to Admin/DON upon a resident seen wandering or exit seeking and immediate notification to Admin/DON should a resident with cognitive impairment get outside of the center. 2. On [DATE] re-education began to include interventions to immediately implement for wandering and exit seeking behavior when noted at the center. Also re-education regarding completing elopement assessment with a score of moderate or imminent risk with immediate interventions put in place and care plan these interventions to include supervision and notification to the Admin/DON. 3. On [DATE] a timeline was created to assist in the investigation of the occurrence. 4. On [DATE] staff members that cover the reception desk to receive education regarding priority of visitors leaving and ensuring they sign out. Staff members who cover reception desk to also receive education that anyone who does not sign out, the staff member needs to go follow them to determine if a visitor or the resident is leaving and intervene to bring back into the center. 5. On [DATE] visitors/residents coming into center and leaving center will be asked to sign in and out. 6. On [DATE] center staff began to complete test to show understanding of education given. 7. On [DATE] a dome mirror was ordered to be installed at the front desk to aid receptionist in seeing who is leaving the center. 8. On [DATE] an elopement drill was conducted. On [DATE] during observation at the receptionist desk, an unknown visitor was observed to walk out of building without checking-out at the front desk and no staff were observed to have noticed or stopped the visitor. 9. On [DATE], Administrator re-educated receptionist. Refer to POR #4. Record review of an email sent by the ADM dated [DATE] revealed the following: Through my investigation I was able to determine the following: 1. Two therapists reported that [R #1's] daughter stated on Saturday [[DATE]] morning during their OT [Occupational Therapy] evaluation, 'Last time I [R #1's daughter] left, he [R #1] followed me. I got to my car and I waited to see what he [R #1] would do. Two staff members came out to get him.' Both therapists confirmed that is what the daughter stated, but both were unclear at the time where or when this occurred, and did not understand that it had just occurred. 2. The only day the daughter visited was Saturday [[DATE]]. 3. [Name of R #1] was seen outside by two staff members on Saturday [[DATE]] morning. The two staff members that saw him outside Saturday morning were [Name of staff and Name of LPN #3]. [Name of LPN #3] is a new employee and was his [R #1's] assigned nurse. [Name of LPN #3] would like to recant his statement he made to the surveyors last week, as it was not truthful. He [LPN #3] was worried about getting into trouble. [Name of staff member] stated she thought his assigned nurse would report it. Neither nurse informed anyone that he [R #1] had been found outside, nor did any of the necessary documentation. Neither staff were aware if the [R #1's] daughter was present at the time, but stated they saw him [R #1] outside on Saturday [[DATE]] morning at about 9:45 [am], around the same time the daughter was visiting. He [R #1] was brought back inside. 4. Both nurses have been disciplined according to policy and we continue to follow through with our plan of correction to ensure this never happens again.

Based on record review and interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 3 (R #'s 37, 164, 167) of 3 (R#'s 37, 164, 167) residents reviewed by: 1. Failing to send R #37 to the emergency room (ER) at the onset of numbness for 10 days where R #37 was diagnosed with having a Stroke (Damage to the brain from interruption of its blood supply). 2. Failing to provide adequate pain relief causing R #164 to experience unrelieved pain for more than 12 hours. 3. Failing to identify chronic constipation and providing treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] These deficient practices resulted in residents experiencing worsened conditions of leg mobility, pain, constipation, and psychosocial harm (harm that causes mental or emotional trauma). The findings are: Findings for R #37: A. Record review of R #37's face sheet revealed R #37 was initially admitted into the facility on [DATE] with multiple diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] B. Record review of R #37's Nursing Progress Notes dated 05/29/22 at 2:44 pm revealed, Provider on call called again for the possible management of the numbness of the right side she is having. C. Record review of R #37's Provider Progress Notes dated 05/30/22 revealed, Today patient is in bed doing a word find. States that she feels well, 'considering what happened yesterday.' She states that instead of the 'orange drink' which she thinks is fiber she was given something else and that she felt 'numb all over.' Says that she's regained sensation now, but that it was very scary. She denies any change in mental status or cognition, any decrease in muscle strength, or any other neurological effects [effects to nervous system especially regarding structure, functions, and abnormalities]. D. Record review of R #37's Provider Progress Notes dated 06/01/22 revealed, Today Pt [patient] is chatting w/ [with] nephew at bedside. She's hoping she can see the Internal Medicine Team soon, she's concerned re [regarding]: episode of 'numbness' she had a few days ago. Today, she states that when it happened she was given a drink that 'paralyzed her completely' and that 'it's only today that she has some feeling back. When asked if her muscles are affected, she says no, they recovered within minutes, 'but that she still feels numb on her right side.' When asked if she can still use her hand and arm, leg, chew etc she says 'yes, she can do everything' but that she just feels numb. [ .] She states she declined to go to the hospital, and just thinks she needs to be seen by internal medicine. E. Record review of R #37's History and Physical dated 06/03/22 revealed, Patient states the numbness and pain have not gone away. She says the left side of her body has resolved however the right side is still numb from her bottom lip all the way down to her toes. Patient is moving all extremities [a limb of the body, such as the arm or leg] well when speaking to me. I explained that this is probably not an emergency for an allergic reaction. I explained this is possibly most likely from a pinched nerve from laying in bed too often. She states she does not want to get out of bed because she was left in a wheelchair for too long a month ago. Patient requested to go to ER for further evaluation. DON [Director of Nursing] notified of patient's request. Plan: New orders- Patient sent to ER for further evaluation. F. Record review of R #37's Provider Progress Notes dated 06/06/22 revealed, Today Pt [Patient] is resting in bed. Says that she had a fever all night that is gone now, so she's been sleeping all day today. She says that she saw internal medicine a few days ago, but doesn't understand why she hasn't been sent to the hospital for work up. We discuss that by all accounts and appearances she seems fine now, and that Pt is welcome to leave at any time in order to go to the hospital if she wishes to do so. She is concerned that she'll have surgery on her pannus [type of extra growth in your joints that can cause pain, swelling, and damage to your bones, cartilage, and other tissue], and wake up paralyzed, numb. We discuss that all surgeries have risks, but that her surgeon will give her a full work up prior to surgery, and that she doesn't have to have any surgical procedure if she doesn't want to. She again states that she declines to go to the hospital (to have the surgery on her pannus), and just thinks she needs to be seen by internal medicine. G. Record review of R #37's History and Physical dated 06/07/22 revealed, Patient states the numbness and pain have not gone away. She says the left side of her body has resolved however the right side is still numb from her bottom lip all the way down to her toes. Patient requested to go to the ER for further evaluation. H. Record review of R #37's Nursing Progress Notes dated 06/07/22 at 2:03 pm revealed, Residents sister, [Name of R #37's sister], spoke with this nurse regarding her sister. Asking when 'CT [computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body] and MRI [an image obtained by magnetic resonance imaging]' would be scheduled. She went on to state that her sister [R #37] is not getting any better and she [R #37] 'needs to have the surgery'. She stated that her sister [R #37] has been having 'numbness' on the right side and now it has gone over to the left side. Advised that I would speak to the resident and review her complaints with her. I. Record review of R #37's Nursing Progress Notes dated 06/07/22 at 2:45 pm revealed, Interview with resident-Spoke with resident regarding her current complaints. She [R #37] stated that she had a fever last night but today feels better. Also states that she is waiting for surgery to remove the mass in her lower abdominal area. She [R #37] stated that she spoke to a 'doctor' last week and was told that a CT scan and MRI would be ordered to encompass the area from the neck to her feet. Resident states she is 'numb' on both sides of her body from the neck down and has some numbness in her lips. She [R #37] relates this to taking a 'medication' last week but doesn't know what it was. In review, when resident states last week, she means the last week of May per her clarification. Provider called and message left to speak with her regarding the complaints. J. Record review of R #37's Provider Progress Notes dated 06/08/22 revealed, Today Pt [Patient] is resting in bed. She is very irritable that 'everyone keeps telling her she's fine,' believes that something must be very wrong. Says that she had a 103 fever last night (EMR [Electronic Medical Record] shows 100.1 degree fever), is still 'numb on one half of her body.' While both internal medicine providers also feel that the Pt's current physical exam does not warrant a hospital visit, spoke w/ [with] interim DON who says she'll send the Pt out anyway to help rule out anything serious and to help assuage (lessen the intensity of something that pains or distresses) Pt's fears. Relayed to Pt that she will be sent to hospital. There is no evidence that R #37 was seen by Internal medicine doctor and there are no new orders or results from any visits. K. Record review of R #37's Nursing Progress Notes dated 06/09/22 at 11:50 pm revealed, Seen patient [R #37] in her bed lying comfortably, complaining of numbness in her left side of face. Patient vital signs is within normal limits. Patient is waiting for transfer. 911 [Emergency Medical Services] came in the facility @ [at] 2150 [11:50 pm]. Called sister to inform that the patient is ready to go to the hospital for further management and care related to chief complaint of numbness. Patient [R #37] left the facility via stretcher @ [at] 2153 [11:53 pm]. L. Record review of R #37's Hospital History and Physical Notes dated 06/10/22 revealed, As per patient [R #37] her symptoms of weakness and numbness insidiously started happening about 10 days back and continued to get worse. Patient apparently spoke with the staff at the SNF [Skilled Nursing Facility] on multiple occasions however did not receive adequate attention. Patient also reports that around the same time patient was also given [MEDICATION(S)] [medication to treat occasional constipation] after which she had difficulty breathing and initially thought it was secondary to the [MEDICATION(S)] leading to allergy. Patient adds that she was able to walk with a walker however it is progressively getting difficult for her to walk. In the ER [emergency room ] she had an NIH [National Institutes oh Health Stroke Scale- a tool used by healthcare providers to quantify the impairment caused by a stroke] score of 6 [5-15 equals moderate stroke] and brain MRI showed left hippocampal acute ischemic stroke [sudden loss of blood circulation to an area of the brain, typically in a vascular territory, resulting in a corresponding loss of neurological function] along with an older hemorrhagic [bleeding] component in the same vascular territory. Hospitalist service was consulted for admission. Neurologist was also consulted. Patient was deemed not a candidate for tPA [a drug used to break up a blood clot and restore blood flow to the brain and can only be administered a within a few hours when stroke symptoms appear] given her late presentation. M. On 07/26/22 at 9:50 am during an interview with R #37, she stated, In June [2022], I had a stroke. I started to feel weird and numb. I felt like I was choking. The guy [staff] that was passing medicine said it looked like a stroke. They [facility] wouldn't take me to the hospital because they said it [numbness] will pass. They [facility] waited until I was half dead until they finally sent me out. The hospital said I had a stroke. They [facility] waited a week [until sending R #37 to the hospital]. They [facility] were changing companies and they [facility] should have sent me [to the hospital]. My sister came in and told them I was getting worse. I knew I wasn't getting better, I was getting worse. I lost the use of my legs after the stroke. R #37 confirmed she could not use her legs as well as she could prior to experiencing the stroke and she was upset that she was not sent to the emergency room sooner. N. On 07/27/22 at 10:27 am during an interview with R #37's sister, she stated, They [facility] said it was all in her [R #37's] head. They [facility] said they looked at her [R #37] and she was ok. I said no, she [R #37] knows her body and there's something wrong and she needs a hospital. [Name of Certified Nurse Practioner (CNP) #1] told her [R #37] that all of those symptoms are in your head. It [R #37's numbness] lasted for ten days. I went to the head nurse [Name of DON] and she saw her and I talked to the administrator. I told them about it and they took her in. I told them [facility] that I think she [R #37] was having a stroke, and she [R #37] was having a stoke. It took 10 days before they [facility] sent her [R #37] out [to the hospital]. The hospital said she had a full blown stroke. I spoke to them [facility] constantly. They [facility] would say they would look into it [sending R #37 to the hospital] and call the doctor. She [R #37] said no one ever came in. I would talk to the nurses in that area and they didn't know anything. It [R #37's stroke] wouldn't have been as bad if they [facility] sent her [R #37] to the hospital sooner. O. On 07/27/22 at 11:25 am during an interview with Licensed Practical Nurse (LPN) #1, she stated, Apparently she [R #37] had that numbness and tingling for awhile and attributed it to taking Metamucil [fiber]. I believe she was seen by the provider [Certified Nurse Practioner (CNP) #1] and was talking and using her extremities. A couple of days later, she was sent to the hospital. There is no evidence that the facility physician had seen R #37. P. On 07/27/22 at 12:09 pm during an interview with the Director of Nursing (DON), she stated, I'm not sure who she [R #37] spoke to. I came in and was making rounds and was talking to patients. I referred it [R #37's symptoms] back to the Nurse Practioner. In this building the provider puts in their orders. If I would have seen that order [CNP's order in R #37 06/03/22 History and Physical to send R #37 to the ER] on the 3rd [06/03/22], I would have sent her [R #37 to the hospital], but I did not see that order. We don't know when that stroke happened. Q. On 07/27/22 at 12:21 pm during an interview with the Vice President of Clinical Operations (VPCO), she stated, The first week when we [facility] were in acquisition [act of acquiring something], we made a big point to get to know the residents. [Name of R #37] stated she was having numbness and tingling. It was brought up to the Nurse Practioner [CNP #1]. She [CNP #1] was adamant she was following the situation and it was in [Name of R #37's] head. She [CNP #1] was convinced she [R #37] was having an allergic reaction [to a fiber supplement]. They [CNP #1 and Physician Assistant] both were assessing her [R #37] weekly and they both felt it was psychosomatic [caused or aggravated by a mental factor such as internal conflict or stress]. I finally pushed it to the point where I said, 'you guys if there is something going on, we need to rule it out.' I kept watching her's [CNP #1] and [Name of Physician Assistant (PA) #1's] notes and saw they were following the signs and symptoms. They [CNP #1 and PA #1] weren't going to send her [R #37] out [to the hospital]. She [CNP #1] kept saying she wasn't going to send her [R #37] to get the CT. There was nothing showing an acute change in condition. It was my understanding she [R #37] didn't want to go the hospital. I had the conversations and the [CNP #1] said it was in her [R #37's] head and she [CNP #1] wasn't sending her [R #37] out [to the hospital]. At the time, I did glance at that [R #37's 06/03/22 History and Physical], but I didn't go down that far [in R #37's 06/03/22 History and Physical to see order to send R #37 to ER] . I went to talk to her [R #37] to see if she had eye droop. She [R #37] just wanted the CT scan but I didn't ask her [R #37 if she wanted to go to the ER]. VPCO confirmed CNP #1 and PA #1 did not want to send R #37 to the ER and VPCO did not ask R #37 if she wanted to go to the ER. R. On 07/27/22 at 4:44 pm during an interview with Vice President of Regulatory Compliance (VPRC), she stated, Nursing documentation could be improved. On 06/03/22, the Nurse Practioner [CNP #1] did do an assessment on this patient [R #37] and she would send her [R #37] to the ER if wanted. According to staff, she [R #37] didn't want to go to the ER, she [R #37] just wanted a CT. There wasn't an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #37 to the hospital] between the 06/06/22 to 06/09/22. At times we [facility] have therapy assist with transfers and the therapist said she [R #37] was more weak. VPRC confirmed she was unaware of CNP #1 order to send R #37 to theER on [DATE], but there were no orders to send R #37 to the ER from 06/06/22-06/09/22. S. On 07/27/22 at 4:49 pm during an interview with the VPCO, she stated, She [R #37] wanted a CT and she had a lot of anxiety. We [facility] really advocated for her [R #37] and got a lot of pushback from [Name of CNP #1]. I wish I could have documented better. We [facility] were saying if she [R #37] wants to go [to the ER], she needs to get an exam. I did assess [R #37] and I didn't document it [R #37's assessment]. She [R #37] didn't say she didn't want to go to the ER to me. She [R #37] just said she wanted a CT. She [R #37] was wanting her body imaged, not her brain because she was having anxiety. Because we failed to document, it appears we did nothing but it wasn't that way. I still don't believe she [CNP #1] gave an order to go [send R #37 to the ER], but it would have to be on a form to be scanned in. I was not given anything [order to send R #37 to the ER]. She [CNP #1] said it's all in her [R #37's] head, but she'll [CNP #1] go and see her [R #37]. VPCO confirmed she did not specifically ask R #37 if she wanted to go to the ER when she assessed R #37. T. On 07/27/22 at 4:50 pm during an interview with the DON, she stated, It was on the afternoon on the 3rd [06/03/22] where they [facility providers] had access [to put in orders]. She [R #37] indicated she wanted a full body CT. The nursing notes are terrible. I never asked her [R #37 if she wanted to go to the ER] and I didn't know about the 06/03/22 [R #37 History and Physical] documentation. The best practice is if they're [providers] standing in front of you, they [providers] need to write it [orders] into the system [Resident's Electronic Health Record (EHR). U. On 07/27/22 at 5:41 pm during an interview with CNP #1, she stated, That's why she [R #37] wanted to see me because she [R #37] was requesting to go to the ER. She [R #37] said she was having pain from her her tongue to her right side and numbing and tingly. I thought she [R #37] had a pinched nerve. That was the only complaint over and over again, a numbing to the side. I said 'she [R #37] was going to go [to theER on [DATE] right?' She [VPCO] said, 'Yes, I'll [VPCO] take care of it [send R #37 to theER on [DATE]].' I noticed she [R #37] was still here [on 06/07/22 and not in the ER]. I think everything was a mistake and I don't know why she [R #37] wasn't sent out [to the ER]. I honestly didn't think she [R #37] was having a stroke. The symptoms she [R #37] was complaining about, she [R #37] had for a week. I didn't have access to the computer [to put in orders] until 06/08/22. It was a verbal order [given to VPCO on 06/03/22 to send R #37 to the ER]. The first week or so [after the new company took over the facility], I didn't have [computer] access [for orders] at all. I should have done a written order [to send R #37 to theER on [DATE]] with the nurse. CNP #1 confirmed R #37 told her that she wanted to go to theER on [DATE] and the CNP #1 gave a verbal order to the VPCO on 06/03/22 to send R #37 to the ER. Resident #164 V. Record review of R #164 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . W. Record review of R #164 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . X. Record review of R #164 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] 07/07/22 at 15:58 (3:58 pm) administered acetaminophen (a non-narcotic pain medication) 2 tablets for pain level rated 7. The medication was rated as ineffective. There was no evidence any other pain medication was administered. 07/07/22 at 21:58 (9:58 pm) administered acetaminophen 2 tablets for pain level rated 7. The medication was rated as effective. 07/08/22 at 4:05 am [MEDICATION(S)] administered for pain level rated 10. The medication was rated as effective. Y. Record review of R #164 daily care notes revealed that on 07/08/22 Interval History: Today this clinician is told to see Pt (R #164) because she arrived in great pain during the evening prior and because there has been some sort of clerical error and she arrived w/no (with no) pain medication . Z. On 07/25/22 at 2:33 pm during interview with R #164, she stated that she was a resident of another long term care facility but chose to transfer to this facility. She stated that on the day she arrived she was in a great deal of pain. She stated she asked for pain medication and was told her pain medication had not come from her last facility. She stated she was given something but she felt no relief from the pain until early the next morning. AA. On 07/26/22 at 3:25 pm during interview with Administrator (ADM) and Executive Nurse (EN), they stated that R #164 did transfer from another facility and that there was some problem with her medications. Both stated that R #164 was provided two doses of Acetaminophen and that per their knowledge the second dose was effective. They stated the nurse did provide [MEDICATION(S)] about 4:00 am. Both stated that [MEDICATION(S)] was available and could have been drawn from another source had the nurse chosen to do so upon admission. Resident #167 BB. Record review of R #167 face sheet dated 07/27/22 revealed she was admitted to the facility on [DATE] with multiple diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . CC. Record review of R#167 care plan dated 07/25/22 revealed no care plan prior to 07/25/22 to monitor or report signs or symptoms of constipation. DD. Record review of physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . EE. Record review of daily point of care documentation revealed that R#167 was monitored for daily bowl movements with the following observations: 07/11/22: No bowel movement 07/12/22: Incontinent of bowel 07/13/22: No bowel movement 07/14/22: Incontinent of bowel 07/15/22: Incontinent of Bowel 07/16/22: No Documentation 07/17/22: No Documentation 07/18/22: No Bowel movement 07/19/22: No Bowel movement 07/20/22: No Bowel movement FF. Record Review of daily care note dated 07/21/22 revealed R #167 was transported by her daughter to the hospital ER. GG. Record Review of (Name of Hospital) care notes dated 07/21/22 revealed R #167 was admitted , and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] HH. On 07/26/22 at 2:20 pm during interview with R #167's daughter, she stated she had been aware for several days that her mother was constipated. Daughter stated that she was visiting with her mother on 07/21/22 and noted that her mother was very uncomfortable and complaining that she was unable to have a bowel movement. Daughter felt that her mother's condition required immediate attention, so she went to staff and told them she was taking her mother to the emergency room . Daughter stated that she then assisted her mother out the building and drove her to a nearby hospital where she was diagnosed with a fecal impaction. She was treated and released and daughter returned R #167 to the facility. II. On 07/28/22 at 9:22 am during interview with Director of Nursing (DON) she stated that nursing staff should have contacted the medical provider as soon as a condition is noted. She stated this included R #167 being constipated. DON stated nurses on duty should have completed a communication form and left the form for the provider. DON stated she was unable to find any such communication form for R #167 to be assessed for constipation.

Based on record review and interview the facility failed to ensure 1 (R#1) of 5 (R #1, 2, 3, 4 and 5) residents who were reviewed for receiving wound care and treatment was free from neglect, when the facility delayed providing wound care and treatment for 11 days, between which new multiple pressure wounds were identified by the hospice nurse and from when new orders for treatment were initiated. This deficient practice likely resulted in worsening pressure wounds for R #1. The findings are: A. Record review of R#1 facesheet indicates he was admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. Chronic Pai[DIAGNOSES REDACTED] Other Pancytopenia (reduced red and white blood cells) Major [MEDICAL CONDITION] [MEDICAL CONDITION] (enlarged prostrate gland) with lower urinary tract symptoms Malignant Neoplasm of the Pancreas (cancer of the pancreas) [MEDICAL CONDITION] Other [MEDICAL CONDITION] Pneumonia [DIAGNOSES REDACTED] (low blood potassium level) B. Record review of R #1 care plan initiated 12/24/19 reveals that R #1 is at risk for skin impairment or has actual skin impairment with goals and intervention. C. Record review of physician orders dated 02/07/20 reveals R#1 was admitted to hospice care (end of life care) with a [DIAGNOSES REDACTED]. D. Record review of physician orders dated 02/07/20 reveal Please call (Name of Hospice Care Provider) for all changes in condition, any new orders, lab draws, X-rays, diagnostic needs, or for any questions or concerns. E. Record review of Hospice Care Nurse (HCN) #1 narrative dated 03/27/20 reveals the following was able to gain access to facility amid Covid 19 outbreak. Patient (R#1) has significantly delcined.Patient has multiple skin tears to BUE (Bilateral Upper Extremities) . motteling (patchy irregular colored skin. Generally recognized as an end of life condition) present to bilateral (both) knees .Patient is completely bedbound, incontinent (uncontrolled illimination of urine and feces) of B/B (bowel and bladder) . at peace with his decline. F. Record review of R#1 weekly skin check dated 03/30/20 reveals a notation of an irregularity of the right heal described as a redness. No other wounds or irregularities are described. G. Record review of R#1's daily care-personal hygiene dated 03/01/20 to 04/30/20 reveals that facility staff provided daily care for personal hygiene with one to two person assist. H. Record review of Hospice Care Nurse (HCN) #1 narrative dated 04/03/20 reveals that HCN#1 arrived at the facility and found R#1 in bed: . Patient (R#1) was found to have significant breakdown on his body (referring to an unidentified pressure ulcer). Patient (R#1) brief (Adult diaper) was on so tight there was breakdown along the waist line. Patient has a very large Stage Two pressure ulcer (a shallow, partial thickness, skin rupture that does not penetrate to the fatty tissue below the surface) to sacrum/coccyx (lower back just above the buttocks). Patient has feces caked on his bottom. (Name of hospice aide) and myself cleansed area thoroughly. Seal barrier cream was placed. Patient has 3 stage 1 pressure ulcers to his back. R (right) fifth rib has an area where blood has pooled due to patient not being turned .I (HCN#1) notified (first name only of Facility Nurse) FN#1 of patients poor skin conditions. I. Record review of physician orders dated on or about 04/03/20 reveal no order for treatment of [REDACTED].#1 on 04/03/20. J. Record review of Treatment Administration Record (TAR) date April 2020 reveals no treatment of [REDACTED]. K. Record review of Daily Notes indicates there is no notation entered on 04/03/20 acknowledging the presence of any new pressure ulcers. L. Record review of Daily Notes dated 04/04/20 makes no notation of any skin damage. The notation indicates R#1 is incontinent (unable to control bowel or bladder) and that incontinence care is being provided per protocol. An adult brief is being utilized and pericare (cleansing and care provided to the groin area) is provided. M. Record review of hospice care daily notes dated 04/07/20 by HCN #2 reveals a notation of a large wound to the coccyx (tail bone-bony prominence just above the buttocks) which she cleaned and covered, there is no indications that this information and treatment was conveyed to any member of the facility staff. N. Record review of Daily Notes dated 04/07/20 makes no notation of any skin damage. The notation indicates R#1 is incontinent and that incontinence care is being provided per protocol. An adult brief is being utilized and pericare is provided. O. Record review of Weekly Skin Check dated 04/14/20 reveals an irregularity that is described as 15x13 centimeters (cm) open area, edges not approximated (joined), granulation tissue (scar tissue) noted, serosanguinous (a bodily fluid composed of blood and clear liquids) drainage noted. P. Record review of R#1's Treatment Administration Record dated April 2020 reveals that on 04/14/20 staff began treatment of [REDACTED]. Q. Record review of R#1 daily nursing notes indicate that on 04/29/20 R#1 became non-responsive. His death was pronounced at 3:47 am. R. On 05/08/20 at 3:30 pm during interview with HCN #1 stated that she conducted a hospice visit with R#1 on 04/03/20. She confirmed that on entering his room she found that R#1 was unkempt and needed bathing and cleaning. She stated that she did this and found the described wounds. HCN#1 stated that following care, she told FN#1of the wounds she found to R#1's back and coccyx. S. On 05/21/20 at 1:50 pm during interview with Certified Nurses Aide (CNA) #1, she stated that she has worked for the facility for four year. She stated that facility CNA's do daily care for all residents including the hospice residents and that this care includes personal care, repositioning and assisted dining. She states that showers are usually done by hospice CNAs who come 3 times per week to provide shower care. CNA#1 stated that if a hospice resident requires a shower between hospice visits then staff would certainly provide such care. T. On 05/22/20 at 2:03 pm during interview with DON, she stated that residents who are on hospice have their care managed by the hospice doctor and that all daily care is managed by the facility nursing staff while the hospice nurses conduct regular visits to monitor resident care. She confirmed that any changes in condition of a resident should be reported by the facility staff to either the hospice nurse or the hospice doctor for orders and follow-up. She stated that their hospice residents have a communication book at the bedside for the hospice nurses to comment on care and needs of residents following their visits. She was unable to produce any such book for R#1 and suggested that it was probably gathered by the hospice care nurses after R#1 passed away. DON stated that both the hospice nurses and the staff nurse should have reported the identified wound on 04/03/20 and treatment should have begun immediately. She also confirmed that any such order for care should have been entered by either the hospice nurse DON confirmed that no physician orders were entered until 04/14/20 and there appears to have been on treatment of [REDACTED].

Based on record review, observation and interview, the facility failed to provide the supervisory services necessary for 15 minutes, to keep a resident (R #1) of 4 (R #1, 2, 3, and 4) safe, who fell out of his wheelchair, and sustained injuries to his head and body. The facility was aware that this resident was a high fall risk, who needed to be supervised closely and had been redirected throughout the day, to not stand up but to sit down in his wheelchair. This deficient practice resulted with the resident being sent from the facility to a local acute care hospital. The findings are: A. Record review of R #1's face sheet indicated that the resident was admitted on [DATE], and had the following Diagnoses: [REDACTED]. prostate hypertrophy (age-associated enlargement of the prostate gland that affects the flow of urine), and muscle weakness. The resident is legally blind and hard of hearing. B. Record review of the Fall assessment dated [DATE], included the following: History of falls within the last 6 months as 1-2 times, he is on NSAIDS (non-steroidal anti-[MEDICAL CONDITION] drugs that reduce pain, fever and inflammation), Vision pattern as adequate (resident is legally blind), he is frequently incontinent of urine and bowel movements, confined to a chair and is disoriented, unable to independently come to a standing position, exhibits loss of balance while standing, requires hands-on assistance to move from place to place . C. Record review of the physician orders [REDACTED]. Pt (patient) requires assistance with feeding. OT (Occupational Therapy) clarification order for OT eval (evaluate) and treat for 30 days, 5 - 7x (times)/week with self-care, therapeutic activities, therapeutic procedures .mobility/management, resident/caregiver education . PT (Physical Therapy) clarification order: PT to eval and treat pt for functional mobility 5 - 7 x/week, for 4 weeks, to address gait, therapeutic activities, therapeutic procedures .w/c (wheelchair) mobility/management, self-care/home management, and family/pt safety training . D. Record review of the Admission MDS (Minimum Data Set, a clinical assessment) dated 06/21/18, with an Assessment Reference Date of 06/28/18, revealed the following: Section B. Hearing, Speech and Vision - Hearing is indicated as adequate, wears a hearing aide, makes self understood, Vision is indicated as adequate, wears glasses. Section C. Cognitive Patterns - BIMS (Brief Interview for Mental Status, is used to get a quick snapshot of how well you are functioning cognitively at the moment.) Summary Score of 12 (scores if 13 - 15 are considered normal cognitive function, scores of 8 - 12 are moderately impaired.) Section G. Functional Status - indicates resident needs extensive assistance with two+ persons physical assist with the following: bed mobility, transfer, dressing, toilet use and personal hygiene. Balance During Transitions and Walking indicates a 2, not steady, only able to stabilize with staff assistance for the following: Moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, Moving on and off toilet and Surface-to-surface transfer (transfer between bed and chair or wheelchair). Functional Limitation in Range of Motion indicates no impairment to the upper extremities and impairment on both sides to the lower extremities. E. Record review of R #1's Care Plan dated 06/21/18, indicated the following: (Name of R #1) is at risk for injury d/t (due to) fall r/t (related to) history of fall, pelvis fracture, [MEDICAL CONDITION]. Interventions included: Assist with toileting and repositioning/mobility needs prn (as necessary); Call light within reach and encourage use for assistance with needs; Keep personal items and frequently used items within reach; and Provide an environment free of clutter, glare, appropriately lit for time of day. No documentation in the care plan to indicate that the resident was needing constant monitoring, brakes on his w/c being locked at all time, footrests being in the appropriate place. F. Record review of the Nurses Notes dated 06/27/18, indicated that R #1 had a fall on that date as well, the note revealed the following: 06/27/18 at 7:15 am, Note Text: Notified by CNA (Certified Nursing Assistant) that he heard guest fall to floor. Upon entry to room, guest noted to be on his back on floor next to bed. No complaints of pain or discomfort. MAE (moves all extremities) x 4 (times 4, meaning the resident is able to move both of his arms and both of his legs) WNL (within normal limits). Neuro checks within normal limits for this guest. He is alert and oriented x 2. Guest noted to have a golf ball size protrusion from posterior head. PERRLA (pupils equal, round, reactive to light and accommodation). Notified (name of Physician Assistant (PA)), PA assessed guest and new orders given to transport non-emergently to (name of local hospital) ER (emergency room ) for further evaluation and treatment. Wife and daughter notified. DON (Director of Nursing) also notified. G. Record review of the Incident Report #1812, dated 07/11/18 at 15:40 (3:40 pm), revealed the following: Client was sitting in his wheelchair by the nurses station (in the commons area). Client was found on the floor bleeding from his head - wheelchair pushed away. Pressure was applied to bleeding to his head. Skin tear to left shin noted and skin tear to right forearm had re-opened. Physician was available for assessment. EMS (Emergency Medical Services) non-emergency was called to take client to (name of local hospital) for further evaluation. Resident was indicated as being alert, oriented to person, was confused, no witnesses found. H. On 10/05/18 at 11:30 am, during interview, PTA (Physical Therapist Assistant) #1 stated that morning of 07/11/18, the resident was more weak, lethargic and confused, than he had been previously when he had worked with him. He stated, I remember asking the nurse if I should work with him? She said to be very careful and that he should not be left unsupervised as he was a fall risk. He stated that he tried working with R #1 in therapy, but that the resident was unable to follow commands, so he took the resident earlier out of therapy, just because of that. PTA #1 stated that he took him to the commons area, near the TV. There was a female who has light complexion, who made a sign of acknowledgement, either a thumbs up or nodded her head, that she would look after the resident. He stated that he had locked the breaks on R #1's wheelchair, he said about an hour later he had found out that the resident had fallen. He could not remember if the foot rests were on or off the wheelchair. I. Record review of the written statement by PTA #1 dated 07/11/18, revealed the following: Pt (patient) presented with significant cognitive deficits upon intro to Tx (treatment). Pt was in front of the nurse's station where he was being monitored due to becoming a high risk for falls. 15 minutes into the treatment, clinician (PTA) realized it would be counterintuitive to continue Tx and decided to D/C (discontinue) Tx. When returning pt to nurse's station to continue being monitored, clinician assured nursing staff was notified. J. On 10/05/18 at 12:05 pm, during interview via telephone, CMA/CNA (Certified Medication Aide) #1 stated that she had been the CMA on the unit that day of 07/11/18. Then at change of shift, at the last minute, she was told that she would be the CNA at 2:30 pm, on the unit. The previous CNA stated that she was going to change R #1, but that he was in therapy. She said that she saw R #1 in the commons area, watching TV. She further stated that all the nurses knew that he would get up by himself and that he was a fall risk. She saw R #1 in the commons area, that he was OK and not trying to stand up. He was sitting in his wheelchair, that had the foot rests on, he couldn't see the TV, but that he could hear it. CMA/CNA #1 stated that she had taken his vital signs and had left to take the vital signs of a resident in their room. She stated that someone said to her, someone was lying on the floor. She continued, we found R #1 face forward on the floor, he was entangled in the foot rests. We have R #1 in the commons area by the nurses station, because there is a lot of staff who are walking by, it is a high traffic area. The therapy department could see R #1 through the window, sitting at the nurses station, so he wouldn't be alone in his room (which is located across from the nurses station). We had been redirecting him during the morning, saying Hey (name of R #1), and he would sit back down, he wanted to go and catch the bus. CMA/CNA #1 stated that she remembers that R #1 was being redirected constantly that morning, to sit back down in his wheelchair. K. Record review of the statement written by CMA/CNA dated 07/11/18 revealed the following: On Wednesday, (MONTH) 11, (YEAR), I took over as (name of R #1's) CNA at about 1420 (2:40 pm), I received report that R #1 was in therapy room. I saw R #1 sitting in his wheelchair in front of the nurses station in the commons area at approximately 1500 (3:00 pm), he was facing the TV and seemed content. Around 1520 (3:20 pm), I took R #1's vital signs he was still sitting in the commons area, near the nurses station sitting area. I then continued (taking) vital signs on other guests. About 1535 (3:35 pm), someone from housekeeping was yelling help at the nurses station, I ran up to the nurses station and saw R #1 on the floor with his legs under his wheelchair. There was another CNA there with R #1 and we lifted the wheelchair off of his legs. The RN (Registered Nurse) came to the area about 2 minutes later. L. On 10/05/18 at 10:30 am, during a tour of the facility, with special attention to the commons area by the nurses station where R #1 was watching TV. Special attention was made to the location of the furniture surrounding the TV viewing area, where R #1 had been sitting. M. Record review of the complaint letter sent to the State dated 07/23/18, revealed the following: .My father's (R #1) injuries included: a large bruise on his forehead and on the bridge of his nose, swelling on the bridge of his nose, bruising on his left chest, bruising and scrapes on his left calf, bruising along his left arm with a large contusion on the top of his left elbow, bruising and cuts on his right arm, a large deep gash on the top of his head that required about 10 stitches and bruising on the left part of his scalp. My father was scared, confused and bleeding profusely. The injuries were sustained in a matter of approximately 15 minutes, when he was unsupervised. N. Record review of the facility's policy titled Falls and Fall Risk Management, last revised on 12/28/16, revealed the following: It is the policy of the center to assess residents for risk of falls, to follow up and evaluate falls of residents in order to assess the resident's condition, to identify the reason for the fall and prepare a Plan of Care to reduce the potential for future falls .Upon admission the nursing staff will complete a fall risk assessment and review the medical record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident/representative about any history of falls .Staff will attempt to identify any environmental factors that may contribute to falling such as lighting and room layout .If falling recurs despite initial interventions, staff will implement additional or different interventions . O. Record review of the facility's policy titled Abuse Prevention Program, last revised (not indicated), revealed the following: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to: facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors, or any other individual.

Based on record review, observation and interview, the facility failed to ensure that residents received adequate supervision and interventions to prevent falls for 1 (R #1) of 4 (R #s 1, 2, 3 and 4) residents who were reviewed for being high risk for falls. The facility's failure as evidenced by failing to provide high fall risk residents with adequate supervision, knowing that the resident was a high fall risk. This deficient practice resulted with the resident being sent from the facility to a local acute care hospital, to evaluate the resident's injuries and condition, that may have been prevented. The findings are: A. Record review of R #1's face sheet indicated that the resident was admitted on [DATE], and had the following Diagnoses: [REDACTED]. prostate hypertrophy (age-associated enlargement of the prostate gland that affects the flow of urine), and muscle weakness. The resident is legally blind and hard of hearing. B. Record review of the Fall assessment dated [DATE], included the following: History of falls within the last 6 months as 1-2 times, he is on NSAIDS (non-steroidal anti-[MEDICAL CONDITION] drugs that reduce pain, fever and inflammation), Vision pattern as adequate (resident is legally blind), he is frequently incontinent of urine and bowel movements, confined to a chair and is disoriented, unable to independently come to a standing position, exhibits loss of balance while standing, requires hands-on assistance to move from place to place . C. Record review of the physician orders [REDACTED]. Pt (patient) requires assistance with feeding. OT (Occupational Therapy) clarification order for OT eval (evaluate) and treat for 30 days, 5 - 7x (times)/week with self-care, therapeutic activities, therapeutic procedures .mobility/management, resident/caregiver education . PT (Physical Therapy) clarification order: PT to eval and treat pt for functional mobility 5 - 7 x/week, for 4 weeks, to address gait, therapeutic activities, therapeutic procedures .w/c (wheelchair) mobility/management, self-care/home management, and family/pt safety training . D. Record review of the Admission MDS (Minimum Data Set, a clinical assessment) dated 06/21/18, with an Assessment Reference Date of 06/28/18, revealed the following: Section B. Hearing, Speech and Vision - Hearing is indicated as adequate, wears a hearing aide, makes self understood, Vision is indicated as adequate, wears glasses. Section C. Cognitive Patterns - BIMS (Brief Interview for Mental Status, is used to get a quick snapshot of how well you are functioning cognitively at the moment.) Summary Score of 12 (scores if 13 - 15 are considered normal cognitive function, scores of 8 - 12 are moderately impaired.) Section G. Functional Status - indicates resident needs extensive assistance with two+ persons physical assist with the following: bed mobility, transfer, dressing, toilet use and personal hygiene. Balance During Transitions and Walking indicates a 2, not steady, only able to stabilize with staff assistance for the following: Moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, Moving on and off toilet and Surface-to-surface transfer (transfer between bed and chair or wheelchair). Functional Limitation in Range of Motion indicates no impairment to the upper extremities and impairment on both sides to the lower extremities. E. Record review of R #1's Care Plan dated 06/21/18, indicated the following: (Name of R #1) is at risk for injury d/t (due to) fall r/t (related to) history of fall, pelvis fracture, [MEDICAL CONDITION]. Interventions included: Assist with toileting and repositioning/mobility needs prn (as necessary); Call light within reach and encourage use for assistance with needs; Keep personal items and frequently used items within reach; and Provide an environment free of clutter, glare, appropriately lit for time of day. No documentation in the care plan to indicate that the resident was needing constant monitoring, brakes on his w/c being locked at all time, footrests being in the appropriate place. F. Record review of the Nurses Notes dated 06/27/18, indicated that R #1 had a fall on that date as well, the note revealed the following: 06/27/18 at 7:15 am, Note Text: Notified by CNA (Certified Nursing Assistant) that he heard guest fall to floor. Upon entry to room, guest noted to be on his back on floor next to bed. No complaints of pain or discomfort. MAE (moves all extremities) x 4 (times 4, meaning the resident is able to move both of his arms and both of his legs) WNL (within normal limits). Neuro checks within normal limits for this guest. He is alert and oriented x 2. Guest noted to have a golf ball size protrusion from posterior head. PERRLA (pupils equal, round, reactive to light and accommodation). Notified (name of Physician Assistant (PA)), PA assessed guest and new orders given to transport non-emergently to (name of local hospital) ER (emergency room ) for further evaluation and treatment. Wife and daughter notified. DON (Director of Nursing) also notified. G. Record review of the Incident Report #1812, dated 07/11/18 at 15:40 (3:40 pm), revealed the following: Client was sitting in his wheelchair by the nurses station (in the commons area). Client was found on the floor bleeding from his head - wheelchair pushed away. Pressure was applied to bleeding to his head. Skin tear to left shin noted and skin tear to right forearm had re-opened. Physician was available for assessment. EMS (Emergency Medical Services) non-emergency was called to take client to (name of local hospital) for further evaluation. Resident was indicated as being alert, oriented to person, was confused, no witnesses found. H. On 10/05/18 at 11:30 am, during interview, PTA (Physical Therapist Assistant) #1 stated that morning of 07/11/18, the resident was more weak, lethargic and confused, than he had been previously when he had worked with him. He stated, I remember asking the nurse if I should work with him? She said to be very careful and that he should not be left unsupervised as he was a fall risk. He stated that he tried working with R #1 in therapy, but that the resident was unable to follow commands, so he took the resident earlier out of therapy, just because of that. PTA #1 stated that he took him to the commons area, near the TV. There was a female who has light complexion, who made a sign of acknowledgement, either a thumbs up or nodded her head, that she would look after the resident. He stated that he had locked the breaks on R #1's wheelchair, he said about an hour later he had found out that the resident had fallen. He could not remember if the foot rests were on or off the wheelchair. I. Record review of the written statement by PTA #1 dated 07/11/18, revealed the following: Pt (patient) presented with significant cognitive deficits upon intro to Tx (treatment). Pt was in front of the nurse's station where he was being monitored due to becoming a high risk for falls. 15 minutes into the treatment, clinician (PTA) realized it would be counterintuitive to continue Tx and decided to D/C (discontinue) Tx. When returning pt to nurse's station to continue being monitored, clinician assured nursing staff was notified. J. On 10/05/18 at 12:05 pm, during interview via telephone, CMA/CNA (Certified Medication Aide) #1 stated that she had been the CMA on the unit that day of 07/11/18. Then at change of shift, at the last minute, she was told that she would be the CNA at 2:30 pm, on the unit. The previous CNA stated that she was going to change R #1, but that he was in therapy. She said that she saw R #1 in the commons area, watching TV. She further stated that all the nurses knew that he would get up by himself and that he was a fall risk. She saw R #1 in the commons area, that he was OK and not trying to stand up. He was sitting in his wheelchair, that had the foot rests on, he couldn't see the TV, but that he could hear it. CMA/CNA #1 stated that she had taken his vital signs and had left to take the vital signs of a resident in their room. She stated that someone said to her, someone was lying on the floor. She continued, we found R #1 face forward on the floor, he was entangled in the foot rests. We have R #1 in the commons area by the nurses station, because there is a lot of staff who are walking by, it is a high traffic area. The therapy department could see R #1 through the window, sitting at the nurses station, so he wouldn't be alone in his room (which is located across from the nurses station). We had been redirecting him during the morning, saying Hey (name of R #1), and he would sit back down, he wanted to go and catch the bus. CMA/CNA #1 stated that she remembers that R #1 was being redirected constantly that morning, to sit back down in his wheelchair. K. Record review of the statement written by CMA/CNA dated 07/11/18 revealed the following: On Wednesday, (MONTH) 11, (YEAR), I took over as (name of R #1's) CNA at about 1420 (2:40 pm), I received report that R #1 was in therapy room. I saw R #1 sitting in his wheelchair in front of the nurses station in the commons area at approximately 1500 (3:00 pm), he was facing the TV and seemed content. Around 1520 (3:20 pm), I took R #1's vital signs he was still sitting in the commons area, near the nurses station sitting area. I then continued (taking) vital signs on other guests. About 1535 (3:35 pm), someone from housekeeping was yelling help at the nurses station, I ran up to the nurses station and saw R #1 on the floor with his legs under his wheelchair. There was another CNA there with R #1 and we lifted the wheelchair off of his legs. The RN (Registered Nurse) came to the area about 2 minutes later. L. On 10/05/18 at 10:30 am, during a tour of the facility, with special attention to the commons area by the nurses station where R #1 was watching TV. Special attention was made to the location of the furniture surrounding the TV viewing area, where R #1 had been sitting in his wheelchair. M. Record review of the complaint letter sent to the State dated 07/23/18, revealed the following: .My father's (R #1) injuries included: a large bruise on his forehead and on the bridge of his nose, swelling on the bridge of his nose, bruising on his left chest, bruising and scrapes on his left calf, bruising along his left arm with a large contusion on the top of his left elbow, bruising and cuts on his right arm, a large deep gash on the top of his head that required about 10 stitches and bruising on the left part of his scalp. My father was scared, confused and bleeding profusely. The injuries were sustained in a matter of approximately 15 minutes, when he was unsupervised. N. Record review of the facility's policy titled Falls and Fall Risk Management, last revised on 12/28/16, revealed the following: It is the policy of the center to assess residents for risk of falls, to follow up and evaluate falls of residents in order to assess the resident's condition, to identify the reason for the fall and prepare a Plan of Care to reduce the potential for future falls .Upon admission the nursing staff will complete a fall risk assessment and review the medical record for a history of falls, especially falls in the last 90 days and recurrent or periodic bouts of falling over time. The nursing staff will ask the resident/representative about any history of falls .Staff will attempt to identify any environmental factors that may contribute to falling such as lighting and room layout .If falling recurs despite initial interventions, staff will implement additional or different interventions .

Based on record review and interview, the facility failed to provide a drug regimen that was free from unnecessary medication and duplicate medication for 1 (R #2) of 4 (R #1, 2, 3, and 4) residents reviewed for falls and accidents. This deficient practice likely contributed to R #2 feeling dizzy and having multiple falls. R #2 eventually left the facility earlier than scheduled prolonging his recovery process. The findings are: A. Record review of the incident log sheet indicated that R #2 had 10 falls, dating from 07/18/18 to 07/25/18. R #2 was admitted on [DATE] and discharged on [DATE]. The falls are as follows: 1. On 07/18/18, R #2 had one fall at 15:30 (3:30 pm). 2. On 07/19/18, R #2 had two falls on this day. One at 1:46 am and another at 16:25 (4:25 pm). 3. On 07/20/18, R #2 had two falls one at 1:06 am and another at 22:20 (10:20 pm). 4. On 07/24/18, R #2 had 2 falls one at 4:45 am and another at 4:54 am. 5. On 07/25/18, R #2 had three falls: one at 1:22 am, 3:01 am and another at 4:22 am. B. Record review of R #2's physician's orders [REDACTED]. 1. [MEDICATION NAME] (promoted to help maintain normal sleep patterns) Tablet Give 9 mg (milligrams) by mouth at bedtime for [MEDICAL CONDITION] ordered 07/18/18 and discontinued on 07/19/18. 2. [MEDICATION NAME] Tablet Give 9 mg by mouth as needed for [MEDICAL CONDITION]. Give at HS (at night) as needed ordered 07/19/18 and discontinued on 07/22/18. 3. [MEDICATION NAME] Tablet Give 9 mg by mouth as needed for [MEDICAL CONDITION]. Give in the evening as needed. ordered on [DATE] and was discontinued when R #2 left the faciity on [DATE]. 4.[MEDICATION NAME] HCl (serotonin uptake inhibitor that is used as an anti depressive agent) Tablet 100 MG. Give 1 tablet by mouth at bedtime for depression aeb (as experienced by) inability to fall asleep. ordered on [DATE] and discontinued on 07/18/18. 5. [MEDICATION NAME] HCl Tablet Give 75 mg by mouth at bedtime for [MEDICAL CONDITION]. ordered on [DATE] and discontinued on 07/19/18. 6. [MEDICATION NAME] HCl Tablet Give 75 mg by mouth as needed for [MEDICAL CONDITION] Give at HS as needed. ordered on [DATE] was discontinued on 07/25/18 when R #2 discharged from the facility. 7. [MEDICATION NAME] (also known as [MEDICATION NAME], is a benzodiazepine. It is used to help you to fall asleep and sleep through the night) Capsule 15 MG. Give 1 capsule by mouth for [MEDICAL CONDITION] QHS (every night) as needed. 8. [MEDICATION NAME][MEDICATION NAME] HCl (It is used to treat the symptoms of an allergic reaction. It is also used to treat [MEDICAL CONDITION]. This medicine is also used to prevent and to treat motion sickness and as a nighttime sleep aid) Tablet 25 MG. Give 1 tablet by mouth as needed for [MEDICAL CONDITION] administer 1 tablet, 25 mgs, qhs (every night) prn (as needed) [MEDICAL CONDITION]. ordered on [DATE] was discontinued on 07/25/18 when R #2 discharged from the facility. C. Record review of R #2's (MONTH) (YEAR) Medication Administration Record [REDACTED] 1. On (MONTH) 17th resident received one [MEDICAL CONDITION] medication 2. On (MONTH) 18th resident received 3 [MEDICAL CONDITION] medications. He received [MEDICATION NAME] 9 mg at 19:00 (7:00 pm), Trazedone 75 mg at 19:00 (7:00 pm), and [MEDICATION NAME][MEDICATION NAME] 25 mg at 22:55 (10:55 pm). 3. On (MONTH) 19th resident received 2 [MEDICAL CONDITION] medications. Resident received 15 mg of [MEDICATION NAME] at 2205 (10:05 pm), and received Trazedone 75 mg at 2205 (10:05 pm). 4. On (MONTH) 20th resident did not receive any [MEDICAL CONDITION] medication. 5. On (MONTH) 21st resident received 3 [MEDICAL CONDITION] medications. Resident received [MEDICATION NAME] 9 mg at 02:18 am, [MEDICATION NAME] 15 mg at 02:18 am, and Trazedone 75 mg at 02:18 am. 6. On (MONTH) 22nd resident received 2 [MEDICAL CONDITION] medications. Resident received [MEDICATION NAME] 9 mg at 19:23 (7:23 pm), and [MEDICATION NAME] 15 mg at 19:22 (7:22 pm). 7. On (MONTH) 23rd resident did not receive any [MEDICAL CONDITION] medication. 8. On (MONTH) 24th resident received 4 [MEDICAL CONDITION] medications. Resident received [MEDICATION NAME][MEDICATION NAME] 25 mg at 21:50 (9:50 pm), [MEDICATION NAME] 9 mg at 21:50 (9:50 pm), [MEDICATION NAME] 15 mg at 21:50 (9:50 pm), and Trazedone 75 mg at 21:50 (9:50 pm). 9. On (MONTH) 25th resident received 1 [MEDICAL CONDITION] medication. Resident received [MEDICATION NAME] 15 mg at 00:48 (12:48 am). D. On 10/05/18 at 1:09 pm during an interview with the Assistant Director of Nursing (ADON), he stated that R #2 insisted he wanted to leave. He wanted to toilet himself so they put him on a toileting program. They put his bed even with the height of the wheelchair because they knew he would try to get up and into his wheelchair. He was going to physical therapy where they were working with him on a daily basis. The ADON confirmed the physician orders [REDACTED]. The ADON also stated that he is not a doctor but it does seem like R #2 had a lot of [MEDICAL CONDITION] medications prescribed to him. E. On 10/05/18 at 1:30 pm, during an interview with the Physician Assistant (PA), he stated that when looking at medications and how much or how many different mediations someone is prescribed they will find out what they are using at home. He stated that when he is prescribing medications he likes to try one at a time. If it is not working than he would he would want to know what has been tried and is anything working. He would likely up the dose of a medication before adding another. He always wants to know what a resident is taking when he gets called about prescribing something else. The PA confirmed that all of the [MEDICAL CONDITION] medications that were prescribed to R #2 had side effects of dizziness. F. On 10/05/18 at 2:30 pm, during an interview with the Director of Nursing (DON), she stated that the first things she would look at is did he come in with those orders. Upon record review completed by the DON she stated that R #2 came in with the [MEDICATION NAME] only and it was prescribed not as PRN (as needed) medication. She stated that the (name of the medical team) does not add that stuff (indicating [MEDICAL CONDITION] medications) very often. They usually start with [MEDICATION NAME] first. Upon further chart review the DON confirmed that R #2 was prescribed four different [MEDICAL CONDITION] medications and did receive multiple doses of them. She stated that a typical dose of [MEDICATION NAME] was 3 to 5 mg and that yes, these medications could cause falls, however R #2 was already falling a lot before he came in. G. Record review of R #2's Social Services Note indicated that R #2's wife indicated that R #2 would adjust better in a familiar environment and had set up 24/7 care at home.

This was an Immediate Jeopardy (IJ) cited as a past non-compliance. The Administrator was notified of past non-compliance IJ on 04/30/18 around 3:00 pm. The IJ was identified during a complaint investigation. The facility had self reported the complaint and began to make immediate changes to ensure that this deficient practice did not reoccur. A total of six residents were looked at and the complaint resident was the only resident identified as being harmed by the deficient practice. The complaint resident was not receiving regular PT([MEDICATION NAME] time, a test used to help diagnose bleeding or clotting disorders) /INR(international normalized ratio, evaluates the pathway of coagulation, are used to determine the clotting tendency of blood) lab work causing two hospitalization s. The following are the corrections that the facility began making after 03/17/18. 1. Physician Telephone orders are checked everyday to make sure they are carried out. 2. DON (Director of Nurses) is monitoring everyone on [MEDICATION NAME] (blood thinner). 3. Lab (laboratory) sheets are being completed by the nurse. The orders are then being put into the electronic medical record; progress notes, by the nurse for all INR's The DON is checking to ensure they are being entered into the notes. 4. The provider is called with the results of the PT/INR. When the physician receives the lab results for the PT/INR a new [MEDICATION NAME] order will be put in based off the last results and a new stop date for that order will also be a part of the new [MEDICATION NAME] order. When the medication reaches its stop date a new lab needs to be done before a new order will be made. 5. The [MEDICATION NAME] log book with the results are being tracked by the DON every Monday and Thursday. 6. Part of the in-service for the staff was on the importance of reporting the bruising that was occuring for the resident. The daughter made the DON aware of the extesnive bruising. The nursing staff were re-trained on reporting extensive bruising. 7. In-services were done on the importance of documenting for [MEDICATION NAME] dosing, labs, stop dates for the meidcation, follow up with more lab work and documenting all of that with a progress note. 8. Audits for all residents on [MEDICATION NAME] and and when the last PT/INR was done. If they just arrived that day, it needs to be done that day. If they arrived tot he facility late it needs to be done no later than the following day. This is also being audited byt the DON. 9. Daily line listing for every PT/INR or [MEDICATION NAME] order, and they are cross checked with the physician telephone orders. 10. They now have two different colored baskets: the red basket is for new orders handwritten by the physician or called in by the physician. Once the nurse enters in all of the orders into the electronic medical chart for each resident the orders will go into the black basket. 11. The Administrator is following up behind the DON and doing random audits. The Administrator is making sure that nursing staff are following all new procedures that have been implemented. 13. The DON is now using the [MEDICATION NAME] PT/INR flowsheet's to keep track of all labs and [MEDICATION NAME] doses in one place. 14. All residents on [MEDICATION NAME] are being monitored more formally than before. There are aduits occuring randomely and there is a process in place that if follwed will ensure that no other residents will be at risk. 15. Employees who were responsible for the lack of entering orders correctly and the failure of PT/INR labs being done were disciplined. §483.25 Quality of care F309 Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, including but not limited to the following: Based on record review and interview the facility failed to provide quality care by not transcribing accurate physician orders [REDACTED].#1) of 6 (R #s 1, 2, 3, 4, 5 and 6) residents looked at for quality of care. This deficient practice caused the following: 1. R #1 had a supratherapeutic INR level (has maintained a level of the drug above the therapeutic level), was prescribed vitamin K to reverse the effects of a high INR level. Blood work then showed that R #1 had very low Hemoglobin (HGB) (Hemoglobin in the blood carries oxygen from the respiratory organs) which was 6.5 (Normal range for men, 13.5 to 17.5 grams per deciliter. For women, 12.0 to 15.5 grams per deciliter) and Hematocrit (volume percentage (%) of red blood cells in blood) was 20 % (Normal range is approximately 45% to 52% for men and 37% to 48% for women). Indicating they were both low. Resident #1 was sent out to the hospital for a blood transfusion due to acute [MEDICAL CONDITION] (when the number of healthy red blood cells in your body is too low). 2. R #1 was noted to have extensive bruising on the left side of her body where blood from an internal bleed was occurring. R #1 was taken to the emergency room where during a rectal exam shows Guaiac positive stool (blood in the stool). Copious amounts of blood in the resident's brief. This deficient practice caused physical harm, and two trips to the emergency room . The findings are: A. Record review of R #1's physician orders [REDACTED]. B. Record review of the laboratory results on the following dates: 1. 03/01/18 INR 4.69. Normal range is 2.0 to 3.0. 2. 03/05/18 INR 5.67 Normal range is 2.0 to 3.0. 3. 03/07/18 NOT DONE C. Record review of R #1's physician orders [REDACTED].#1 was started on [MEDICATION NAME] (an antibiotic) 500/125 mg (milligram) every 8 hours for 10 days for pneumonia starting on 03/06/18 to 03/16/18. D. Record review of the laboratory results dated [DATE], indicated R #1 had an INR at 14.68 Normal range is 2.0 to 3.0. E. Record review of the nursing notes dated 03/17/18, indicated family had concerns about weeping/bleeding of shin on left lower extremity (LLE). Skin intact, bruise present, and covers from knee to ankle anteriorly (the front of). Family stated the bruise appeared spontaneously yesterday 03/16/18. Received new STAT order (immediately), CBC (Complete Blood Count lab), and PT/INR. F. Record review of the nursing note dated 03/17/18, received call from lab indicating critical INR of 14.68 (normal is 2.0 to 3.0) called (name of physician) for orders of Vitamin K 5 mg (milligram) po (by mouth) x 1 and to redraw INR on Sun 03/18/18. G. Record review of the nursing note dated 3/17/18, indicated there were concerns of low blood pressure (BP) on 3/16/18 at 1600 (4:00 pm) being 90/45 per the CNA (certified nruing assistant). (Name of resident) was to be completing antibiotics for PNA(pneumonia). At 1800 (6:00 pm) (name of family) notified me that (name of resident) has bruising on her left leg and had found more bruising on her left arm. Nurse (nurse's name) went to assess the bruising and noted extensive purple bruising on left outer leg and calf and (name of resident) knee was noted to be swollen. H. Record review of the nursing note dated 3/17/18, indicated that .she had several bruises on her left lower leg and left arm. Looked at her body and she has bruising throughout her body on the left extremities. No recent falls were reported. CNA reported low BP readings and nausea. Daughter also reported (R #1) she was not feeling well. Last PT/INR was drawn on 3/5/18 and was still on the 3 mg dose of [MEDICATION NAME]. I. Record review of the nursing notes dated 03/17/18, I reviewed meds and noted (name of resident) was getting 3 mg of [MEDICATION NAME]. I reviewed labs and found that the INR had not been checked since 3/5 (2018) with an order to check on 3/7 (2018) and was not able to find that result. (Name of nurse) called the provider and got an order for [REDACTED].discussed possibly getting the provider to start vitamin K and a call was placed to the provider provider gave order to send to the hospital for evaluation. (Name of daughter) was deciding whether or not to have (name of resident) sent to the hospital due to concerns of a long wait in the ER (emergency room ) and (name of resident) tolerating it. Reviewed lab results and INR was 14.68, (normal range is 2.0 to 3.0). Nurse notified provider and gave vitamin K 5 mg with a new order to check the INR on 3/18 (2018). J. Record review of the nursing note dated 3/18/18, indicated the following lab results: 1. Hemoglobin (HGB, is one of the parameters which may tell us that someone has [MEDICAL CONDITION]) was 6.5, 2. white blood count (WBC) 26.4 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter) 3. red blood count (RBC) 2.11 4. Hematocrit (HCT, percentage of red blood cells in the blood) was 20%, 5. red blood cell distribution width (RDW red blood cell distribution width is a measure of the range of variation of red blood cell volume) was 17.2 6. [MEDICATION NAME] time (PT, is a test used to help diagnose bleeding or clotting disorders) was 47.0 7. international normalized ratio (INR, are evaluating the pathway of coagulation and are used to determine the clotting tendency of blood) was 4.04 K. Record review of the Activity Note dated 3/19/18, call from the lab with the following results: Hemocrat (sic)-19, Hemoglobin-6.00, WBC-22.40 (The normal number of WBCs in the blood is 4,500 to 11,000 WBC per microliter). Pt (patient) at hospital at this time for blood transfusion. L. Record review of the nursing note dated 3/19/18, indicated that Certified Nurse Practitioner gave the order for a STAT Blood transfusion for R #1. R #1 will be sent to (name of hospital) ER (emergency room ) the DX (diagnosis) of [MEDICAL CONDITION]. M. Record review of the hospital records dated 03/19/18 indicated the chief complaint was abnormal lab. PT transferred from (Name of Facility), per EMS (emergency medical services) facility reports patient needs a stat blood transfusion. In the History of Present Illness Section it indicated that .Today she presents to the ED (emergency department) with abnormal labs. She is currently staying at (Name of Facility) and her [MEDICATION NAME] administration was not controlled properly. INR was 14 which decreased down to 4 after vitamin K administration 2 days ago. Her INR this am was 1.3(normal was 2.0 to 3.0) but daughter was informed to take pt to the ER (emergency room ) for a blood transfusion due to low H&H (hemoglobin/hematicrit) results. Pt also has bilateral skin tears on both arms and L lower leg discoloration onset 4 days ago. Patient's daughter states that the bruising has been spreading on her arm and leg. She has had some oozing blood out of her skin tears. They did not notice any black stool or blood in her urine. N. Record review of the hospital records dated 03/19/18 indicated the Physical Exam Section [MEDICAL CONDITION]: rectal exam shows Guaiac positive stool (blood in the stool). O. Record review of the hospital records Assessment and Plan Section dated 03/19/18 indicated .low hemoglobin, severe ecchymosis (bruising) of her left arm and leg, and GI (gastrointestional) bleeding. Patient had Guaiac positive brown stool. She was provided with IV (intravenous) vitamin K, FFP (used to treat conditions in which there are low blood clotting factors) and PRBC's (packed red blood cells used to treat conditions such as hemorrhage or symptomatic [MEDICAL CONDITION] that require [MEDICAL CONDITION]). She was admitted for further management. P. Record review of the nursing note dated 3/25/18 (name of provider) indicated the last INR was 1.06 (normal is 2.0 to 3.0) on 3/22/18. Physician gave new order for STAT PT/INR 3/25/18 Q. Record review of the nursing note dated 3/26/18, (name of provider) was called in regard to STAT PT/INR results from 3/25/18. The following orders received: No changes, no new orders, PT/INR within normal range. R. Record review of the laboratory results indicated that on 03/30/18 INR was .98. [MEDICATION NAME] was upped by physician from 1.5 to 2.5 milligram until 04/03/18. S. Record review of the physician order [REDACTED]. T. Record review of the lab results on 04/03/18 INR was 1.03 (normal was 2.0 to 3.0) and on 04/06/18 INR was 1.58. U. Record review of the lab results on 04/09/18 INR was 3.87 (normal was 2.0 to 3.0). V. Record review of the nursing note dated 04/10/18, indicated (name of provider) was given results of INR of 3.87 (normal was 2.0 to 3.0). New orders for [MEDICATION NAME] 2.5 mg daily and repeat PT/INR on 04/13/18. W. Record review of the Skin/Wound Note dated 04/12/18, indicated that R #1 had a left outer calf wound, and open cutaneous (of, relating to, or affecting the skin) hematoma, 1.75cm X 2.5cm X 0.75cm. Type: Unabsorbed open cutaneous hematoma (bruise) from cutaneous bleeding related to anticoagulation sub-therapeutic levels (not at a therapeutic level). Wound appears with defined wound edges, no undermine, serosanguinous (yellowish with small amounts of blood), moderate drainage, without foul odor, wound bed beefy red, and surrounding skin intact discolored. X. Record review of the nursing note dated 04/13/18, indicated (name of provider) changed [MEDICATION NAME] order for INR at 6.22 (normal range 2.0 to 3.0). Order indicated to give [MEDICATION NAME] 1.5 mg on 04/13/18, start 2 mg 04/14/18 and to draw INR on 4/15 to follow up. Y. Record review of the nursing note dated 04/13/18, received call back from (name of provider) regarding previous [MEDICATION NAME] orders. New order to keep [MEDICATION NAME] at 1.5 mg and to discontinue 2 mg as previously given. Z. Record review of the nursing note dated 04/15/18, indicated that CNA reports rectal bleeding from patient this morning with multiple brief changes. This nurse observed large clots soaking through brief, no wounds present. LLE (left lower extremity) wound also bleeding. [MEDICATION NAME] was held last night, with PT/INR to be drawn today. Notified on call provider, (name of provider) who advised to send to ER. AA. Record review of the hospital records indicated that on 04/15/18 indicated that the chief complaint was possible GI bleed. Per EMS staff reports pt has blood in stool at this time. EMS advised pt (patient) resides at the (name of facility). Per EMS, staf (sic) reports dark stool at this time and pt denies pain and N/V (nausea and vomiting). Blood thinners held by facility. PT does take [MEDICATION NAME]. BB. Record review of the hospital records dated 04/15/18 indicated the Physical Exam Section [MEDICAL CONDITION]: rectal exam shows Guaiac positive stool (blood in the stool) grossly positive. [MEDICAL CONDITION] comments: Maroon Blood. Copious amounts of blood (maroon with clots) in diaper. CC. Record review of the hospital records dated 04/15/18, Assessment and Plan Section: Active hospital Diagnosis: [REDACTED].multiple medical problems presented with Hematochezia (the passage of fresh blood through the anus, usually in or with stools). The patient had a supratherapeutic (has maintained a level of the drug above the therapeutic level) INR level and had previous bouts of diverticular (small, bulging pouches that can form in the lining of your digestive system) bleeding . DD. Record review of the policies and procedures for Anticoagulation-Clinical Protocol revised (MONTH) 2012, indicated in the Monitoring and Follow-up Section: 1. The physician will order appropriate lab tests to monitor anticoagulant therapy and potential complications; for example, periodic daily checking Hemoglobin/Hematocrit, platelets, PT/INR, and stool for occult blood. a. The staff should use a [MEDICATION NAME] flow sheet or comparable monitoring tool to follow trends in anticoagulant dosage and response. EE. On 04/27/18 at 3:00 pm, during an interview with the DON, she stated R #1 arrived on [DATE], (YEAR) with a [MEDICAL CONDITION] and was on therapy INR from a [MEDICAL CONDITION] blood clot. The DON stated there were [MEDICATION NAME] medication errors and lab work that was ordered by physician that did not get done. In early (MONTH) (2018) R #1 was sent out to the hospital due to respiratory issues and was diagnosed with [REDACTED]. The DON stated that the antibiotic can make the INR go even higher. On (MONTH) 16th (2018) it was brought to her attention by the daughter that R #1 had some bruising on the left side. She started looking into R #1's medical chart and saw that R #1's [MEDICATION NAME] had not been monitored recently. She called the physician and the physician ordered a STAT PT/INR on the 16th (03/16/18). The result was an INR of 14.76 (normal 2.0 to 3.0). She stated that R #1 was given vitamin K and a new lab was done on 03/17/18 and the INR level was 4.04 (normal 2.0 to 3.0). However, the same lab results indicated that the H & H was 6.5 and 20. Physician ordered it to be checked again 03/19/18 call from the lab with the following results: Hemocrat (sic)-19, Hemoglobin-6.00, WBC-22.40. Pt (patient) at hospital at this time for blood transfusion. The DON also stated when the bruising started to occur on her left side, R #1 was bleeding internally and it was more pronounced on her left side because she laid on that side more frequently. FF. On 04/27/18 at 4: 06 pm, during a follow up interview with the DON, she stated that on 03/18/18 the PT/INR flowsheet was implemented. She did not use them before. GG. On 04/07/18 at 3:05 pm during an interview with the ADON (Assistant Director of Nurses), she stated on 03/22/18, the resident came back to her unit. She was not on [MEDICATION NAME] at that point. She stated that her understanding was R #1 was bleeding because she was lying on her side, that is where the blood was settling. It was no longer circulating through the body and that caused the bruising on her left side.

The facility failed to ensure that residents were free from missed medications, treatment for [REDACTED].#213 who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. After removal R #213's foley catheter (a type of flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) she developed a urinary tract infection, she was also suffering from nausea and vomiting (n/v) and was likely suffering from a UTI, she was prescribed [MEDICATION NAME] (an antibiotic) that she was allergic to and was not given another antibiotic to treat the UTI and she was being transported to the hospital when she told the emergency medical technician (EMT) that she had not had diabetic mediations in six days. When her blood sugar was taken by EMT it was noted that R #213's blood sugar was 338 (Normal fasting range is 72 to 108 mg/dL (milligrams/deciliter)). These deficient practices resulted in an Immediate Jeopardy (IJ) at a Scope and Severity of J being identified on 01/25/18 at 1:17 pm. The Administrator was notified at this time and a Plan of Removal was requested. The facility took corrective action by providing an acceptable Plan of Removal on 01/26/18 at 4:56 pm. The Plan of Removal included the following: Diabetic Management: 1. The facility reviewed all provider orders for any resident receiving Capillary Blood Glucose (CBG) with no diabetic medication orders. Physician notified and facility received clarification orders. 2. The Assistant Director of Nursing (ADON) stated educational in-services on 01/25/18 for the Licensed Nurses on notification to provider for CBGs out of normal range (75-110 ml/dl (milliliters/deciliter), when a resident is not on medications for diabetic management. In-services will be completed on 02/02/18. 3. The ADON was in-serviced on 01/26/18 for reviewing residents with diabetic [DIAGNOSES REDACTED]. The ADON will clarify with the provider the need for additional orders as identified. Discontinuation of medications: [REDACTED] 1. The facility reviewed all antibiotics discontinued for the last seven days for provider orders. 2. The facility reviewed the 24 hour summary for the last seven days of progress notes indicating a potential symptom of a UTI. 3. The facility reviewed lab orders for the last seven days for STAT orders. 4. The ADON initiated educational in-services on 01/25/18 for the Licensed Nurses on writing antibiotic discontinuation orders as they are received from the medical provider. In service will be completed on 02/02/18. 5. The ADON initiated educational in-services on 01/26/18 for the Licensed Nurses regarding signs and symptoms of urinary tract infection that meet the McGeer's (Criteria for Infections in LTC Facilities) definition of infection and documenting those signs and symptoms. In-services complete on 02/02/18. 6. The ADON initiated educational in-services on 01/26/18 for the Licensed Nurses ordering STAT (instantly/immediately) labs. In service completed 02/02/18. 7. The ADON audited on 01/25/18 all medications against the resident allergy listing and notified the provider regarding the medication allergy. Medication allergies [REDACTED].> 1. The facility reviewed medication allergies [REDACTED]. 2. The ADON audited on 01/25/18 all medications against the resident allergy listing and notified the provider regarding the medication allergy. 3. The ADON initiated educational in-services to the Licensed Nurses on 01/26/18 regarding verification of allergies [REDACTED]. STAT Labs: 1. The facility reviewed lab orders for the last seven days for STAT lab orders. 2. The ADON initiated educational in-services on 01/26/18 for the Licensed Nurses regarding ordering of STAT labs and provider notification of lab results. Based on the Plan of Removal, the IJ was lifted on 01/26/18 at 4:56 pm. This resulted in the scope and severity being reduced from level J to level G. Based on record review and interview, the facility failed to provide quality care to 4 (R #s 15, 102, 212 and 213) of 4 (R #s 15, 102, 212 and 213) residents reviewed for neglect by: 1. not ensuring that residents (#212 & #213) received diabetic medication or diabetic monitoring when blood sugar levels were either too high or too low. 2. administering an antibiotic medication to treat a UTI that the resident (#213) was allergic to. 3. failing to treat the UTI after the discontinuation of the antibiotic ([MEDICATION NAME]) that R #213 was allergic to and the Urinalysis and Culture and Sensitivity labs were found to be abnormal. 4. failing to inform a physician when a resident (#102) experienced bleeding during a bowel movement. 5. failing to identify a resident's (#15) broken leg in a timely manner These deficient practices caused a hospitalization for five days for R #213, a broken leg that went unidentified for 8 days for R #15 and had the potential to result in continued bleeding without physician intervention for R #102 and a blood sugar level of 30 (Normal fasting range is 72 to 108 mg/dL) for R #212. The findings are: Resident #213 A. On 01/24/18 at 8:22 am, during an interview with a family member of R #213, she stated that the previous acute care rehabilitation facility that her mother was at, sent over medication orders to this facility for her mother. The medication orders included insulin (regulates the amount of glucose in the blood) for her mother's diabetes. She stated that her mother was supposed to be getting insulin while at this facility but was not. She was also aware that her mother's blood sugars were high and when she would ask for diabetic medication she would not get any. She also stated that after six days her mother went out to the hospital for [MEDICAL CONDITION] (high blood sugar level), a severe UTI (Urinary Tract Infection), and a [MEDICAL CONDITION] Blood Clot ([MEDICAL CONDITION] is a condition that occurs when a blood clot forms in a vein located deep inside your body). She stated that the facility was aware of the high blood sugar levels because her mother would ask about the insulin every time they checked her blood sugars, but they never did anything about it. She also stated that she had a conversation with the previous DON (Director of Nursing) and the previous DON told her that she was not sure why she never got the insulin. She also stated that she did not think that her mother ever got treatment for [REDACTED]. B. On 01/24/18 at 9:00 am, during an interview with Unit Manager #1, he stated that R #213 does ring a bell to him. He stated that looking at her medication orders he is only seeing an order to check CBGs three times per day. He does not see an order for [REDACTED].#1 also stated that he would have notified the physician about CBGs that were consistently in the high blood sugar range. C. On 01/24/18 at 9:12 am, during an interview with LPN #1, she stated that R #213 was receiving CBGs with meals only. She stated that she typically will see this if a resident was on a diabetes medication like Juneva or [MEDICATION NAME] but R #213 was not getting any medication for her diabetes. She stated that if she were to see high blood sugars that are uncontrolled she would notify the physician and suggest a sliding scale or something, especially if they don't come in with medication. LPN #1 also stated that R #213 did not have a diabetic diet so she was not being treated through diet either. D. On 01/24/18 at 10:36 am, during an interview with the physician #1, he stated the following: 1. People can control their diabetes without medication. He stated that R #213 did not come from the acute care facility receiving any diabetes medication. The physician stated that he saw R #213 the first couple of times and then other physician's saw her after that. 2. He stated that her Hemoglobin A1C (measures average blood glucose over the past two to three months) was at 11 (%) (Type 2 diabetes is diagnosed when the A1C is over 6.5 percent) which means she is definitely diabetic. 3. There were five other people that saw her after him and nothing was prescribed for her diabetes and there is no documentation in the progress notes. 4. He also confirmed that if a resident was controlling their diabetes through food and diet you would expect to see them on something more than just a no salt added diet. 5. He indicated not being aware of R #213 diabetes and/or some diabetics don't need medication to be treated. 6. He saw her for a UTI and prescribed [MEDICATION NAME] (an antibiotic used to treat urinary tract infections) and [MEDICATION NAME] for the urgency and pain during urination. He did not know why someone made the decision to stop the antibiotic and he does not see a stop or discontinue order for this medication. Upon looking further at her chart he stated that In his opinion she should of gone on something. 7. He was unaware that R #213 had an allergy to [MEDICATION NAME]. The physician confirmed that he did not see an order for [REDACTED]. 8. He also stated that communication at this facility was a problem and that he depends on staff to notify him when there are issues or problems. E. On 01/25/18 at 10:38 am, during an interview with Administrator, she stated that she would need to look into the issue with the diabetes medication and the medication prescribed that R #213 was allergic to. At 11:05 am the Administrator was unable to answer questions related to the medications due to not being a medical professional. F. On 01/25/18 at 1:07 pm. during an interview with R #213, she stated that while she was at the acute rehabilitation facility she was being treated for [REDACTED]. She knows for a fact that orders were sent over when she was transferring from that facility to the one she went to on 11/01/17. She stated that while she was at the facility she did ask nurses what they were going to do about her high blood sugars. She stated that they never did anything. She stated that one time one of the nurses told her that she wasn't concerned about her diabetes. She stated that they would just leave her lying in bed and no one would come and get her up. When they brought food in they would leave it on the table and not bring it over to her. She stated that when they would come in to check her CBG levels she would always ask what they were going to do about the high reading. Three or four times per day she would ask. She stated that she is currently on diabetic medication. When asked about her allergy to [MEDICATION NAME], R #213 stated that she had become very nauseated and started vomiting and did not want to take it again. R #213 stated that she was not told that her UTI was being treated with medication and she was not told that she was given [MEDICATION NAME]. She stated that she asked about getting something for the UTI and that staff would tell her there were no physician's order to treat it. R #213 stated that by the time she got to the hospital on [DATE] she had a [MEDICAL CONDITIONS] blood clot in her leg, a UTI and her blood sugar was around 348 (Normal fasting range is 72 to 108 mg/dL). She stated that she was in the hospital for 5 days and when she was released she decided to go to a different nursing facility. G. On 01/25/18 at 9:11 am, during an interview with the previous DON, she stated that there were no diabetes medications ordered. She stated that she remembers talking (no date given)with R #213, Physician #1, and R #213's daughter about the diabetes medication. Physician #1 stated that he would order the diabetes medication after he looked at her chart again. She stated that she was not aware that the medications were never ordered until R #213 went to the hospital and the daughter came in to speak with her and was very upset. H. On 01/25/18 at 3:13 pm, during an interview with Physician #2, he stated that R #213 having a UTI likely compounded the problem with the high blood sugars. A UTI would likely make the blood sugars go even higher. I. Record review of a complaint submitted on 01/09/18 to the Licensing Authority, indicated that R #213 was transported by (Emergency Medical Technicians) to the hospital on [DATE]. The complainant indicated that R #213 stated that her nurses and doctors did not believe she had diabetes, and were not administering her diabetic medications. She also stated that she had not received her medication in 6 days. The complainant's ambulance was called to the facility in response to a fever and nausea/vomiting. The nurse stated she (R #213) was most likely suffering from a UTI. The resident's skin was noticeably hot and dry, an indication of [MEDICAL CONDITION]. Her blood glucose level registered at 338 (Normal fasting range is 72 to 108 mg/dL). J. Record review of the admission orders [REDACTED] 1. Cervical Disc Disorder at C4-C5 level with [DIAGNOSES REDACTED] (disease of the spinal cord) 2. Postprocedural States (Factors influencing health status ) 3. Type 2 Diabetes Mellitus with Diabetic [MEDICAL CONDITION] (a type of nerve damage) 4. Other Disorders of Peripheral Nervous System 5. Major [MEDICAL CONDITION], Recurrent, Mild 6. Elevated Blood-Pressure Reading, without [DIAGNOSES REDACTED].> 7. Other lack of Coordination 8. Muscle Weakness (Generalized) 9. Unsteadiness on Feet 10. Gastro-[MEDICAL CONDITION] Reflux Disease (a muscle at the end of your esophagus does not close properly) with Esophagitis [MEDICAL CONDITION] (inflammation of the esophagus/an abnormally high concentration of fats or lipids in the blood), Unspecified K. Record review of the entry 5 day MDS (Minimum Data Set) dated [DATE]th, 2017, indicated that resident had a [DIAGNOSES REDACTED]. L. Record review of the physicians orders dated 11/07/17 on the medication administration note that a CBG (Capillary Blood Glucose) AC (before meals) only for DM was ordered. M. Record review of the November 2017 MAR (Medication Administration Record) indicated that R #213 had her CBGs checked before meals starting on the evening of 11/01/17. CBGs were as follows: (Normal fasting range is 72 to 108 mg/dL) 1. 11/01/17- 254 2. 11/02/17- 206, 170 and 317 3. 11/03/17- 260, 132 and 260 4. 11/04/17- 277, 344 and 298 5. 11/05/17- 185, 283 and 154 6. 11/06/17- 311 and 258 N. Record review of the discharge MEDICATION ORDERS FOR [REDACTED]. That list consisted of several medications ([MEDICATION NAME] (fast acting insulin), [MEDICATION NAME]) to include: an Accucheck (device to check blood sugar) before meals and at bedtime. The following is the sliding scale protocol: < (less than) 60 follow Hypoglycemic (is a condition characterized by an abnormally low level of blood sugar) protocol and call MD (Medical Doctor) 60-150 0 units 151-200 2 units 201-250 4 units 251-300 6 units 301-350 8 units 351-400 10 units > (greater than) 400 call MD. O. Record review of the discharge medication orders from the previous acute care facility indicated that R #213 had an allergy to: [MEDICAL CONDITION] Vaccine, [MEDICATION NAME], and [MEDICATION NAME]. P. Record review of the Admission Record dated 11/01/17 indicated that R #213 had the following allergies [REDACTED]. Q. Record review of the MAR indicated [REDACTED]. R. Record review of all of the Nursing Progress notes and the History and Physical Physician Notes in the medical chart (dates 11/01/17 to 11/06/17), indicated that there was not a discontinue order from the physician in the medical chart for the [MEDICATION NAME]. There was no note from the physician or nursing staff that R #213 did not have a UTI and no longer needs to be treated with the [MEDICATION NAME] medication, and there was no new order put in by the physician for a new antibiotic. S. Record review of an email provided by the Administrator on 01/26/18 of a physician giving orders to the facility nurse about R #213. The email indicated that R #213 was placed on [MEDICATION NAME], vomiting for greater than twelve hours without relief of Zoran (for the treatment of [REDACTED]. [MEDICATION NAME] (treats nausea and vomiting) 25 mg rectal now and every 8 hours pro, discontinue in three days. Obtain UA (urninalysis), Culture and Sensitivity, BMP (basic metabolic panel), CBC (complete blood count) with Dif (differential) (measures the levels of red blood cells, white blood cells, platelet levels, hemoglobin and hematocrit. Many times it is ordered as a screening test as an [MEDICAL CONDITION] check or detection of infections). Aware UA may now have false results based on abc (sic) and pygidium (sic) use. Offered emergency room services, declined at present. T. Record review of lab work completed on 11/05/17 indicated that R #213 had a glucose level of 342 (Normal fasting range is 72 to 108 mg/dL). R #213 also had false/abnormal readings on the UA due to the dye and cloudy appearance of the urine. The lab results also indicated that there were several bacteria present in the urine. U. Record review of the nursing notes dated 11/06/17, indicated that R #213 had c/o (complaints) of N/V (nausea and vomiting), UTI s/s (signs and symptoms), abnormal lab results and not receiving DM meds (medications). Called on call provider who reviewed chart and ordered that guest be sent nonemergently to hospital for further evaluation. V. Record review of an Addendum to the H & P (history & physical) dated 11/11/17, indicated that R #213 was taken to emergency roiagnom on [DATE] for N&V, UTI sx (symptoms) and not being on DM meds. W. Record review of the hospital admission record dated 11/06/17, indicated on the Assessment and Plan: 1. IV (intravenous) NS (normal saline) 1 liter bolus (a single dose of a drug or other medicinal preparation given all at once) 2. IV [MEDICATION NAME] (antibiotic used to treat certain kinds of bacterial infections) 1 gm 3. Regular Insulin 7 units SC (subcutaneous) 4. Complicated UTI, DM uncontrolled [MEDICAL CONDITION] (is the medical term for a high blood sugar level), [MEDICAL CONDITION] left lower extremity. X. Record review of the Nutritional Assessment completed on 11/03/17 indicated that a therapeutic diet of NAS (no added salt) reg (regular) texture was ordered. Y. Record review of the physician's orders indicated that a NAS (No Added Salt) diet, Regular texture, thin consistency due to, Elevated blood-pressure reading, without [DIAGNOSES REDACTED]. Resident #212 Z. Record review of the complainant's statement attached to complaint sent to the Licensing Authority stated, I got there to the (nursing home) around 7:30 - 8:30 p.m. when (R #212) was laying there asleep and notice he didn't eat his dinner. I woke him up and asked him if he ate, he said no so I was concern; while I was there from 7:30 p.m.-2:00 a.m. no one came in to check on him. I become even more concern press the button for assistant and no one never came in until I pressed several more times before someone came around 3:30 a.m. I asked them when they last check his blood sugar, the nurse on call said they normally don't check his blood sugar. i stated, that he did not eat his dinner, and that he has been sleeping. At that time, the nurse checked his B/S (blood sugar) and it was 30 (Normal fasting range is 72 to 108 mg/dL), she rush to get him something to drink she brought back a can of Gatorade, it was her because the kitchen was lock and there was nothing to give him. At this time, she had given him a shot to get his blood sugar up, she check a few minutes later and his blood sugar did not go up; she gave him another shot; check again, it had gone up to 31; so she gave him another shot - when I ask her, where is the doctor, and if she called the doctor. I was very annoyed with her as she became upset with me and started snapping at me, she stated that she called the doctor and the doctor told her to call the EMT (Emergency Medical Transport) and take to hospital. It seem like forever, before, she called the EMT and when they arrived they took his blood sugar and it was now that 37-40; (R #212) was not take to the hospital but continued his stay at the (nursing home). AA. Record review of a nurse's note dated 06/01/17 stated, The patient's daughter requested to have the patient's blood sugar check at 04:30 (am). The note indicated the result of the first CBG (capillary blood glucose) completed at 4:35 am was 31 (Normal fasting range is 72 to 108 mg/dL), and the first dose of [MEDICATION NAME] (medicine is used as an emergency treatment for [REDACTED]. The note indicated the result of the second CBG (no time noted) was 34 and the second dose of [MEDICATION NAME] was administered at 5:12 am. The note indicated the result of the third CBG completed at 5:17 am was 39 and the third dose of [MEDICATION NAME] was administered at 5:19 am. The note stated the nurse monitored the resident every 15 minutes, offering juice, yogurt and soda but resident's blood sugar would not rise within normal limit. The note also states that both the on-call provider and the Director of Nursing were both notified. It stated they agreed to send the resident to the hospital however the resident refused. It also stated that even after education was provided to the resident as to the serious consequences to include possible death, the resident still refused. BB. Record review of R #212's face sheet revealed he was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. CC. Record review of R #212's physician orders regarding CBG checks revealed the following: 1. Order dated 05/29/17 stated Dc (discontinue) CBG's (pt not on Tx (treatment) for diabetes.) 2. Order dated 06/08/17 stated CBG check one time a day related to diabetes mellitus due to underlying condition with unspecified complications. This order was discontinued on 06/15/17. 3. Order dated 06/15/17 stated CBG check as needed related to diabetes mellitus due to underlying condition with unspecified complications. DD. Record review of R #212's CBG readings from his admission 05/27/17 until being initially discontinued on 05/29/17 revealed the following: 1. On 05/27/17 at 8:55 am his CBG reading was 76 mg/dl. 2. On 05/27/17 at 11:59 am his CBG reading was 88 mg/dl. 3. On 05/27/17 at 5:46 pm his CBG reading was 114 mg/dl. 4. On 05/28/17 at 8:02 am his CBG reading was 58 mg/dl. 5. On 05/28/17 at 12:20 pm his CBG reading was 109 mg/dl. 6. On 05/28/17 at 7:19 pm his CBG reading was 108 mg/dl. 7. On 05/29/17 at 7:21 am his CBG reading was 86 mg/dl. 8. On 05/29/17 at 11:13 am his CBG reading was 104 mg/dl. (Normal fasting range is 72 to 108 mg/dL) EE. On 01/25/18 at 9:35 am, during an interview with the former Director of Nursing, she stated that she could not explain why a physician discontinued R #212's daily CBG checks on 05/29/17 especially since he had some low readings of 76 on 05/27/17 and 58 on 05/28/17. She also stated that she could not explain why a physician discontinued R #212's daily CBG checks and changed them to as needed CBG checks on 06/15/17 after he recently had readings in the low 30's and needed to be hospitalized . FF. Record review of R #212's History and Physical completed by a physician dated 06/15/17 stated under the Plan section DM (Diabetes Mellitus): not on meds, no recurrent [DIAGNOSES REDACTED] (low blood sugar) since eating better change monitoring to prn (as needed) GG. Record review of R #212's meal intake record dated May 2017 and June 2017 revealed the following: 1. On 05/31/17, (the day prior to R #212's CBG readings in the low 30s) the record indicates he ate between 26-50% of his breakfast and 51-75% of his lunch. The dinner entry was left blank. 2. On 06/17/17, R #212 ate between 26-50% of his meal for both breakfast and dinner. The lunch entry was left blank. 3. On 06/23/17, R #212 ate between 26-50% of his breakfast and 51-75% of his dinner. The lunch entry was left blank. 4. On 06/24/17, R #212 R ate between 26-50% of his meal for both breakfast and lunch. HH. Record review of R #212's hospital records obtained via the facility's medical record revealed a history and physical completed by a physician dated 05/16/17 and it stated under the Impression/Assessment/Plan section: DM2 (Diabetes Mellitus 2): accu-check (device to check blood sugar) q (every) ac (before meals) & hs (at bedtime), sliding scale insulin. Record review of the hospital records under the medication section stated, Insulin [MEDICATION NAME] (rapid-acting human insulin analog used to lower blood glucose) Low dose Correctional - [MEDICATION NAME] Insulin BG Last administered on 5/21/17 at 8:30 (am). II. On 01/25/18 at 1:38 pm, during an interview with the interim DON, she stated that even for resident's who have well controlled blood sugars they should have their CBG checked at least daily however the physician has the final say in the matter. The DON stated she is not sure if the physician knew that R #212 received low dose insulin at the hospital prior to admission. The DON also stated she is not sure if the physician knew about R #212's decreased meal intake on some days after the routine CBG's were discontinued on 06/15/17. Resident #15 JJ. Record review of R #15's Admission Record, revealed R #15 is [AGE] years old and she was admitted to the facility on [DATE] for surgical aftercare for a fracture to her femur (thighbone). R #15 was discharged to the hospital on [DATE]. KK. Record review of Physician Orders dated 12/26/17, revealed R #15 was NWB LLE (non weight bearing to left lower extremity) and Weight bearing status: knee immobilizer to be worn at all times related to surgical aftercare and closed fracture. LL. Record review of the Admission Minimum Data Set (MDS) assessment dated [DATE], indicated R #15 had a Brief Interview for Mental Status (BIMS) score of 15, indicating she is cognitively intact. She requires extensive assistance with the physical help of two people for bed mobility, transfers, personal hygiene, and she was total dependent for bathing. MM. On 01/22/18 at 9:34 am, during an interview with R #15 and her daughter, R #15 stated that last Monday (01/15/18) while staff were transferring her from the commode to the shower chair in the bathroom, staff bent her left leg. R #15 stated that she is not supposed to bend her leg, but during the transfer her leg got caught under the chair and it bent and staff had to pull it out from underneath the chair. R #15 stated that since the incident, she has had more pain in her leg and is requesting more Tylenol for the pain. During the interview, R #15's daughter stated that her mother is in the facility due to her broken femur and that they asked the facility to do an x-ray on her leg before she discharges the next day. NN. Record review of R #15's Nursing Progress notes revealed, a late entry note created on 01/25/18, stating 01/17/18, Note text: r/t (related to) LLE increased pain. MD (Medical Director) advised that X-ray was not clinically indicated at this time. Ordered venous doppler (an ultrasound provides pictures of the veins throughout the body) to r/o (rule out) [MEDICAL CONDITION] at this time. Also, on 01/22/18, states Due to continued c/o (complaint of) LLE pain family requesting X-ray. X-ray performed showed fracture. (Physician #1) notified. Orders received to send to ER (emergency room ) for evaluation and treatment. There is no documentation in the progress notes indicating an incident occurred while transferring R #15 on 01/05/18 or documentation that the Physician was notified. OO. Record review of Physician #1's Progress Notes revealed the following: 1. On 01/17/18, Patient (R #15) complaining of left knee/thigh pain, pressure. Patient today has been complaining of worsening left knee/thigh pains, some swelling and feels like there is a lot of pressure. Patient having trouble putting any weight on her left leg due to the pain. 2. On 01/18/18, states Follow up on patient's left leg pain, and venous doppler results. Patient had been complaining of left leg pains, that are getting worse, and unable to bear weight along her leg. Patient tries not to move because of her pains. That are sharp, and pressure like pains. Patient had some leg swelling and pains yesterday, and a stat (immediately) doppler study was order (sic), showing no evidence of a blood clot/[MEDICAL CONDITION]. Patient today states that she feels a little better to about the same as yesterday. Physician #1 increased pain medications, but did not order an X-ray. 3. On 01/22/18, According to Nurse, and patient's caretaker, (R #15) had pivoted and twisted her leg while getting up to go to the bathroom on Monday, and patient felt increased pain and discomfort along her left leg. Today, patient has continued pains along her left leg after pivoting, to get up to go to the bathroom [ROOM NUMBER] January. Patient has not been able to put any weight on the leg, and there was initially concern for blood clot in her leg, which was ruled out. Patient was shortly placed on low dose baby aspirin once I saw patient and was evaluating her leg early last week. Patient's pain has been mild to moderate, and mostly described as a pressure. Stat X-ray 2 view of the L (left) femur (thighbone) and tib (tibia) fib (fibula) (tibia is one of two bones in the lower leg, the other being the fibula, and is a component of the knee and ankle joints) show complex distal comminuted fracture (a break or splinter of the bone into more than two fragments) that is displaced, with disruption of the plate and screws that she had placed previously. PP. Record review of Physician's Telephone Orders dated 01/22/18, revealed Portable x-ray L leg pain femur/tib fib. The order was placed 8 days after the incident with R #15's transfer. QQ. Record review of R #15's Hospital Emergency Department notes dated 01/22/18, indicated Patient presents with broken left femur. Arrives from (nursing home) with daughters via EMS (emergency medical services) with reported new left distal (situated away from the center of the body or from the point of attachment) femur fracture .Daughters says she twisted in shower Jan (January) 15 when splint was off and has had increased pain since .doppler [DATE] was negative for [MEDICAL CONDITION], but portable x-rays this morning showed displaced hardware. Current episode started 5 to 7 days ago the pain is associated with injury. The pain is present in left thigh, pain is moderate. The symptoms are aggravated by movement .family at bedside was informed about surgery in the next day or so. RR. On 01/27/18 at 10:28 am, during an interview with R #15's Family Member she stated, that she was at the facility at the time of the incident, (TRUNCATED)

Based on record review, observation and interview, the facility failed to provide the necessary care to effectively manage pain for 5 (R #s 38, 44, 101, 102 and 209) of 10 (R #s 7, 15, 38, 44, 101, 102, 105, 204, 209 and 249) residents reviewed for pain. This deficient practice resulted in 1. R #44 experiencing prolonged periods of pain without sufficient relief, lack of sleep and limited day-to-day activities. 2. R #209 going without pain medication due to an error that a nurse had made by crushing all of her evening medications instead of giving them whole and not offering replacements. 3. R #101 and #102 reporting significant pain resulting from delays in the provision of ordered medications. 4. R #38 family member reporting prolonged ineffective pain relief for R #38, despite her frequent requests for more effective pain management. If residents are not getting their pain medications as ordered it could cause the resident to not reach their highest level of physical, mental and psychosocial wellbeing. The findings are: Findings for R #44: A. On 01/22/18 at 9:32 am, during an interview with R #44, she stated that she had a problem with not getting enough pain medications. She stated that she needs her pain medication every 4 hours but that some nurses do not do that. She stated some nurses do not give me pain medication until my pain level is at a 8 or 9 out of 10 but by that point it is too late. B. On 01/24/18 at 3:27 pm, during an interview with R #44's daughter and representative (Family Member #1), she stated that her mother has had severe lower back pain due to spinal bifida (type of birth defect where the bones of the spine don't form properly) and she has been taking 30 mg (milligrams) of [MEDICATION NAME] ([MEDICATION NAME]) (a narcotic used to treat moderate to severe pain) every day for the past 7 years. She stated that her mother was admitted on a Friday (01/05/18) and the on-call physician wrote her a prescription for [MEDICATION NAME] (a narcotic used to treat moderate to severe pain). When Physician #1 showed up on Monday (01/08/18) he discontinued the [MEDICATION NAME] without talking with R #44 or notifying me. She stated she found out of the discontinued medication by coincidence the same day and confronted Physician #1 about it. The physician refused to order any narcotics and did not give an explanation as to why he was doing it. Family Member (FM) #1 stated she was really concerned about R #44's pain as well as possible withdrawal symptoms. She stated the physician only prescribed Tylenol and [MEDICATION NAME] (a medication used to control partial [MEDICAL CONDITION] in adults with [MEDICAL CONDITION]. It is also used to treat certain types of nerve pain) which was not effective in managing R #44's pain. FM #1 stated that the nurses at the facility were in agreement with her that R #44 needed stronger pain medications to manage her pain however Physician #1 refused to prescribe narcotics. FM #1 stated she had to speak to Physician #1's boss to finally get a prescription for [MEDICATION NAME]. FM #1 stated that during the week that R #44 only had Tylenol and [MEDICATION NAME] (01/08/18 to 01/14/18) she could not concentrate on what she liked to do which included crossword puzzles and looking through catalogs. She also stated that R #44 would refuse to do certain exercises during physical therapy/occupational therapy because of the pain in her back. FM #1 stated she also had trouble sleeping and could not reposition herself using the trapeze bar above her bed. FM #1 stated that 2 days after being prescribed the [MEDICATION NAME] (01/16/18) she slept through the night, resumed her day-to-day activities with ease and participated in all therapy exercises. C. Record review of LPN (Licensed Practical Nurse) # 1's nurse's note dated 01/06/18 stated Guest (R #44) was in severe #10 (10 out of 10) back pain throughout this shift, guest stated that she has been on [MEDICATION NAME] 10 mg for years and requested that I call her daughter immediately because [MEDICATION NAME] was not on her med list. The guests daughter was very upset and I informed her that I would contact the on-call immediately. Spoke with (Name of Assistant Director of Nursing) who stated that the guest's discharge orders from the hospital included [MEDICATION NAME] 5 mg tabs and that he would add it to the med (medication) list. I then contacted (Name of on-call physician) on call for Physician #1, (he) wrote new orders for [MEDICATION NAME] 5 mg tabs, 1 tab po (by mouth) q4h (every 4 hours) prn (as needed) for pain (01/14/18). Guest's daughter stated that she would come in today to request her mother's original order be placed onto her med list, the order that the guest has been on for 7+ years. D. Record review of Daily Skilled Nursing Note dated 01/09/18 stated Guest is alert and oriented. She is able to make needs known. Her and her daughter remain very upset that (Name of Physician #1) will not order her narcotics . E. Record review of R #44's physician orders [REDACTED]. 1. an order for [REDACTED]. 2. an order for [REDACTED]. 3. an order for [REDACTED]. 4. an order for [REDACTED]. 5. an order for [REDACTED]. 6. an order for [REDACTED]. F. Record review of R #44's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. G. Record review of LPN #1's nurse's note dated 01/12/18 revealed resident was administered Tylenol Tablet 325 MG. The note also stated PRN Administration was: Ineffective. Follow-up Pain Scale was: 7. H. Record review of LPN #1's nurse's note dated 01/14/18 revealed resident was administered Tylenol Tablet 325 MG. The note also stated PRN Administration was: Ineffective. Follow-up Pain Scale was: 5. I. On 01/24/18 at 2:39 pm, during an interview LPN #1, she stated that there are many residents who don't have effective pain management since Physician #1 refuses to prescribe narcotics and puts everyone on Tylenol or [MEDICATION NAME]. She stated that Physician #1 discontinues narcotics for admitting residents before they have been admitted and before he has laid eyes on them. LPN #1 states she has reported his behavior to the State Licensing Authority. LPN #1 stated that other nurses were also frustrated including the former Director of Nursing so they scheduled a nurses meeting where Physician #1 was supposed to explain his philosophy on pain management however Physician #1 never showed up to the meeting. LPN #1 stated that she marked Ineffective for R #44's Tylenol administration because the resident was still in pain and she reported it to the Physician and the Administrator. LPN #1 stated that that Administrator supports Physician #1's pain management philosophy to prescribe as little narcotics as possible. She stated that some nurses are scared to mark ineffective out of fear they might get in trouble with management. J. On 01/25/18 at 9:18 am, during an interview with the former Director of Nursing (DON), she stated was the Director of Nursing from May 2017 until mid-January 2018. She verified that many nurses became frustrated about not being able to administer narcotics to residents in pain. She also verified that Physician #1 did not attend the scheduled nurses meeting to discuss pain management. The former DON stated that she had several meetings with the Administrator, Physician #1 and Physician #2 (Physician #2 is a senior physician of the practice that Physician #1 is a part of) to discuss Physician #1's philosophy on pain management. The former DON stated that no change came as result of these meetings. She stated when she failed to see any change, that was the turning point for her to resign as it was a completely different approach than what she was used to. The former DON verified that Physician #1 sometimes discontinued pain medications before the resident had been admitted and before he had visited with the resident. The former DON verified that Family Member #1 was very upset after she found out Physician #1 had discontinued R #44's [MEDICATION NAME]. She stated she spoke to Physician #1 about getting R #44 narcotics but Physician #1 declined to prescribe any. She also stated that she had heard several complaints about Physician #1 being disrespectful to residents/family member. She stated she remembers a particular resident who had a pelvic fracture but does not recall her name. She stated that for this particular resident, Physician #1 told her family member that she was addicted to narcotics and they needed to be discontinued. K. On 01/25/18 at 10:40 am, during an interview with the Administrator, she verified that she does agree with Physician #1's philosophy on pain management and that she has seen a decrease in complaints of pain. She stated that the physician should have a conversation with the resident/family before making changes to their medications but that the physician has the final say in the matter. The Administrator verified that she has received many complaints about Physician #1 being rude to residents/family and stated that he needs to improve his bedside manner. L. On 01/24/18 at 11:35 am, during an interview with Physician #1, he stated that he did discontinue R #44's [MEDICATION NAME] as he was worried it would decrease her respiration rate too much since she recently had pneumonia (an infection that inflames the air sacs in one or both lungs) which also affected her lung function. He also stated that most residents have their pain more effectively managed without narcotics. He stated that [MEDICATION NAME] makes the user more susceptible to pain over time. He stated that if residents have pain that is not effectively managed he expects the nurses to notify him. Physician #1 verified that has he sometimes discontinues residents' pain medications prior to their admission to the facility. M. On 01/25/18 at 3:13 pm, during an interview with Physician #2, he stated he is not Physician #1's boss but is a senior member of the physician group that they both work for. He stated he has had 3 meetings with Physician #1 regarding his philosophy on pain management. Physician #2 stated that as a physician he cannot tell other physicians how to practice medication. He stated that regarding pain management, Physician #1 has his medical literature that he refers to and we have ours. Physician #2 stated that Physician #1 is leaving the group because of this disagreement they have. Physician #2 also stated that he has counseled Physician #1 on not discontinuing medications prior to meeting and reviewing the resident in person. Findings for Resident #209 N. On 01/21/18 at 12:51 pm, during an interview with R #209, she stated that at 6:00 pm she started requesting pain medication. She stated that she did not get the pain medication until 8:00 pm. She stated that later that same night a nurse came into her room and told her that it is for him to decide whether she was in pain and whether or not she would get any pain medication. Which she felt was inappropriate. She stated that last night an agency nurse was taking care of her. At 10:00 pm that night she started asking for pain medication. At 12:00 am the nurse showed up with crushed medications. She stated that she doesn't take her medication crushed up and she is aware that some of the medication are not supposed to be cut up or crushed because it may make the medication less effective or may release the medication too fast causing other issues. So she refused to take the medication. She knew that some of her pain medications were part of the medications that were crushed up and it scared her to take them because she was not sure if she would get too much of the medication. She stated that the agency nurse did not offer her to replace the crushed medications with whole pills. So she went without her pain medication. O. On 01/23/18 at 12:55 pm, during an interview with Medication Technician (Med Tech) #1, she stated that she does hear a lot of complaints from R #209 about pain. She does take her pain medication regularly and she will ask for the PRN pain medications. She has heard complaints from R #209 about the evening shift not bringing medications on time. P. On 01/27/18 at 7:43 am, during an interview with LPN #2, she stated that R #209 complains of pain all the time. She is aware of when her pain medications are due and she will always start asking for them. She is also aware of when her PRN (as needed) pain medications are due and she will typically ask for those too. LPN #2 stated that R #209 can tell you she is in pain but she has also seen her groaning and breathing really deep, indicating to her that she may be in pain. LPN #2 also stated that she doesn't question whether residents are in that much pain or not because that is not her place. She stated that if they say they are in pain than she will get something for them. She also stated that she had heard about the incident with a nurse telling her that he would say whether or not she (R #209) was in pain this past weekend. She stated that R #209 was upset about it and although she does not know that this actually happened because she was not present, she could see a nurse saying something like that. LPN #2 also stated that last weekend she was aware of an agency nurse working and the agency nurse told her when she came to work that morning that she had accidentally crushed R #209's medications and R #209 refused to take them because of this. LPN #2 also stated that there have been a lot of issues with pain medications recently. She is aware of pain medications being discontinued before a resident is even admitted to the facility. There have also been occasions when a resident may be two days post operation and their pain medications would be discontinued, or a resident might choose to discharge against medical advice (AMA) due to not getting their pain managed. Q. On 01/27/18 at 9:32 am, during an interview with Unit Manager #1, he stated that he had not heard anything about crushed medications and R #209 not taking her medications because of this. He indicated that if the medications were not to be crushed and the nurse crushed them on accident he would expect to see that the medications were re-offered to a resident. A note would be made in the chart about the crushed medications and that a new set of medications was offered to the resident. He stated that the policy around disposing of medications would be if a narcotic was involved that two nurses would sign off on that. Otherwise if it was just one medication and was not a narcotic they have a drug buster bin in the med room where it could be disposed of. R. On 01/23/18 at 1:10 PM during an interview with LPN #3, she stated that R #209 complains all the time about being in pain. She stated that she is on pain medication and has PRN pain medications that she requests every time she can, but she still complains of pain. She stated that she will be in pain at a 9 (on a scale of 1-10) and after the medication she will be in pain at a 9. S. On 01/24/18 at 2:00 prn, during an interview with PTA (Physical Therapy Assistant), he stated that R #209 is doing well in therapy and always participates. She is making progress. She does complain about pain but he feels like she regulates her pain fairly well. She has complaints of pain in her legs but also in her shoulders. He was aware that she had some problems a week ago with some of her medication and stated that she wrote a grievance about it. T. Record review of the MAR for the month of January 2018 indicated that on January 20th (01/20/18) R #209 had several medications reported as refused. The medications are as follows: 1. [MEDICATION NAME] Tablet (pain reliever) 325 mg take two tablets by mouth every 4 hours for pain and inflammation do not exceed 4 gram in one day. Marked as refused at 2200 (10:00 pm). 2. [MEDICATION NAME] (treat moderate to severe pain) ER (extended release) 30 mg take one tablet by mouth every 8 hours for pain. Marked as refused at 2200 (10:00 pm). This medication was not offered again until 6:00 am on January 21st (01/21/18). 3. [MEDICATION NAME] HCl (anti-anxiety) tablet 5 mg take one tablet by mouth three times a day for anxiety. Marked as refused at 2000 (8:00 pm). This medication was not offered again until at 9:00 am on January 21st (01/21/18). 4. [MEDICATION NAME] Capsule 300 mg take one capsule by mouth two times a day for neuralgia (intense, typically intermittent pain along the course of a nerve, especially in the head or face). Marked as refused at 2000 (8:00 pm). This medication was not offered again until 9:00 am on January 21st (01/21/18). 5. [MEDICATION NAME] Tablet (an anticonvulsant medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] disorder) 200 mg take 200 mg by mouth two times per day for [MEDICAL CONDITION] disorder. Marked as refused at 2000 (8:00 pm). This medication was not offered again until 9:00 am on January 21st (01/21/18). 6. [MEDICATION NAME] Capsule (treat occasional constipation) 100 mg take one capsule by mouth two times a day for risk for constipation do not open or crush capsules hold for loose stool. Marked as refused at 2000 (8:00 pm). U. Record review of the nursing progress notes dated 01/20/18 through 01/27/18 indicated that there was no documentation of medications being crushed accidentally for R #209, no documentation of replacement medications being offered or given. No documentation of R #209 refusing the medications. V. Record review of the MAR for January 2018 indicated that on 01/20/18 R #209 had a PRN [MEDICATION NAME] HCI tablet 5 mg take 10 mg by mouth every four hours as needed for pain. R #209 received this medication at the following times: 1. At 1:16 am R #209 had a pain level of 8 and the pain medication was ineffective. 2. At 9:24 am R #209 had a pain level of 8 and indicated that the pain medication was ineffective. 3. At 14:19 (2:19 pm) R #209 indicated that her pain level was at a 7 and that the pain medication was ineffective. 4. At 19:00 (7:00 pm) R #209 had a pain level of 8 and it was undetermined whether or not the pain medication was effective. 5. Resident was not offered this PRN pain medication again until January 21st (01/21/18) at 7:26 am. Findings for Residents #101, #102 and #38: W. On 01/22/18 at 10:38 am, during interview with R #101, she stated that she has pain in her knees, and that she is only taking [MEDICATION NAME] for pain relief. She stated that the facility has been unable to give her the [MEDICATION NAME] on a regular schedule, every 4 hours at 2:00 am & pm, 6:00 am & pm and 10:00 am & pm (around the clock), as it was ordered by the physician. She stated that sometimes they'll bring it at 3 hours, or at 5 1/2 hours, and that her pain becomes severe if the gap is too long. She indicated that, on one occasion, she received nothing from 9:00 pm until 8:00 am the following day, and was in substantial pain in the morning. She stated that she is also afraid that, if she receives the doses too close together, she could risk liver damage. X. On 01/22/18 at 10:38 am, during observation of R #101, she was noted to show non-verbal signs of pain. She was moving stiffly, with a pained facial expression, and grunting with movement. Y. Record review of R #101's medical record indicated that she was recovering from bilateral (both sides) knee replacements. Z. On 01/25/18 at 9:54 am, during interview with R #102, she indicated that she was experiencing severe pain in her right groin at that time. She stated that she was due to receive her narcotic pain medication at about 8:30 am, and had asked for it several times, but that it still hadn't come. AA. Record review of R #102's medical record indicated that she had suffered multiple fractures of her pelvis. BB. Record review of a grievance form dated 01/17/18 filed by a family member of R #38 found statements indicating . attending doctor is refusing there (sic) meds, they are in pain and need some kind of help with pain . Please I asked for my (family member) to be attended to for a week and nothing was done for my (family member.)

Based on interview and record review, the facility failed to comprehensively assess the resident in order to develop an effective pain management plan of care for one (R #377) of three (R #s 377, 382 and 397) residents reviewed for pain. Assessments of the resident's pain and its source were not found, and treatment of [REDACTED]. This deficient practice resulted in severe pain for this resident, which likely resulted in her failure to reach her highest level of physical and emotional well-being. The findings are: A. On 02/10/15 at 9:16 am, an interview was conducted with R #377. 1. She was asked about her participation in decisions about her daily care and she stated, "I thought I was having a urinary tract infection, and I really didn't get a response from them. It was burning and itching. This has been going on for about a week. As far as I know, they're not doing anything about that. And I really don't want an infection, having just had surgery. I've been on antibiotics many times for various things, and my doctor told me that they could cause a yeast infection." 2. She was asked about unrelieved pain, and she stated, "The vaginal infection. It's really painful. Today when I cleaned myself with soap, it felt like there was a torch on it." B. Record review of R #377's physician orders [REDACTED]. Diagnosis: [REDACTED]. C. Record review of the Medical Diagnoses tab in R #377's electronic medical record found that no diagnoses, other than "Lack of Coordination," had been documented. D. Record review of R #377's MAR (Medication Administration Record) indicated that [MEDICATION NAME] (a narcotic pain medication) PRN (as needed) doses were given 43 times between 02/01/15 and 02/12/15. Nothing on the record was found to indicate the cause or location of the resident's pain. E. Record review of the treatment administration record for R #377 revealed that pain assessments on 3 of 14 12-hour shifts between 02/03/15 and 02/09/15 had not been completed. Of the remaining 11 shifts, two had pain scores of "0" noted. The remaining scores were between "2" and "8", with four shifts at the "8" level. Nothing was found on the treatment administration record to indicate where in her body she was experiencing the pain. F. Record review of R #377's Pain Level Summary, dated 01/31/15, indicated that the resident reported pain at level 8 of 10 at that time. The remainder of the form was not completed, and no information as to the cause or location of the resident's pain was found. G. Record review of R #377's care plan found no entries related to pain. H. Record review of R #377's Skilled Nurses' Notes, dated 02/03/15 through 02/10/15, found that the GU (urinary) section indicated no problems. I. Record review of R #377's Skilled Progress Notes dated 02/03/15 through 02/10/15, found no indication that the resident was having difficulty with urination or vaginal pain. J. On 02/12/15 at 11:05 am, during an interview with the Director of Nurses (DON), he accessed R #377's electronic medical record, and was asked to find documentation of the body location of her pain. He stated "I don't see where the location of her pain is documented. I don't see anything about GU pain."

Based on record review and interview the facility failed to ensure that heat application did not result in an injury to one resident (R #2) of 7 (R #s 1, 2, 3, 4, 5, 6 and 7) sampled residents with similar care areas. When R #2 was administered heat application she acquired second [MEDICAL CONDITION] her right buttock. This failed practice had the potential to [MEDICAL CONDITION] any resident being administered heat applications. The findings are: A. Review of the Medical Record for R #2 revealed the following: 1. Nurse Progress Note dated 12/20/12 indicated: "Patient (R #2) states a hot water bottle opened up and burned her when she had it on her right hip/back. It doesn't hurt. Patient (R #2) has cherry red area on right buttock and several adhesive dressings covering what she states are 2 other areas. She did not want me to undo the dressings because she was on her way to therapy. I informed her that I would have the wound care nurse come see her. I informed the wound care nurse and DON (Director of Nursing)." 2. Physician Treatment Orders identified: a. "S/P (status [REDACTED]. Change every other day and prn if soiled or dislodged." Start Date: 12/20/2012. b. [MEDICATION NAME] ointment to right buttock twice daily and prn (as needed). Start Date: 01/02/2013. 3. physician progress notes [REDACTED]. [DIAGNOSES REDACTED]." 4. MDS (Minimum data set) dated 11/06/12 indicated: Extensive two person assist with all Activities of daily living; No cognitive deficits; Antidepressants; Speech Therapy (ST), Occupational Therapy (OT) and Physical Therapy (PT). 5. Care Plan dated 12/10/12 indicated: Alteration in skin integrity noted. Resident has superficial partial thickness burn to right buttock. Wound will show signs of wound healing without symptoms of infection by next review. Administer treatments as ordered... . B. Incident Accident Log indicated: On 12/19/12 at 9:20 pm, resident acquired a burn in her room. "Guest (R #2) asked CNA to get her a hot pack by filling an ice bag with hot water. CNA filled ice bag with hot water dispenser from a coffee machine and took it to resident (R #2). She place the hot water bag on the wheelchair and left the room. The resident (R #2) picked up the bag to place it on her thigh and the bag leaked onto her thigh and bed sheets. The Resident (R #2) attempted to move quickly away from the hot water and used call light to request help. Nurse on unit was immediately notified and went in to assess resident (R #2). Resident (R #2) sustained a burn on her right thigh and right buttock. Ice packs were applied to area and pain medication was administered." C. The Following Interviews revealed: 1. On 01/02/13 at 1:45 pm, R #2 stated "I asked for a hot water bottle and the GCS Tech (identified as Certified Nursing Assistant - CNA) Staff #1 brought me a bag pretty much like a ice bag filled with hot water. I can't get out of bed by myself so she put it so I could reach it when I was ready to use it. I got it to put on my right arm and when I did the top came loose and the water soaked my bed all the way to my right buttock. I put my light on right away and the tech came. It was about 15 minutes before the nurse (identified as License Practical Nurse - LPN) (Staff #2) came. He looked at my butt and said 'It's not too bad.' He got a ice bag which looked just like the one the hot water was in and put it under my butt. It came open and wet my butt too. By now my butt felt really hot. I put my light on and called the nurse again. He got another ice bag and I finally fell asleep but I woke up covered in ice water. It had leaked too. I was soaked again. He (Staff #2) then took it off and put a big dressing on my whole butt with lots of tape. I asked for some [MEDICATION NAME] for pain. (Name of Wound Nurse) came in the next morning to look at it and it was a second degree burn. My whole right cheek had a 2nd degree burn. I feel really bad because I asked for it. The CNA and the LPN got fired because I asked for it." 2. On 01/02/13 at 2:20 pm, Staff #3 Registered Nurse (RN) stated "I saw her (R #2) the next morning after this happened. It had a bunch of little blisters and was pink. I notified the wound nurse and she started treatment." 3. On 01/02/13 at 3:15 pm, the Wound Nurse stated, "I came in at 8:00 am the next morning and the nurse (Staff #3, RN) told me that the guest/resident had a burn. I went to see her in her room and she was in the shower. There was a large [MEDICATION NAME] bandage on it. I took off the bandage. It was red with blisters and painful to touch. She said it was from hot water that poured all over her. I identified it as a Superficial Partial Burn. The doctor later identified it as a 2nd degree burn. If there is a need for hot packs, they should be initiated by the nurse or therapist." 4. On 01/03/13 at 9:00 am, the Administrator stated, "Therapist are the only ones that should be applying heat to guests/residents. They (Therapist) have the thermal heat packs." 5. On 01/03/13 at 12:45 pm, Staff #1 (CNA) stated "I was working the night shift. (Name of resident #2) asked me to fill the ice pack in her room with hot water. I asked her how to do this and she said 'From the coffee machine out front. The other shift got it from the coffee machine.' When I took it back to her, she was in bed and there was a wheelchair (W/C) next to her bed. She took it and put it on the W/C. I left the room and shut the door. Within a half hour, she turned her light on again. When I went in she was in a standing position waving her gown and saying 'It Spilled'. She wanted the nurse. She said it worked fine the night before; the day shift too. I asked her where she was putting it and she said she was resting her right forearm on it. The fact that it was a ice pack didn't run through my mind. She told me others were doing it so I just went ahead and did it. Nobody never talked to me about applying heat of any kind." 6. On 01/03/13 at 11:30 am, Staff # 4 (CNA) stated, "The Occupational Therapist gives it (heat treatments). Someone (discharged resident) asked me once for a heat pack so I just told the nurse. They told us in the initial training not to apply heat." 7. On 01/04/13 at 10:00 am, Staff #2 (LPN) stated, "She (R #2) had been asking for a hot pack. She said she was allowed to use one during the day. I told her I would get it in a few minutes. In the mean time, she started discussing it with the GCS (CNA identified as Staff #1) so she (Staff #1) put water from coffee machine in the ice pack. The patient put it on her right hip while she was in bed. I didn't know anything about this until after it happened. I was informed that the hot pack leaked. I checked her buttock and it was scalding (red) so I applied an ice pack immediately. In twenty minutes there were blisters starting. The ice pack leaked too. I put a dressing on the site but the adhesive was not touching blisters. I was told the next day that tape pulled off some of the skin. It was worse than I thought. The next night she told me that she laid there several minutes after the hot water leaked on her. She was able to move. The protocol here is no hot packs unless ordered by therapy." 8. On 01/04/13 at 10:45 am, The Director Of Therapy Services stated "Hot and cold packs are therapy specific. If it's needed when therapy is not available the nurse gets an order and administers and supervises the treatment." 9. On 01/04/13 at 11:30 am, The Assistant Director of Nursing (ADON) stated "Heat modality is provided by therapy. If therapy is not available, the nurse will get an order from the doctor and administer the treatment. It is our policy that CNAs do not apply heat."