Every finding on record at Focused Care at Westwood

Based on interview and record review, the facility failed to ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider and before transferring or discharging to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 (CR #5) residents reviewed for proper discharge. -The facility did not send a copy of Resident #2's 30-day discharge notice of the intended discharge date to the Ombudsman at the same time the facility notified Resident #2 on 06/17/2026. The Ombudsman was first notified of Resident #2's discharge on [DATE] by e-mail exchange. This failure could place residents at risk of improper discharge and not having access to a knowledgeable advocate and a support system to guide them through the process of finding new placement or to access their right to appeal their discharge. Findings included: Record review of CR #5 face sheet, dated 08/12/2026, indicated a [AGE] year-old male originally admitted [DATE] with medical diagnoses including nontraumatic intracranial hemorrhage (brain bleed), cerebral infarction (stroke), cognitive communication deficit, profound intellectual disabilities, bipolar disorder (lifelong mental health condition causing extreme shifts in mood, energy, activity levels and the ability to focus) and schizophrenia (a serious mental health condition characterized by hallucinations and delusions and can make daily living hard). CR #5 was his own RP. CR #5 was discharged [DATE]. Record review of CR #5's most recent Quarterly MDS Assessment, dated 06/07/2026, indicated no discharge status at the time of the MDS. CR #5had a BIMS score of 4, indicating severe cognitive impairment. CR #5 was total independence or required set-up assistance for all his ADLs including showering, dressing, oral and personal hygiene and eating. He was totally independent for bed mobility. He was coded as having fluctuating inattention, disorganized thinking and altered levels of consciousness like being lethargic or vigilant to sound or touch. He was coded as having no physical or verbal behaviors directed towards others. Record review of CR #5's 30-day notice effective date 08/07/2026, CR #5 had the following reasons marked as requiring a discharge and needing a physician's signature, which were: needs not being able to be met at the facility and the health and safety of other individuals in this facility was endangered due to sexual behaviors. The form did not have a physician's signature. There was a letter attached to CR #5's family member and signed by the SW and undated which said they made several attempts to each the family member and informing them of the decision to transfer CR #5 to another facility due to ongoing behavioral concerns. Record review of the email the Administrator sent to the Ombudsman, he emailed the Ombudsman on 08/10/2026 at 11:07a.m. notifying the Ombudsman CR #5 was discharged on 8/8/2026 to another facility. Record review of CR #5's progress notes:-6/28/2026, CR #5 was alert and talked to himself most of the time, confused about room number daily and being redirected. CR #5 was playing with himself/private area with other residents and family members around. The nurse writing the note said she educated him to stay in his room.-7/14/2026, PASSR said they would request support for resident's sexually stimulating himself.-8/5/2026, the facility contacted the Ombudsman at 7:07p.m. regarding sexually inappropriate behavior. CR #5 was PASSR positive, services expected to begin soon. The SW discussed with the Ombudsman to maybe being referred to specialized program in another setting.-8/6/2026 at 9:31p.m., he was on 1 to 1 observation and seen attempting going into other residents' rooms.-8/8/2026 at 10:23a.m., LVN A documented CR #5 was discharged to another facility. Record review of CR #5's psych notes:-7/1/2026, he had progressively worse sexual behaviors and worsening anxiety, increased self-fondling and sexually inappropriate comments, focused on desire for women.-7/19/2026, he had hypersexual behavior, masturbation in common areas inappropriate, remained calm and receptive during redirection.-7/26/2026, he was redirected from another resident room after being found masturbating in another resident's bed. CR #5 was reminded of appropriate locations and unit activity expectations. he became agitated and yelled in response to redirection but remained verbally engaged with staff. He would go to bathroom and acknowledged that he was not in the bathroom when activity happened. He complied with initial resistance. He benefitted from supportive psychotherapy. Record review of the grievance log, documented CR #5 was observed sleeping in Resident #2's room and drinking her milk and was not observed near Resident #2's bed. Record review of CR #5's care plan last captured 08/12/2026, he had behavior problems with sexual remarks, talking to self and laughing out loud documented on 07/14/2026 with interventions including redirecting him to room, intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause and discuss resident behavior. CR #5 was also care-planned for inappropriate behavior of masturbation documented on 07/27/2026, with interventions including staff to redirect, having him on 1 to 1 observation, maintaining dignity by avoiding confrontation or shaming, actively searching for proper placement elsewhere, consult with SW, psychiatry or psychology as indicated. Interview on 08/12/2026 at 10:28 a.m. with the Ombudsman, she said she received CR #5's medical records on 08/07/2026, but did not receive any notice of his discharge until 08/12/2026. The Ombudsman said the facility contacted her on what to do about CR #5's public sexual behaviors on 08/04/2026 or 08/05/2026 and they discussed discharge options with CR #5, who said he wanted to go, but the Ombudsman said it was not clear if CR #5 understood what was happening. The Ombudsman also said the facility considered discharging CR #5 to a family member's house. The Ombudsman said the facility hand-delivered an emergency discharge letter to CR #5's family member's house but at one point in time the Ombudsman understood the family member to be homeless, so when she heard about CR #5's discharge on [DATE], she had concerns about the discharge process that took place without her being notified and she could have ensured he had an advocate during the process. The Ombudsman stated she never received a 30-day discharge notice until 08/12/2026 and had to call the admitting facility to confirm where CR #5 was located.Interview on 08/12/2026 at 11:07a.m. with NP B, she was CR #5's psych NP. NP B said the facility did not tell her about CR #5's discharge, they told her he was touching himself and the anxiety medication he was on was not appropriate for him anymore due to weight loss so the last change she made a few weeks ago was to put him on another anxiety medication. NP B said CR #5 had cognitive impairment and could not express himself and could not hold a conversation. If she was told by staff that his behavior progressed, she would have considered sending him out to a psych facility for treatment or reviewing his medications. Attempted interview on 08/12/2026 at 11:50a.m. with NP C, CR #5's regular NP, she did not answer the phone, and voicemail was left with no returned communication as of exit. Interview on 08/12/2026 at 12:29p.m. with CNA C, she said CR #5 was young and would touch himself in his room. CNA C would see CR #5 go from room to room and get other residents' stuff, so they moved him to another hall but the behavior continued so he was discharged . CNA C said she never had residents discharged for wandering, and she had not seen any residents complain about his behavior. Interview with CNA M on 08/12/2026 at 1:47p.m., he was called into Resident #2's room after her family member found CR #5 sleeping in the room. CNA M said CR #5 was able to follow CNA M's directions, but he did wander into other resident's room. CNA M said the situation was concerning because Resident #2 was nonverbal and was unable to move, so the facility found a new place CR #5. CNA M said CR #5 was offered snacks but preferred drinking liquid nutrition from residents on g-tube. Interview with the SW on 08/12/2026 at 3:47 p.m., she assisted with discharges and would explain safe discharges to families. The SW said CR #5's sexual behaviors rapidly progressed in the last two to three weeks. The PASSR representative was going to schedule an appointment for him to go somewhere to work on his life skills. CR #5 went from self-pleasure in his room to the cafeteria and day room. The facility decided on emergency discharge due to some ladies telling staff they were afraid, but when the SW asked them, they would also laugh about it but out of an abundance of caution they discharged him. CR #5 was also found by a resident's family member sleeping in the bed in her room the prior week. That resident was unable to speak and was comatose so she could not get out of bed on her own. The SW said the facility tried redirecting CR#5, changing rooms, changing his medications and had him on 1-to-1 observation but nothing worked. The SW said she did not think sending CR #5 to a psych facility would have helped because he was unable to remember directions after a minute or so. The SW found another facility with more employees to be able to monitor CR #5 . The SW remembered talking to the Ombudsman on 08/05/2026 about the discharge. Interview with ADON C on 08/12/2026 at 4:40 p.m., she said she never saw CR #5 do anything inappropriate but was aware of him going into resident and management rooms and he was a wanderer. ADON C said he ww as discharge due to being found by a resident's family member in her room and had concerns. ADON C said he was able to hold a conversation sometimes, but she would not know if he would understand what a discharge was. ADON C said the Administrator or DON would be responsible for notifying the Ombudsman of any discharges. Interview with the DON on 08/12/2026 at 5:10p.m., she said CR #5 was discharged due to inappropriate sexual behaviors, going into residents' rooms and drinking milk from g-tube residents. The facility had interventions like redirecting him, moving rooms and putting him on 1 to 1 but nothing worked. The DON said the facility would have told NP C about CR #5's discharge and said she would look for any notes or communication. The DON said the Administrator sent an email to the Ombudsman regarding CR #5's discharge but could not say when. Interview with the Administrator on 08/12/2026 at 5:26 p.m., he said CR #5 was having sexual misbehaviors and masturbating near the couch near the dining room and it escalated quickly in the last few weeks even with other interventions like changing hallways and rooms. The Administrator said psych hospitals did not treat sexual behaviors, and it was CR #5's right to masturbate so it would not have helped CR #5 from being sent there. After the Administrator received photos from Resident #2's family member of CR #5 sleeping on the other bed in Resident #2's room, the Administrator asked the SW to find another home who would take him. The Administrator said he knew the SW reached out to the Ombudsman on suggestions but that the Administrator said while trying to get CR #5 safely discharged he forgot to tell the Ombudsman about CR #5's eventual discharge on [DATE]. The Administrator said the purpose of notifying the Ombudsman was to ensure CR #5 had an advocate during the discharge process. The Administrator said the Ombudsman told him that he should have told the Ombudsman about CR #5's discharge at the same time he told the Ombudsman. The Administrator said going forward he would ensure the Ombudsman was included in notifications. Interview with LVN G on 08/12/2026 at 5:57 p.m., she said she was CR #5's discharge nurse and discharged him to another nursing home on 8/8/2026. LVN G said she used to see CR #5 groping himself in open spaces and other residents did not say anything about it but did look uncomfortable. LVN G could not say when it started but she would redirect him to his room. LVN G said she did the discharge note in CR #5's medical records and she did not know who notified the doctor or family and other responsible parties but at discharge someone on the team would have done that and it was not part of her discharge duties to do so. Record review of the facility's policy titled Resident Rights last revised December 2016, read in part, 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to. f. communication with and access to people and services, both inside and outside of the facility.h. be supported by the facility in exercising his or her rights.x. communicate with outside agencies e.g., .state long-term care ombudsman, protection or advocacy organizations, etc.) regarding any matter.Record review of the facility's, undated, admission agreement, titled Nursing Facility admission and Financial Agreement, it read in part, .19. Transfer and Discharge. Resident may be transferred or discharged if: necessary for Resident's welfare and Resident's needs cannot be met in facility. Resident is endangering the safety of other persons in Facility, Resident is endangering the health of other individuals in Facility.Written notice will be given to Resident/Resident Representative for all planned discharges and transfers. Unless waived by the Resident/Resident Representative, thirty (30) days written notice will be given for discharges and transfers planned pursuant to subsections a and b, above. It did not state any notification of the Ombudsman.

Based on interview and record review the facility failed permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure the transfer or discharge was documented in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for 1 of 1 (CR #5) resident reviewed for discharge planning.1. LVN A failed to notify CR #5's physician or NP when he was discharged on 8/8/2026.2. The facility failed to ensure CR #5's NP documented the reason for his discharge to a new facility.This failure could place residents at risk of a decline in health due to not having continuity of care after they leave the facility. Findings include:Record review of CR #5 face sheet, dated 08/12/2026, indicated a [AGE] year-old male originally admitted to the facility on [DATE]. CR #5 had medical diagnoses which included nontraumatic intracranial hemorrhage (brain bleed), cerebral infarction (stroke), cognitive communication deficit, profound intellectual disabilities, bipolar disorder (lifelong mental health condition causing extreme shifts in mood, energy, activity levels and the ability to focus) and schizophrenia (a serious mental health condition characterized by hallucinations and delusions and can make daily living hard). CR #5 was his own RP. CR #5 was discharged from the facility on 8/8/2026. Record review of CR #5's most recent Quarterly MDS Assessment, dated 06/07/2026, indicated no discharge status at the time of the MDS. CR #5 had a BIMS score of 4, which indicated severe cognitive impairment. CR #5 was total independence or required set-up assistance for all his ADLs including showering, dressing, oral and personal hygiene and eating. He was totally independent for bed mobility. He was coded as having fluctuating inattention, disorganized thinking and altered levels of consciousness like being lethargic or vigilant to sound or touch. He was coded as having no physical or verbal behaviors directed towards others. Record review of CR #5's 30-day notice, effective date 08/07/2026, CR #5 had the following reasons marked as requiring a discharge and needing a physician's signature, which were: needs not being able to be met at the facility and the health and safety of other individuals in this facility was endangered due to sexual behaviors. The form did not have a physician's signature. There was a letter attached to CR #5's family member and signed by the SW and undated which said they made several attempts to each of the family member and informed them of the decision to transfer CR #5 to another facility due to ongoing behavioral concerns. Record review of the email the Administrator sent to the Ombudsman, documented he emailed the Ombudsman on 08/10/2026 at 11:07 a.m. notifying the Ombudsman CR #5 was discharged on 8/8/2026 to another facility.Record review of CR #5's medical chart, there was no documentation that an NP was notified.Record review of CR #5's progress notes:-7/14/2026, PASSR said they would request support for resident's sexually stimulating himself.-8/5/2026, the facility contacted the Ombudsman at 7:07 p.m. regarding sexually inappropriate behavior. CR #5 was PASSR positive, services expected to begin soon. The SW discussed with the Ombudsman to maybe being referred to a specialized program in another setting.-8/6/2026 at 9:31p.m., he was on 1 to 1 observation and seen attempting going into other residents' rooms.-8/8/2026 at 10:23a.m., LVN A documented CR #5 was discharged to another facility.Record review of CR #5's care plan, last captured 08/12/2026, he had behavior problems with sexual remarks, talking to self and laughing out loud documented on 07/14/2026 with interventions which included redirecting him to room, intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause and discuss resident behavior. CR #5 was also care-planned for inappropriate behavior of masturbation documented on 07/27/2026, with interventions which included staff to redirect, having him on 1 to 1 observation, maintaining dignity by avoiding confrontation or shaming, actively searching for proper placement elsewhere, consult with SW, psychiatry or psychology as indicated.Attempted interview with CR #5's family member on 08/12/2026 at 11:00a.m. was unsuccessful, a voicemail was left and text at 11:02 a.m. No returned communications as of exit.Interview on 08/12/2026 at 11:07 a.m. with NP B, she was CR #5's psych NP. NP B said the facility did not tell her about CR #5's discharge, they told her he was touching himself and the anxiety medication he was on was not appropriate for him anymore due to weight loss so the last change she made a few weeks ago was to put him on another anxiety medication. NP B said CR #5 had cognitive impairment and could not express himself and could not hold a conversation. If she was told by staff his behavior progressed, she would have considered sending him out to a psych facility for treatment or reviewing his medications. Attempted interview on 08/12/2026 at 11:50 a.m. with NP C, CR #5's regular NP, was unsuccessful, a voicemail was left with no returned communication as of exit. Interview on 08/12/2026 at 12:29 p.m. with CNA C, she said CR #5 was young and would touch himself in his room. CNA C would see CR #5 go from room to room and get other residents' stuff, so they moved him to another hall, but the behavior continued so he was discharged by the facility for the safety of other residents. CNA C said she never had residents discharged for wandering, and she had not seen any residents complain about his behavior. Interview with CNA M on 08/12/2026 at 1:47 p.m., he was called into Resident #2's room after her family member found CR #5 sleeping in the room. CNA M said CR #5 was able to follow CNA M's directions, but he did wander into other resident's rooms. CNA M said the situation was concerning because Resident #2 was nonverbal and was unable to move, so the facility found a new place for CR #5. Interview, observation and record review with Resident #2's family member on 08/12/2026 at 2:20 p.m., she said she saw CR #5 in Resident #2's room two weeks ago and he was sleeping in the next bed. The family member woke CR #5 and told him to get out. Resident #2's family member showed pictures of CR #5 sleeping in the room on 08/01/2026. Resident #2's family member sent the photos to the Administrator who moved him to another hallway, but he would come back to Resident #2's hallway. The facility placed Resident #2 on 1 to 1 on 08/04/2026 and told her they were working on finding a new place for CR #5. The family member said she felt like Resident #2 has in a safer environment now that CR #5 could not wander into her room. Resident #2 was lying in bed with her eyes closed and appeared to be comfortable and did not appear to be in respiratory distress. Interview with the SW on 08/12/2026 at 3:47 p.m., she said she was part of the discharge committee which included nursing management like the ADONs and DON. CR #5 had these behaviors of self-pleasure in the last week or so and he was on 1 to 1 in the 4-5 days before he was discharged , which was around the time the SW was starting to look at facilities for him. Interview with ADON C on 08/12/2026 at 4:40 p.m., she said she was aware of him going into resident and management rooms and he was a wanderer. ADON C said CR #5 was discharged due to being found by a resident's family member in her room and had concerns. ADON C said the resident was able to hold a conversation sometimes, but she would not know if he could understand what a discharge was. Interview with the DON on 08/12/2026 at 5:10 p.m., she said CR #5 was discharged due to inappropriate sexual behaviors, going into residents' rooms and drinking milk from g-tube residents. The facility had interventions like redirecting him, moving rooms and putting him on 1 to 1 but nothing worked. The DON said the facility would have told NP C about CR #5's discharge and said she would look for any notes or communication. The ADON and DON were responsible for ensuring the discharge process was followed. The DON talked to NP C who told the DON they could not locate any notes, texts or email messages telling NP C CR #5 was discharged . The DON said a negative effect of physicians not being notified was the physicians could still write orders for residents not in the facility anymore. Residents could also be discharged without a physician's awareness and would not have a proper transition of care no matter where residents were discharged to. The DON said LVN G should have gotten an order for the physician to discharge the resident. Interview with LVN G on 08/12/2026 at 5:57 p.m., she said she was CR #5's discharge nurse. LVN G said she used to see CR #5 groping himself in open spaces and other residents did not say anything about it but did look uncomfortable. LVN G could not say when it started but she would redirect him to his room. LVN G said she did the discharge note in CR #5's medical records and she did not know who notified the doctor or family but at discharge someone on the team would have done that and it was not part of her discharge duties to do so. Record review of the facility's, undated, admission agreement, titled Nursing Facility admission and Financial Agreement, read in part, .19. Transfer and Discharge.Except in an emergency, Resident shall not be transferred or discharged without prior consultation with Resident, Resident's Attending Physician and resident Representative and written notification describing the reason(s) for the transfer or discharge and Resident's right to appeal the transfer or discharge.Resident may be transferred or discharged if: necessary for Resident's welfare and Resident's needs cannot be met in facility. Resident is endangering the safety of other persons in Facility, Resident is endangering the health of other individuals in Facility.Written notice will be given to Resident/Resident Representative for all planned discharges and transfers. Unless waived by the Resident/Resident Representative, thirty (30) days written notice will be given for discharges and transfers planned pursuant to subsections a and b, above.

Based on interview and record review, the facility must consult with the resident's physician when there is a decision to transfer or discharge the resident from the facility for 1 of 4 (CR #5) resident reviewed for physician notification. -LVN A did not notify CR #5's psych NP or regular NP when he was discharged on 8/8/2026.This failure could cause residents to not have continuity of care and an incomplete health record at their new facility. Findings included: Record review of CR #5 face sheet, dated 08/12/2026, indicated a [AGE] year-old male originally admitted [DATE] with medical diagnoses including nontraumatic intracranial hemorrhage (brain bleed), cerebral infarction (stroke), cognitive communication deficit, profound intellectual disabilities, bipolar disorder (lifelong mental health condition causing extreme shifts in mood, energy, activity levels and the ability to focus) and schizophrenia (a serious mental health condition characterized by hallucinations and delusions and can make daily living hard). CR #5 was his own RP. CR #5 was discharged [DATE]. Record review of CR #5's most recent Quarterly MDS Assessment, dated 06/07/2026, indicated no discharge status at the time of the MDS. CR #5had a BIMS score of 4, indicating severe cognitive impairment. CR #5 was total independence or required set-up assistance for all his ADLs including showering, dressing, oral and personal hygiene and eating. He was totally independent for bed mobility. He was coded as having fluctuating inattention, disorganized thinking and altered levels of consciousness like being lethargic or vigilant to sound or touch. He was coded as having no physical or verbal behaviors directed towards others. Record review of CR #5's 30-day notice effective date 08/07/2026, CR #5 had the following reasons marked as requiring a discharge and needing a physician's signature, which were: needs not being able to be met at the facility and the health and safety of other individuals in this facility was endangered due to sexual behaviors. The form did not have a physician's signature. There was a letter attached to CR #5's family member and signed by the SW and undated which said they made several attempts to each the family member and informing them of the decision to transfer CR #5 to another facility due to ongoing behavioral concerns. Record review of the email the Administrator sent to the Ombudsman, he emailed the Ombudsman on 08/10/2026 at 11:07a.m. notifying the Ombudsman CR #5 was discharged on 8/8/2026 to another facility. Record review of CR #5's progress notes:-7/14/2026, PASSR said they would request support for resident's sexually stimulating himself.-8/5/2026, the facility contacted the Ombudsman at 7:07p.m. regarding sexually inappropriate behavior. CR #5 was PASSR positive, services expected to begin soon. The SW discussed with the Ombudsman to maybe being referred to specialized program in another setting.-8/6/2026 at 9:31p.m., he was on 1 to 1 observation and seen attempting going into other residents' rooms.-8/8/2026 at 10:23a.m., LVN A documented CR #5 was discharged to another facility. Record review of CR #5's care plan last captured 08/12/2026, he had behavior problems with sexual remarks, talking to self and laughing out loud documented on 07/14/2026 with interventions including redirecting him to room, intervene as necessary to protect the rights and safety of others, monitor behavior episodes and attempt to determine underlying cause and discuss resident behavior. CR #5 was also care-planned for inappropriate behavior of masturbation documented on 07/27/2026, with interventions including staff to redirect, having him on 1 to 1 observation, maintaining dignity by avoiding confrontation or shaming, actively searching for proper placement elsewhere, consult with SW, psychiatry or psychology as indicated. Attempted interview with CR #5's family member on 08/12/2026 at 11:00a.m., a voicemail was left and text at 11:02a.m. and no returned communications as of exit. Interview on 08/12/2026 at 11:07a.m. with NP B, she was CR #5's psych NP. NP B said the facility did not tell her about CR #5's discharge, they told her he was touching himself and the anxiety medication he was on was not appropriate for him anymore due to weight loss so the last change she made a few weeks ago was to put him on another anxiety medication. NP B said CR #5 had cognitive impairment and could not express himself and could not hold a conversation. If she was told by staff that his behavior progressed, she would have considered sending him out to a psych facility for treatment or reviewing his medications. Attempted interview on 08/12/2026 at 11:50a.m. with NP C, CR #5's regular NP, she did not answer the phone, and voicemail was left with no returned communication as of exit. Interview on 08/12/2026 at 12:29p.m. with CNA C, she said CR #5 was young and would touch himself in his room. CNA C would see CR #5 go from room to room and get other residents' stuff, so they moved him to another hall but the behavior continued so he was discharged . CNA C said she never had residents discharged for wandering, and she had not seen any residents complain about his behavior. Interview with CNA M on 08/12/2026 at 1:47p.m., he was called into Resident #2's room after her family member found CR #5 sleeping in the room. CNA M said CR #5 was able to follow CNA M's directions, but he did wander into other resident's room. CNA M said the situation was concerning because Resident #2 was nonverbal and was unable to move, so the facility found a new place CR #5. CNA M said CR #5 was offered snacks but preferred drinking liquid nutrition from residents on g-tube.Interview with the SW on 08/12/2026 at 3:47p.m., she said she was part of the discharge committee. CR #5 had these behaviors in the last week or so and he was on 1 to 1 in the 4-5 days before he was discharge, which was around the time the SW was starting to look at facilities for him. Interview with ADON C on 08/12/2026 at 4:40p.m., she said she never saw CR #5 do anything inappropriate but was aware of him going into resident and management rooms and he was a wanderer. ADON C said he was discharged due to being found by a resident's family member in her room and had concerns. ADON C said he was able to hold a conversation sometimes, but she would not know if he would understand what a discharge was. ADON C said the Administrator or DON would be responsible for notifying the Ombudsman of any discharges. Interview with the DON on 08/12/2026 at 5:10p.m., she said CR #5 was discharged due to inappropriate sexual behaviors, going into residents' rooms and drinking milk from g-tube residents. The facility had interventions like redirecting him, moving rooms and putting him on 1 to 1 but nothing worked. The DON said the facility would have told NP C about CR #5's discharge and said she would look for any notes or communication. The ADON and DON were responsible for ensuring that discharge process was followed. The DON talked to NP C who told the DON they could not locate any notes, texts or email messages telling NP C that CR #5 was discharged . The DON said a negative effect of physicians not being notified was that physicians could still write orders for residents not in the facility anymore. Residents could also be discharged without a physician's awareness and would not have a proper transition of care no matter where residents were discharged to. The DON said LVN G should have gotten an order for the physician to discharge the resident. Interview with LVN G on 08/12/2026 at 5:57p.m., she said she was CR #5's discharge nurse. LVN G said she used to see CR #5 groping himself in open spaces and that other residents did not say anything about it but did look uncomfortable. LVN G could not say when it started but she would redirect him to his room. LVN G said she did the discharge note in CR #5's medical records and she did not know who notified the doctor or family but that at discharge someone on the team would have done that and that it was not part of her discharge duties to do so. Record review of the facility's admission agreement, undated, titled Nursing Facility admission and Financial Agreement, it read in part, .19. Transfer and discharge: .Except in an emergency, Resident shall not be transferred or discharged without prior consultation with Resident, Resident's Attending Physician and resident Representative and written notification describing the reason(s) for the transfer or discharge and Resident's right to appeal the transfer or discharge. Resident may be transferred or discharged if: necessary for Resident's welfare and Resident's needs cannot be met in facility. Resident is endangering the safety of other persons in Facility, Resident is endangering the health of other individuals in Facility. and continued with Written notice will be given to Resident/Resident Representative for all planned discharges and transfers. Unless waived by the Resident/Resident Representative, thirty (30) days written notice will be given for discharges and transfers planned pursuant to subsections a and b, above. It did not state any notification of the Ombudsman.

Based on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 (Resident #1) residents reviewed for respiratory care.-The facility failed to ensure Resident #1 had an order for oxygen before administering oxygen at 3.5 L via nasal cannula from 05/12/26 through 06/16/26.This failure could have placed residents at risk of developing respiratory complications and a decreased quality of care.Findings included:Record review of Resident #1's face sheet dated 06/19/26 revealed she was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. Resident #1 had diagnoses which included dementia (a loss of memory, language, and thinking abilities that were severe enough to interfere with daily life), COPD (lung disease that made it hard to breathe), and chronic respiratory failure (a long-term, ongoing condition where the lungs could not properly exchange oxygen and carbon dioxide).Record review of Resident #1's quarterly MDS assessment dated [DATE] revealed a BIMS score of 07, indicating moderate cognition. Further review of the MDS did not reveal that the resident was on oxygen.Record review of Resident #1's care plan initiated on 11/06/23 revealed the resident had oxygen therapy related to COPD. Intervention: oxygen setting: O2 at 2-3 L as ordered.Record review of Resident #1's May 2026 order revealed oxygen at 2-3 L/NC continuous R/T COPD was discontinued on 05/11/26.Record review of Resident #1's June 2026 order revealed Resident #1 was readmitted to the facility on [DATE], an order for O2 at 3-4 L via NC continuously to maintain O2 sats greater than 90% every shift for oxygen supplementation was initiated on 06/16/26.Record review of Resident #1's June 2026 order revealed Resident #1 was readmitted to the facility on [DATE] an order for O2 at 2-3 L via NC continuously to maintain O2 sats greater than 90% every shift for oxygen supplementation was initiated 06/16/26.During an observation and interview on 06/16/26 at 10:35 a.m., Resident #1's oxygen setting on the concentrator read 3.5 L, and Resident #1 was on her back in bed with the nasal cannula in her nostrils. Resident #1 said she did not touch or change the setting on the concentrator. She said she was not experiencing any shortness of breath.During an observation and interview on 06/16/26 at 10:37 a.m., RN A said the oxygen was set at 3.5 L and Resident #1 had an order for oxygen at 3 to 4 liters. She then checked Resident #1's order on her computer and said she did not see the order for oxygen and was going to talk to the DON.During an interview on 06/16/26 at 11:55 a.m., RN A said Resident #1 was on oxygen at 3 to 4 liters before she went to the hospital, and the order was discontinued and was not transcribed after Resident #1 returned from the hospital. She said the resident was administered oxygen without an order. RN A said she put back the order for 3 to 4 liters after she talked to the DON at 11:00 a.m. She said the facility protocol was to have a physician order for oxygen administration before oxygen was administered to any resident. She said oxygen could have affected Resident #1 in a negative way when the correct liter flow was not administered because oxygen had effects on the resident's brain. RN A was reviewing Resident #1's order during this interview and said she had just found the discontinued oxygen order, which was 2 to 3 liters, and the setting on the concentrator was 3.5 L, which was higher than the previous order. RN A said Resident #1 had COPD and when more oxygen was administered, the resident could have suffocated because the resident was not able to exhale carbon dioxide in a timely manner. She said she had just discontinued the order for 3 to 4 liters and entered 2 to 3 liters oxygen now. RN A said she thought the resident's previous order was 3 to 4 liters because the setting on the concentrator was 3.5 liters.During an interview on 06/16/26 at 2:20 p.m., the ADON said RN A should have checked the setting on the concentrator and it should have matched the order. She said Resident #1 was readmitted back to the facility on [DATE] from the hospital. She said the nurses were supposed to fax the orders to the physician when a resident returned from the hospital, and she did not see any order for oxygen. The ADON said the nurse should not have gone off the previous order because it was discontinued when Resident #1 went to the hospital. She said Resident #1 may not have needed oxygen because the resident may have been saturating at 100%. She said Resident #1 had COPD and should not have received oxygen without an order because Resident #1 could have gone into respiratory distress if administered more oxygen than needed. She said the nurse managers followed up the next day after admission or readmission and made sure the resident's orders were entered into the computer correctly. She did not respond when asked if she had checked Resident #1's oxygen order.During a telephone interview on 06/16/26 at 2:37 p.m., the NP said none of the nurses called her for an oxygen order when Resident #1 was readmitted and today. The NP said Resident #1 should not have been on oxygen if there was no order. She said if Resident #1 was given more oxygen than prescribed, the resident would have retained CO2 because Resident #1 had COPD.During an interview on 06/16/26 at 3:47 p.m., the DON said the nurse who admitted Resident #1 should have reviewed Resident #1's medication with the physician when the resident returned from the hospital. She said if the resident returned to the building with oxygen on, the admitting nurse should have notified the physician that the resident had oxygen on but no order, and then the physician would have either given an order for oxygen or discontinued the oxygen. She said the nurse should have completed the resident medication review on the admission day, and the ADON should have checked and ensured Resident #1's orders were transcribed properly and should have noted that there was no order for oxygen while the resident had oxygen on. The DON said there was a problem because there was no proper oxygen administration order for Resident #1 when she returned from the hospital. She said Resident #1 could have had an adverse reaction from not having an order because Resident #1 could have had a nosebleed if she was administered more oxygen than required. She also said Resident #1 had COPD and may have gone into exacerbation when given more oxygen than required.During a telephone interview on 06/16/26 at 4:01 p.m., an attempt was made to reach LVN B, who was the nurse that readmitted Resident #1 back to the facility on [DATE].Requested facility policy on oxygen administration from the administrator and DON, but it was not provided upon exit.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 1 medication storage rooms, 1 of 8 (100 Hall Nurse Cart) medication carts, and 1 of 1 (Resident #77) residents, reviewed for pharmacy services.-The facility failed to ensure Resident #77's expired Furosemide 20mg was not stored with current medications on the 100 Hall Nurse Cart.-The facility failed to ensure 9 expired wound cultures were not stored with current medications and cultures in the medication storage room.These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.Findings included: Record review of Resident #77's undated face sheet revealed she was a [AGE] year old female who admitted to the facility on [DATE]. She had diagnoses of acute respiratory failure with hypoxia (not enough oxygen in the blood), type 2 diabetes mellitus (body does not produce insulin or resists it), and congestive heart failure (fluid build up due to heart not pumping).Record review of Resident #77's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 7 out of 15 which indicated severely impaired cognition. Resident #77 was partial/moderate assistance (helper does less than half the effort) for all ADLs. The assessment revealed the resident had shortness of breath with exertion (movement), when sitting at rest, and when lying flat. The resident was not taking a diuretic (medication to increase urination) like furosemide.Record review of Resident #77's Care Plan dated 4/5/22 revealed a Focus: Resident #77 had the potential for dehydration/fluid deficit r/t daily diuretic use. Interventions included administering medications as ordered. Focus: Resident #77 had CHF and was at risk for activity intolerance r/t fatigue d/t cardiac insufficiency, and at risk for excess fluid volume r/t cardiac failure. Interventions included administering medications per orders.Record review of Resident #77's Physician Orders from 5/22/26, revealed the following orders from MD D:-Lasix Oral Tablet 20mg, 1 PO Q Mon/Wed/Fri in the AM. Ordered on 8/6/24, discontinued 11/20/24.-Lasix Oral Tablet 20mg, 1 PO QD. Ordered on 2/12/26, discontinued on 2/19/26.-There were no current orders for Lasix.In an observation and interview on 5/22/26 at 9:09am, Resident #77's blister pack of Furosemide (increases urination) 20mg that had expired on 11/12/25 was found on the 100 hall Nurse Cart. LVN K said she checked her cart weekly for expired medications and if a resident received an expired medication they could have a bad reaction or it may not work.In an observation and interview on 5/22/26 at 10:19am, 9 wound cultures were found in the medication storage room that had expired on 4/9/26. LVN K said if the culture was used and it was expired the lab would not accept it or it may not work.In an interview on 5/22/26 at 12:15pm, the DON said she expected staff to check their medication carts daily before each shift. She said the ADON also checked the carts and the medication room weekly. She said if an expired medication was given to a resident it could cause adverse effects or not be effective.Record review of the facility's policy and procedures on Medication Packaging (no date) read in part: Medications are provided in packaging to facilitate accurate administration and accountability of the medication. All packaging meets USP (United States Pharmacopeia) standards.Unit-dose packages have an expiration date (beyond-use date) on them that is checked before administering the medication to the resident.Record review of the facility's policy and procedures on Administering Medications (revised April 2019) read in part: Medications are administered in a safe and timely manner, and as prescribed.The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #67 and Resident #3) reviewed for comprehensive care plans. 1.The facility failed to provide Resident #67 with a comprehensive person-centered care plan to address colostomy. 2.The facility failed to address Resident #3's digoxin and insulin on his care plan.This failure could place residents at risk of not having personalized plans developed to address their specific care needs.Findings included:1. Record review of Resident #67's face sheet, dated May 20, 2026, revealed a [AGE] year-old male, with an admission date of 02/18/2024, with diagnosis including Unspecified Dementia, unspecified severity, with agitation (a decline in mental ability including memory, language, reasoning, and problem solving severe enough to interfere with daily life) and colostomy status (a medical term used to describe a patient who has a surgically created opening in their abdomen (called stoma) that connects a part of the large intestine (colon) to the outside of the body).Record review of Resident #67's Quarterly MDS assessment, dated 03/21/2026, revealed BIMS 03, indicating a severe cognitive impairment status in section C. In Section GG revealed that Resident #67 was triggered as dependent on staff for tub/shower and transfers. In section H revealed that Resident #67 required an ostomy (including urostomy, ileostomy, and colostomy). Record review of Resident #67's May 2025 physician orders, revealed the following orders: Colostomy bag cut to fit QD & PRN with a start date of 01/08/2024, Colostomy Care Q shift & PRN with a start date of 01/08/2024, Colostomy-Empty Bag Q shift, with a start date of 01/08/2024. Record review of Resident #67's undated care plan revealed no focus, goal, or interventions for colostomy. In an observation and interview on 05/20/2026 at 2:25pm with ADON A, she stated the MDS Nurse, ADONs, and DONs were responsible for updating the care plans. She stated the residents should not be care planned for things that they do not have. ADON A reported she could not remember if Resident #67 had a colostomy bag or not. Surveyor and ADON A did an observation of Resident #67's, upon entering the room, ADON A asked Resident #67 if he still had his colostomy bag and he reported he did not,. ADON A did an observation of Resident #67 and observed that he did have a colostomy bag, then Resident #67 replied and stated, oh that's what that is. ADON A stated the resident should have been care planned for it. She stated she was not sure why it was not included in his care plan and reported it may have been an oversight. ADON A stated residents should be care planned for orders such as colostomy, insulin, and oxygen; when asked about the risk of it not being care planned, she stated she did not know what the risk was. Record review of Resident #3's undated face sheet revealed an [AGE] year old male who admitted to the facility on [DATE]. He had diagnoses of type 2 diabetes mellitus (body does not produce insulin or resists it), and atrial fibrillation (irregular heart rate).Record review of Resident #3's Quarterly MDS assessment, dated 3/31/26, revealed a BIMS score of 3 out of 15 which indicated severely impaired cognition. Resident #3 was partial/moderate assistance (helper does less than half the effort) for all ADLs. The assessment revealed the resident received insulin injections daily and he was not on an anti-coagulant.Record review of Resident #3's Care Plan, dated 9/2/25, revealed a Focus: Resident #3 was on anticoagulation therapy r/t atrial fibrillation (Initiated 9/16/25 Revised: 9/26/25). The interventions included administering the anti-coagulant as ordered. There was no mention of insulin or digoxin.Record review of Resident #3's Physician Orders on 5/21/26 revealed the following orders from MD D:-Digoxin Oral Tablet 62.5mcg, Give 1 PO QD for afib/heart failure. Ordered 11/7/25.-Humalog Kwikpen Subcutaneous Solution Pen-injector 100u/ml, Inject per sliding scale ac/hs (before meals and at bedtime). Ordered 11/7/25.-Lantus SoloStar Subcutaneous Solution Pen-injector 100u/ml, Inject 12u SQ Q am for DM2. Ordered 3/23/26.-Lantus SoloStar Subcutaneous Solution Pen-injector 100u/ml, Inject 12u SQ Q am for DM2 Hold if BS <100. Ordered 5/21/26.In an interview on 05/21/2026 at 7:11A.M. with the DON, she stated if the care plan was acute then the DON, ADON, MDS or floor nurse would update the care plan and if it was comprehensive, the MDS Nurse updated it. She stated a care plan should be updated when there was a change. She stated when something was discontinued, they tried to update it as soon as possible. She stated the residents should not be care planned for things they did not have, ex. such as foley, g tube, or trachs. She stated Resident #67 should have been care planned for his colostomy bag because it was something that he currently had. She stated the care plans were for family and goal purposes. The DON stated and reported she could not say there was an actual risk of negative outcome for the resident by it not being care planned because the staff could follow the orders. She stated the care plan should be in place so it will follow through with the residents' total care. She stated Resident # 3's insulin should be care planned. She stated if Resident #3 was prescribed Digoxin for his heart, then it should be care planned as well. She stated she did not know why it was not included in the care plan and she stated it may have been overlooked. She stated the risk of those things not being in the care plan was not having the interventions in place for the residents to tell staff what to do if something happened.In an interview on 05/22/2026 at 10:22A.M. with MDS Nurse, she stated she had been employed at the facility since March 2026 and reviewed some of the care plans, but she had not gotten around to review all care plans in their entirety. Record review of the facility policy titled, Resident Assessment, Comprehensive Care Plan, dated 01/20/2021, read in part, Policy .Every resident will have an individualized interdisciplinary plan of care in place. The Care Plan is revised every quarter, significant change of condition, Annual or as the resident condition change on an individualized basis.5. The Interdisciplinary Team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments, etc.) and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to: .a. Initial goals based on an admission include GG Section discharge goals. b. Physician orders.

Number of residents sampled: Number of residents cited: The facility failed to ensure physician orders were obtained and care plans were updated to reflect the use of bed rails for 5 of 5 residents reviewed with bed rails. This failure had the potential to result in the inappropriate use of bed rails and increased risk of entrapment, injury, and decline in resident well-being.This failure could place residents at risk for entrapment, injury, restricted movement, and the use of unnecessary physical restraints. Findings included: During observations on 05/19/26 at 10:00am time, bed rails were in use for Resident #1 , Resident #3 Resident #5 Resident #7, and Resident #9.Record reviews conducted on 05/20/26 revealed that Residents #1, #3, #5, #7, and #9 had no physician orders authorizing bed rail use and no care plans addressing the use, monitoring, risks, benefits, or clinical necessity of bed rails. During an interview on 05/20/26 at 1:35 p.m., the Administrator stated the facility was a restraint-free facility; however, some residents had bed rails because they were hospice residents. The Administrator further stated that physician orders were required for residents utilizing bed rails.During an interview on 05/21/26 at 9:00 a.m., the Director of Nursing (DON) stated the facility was restraint-free and confirmed that none of the residents identified with bed rails had physician orders or care plans addressing bed rail use.During an interview on 05/21/26 at 9:10 a.m., the Assistant Director of Nursing (ADON) stated she was unaware that physician orders were required for residents using bed rails.Durning an interview with Resident#1 on 05/19 at 10:10 am she stated that she uses the bedrails to help her move around in her bed. Record review of facility policy on 05/22/26 at 10:00 a.m., titled ,Restraint Management, dated 04/2021 revealed that physician orders must be obtained and care plan updated to reflect appropriate use of siderails.

Number of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure residents were free from any significant medication errors for 1 of 7 (Resident #65) residents reviewed for pharmacy services.-The facility failed to administer Resident #65's ordered Insulin Glargine on 5/20/26.This failure could place residents at risk of not receiving the therapeutic benefits of their medication and possible hyperglycemia (high blood sugar).Findings include:Record review of Resident #65's undated face sheet revealed he was an [AGE] year old male who admitted to the facility on [DATE]. He had diagnoses of diverticulitis (inflammation or infection of pouches) of large intestine, PNA (lung infection), dysphagia (trouble swallowing), type 2 diabetes (body does not produce insulin or resists it), heart failure (heart does not pump effectively, and gastrostomy (tube into stomach for nutrition).Record review of Resident #65's Quarterly MDS assessment, dated 3/4/26, revealed a BIMS score of 99, which indicated it was unable to be performed due to the resident's medical condition. The assessment revealed the resident had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. Resident #65 was dependent (helper does all the work, resident does none of the effort to complete the activity) for all ADLs. The resident was receiving PEG (tube into stomach for nutrition) feeding while a resident and received 51% or more total calories through the tube feeding and 501 cc/day per day through it. The assessment revealed the resident had received daily insulin injections.Record review of Resident #65's Care Plan, dated 8/14/25, revealed a Focus: Resident #65 was at risk for hyper/hypoglycemia related to insulin glargine/Jardiance. Interventions included giving diabetes medication as ordered by the doctor and monitoring/documenting for side effects and effectiveness.Record review of Resident #65's Physician Orders as of 5/20/26 revealed the following orders from MD J:-Calcium Carbonate Oral Tablet 600mg, 1 via g-tube BID. Ordered 3/6/26.-Famotidine Oral Tablet 20mg, 1 via g-tube QD. Ordered 3/18/26.-Jardiance 25mg Tablet, 1 via g-tube QD. Ordered 4/16/26.-Insulin Glargine Subcutaneous Solution 100u/ml, 5u SQ QD. Ordered 8/8/25.In an observation on 5/20/26 at 10:00am, LVN O gave Resident #65 the following medications:-Jardiance 25mg 1 via g-tube-Calcium with Vitamin D 600mcg/10mcg 1 via g-tube-Famotidine 20mg 1 via g-tubeIn an interview on 5/20/26 at 11:34am, LVN O said he held the Insulin Glargine 5u because the resident's blood sugar was less than 100 and it was common knowledge to hold the insulin if the blood sugar was less than 100. He said it was ok to hold the insulin even though there was not a doctor's order to hold it or parameters on the insulin. LVN O said he was going to contact the doctor later to let him know. In an interview on 5/20/26 at 12:17pm, the DON said LVN O should not have held the insulin unless there was an order to hold it, because staff must follow doctor's orders and cannot practice medicine by taking it upon themselves to not give a medication. Record review of Resident #65's blood sugar results as of 5/20/26 revealed his blood sugar was not taken until 2:17pm and was 117.Record review of the facility's policy and procedures on Preventing and Detecting Adverse Consequences and Medication Errors (effective 8/2020) read in part: .Significant medication related problems are assessed, documented, and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy; the consultant pharmacist, and the Food and Drug Administration MedWatch Program or USP/ISMP Medication Error Reporting Program (when applicable).The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis in accordance with the policy on Medication Management.Facility staff monitor the resident for possible medication-related adverse consequences, including mental status changes and/or changes in level of consciousness, when the following conditions occur:.Medication error, such as wrong or expired medication. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safely and welfare. Significant is defined as: Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization. Resulting in disability. Requiring treatment with a prescription medication. Resulting in cognitive deterioration or impairment. Life threatening. Resulting in death.Data regarding medication adverse consequences and errors (i.e., total number of incidents, number of Incidents by category/type, trends) will be compiled and presented to the Quality Assessment and Assurance (QM) Committee by the Director of Nursing on a monthly basis. The QAA Committee then conducts a root cause analysis of medication administration errors to determine the source of errors and implement process improvement steps and compares results over time to determine that system improvements are effective in reducing errors.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 6%, based on 2 errors out of 33 opportunities, which involved 1 of 7 residents (Resident #65) and 1 of 4 staff (LVN O) observed during medication administration reviewed for medication errors.-The facility failed to administer Resident #65 the correct medication (Calcium 600mg) and instead gave Calcium with Vitamin D 600mcg/10mcg, on 5/20/26.-The facility failed to administer Resident #65 their Insulin Glargine on 5/20/26.These failures could place residents at risk of not receiving the therapeutic effects of their prescribed medications and possible adverse reactions.Finding include: Record review of Resident #65's undated face sheet revealed he was an [AGE] year old male who admitted to the facility on [DATE]. He had diagnoses of diverticulitis (inflammation or infection of pouches) of large intestine, PNA (lung infection), dysphagia (trouble swallowing), type 2 diabetes (body does not produce insulin or resists it), heart failure (heart does not pump effectively, and gastrostomy (tube into stomach for nutrition).Record review of Resident #65's Quarterly MDS assessment, dated 3/4/26, revealed a BIMS score of 99, which indicated it was unable to be performed due to the resident's medical condition. The assessment revealed the resident had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. Resident #65 was dependent (helper does all the work, resident does none of the effort to complete the activity) for all ADLs. The resident was receiving PEG (tube into stomach for nutrition) feeding while a resident and received 51% or more total calories through the tube feeding and 501 cc/day per day through it. The assessment revealed the resident had received daily insulin injections.Record review of Resident #65's Care Plan, dated 8/14/25, revealed a Focus: Resident #65 was at risk for hyper/hypoglycemia (high or low blood sugar) related to insulin glargine/Jardiance. Interventions included giving diabetes medication as ordered by the doctor and monitoring/documenting for side effects and effectiveness.Record review of Resident #65's Physician Orders as of 5/20/26 revealed the following orders from MD J:-Calcium Carbonate Oral Tablet 600mg, 1 via g-tube BID. Ordered 3/6/26.-Famotidine Oral Tablet 20mg, 1 via g-tube QD. Ordered 3/18/26.-Jardiance 25mg Tablet, 1 via g-tube QD. Ordered 4/16/26.-Insulin Glargine Subcutaneous Solution 100u/ml, 5u SQ QD. Ordered 8/8/25.In an observation on 5/20/26 at 10:00am, LVN O gave Resident #65 the following medications:-Jardiance 25mg 1 via g-tube-Calcium with Vitamin D 600mcg/10mcg 1 via g-tube-Famotidine 20mg 1 via g-tubeIn an interview on 5/20/26 at 11:34am, LVN O said he held the Insulin Glargine 5u because the resident's blood sugar was less than 100 and it was common knowledge to hold the insulin if the blood sugar was less than 100. He said it was ok to hold the insulin even though there was not a doctor's order to hold it or parameters on the insulin. LVN O said he was going to contact the doctor later to let him know. The nurse said he should not have given the Calcium with Vitamin D and should have asked his supervisor about it. LVN O said giving the wrong medication to a resident could be harmful.In an interview on 5/20/26 at 12:17pm, the DON said LVN O should not have held the insulin unless there was an order to hold it, because staff must follow doctor's orders and cannot practice medicine by taking it upon themselves to not give a medicine. She said the nurse should have clarified the Calcium order if he had questions. Otherwise, he should have looked for the right medication that was Calcium by itself and not with the Vitamin D in it. The DON said he gave the wrong medication to the resident and giving the wrong medication could cause adverse effects.Record review of Resident #65's blood sugar results as of 5/20/26 revealed his blood sugar was not taken until 2:17pm and was 117.Record review of the facility's policy and procedures on Administering Medications (revised April 2019) read in part: Medications are administered in a safe and timely manner, and as prescribed.The Director of Nursing Services supervises and directs all personnel who administer medications and/or have related functions.Medications are administered in accordance with prescriber orders.Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training.The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.If a drug is withheld, refused, or given at a time other than the scheduled time, the individual administering the medication shall initial and circle the MAR space provided for that drug and dose.Record review of the facility's policy and procedures on General Guidelines for Medication Administration (effective 9/2018) read in part: Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to administer.At a minimum, the 5 Rights - right resident, right drug, right dose, right route, and right time should be applied to all medication administration and reviewed at three steps in the process of preparation: (1) when medication is selected, (2) when the dose is removed from the container, and (3) after the dose is prepared and the medication is put away. Check #1: Select the medication, check the label, container, and contents for integrity, and compare the medication against the Medication Administration Record (MAR) by reviewing the 5 Rights.Always employ the MAR during medication administration. Prior to the administration of any medication, the medication and dosage schedule on the resident's MAR are compared with the medication label. If the label and the MAR are different and the container has not already been flagged indicating a change in directions, or if there is any other reason to question the dosage or directions, the physician's orders are checked for the correct dosage schedule.If a medication with a current, active order cannot be located in the medication cart/drawer, other areas of the medication cart, medication room, and facility (e.g. other units) are searched, if possible. If the medication cannot be located after further investigation, the pharmacy is contacted or medication removed from the emergency kit.Record review of the facility's policy and procedures on Preventing and Detecting Adverse Consequences and Medication Errors (effective 8/2020) read in part: .Significant medication related problems are assessed, documented, and reported as appropriate to the resident's attending physician, the Quality Assessment and Assurance Committee, the pharmacy; the consultant pharmacist, and the Food and Drug Administration MedWatch Program or USP/ISMP Medication Error Reporting Program (when applicable).The interdisciplinary team reviews the resident's medication regimen for efficacy and actual or potential medication-related problems on an ongoing basis in accordance with the policy on Medication Management.Facility staff monitor the resident for possible medication-related adverse consequences, including mental status changes and/or changes in level of consciousness, when the following conditions occur:.Medication error, such as wrong or expired medication. In the event of a significant medication-related error or adverse consequence, immediate action is taken, as necessary, to protect the resident's safely and welfare. Significant is defined as: Requiring medication discontinuation or dose modification. Requiring hospitalization or extending a hospitalization. Resulting in disability. Requiring treatment with a prescription medication. Resulting in cognitive deterioration or impairment. Life threatening. Resulting in death.Data regarding medication adverse consequences and errors (i.e., total number of incidents, number of Incidents by category/type, trends) will be compiled and presented to the Quality Assessment and Assurance (QM) Committee by the Director of Nursing on a monthly basis. The QAA Committee then conducts a root cause analysis of medication administration errors to determine the source of errors and implement process improvement steps and compares results over time to determine that system improvements are effective in reducing errors.

Based on observation, interview, and record review, the facility failed to administer parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 1 resident (Resident #41) sampled for parenteral fluids.-The facility failed to ensure Resident #41's PICC line was clean before an IV line was attached to it on 5/20/26.-The facility failed to ensure Resident #41 received all of his ordered antibiotic on 5/20/26.These failures could place residents at risk for infection and risk for not receiving the full therapeutic benefits of the antibiotic.Findings included:Record review of Resident #41's undated face sheet revealed he was a [AGE] year old male who admitted to the facility on [DATE]. He had diagnoses of osteomyelitis of his left ankle and foot (bone infection), infection following surgical site incision, cellulitis of left lower limb (skin infection of left lower leg), type 2 diabetes mellitus (body does not produce insulin or resists it), necrotizing fasciitis (severe infection that destroys soft tissue), and ESBL resistance (drug resistant bacteria).Record review of Resident #41's admission MDS assessment dated [DATE] revealed a BIMS score of 15 out of 15, which indicated normal cognition. The resident was independent with all ADLs. Resident was receiving IV antibiotics.Record review of Resident #41's Care Plan dated 4/6/26 revealed a Focus: Resident #41 was on antibiotic therapy Cefepime 1g IV x 14d. Interventions included administering the antibiotics as ordered. Focus: Resident #41 had a PICC (deep line that ends near the heart) line to his LUA. Interventions included treating the site using sterile technique.Record review of Resident #41's Physician Orders as of 5/20/26 revealed the following orders from MD D:-Monitor PICC line for s/s of infection every shift. Ordered 4/3/26.-PICC line dressing and cap change weekly using sterile technique per protocol, one time a day every Thursday. Ordered 4/6/26.-Cefepime HCl Injection Solution Reconstituted (mixed together) 1gm, 1gm IV Q6hr for ESBL for 14 days. Ordered 5/7/26.-Normal Saline Flush Solution, Use 10ml IV every shift for ABT therapy, PICC Line-Flush with 10ml NS prior to med administration. Ordered 4/3/26.In an observation and interview on 5/20/26 at 11:38am, LVN O took the cap off of Resident #41's PICC line and wiped it with an alcohol wipe. He then flushed the line with 10ml of NS. LVN O took the NS syringe off the PICC line and left the PICC line dangling with no cap covering the tip, while he set up his IV line, and reconstituted the antibiotic. During this time Resident #41 put his arm down and the tip of the PICC line was against his arm and his side. Once LVN O had reconstituted (mixed) the Cefepime he did not get all of the liquid antibiotic back into the IV bag and left a moderate amount in the vial that would not be delivered. He spiked (put the IV tubing into the IV bag) the IV tubing and primed it (drained the medication through the line). Then he hooked the tubing up to Resident #41's PICC line without cleaning the tip again, after the resident had been rubbing the tip against his shirt the whole time. LVN O said the medication that was left in the vial was just foam and that happened sometimes when medication was reconstituted. He did not think to clean the tip of the PICC line again and did not see the resident rubbing it against his clothes. He said not cleaning the tip could cause infection control issues.In an interview on 5/20/26 at 12:17pm, the DON said the antibiotic vial should be empty and all of it should be in the IV bag to ensure the resident got all of the medication. She also said the tip of the PICC line should have been cleaned before the IV line was attached to prevent any infection.Record review of the facility's policy and procedures on Administration Procedures: Reconstitution of Medications (effective 2/2009) read in part: To provide guidelines for mixing additives into a sterile IV solution.IV certified nurses with proper training and authority may prepare admixtures when: Medication stability requires mixing immediately prior to administration. Immediate administration of a medication is indicated.Gently shake to dissolve the medication into the solution. Hold the bag with the vial upside down and squeeze the bag to force air into the vial. Release to drain the dissolved drug from vial. Repeat steps 8-11 until vial is empty of drug and solution is thoroughly mixed.Prime the IV tubing after hanging the container on an IV pole ensuring that the vial is completely empty of medication and solution.A policy on IVs/PICC lines was requested but not received.

Number of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 1 (Resident #65) residents reviewed for tube feeding. -The facility failed to ensure Resident #65's G-tube was in the correct place before he was administered medications on 5/20/26.This failure could place residents at risk for the medications going into the abdominal cavity, pain, infection, and hospitalization.Findings include:Record review of Resident #65's undated face sheet revealed he was an [AGE] year old male who admitted to the facility on [DATE]. He had diagnoses of diverticulitis (inflammation or infection of pouches) of large intestine, PNA (lung infection), dysphagia (trouble swallowing), type 2 diabetes (body does not produce insulin or resists it), heart failure (heart does not pump effectively, and gastrostomy (tube into stomach for nutrition).Record review of Resident #65's Quarterly MDS assessment, dated 3/4/26, revealed a BIMS score of 99, which indicated it was unable to be performed due to the resident's medical condition. The assessment revealed the resident had severely impaired (never/rarely made decisions) cognitive skills for daily decision making. Resident #65 was dependent (helper does all the work, resident does none of the effort to complete the activity) for all ADLs. The resident was receiving PEG (tube into stomach for nutrition) feeding while a resident and received 51% or more total calories through the tube feeding and 501 cc/day per day through it. The assessment revealed the resident had received daily insulin injections.Record review of Resident #65's Care Plan, dated 8/14/25, revealed a Focus: Resident #65 required tube feeding of Glucerna 1.5 (type of g-tube feed) @ 50ml/hr r/t dysphagia (trouble swallowing). Interventions included keeping the resident's HOB elevated 45 degrees during and 30min after feeding, checking for tube placement and gastric contents/residual volume per facility protocol and record, holding feed if aspirating (going into the lungs).Record review of Resident #65's Physician Orders as of 5/20/26 revealed the following orders from MD J:-Calcium Carbonate Oral Tablet 600mg, 1 via g-tube BID. Ordered 3/6/26.-Famotidine Oral Tablet 20mg, 1 via g-tube QD. Ordered 3/18/26.-Jardiance 25mg Tablet, 1 via g-tube QD. Ordered 4/16/26.-Glucerna 1.5 @ 50ml/hr and water 45ml/hr x 22hr, every shift. Ordered 3/5/26.In an observation on 5/20/26 at 10:00am, LVN O did not check Resident #65's g-tube placement and then gave the following medications:-Jardiance 25mg 1 via g-tube-Calcium with Vitamin D 600mcg/10mcg 1 via g-tube-Famotidine 20mg 1 via g-tubeIn an interview on 5/20/26 at 10:10am, LVN O said to check for placement (ensuring the g-tube is in the right place) on a g-tube, the facility checks the resident's residual (pulling back on a syringe to see how much comes back). He said he did not check for placement because he had checked placement earlier in the morning. LVN O agreed that placement should be checked before each time anything was put in the g-tube because if the residual was not checked and it was too high, the resident could choke.In an interview on 5/20/26 at 12:17pm, the DON said the protocol for checking placement on a g-tube was to check residual each time, before anything is given through the PEG tube. She said checking for placement was to prevent the resident from being too full and aspirating.Record review of the facility's policy and procedures on Enteral Tube Medication Administration (effective 9/2018) read in part: Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medication with an enteral tube. Nursing policies developed by the facility may supersede the procedures outlined in this policy.With gloves on, check for proper tube placement in accordance with facility policy. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100ml.

Based on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN A used the required PPE for Resident #1, who was on enhanced barrier precautions while performing pressure ulcer treatment on 11/5/25. These failures could place residents at risk of cross-contamination and development of infection.Finding include:Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE]. Resident #1 had diagnoses which included history of neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation (bowel movements that are infrequent, hard ,dry or difficult to pass), , orthostatic hypotension (sudden drop blood pressure), bacterial infection, unspecified, cognitive communication deficit need for assistance with personal care.Record review of Resident #1's quarterly MDS assessment, dated 10/20/2025, Section C (Cognitive Patterns) reflected BIMS score was 04 which indicated severely impaired cognitively. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #1's functional status revealed he was dependent with supervision of staff with bed mobility, transfer, and toilet use. Further review revealed Resident #1 had a supra pubic Foley catheter.Record Review of Resident's #1's care plan dated 9/28/2025 reflected I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days.Observation on 11/5/25 at 11:59 AM, revealed Resident #1 lying in bed, a EBP sign was posted inside the room. LVN A entered Resident #1's room without donning PPE and performed pressure ulcer treatment to Resident #1. Interview with the LVN A on 11/5/25 at 12:30 PM revealed she forgot to don PPE. LVN A said she realized she should have donned PPE to protect the resident and herself for infection. She knew not donning PPE could cause infection. LVN A said she would be more careful. In an interview with the DON on 11/5/25 at 5:15 PM, she stated any resident who had wounds, contact isolation, Gastrostomy tube feeding, or Foley catheter was placed on Enhanced Barrier precautions to help reduce the spread of MDRO's. She stated signage was posted inside the head of Resident #1's bed, which explained what PPE was to be worn and for what task the PPE was to be worn for. She stated any contact with a resident with pressure ulcer required the use of gown and gloves. She stated the staff received training on the use of Enhanced Barrier Precautions. Record review of the facility's policy revised, 04/01/2024, on Enhanced Barrier Precautions, reflected the following: Policy Statement: Enhanced barrier precautions (EBPs) are a CDC guidance to reduce the transmission of multi-drug resistant organisms (MDRO) in health care settings, including nursing homes, EBP require team members to wear a gown and gloves while performing high-contact care activities with residents who are infected or colonized with a targeted MDRO or who have open wound or indwelling medical device.Record review of CDC guidelines reflected: https://www.cdc.gov/infection-control/hcp/basics/transmission-based-precautions.html: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. Donning Personal protective equipment upon room entry and properly discarding before exiting the patient room is done to contain pathogens.

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinent care. The facility failed to ensure Resident #1's supra pubic Foley catheter was placed below the bladder during wound care by LVN A and CNA A.These failures could place residents at risk for pain, infection, injury, and hospitalization.Findings include:Record review of Resident #1's face sheet reflected, the date of admission was 11/20/21 and was readmitted on [DATE]. Resident #1 had diagnoses which included history of recurrent, mild, neuromuscular dysfunction of bladder, (the nerves controlling your bladder are damaged and can no longer coordinate properly with the bladder muscles), constipation ( bowel movements that are infrequent, hard, dry or difficult to pass), bacterial infection, unspecified, cognitive communication deficit, , need for assistance with personal care.Record review of Resident #1's quarterly MDS assessment, dated 10/20/2025, Section C (Cognitive Patterns) reflected a BIMS score was 04 which indicated resident was severely impaired cognitively. Section H (Bladder and Bowel) reflected the resident had an indwelling catheter. Resident #1's functional status revealed he was dependent with supervision of staff with bed mobility, transfer, and toilet use. Further review revealed Resident #1 had a supra pubic Foley catheter.Record Review of Resident's #1's care plan dated 9/28/2025 reflected I have ADL self-care performance deficit and totally dependent on staff for all ADLs and requires assistance with activities of daily living due to decreased physical and functional mobility secondary to weakness and multiple medical comorbidities.I will remain clean, dry, without odor and comfortable every shift on a daily basis, with all needs to be anticipated and met by staff through the next 90 days. Record review of Resident #1's physician order, dated 10/27/2025, read in part .check supra pubic Foley catheter every shift and keep catheter from kinks and drainage bag lower than bladder at all times. Observation of Resident #1 on 11/5/25 at 11:55 AM, CNA A and another staff transferred Resident #1 on the shower bed via Hoyer lift to his bed . CNA A placed Resident #1's supra pubic Foley catheter on the bed with 40cc of urine and some urine along the catheter tubing. At 11:59 AM, LVN A came in Resident #1's room to perform Resident #1's pressure ulcer treatment to sacral, ischium, bottom and upper back, Resident #1's supra pubic remained on the bed during treatment.Interview with LVN A on 11/05/25 at 12:25PM, about the suprapubic F/C left on Resident #1's bed during pressure ulcer treatment, LVN A said she did not realized that the F/C bag was not hung at the bedside. LVN A said the F/C should be hung below Resident #1's bladder to prevent back flow of urine to bladder. Interview with CNA A on 11/05/25 at 1:41PM, regarding F/C left on the bed during pressure ulcer treatment, CNA A said he forgot, he was nervous and knew the F/C should be below the bladder to prevent urine flowing back in the bladder, which could cause a UTI. CNA A said he had in-service on Foley catheter care. Interview with the DON on 11/5/25 at 5:22 PM, she said the F/C should be hung below Resident #1's bladder and this is to prevent back flow of urine to bladder which could result in Resident #1 acquiring a UTI. The DON said she would be monitoring the CNAs randomly now. The DON said she does have monthly in -services on F/C and incontinent care. Record review of the facility's policy for Catheters and Care: Indwelling, straight, supra-pubic, and External Urinary, revised date of 4/2021 reflected: RN/LVN to insert catheter using following procedure.6. Secure urinary drainage bag below the level of the bladder and keep off the floor. Coil extra tubing and secure.

Based on observation, interview, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. The facility failed to ensure staff did not store their personal items on the left second shelf of the walk-in cooler, including:. 1. Jumex mango energy drink can. 2. Red bull watermelon drink can 3. Coffee mate coconut liquid creme 32fl oz 4. A black and white with yellow brown flower lunch bag with 2 bottles of water, and one of the bottled water was open. The facility failed to ensure staff did not store three gray crates on the floor by Dishwasher A. These failures could place residents at risk for cross contamination and air-borne illnesses. Findings include: During an observation on 03/11/25 at 8:21 a.m., the following items were on the left second shelf of the walk-in cooler: a Jumex mango energy drink can, a Red Bull watermelon drink can, a Coffee-mate coconut liquid creme 32fl oz, and a black-and-white with yellow-brown flowers lunch bag with two bottles of water, one of which was open. They were staff personal items stored on the left second shelf of the walk-in cooler. During an interview on 03/12/25 at 8:24 a.m., the DM said the items in the cooler belonged to staff and should not be kept in the walk-ing cooler because it was cross-contamination. The DM said he was responsible for monitoring the staff and ensuring that only the items bought by the facility were stored in the walk-ing cooler. He said the kitchen staff had in-service on infection control and storage. During an observation on 03/11/25 at 8:26 a.m., three gray dish crates were on the floor by the dish washer and the three-compartment sink and the floor was wet. Dish washer A picked up the three crates and placed them on top of the clean stacked crates which were stored off the floor. During an observation and interview on 03/11/25 at 8:28 a.m., the DM said he saw the three crates were on the wet floor between the washing machine, and the three-compartment sink. The DM said the dish crates should not have been placed on the floor because of infection (cross - contamination). He said he monitors the staff throughout the shift. The DM stated if clean plates were placed in the dirty crates, the residents could get sick if the residents ate from the plates. During an interview on 03/11/25 at 8:49 a.m., Dishwasher A said he placed the three crates on the floor, removed them, and placed them on top of the clean crates. Dishwasher A said he should not have put the crates on the floor because of infection control. Dishwasher A said if a resident ate off any plate that came in contact, the resident could become sick because the germs from the crates could be transferred to the plate. Dishwasher A said he had infection control training and in service, and the dietary manager monitors the kitchen staff throughout the shift. During an interview on 03/11/25 at 3:25 p.m., the Administrator said none of the kitchen equipment, including crates, should be placed on the floor. The crates are not supposed to be picked up and placed on a clean surface because of infection control (cross-contamination). The Administrator said the staff should not place their personal belongings in the walk-in cooler because it would cause cross-contamination. Record review of the facility food receiving and storage dated 2001 MED - PASS, Inc. (Revised October 2017) read in part . foods shall be received and stored in a manner that complies with safe food handing practices . policy interpretation and implementation .

Based on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 refrigerator reviewed for food safety. The refrigerator located on the 400 hall contained undated and unlabeled perishable food items. These failures could place residents at risk for cross contamination and other air-borne illnesses. Findings include: Observations/Interview on 03/12/2025 at 02:12 p.m. revealed within refrigerator located on hall-400 behind locked code accessed glassed wooden door designated for resident's food brought from the outside contained: 1. Undated bag of plastic containers containing green vegetables and soup. 2. Unlabeled/undated bagged and boxed chicken and other unidentifiable food items. 3. Unlabeled/undated bagged containers of supplement shakes, and protein drinks. 4. Unlabeled/undated clear wrapped cup of sugar. 5. Unlabeled/undated bagged drink container not labeled or dated. 6. Unlabeled/undated bagged oranges not labeled or dated. Assistant Director of Nursing (ADON) A stated that the food in a brown plastic bag with containers of green vegetables and broth like soup labeled with Resident #74's name and not dated belonged to the Resident #47 whose wife had brought and left the food for the resident today. She stated that the wife had the code to the room and was supposed to inform nursing staff that the 2-bagged items with food were being stored so that the nursing staff could label, date, and ensure that the food sat leveled in the refrigerator. ADON A then pulled out a white paper bag sealed with a fast-food restaurant sticker. Inside contained a box with what appeared to be chicken and other unidentifiable food items. The food box was flimsy, worn and not labeled and not dated. ADON A then pulled at a white plastic bag with slight difficulty as the bag was frozen to back of refrigerator wall. Inside the bag contained 2-meal supplement shakes and 8-protein drinks. The bag nor the drinks were labeled or dated. She stated that possibly the nursing staff had stored the shakes/supplemental drinks there for medication pass usage. She stated that the bag being frozen to the back of the refrigerator indicated to her that the drinks had been in there for some time. On the door of the refrigerator ADON was observed removing a white syrofoam cup wrapped in clear plastic wrap resembling sugar, not labeled, or dated. She stated that the nursing staff probably stored the sugar for a resident. She was then observed removing a brown and black drink container not labeled or dated. She stated that the container probably belonged to a nursing staff. The ADON was than observed removing 3-oranges in a clear bag not labeled or dated. The ADON stated that she was unaware who the oranges belonged to. She stated that she would immediately discard the unlabeled and undated items. She stated that the refrigerator was for the storing of resident food items only. She stated that the nursing staff were responsible for monitoring the refrigerator and ensuring foods were leveled to avoid spillage and had not stayed in there too long. During an interview on 03/12/25 at 3:32 p.m., the Administrator said the facility had an area where the family could store food brought from home, and the family should tell the staff whenever the family brought food from home for residents. The Administrator said when the family notified the nurse, the nurse would date the food with the start date, discard date, and resident information. She said if the food was cooked, the facility kept the food for 24 hours. Record review of policy dated effective: 01/2018 and last revised: 03/2021 Section: Nutritional Management Department: Food & Nutrition Services. Policy: Food from Outside Sources. POLICY Residents may have outside sources of food brought in. The community will ensure that proper steps are taken so that the food remains safe. PROCEDURE 1. Community team members will educate residents and/or family members on food brought in from outside the community on: a. Proper Storage i. Cold items stored in resident refrigerator & discarded appropriately based on labeled dates and/or 3 days after opening to prevent food borne illness ii. Dry goods properly sealed to prevent pests & discarded appropriately based on labeled dates . If residents would like the Food & Nutrition Services Team to store their food item, the following conditions must be met: a. Food is unopened b. Resident Name is labeled on food product c. Receive date added d. Open date is added (once opened)

Based on observations, interviews, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices goals and preferences for 1 of 3 (Resident #49) residents reviewed for pain management. -CNA H failed to stop performing incontinent care while Resident #49 was in pain. -CNA H failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner after incontinent care. These failures could place resident at risk for increased pain causing undue suffering. Findings included: Record review of Resident #49's face sheet, reflected she was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue being acutely or chronically compressed commonly due to a traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood) Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance. Section GG of Resident #49's MDS indicated Resident #49 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #49's MDS assessment indicated Resident #49 was at risk for developing pressure ulcers. Record review of Resident #49's care plan with a revision date of 02/10/2025 revealed Resident #49 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Resident #49 was also care-planned for potential pain due to brain injury and stroke, with interventions including assess characteristics of pain, administering pain medications as ordered, discussing with resident regarding factors of pain and what can reduce it, and discuss with physician that for maximum pain to give medications as ordered and as needed. Record review of Resident #49's Physician Orders, she had orders for pain monitoring starting 12/16/2024 and document interventions such as applying heat or cold or re-positioning. Record review of Resident #49's weekly wound evaluation and summary report dated 3/6/2025 revealed Resident #49 had no wound on her sacrum. Record review of Resident #49's MAR dated 3/1/25 through 3/13/25 for monitoring pain every shift (day, evening and night) documented zero every shift, indicating no pain. Record review of Resident #49's skin assessment progress notes dated 3/13/25 reflected an open skin area to the sacral and coccyx bone area measurement was 5cm (Length) x 0.3cm (width). Observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H revealed Resident #49 was lying in bed on her back. CNA H entered Resident #49's room then began cleaning in between Resident #49's buttock with the wet wipes . At the same time CNA H was wiping, Resident #49 was grimacing and said ouch, ouch. CNA H applied Zinc Oxide 20 % cream which was a skin protectant. Resident had an open area between her buttocks measuring about 5 cm. In an interview with CNA H on 3/12/25 at 2:10 PM, she said she had been working with the facility for 1 year and she had an in-services on reporting to her charge nurse when a resident was is in pain. She stated that she failed to notify the Wound Care Nurse of Resident #49's pain in a timely manner. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. Resident #49 had a large bowel movement. Wound Care Nurse repositioned Resident #49 to the left side, and used the wet wipes to clean in-between the buttocks, where the sacral and coccyx bones meet. Resident #49 was grimacing and hitting the bed. The Wound Care Nurse did not assess Resident pain level . In an interview with Wound Care Nurse on 3/12/25 at 6:35 PM, she said she was not aware of the open area on Resident #49's buttock and that she was grimacing during incontinent care. The nurse said she did assess Resident #49 afterward, and the resident was still grimacing. When the nurse asked if she was in pain, she said Resident #49 told her she was not in pain but that it burned. The nurse said if someone looks like they're in pain, she will assess and provide pain treatment. If they're in pain during care she said she would stop and ask them. The Wound Care Nurse said she told the doctor about the burning pain, and the resident had a standing order for pain and doctor didn't give anything new. The nurse's expectation for nurses and aides are that they would tell her or nurses on the floor when they find something new. During an interview on 3/12/25 at 6:42 PM the DON said the Wound Care Nurse was supposed to measure the open area and notify the wound doctor and RP of any changes. The DON said she would in-service on notification. In an interview with the DON on 3/13/25 at 12:52 PM she stated CNA H and Wound Care Nurse should have stopped incontinent care when Resident #49 was in pain. The DON stated nurses were instructed to monitor for pain every shift. She stated the negative effects for not monitoring residents' pain would be the pain would be unmanaged.

Based on observation, interview and record review the facility failed to ensure based on a resident's comprehensive assessment, a resident who was fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 3 (Residents # 32, #37 and #49) of 4 residents reviewed for g-tube medication administration . RN A failed to ensure Resident #32's GT (g-tube, a surgically placed device including a tube that leads from the outside of the body to the stomach to provide nutrition or medication) medications and water were administered by gravity, not by pushing the water via Resident #32's g-tube. RN A failed to ensure Resident #49's GT medications and water were administered by gravity, not by pushing the water via Resident #49's g-tube. LVN A did not check Resident #37's feeding bag for dates on 03/14/2025 during her shift. This failure could place residents at risk of abdominal discomfort, tube dislodgement, and tube occlusion (blockage) and possible infection. Findings include: Record review of Resident #32's Admission Record dated 03/14/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #32's quarterly MDS Assessment, dated 02/25/25, ref lected his diagnoses included cerebral arteriosclerosis (a narrowing of arteries due to fatty buildup and limits supply of blood to the brain), aphasia (language disorder) following cerebral infarction (stroke), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties). Resident #32's BIMS score was 00 which indicated severe cognitive impairment. The MDS further reflected Section K - Swallowing/Nutritional Status indicated the resident's nutritional approach was a feeding tube. Record review of Resident #32's care plan, revised date 03/03/25, reflected: Feeding Tube: Resident requires the use of a feeding tube and is at risk for aspirations, weight loss, and dehydration. Goal: Resident will maintain adequate nutritional and hydration status as evidenced by weight being stable, no signs or symptoms of malnutrition, or dehydration through review date. Interventions: Check for tube placement and monitor gastric contents 'residual volume' (amount of liquid drained from a stomach following administration of enteral feed) per facility protocol. Hold tube feedings and notify physician if residual volume is greater than threshold as dictated by the physician. Record review of Resident #32's physician order, dated 03/01/2025, reflected: Enteral Feed Order every shift Check gastric residual volume. Hold feeding and notify physician for residual greater than 150cc. Flush with 30ml of water and reconnect feeding tube. Record review of Resident #32's physician order, dated 03/01/25, reflected: Enteral Feed Order every shift Flush enteral tube with 30ml water pre/post medication administration and 5-10 ml water between each medication. Observation on 03/12/25 at 9:09 AM revealed RN A stood outside Resident #32's door. She was preparing to provide Resident #32's medications. RN A performed hand hygiene and donned a pair of gloves. RN A disconnected Resident #32 from his g-tube feeding and checked the residual with the syringe. RN A proceeded to flush with 30 cc of water with a syringe by pushing down the plunger on the GT , then administered medications and flushed with water by pushing water through the syringe. RN A connected the resident back to the g-tube and turned-on the feeding pump. Record review of Resident #49's face sheet last captured 03/12/2025 Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (brain tissue that is acutely or chronically compressed commonly due to traumatic brain injury), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus (high glucose in the blood), Post-Traumatic Hydrocephalus, (PTH- is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. She was totally dependent on staff for all efforts for ADLs including eating. Record review of Resident #49's physician order, dated 03/01/2025, reflected: Enteral Feed Order every shift Check gastric residual volume. Hold feeding and notify physician for residual greater than 150cc. Flush with 30ml of water and reconnect feeding tube. Observation on 03/12/25 at 9:09 AM revealed RN A stood outside Resident #49's door. She was preparing to provide Resident #49's medications. RN A performed hand hygiene and donned a pair of gloves. RN A disconnected Resident #49 from his g-tube feeding, checked residual with the syringe, then she proceeded to flush with 30 cc of water with a syringe by pushing down GT plunger. Then she administered medications and flushed with water by pushing water through the syringe. RN A connected the resident back to the g-tube and turned-on the feeding pump. Interview on 03/12/25 at 12:05 PM with RN A, revealed she always checked for placement and residual before giving medications. She stated she was pushing down the water with the syringe. She stated she was pushing but not hard. She stated pushing down water instead of using gravity could cause stoma (opening in the abdomen) problems, or cause pressure or bleeding. Interview on 03/13/25 at 5:55 PM with the ADON revealed the expectation when administering medication was nurses should be following the physician order, checking for placement, residual, each medication should be given in separate cups and flush with water in between medications. She stated pushing fluid instead of using gravity could cause discomfort to the resident. Interview on 03/13/25 at 6:07 PM with the DON revealed the expectation when administering medication was nurses should be following the physician order and checking for placement and residual. She stated when administering medication or water it should always be via gravity to prevent aspiration pneumonia. Record review of Resident #37's face sheet reflected she was a [AGE] year-old, she was originally admitted on [DATE] and most recently readmitted on [DATE]. Her medical diagnoses included cerebral infarction (stroke), Parkinson's Disease (movement disorder of the nervous system that worsens over time), hypertension (high blood pressure) , muscle wasting, cognitive communication deficit, and nontraumatic subarachnoid hemorrhage (bleeding in the brain with symptoms including paralysis and impairments of nerve and brain function). Record review of Resident #37's care plan last updated 1/23/25, reflected Resident #37 required tube feeding related to Dysphagia with interventions including checking for tube placement and gastric contents or residual volume per facility protocol and record and providing local care to the g-tube site as ordered. Record review of Resident #37's Physician Orders, reflected she had orders for Jevity feeding 1.5 at 45 ML/HR for 20 hours and turn off from 8:00am to 12:00pm starting 04/24/24. Record review of Resident #37's MAR/TAR for March 2025, reflected LVN A documented turning off Resident #37's feeding machine on 3/14/25 at 8:00am . Observation of Resident #37 and interview on 03/14/2025 at 11:04am with the ADON, revealed the feeding bag had no label. The ADON said that the bag should have a labelled and have been dated and initialed by the nurse, and she would talk to the nurse about it. She said if nurses don't document something you cannot prove that they did it. In an interview with LVN A on 3/14/2025 at 12:01pm, she said she did not change Resident #37's feeding bag but did turn it off per Physician Orders. She said she did not notice there was no label on the bag, but she should have checked it for a label and created a label if the feeding bag did not have one. She said that labelling the feeding bag is important so nurses could identify what the resident is receiving and if they're getting the right rate. The bag could have been there for days, and no one would know it was an old feeding. A risk to residents would be infection or abdominal issues if the feeding was sour. Record review of Enteral Tube Medication Administration Policy # 9.12, Effective Date 09-2018 with Revision Date 08-2020, reflected the policy read in part: Medications will be administered in a safe and effective manner. The guidelines in this policy detail how to administer medication with an enteral tube. Nursing policies developed by the facility may supersede the procedures outlined in this policy. 12. With gloves on, check for proper tube placement in accordance with facility policy. 13. Check gastric content for residual feeding. Return residual volumes to the stomach. Report any residual above 100 ml. 14. If a pump is being used for feedings, turn it off. 15. Remove the plunger from the 60 ml syringe and connect the syringe to the clamped tubing using the appropriate port. 16. Administer each medication separately and flush the tubing between each medication. a. Place 15 ml (or the prescribed amount) of water in the syringe and flush the tubing using gravity flow. b. Pour dissolved/diluted medication in the syringe and unclamp tubing, allowing medication to flow by gravity. c. Flush the tube with 15 ml (or the prescribed amount) of water between each medication. Pinch the tubing below the syringe tip when each volume of liquid clears the syringe to avoid excessive air entering the stomach, as this can cause discomfort or emesis. d. Clamp tubing and detach the syringe.

Based on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #45) reviewed for incontinent care. The facility failed to ensure CNA O did not place the foley catheter bag on Resident #45's bed during wound care. This failure could place residents at risk for pain, infection, injury, and hospitalization . Findings included: Record review of Resident #45's sheet dated 03/14/25 revealed a [AGE] year-old female was initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #45 had diagnoses which included: hypertension (force of blood pushing against artery walls consistently too high pressure), respiratory failure (a serious condition that makes it difficult for a person to breathe without help) and pressure ulcer of right hip (injuries to the skin and the tissue below the skin that are due to pressure on the skin). Record review of Resident #45's Quarterly MDS assessment dated [DATE] revealed Resident had memory problem which indicated severely impaired cognition. Resident #45 was dependent on staff for all ADLs with two staff assistance. Further review revealed the resident was incontinent of bowel and she had an indwelling catheter. Record review of Resident # 45's care plan revised on 04/04/24 revealed Resident #45 had an Indwelling Catheter for dx: neurogenic bladder (lacks bladder control due to brain, spinal cord or nerve problem) and multiple pressure ulcers. Interventions: staff to ensure to position catheter bag and tubing below the level of the bladder and with a privacy bag. Record review of Resident #45's order summary report for March 2025 read in part . urinary catheter 20 FR(measurement for the size of catheter), 30CC . diagnosis: neuromuscular dysfunction of bladder: ordered date 02/27/24 . During an observation on 03/12/25 at 9:45 a.m., Resident #45's wound care treatment was provided by the Wound care nurse and CNA O. CNA O placed Resident #45's foley catheter bag on the bed at the same level of the resident's bladder from 9:45 a.m. to 10:00 a.m. During an interview on 03/12/25 at 10:18 a.m., the Wound care nurse said they typically put the Foley bag on Resident #45's bed so the Foley would not pull out when they turned the resident. The Wound care nurse said since the Foley was on the same level as Resident #45's, bladder and urine would back up, the resident could get an infection. The Wound care nurse said the charge nurse on the floor monitored the aides during rounding. The Wound care nurse said she had in-service and skills check-off training on how to work with a resident with a Foley, and she said she could not recall what was taught during the training. The Wound care nurse said the ADON and DON monitored the nurses during random rounding. During an interview on 03/12/25 at 10:59 a.m., CNA O said she placed Resident #45's Foley bag on the bed because they were about to turn the resident to the right for wound care. CNA O said Resident #45's Foley bag was at the same level as the bladder, and the urine would back up to the resident's bladder. CNA O said she had training on Foley care and was educated to place the Foley bag on the side of the bed, to which the resident would be turned, and hang the Foley bag below the bladder. CNA O said when the urine flows back into Resident #45, it could cause an infection for the resident. She said the charge nurse monitored the aides during rounding. During an interview on 03/12/25 at 1:22 p.m., the DON said Resident #45's foley bag should always be placed below Resident #45's bladder when CNA O turned her or during care so the urine would flow through gravity. The DON said if Resident #45's Foley bag was placed on the bed, which was the same level as the bladder, the urine could flow back and could cause a UTI for Resident #45. She said the Wound care nurse and CNA O had training on Foley care, and the bag should be below the bladder. The DON said the nurse monitors the aides during rounding, and the ADON and DON monitor the nurses during random rounding. Record review of the facility policy indwelling catheter dated 04/20/21 read in part . it is the policy of this community that the resident with a urinary catheter will be provided services in a safe and appropriate manner to minimize the risk of urinary tract complications . procedure indwelling catheter #6 .secure urinary drainage bag below the level of the bladder .

Based on observations, interviews, and record reviews, the facility failed to ensure residents received care and treatment consistent with professional standards of practice to prevent pressure ulcers for one (Resident #49) of eight residents reviewed for pressure ulcers. 1. The facility failed to ensure Resident #49 was repositioned every two hours as indicated in Resident #49's physician orders on 3/11/2025 at 1:24 p.m. and 3/12/2025 at 11:49 a.m. 2. The facility failed to ensure Resident #49 was repositioned every frequently and as necessary as indicated in Resident #49's care plan. These failures could place residents at risk for worsening pressure ulcers, new pressure ulcers, or infection. Findings included: Record review of Resident #49's face sheet dated 03/12/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included compression of brain (commonly occurring as a traumatic brain injury where the brain tissue is acutely or chronically compressed), other speech and language deficits, cognitive communication deficit, Type 2 Diabetes Mellitus ( high glucose in the blood), Post-Traumatic Hydrocephalus (PTH is a condition where there is a buildup of excess fluid in the brain after a traumatic brain injury, potentially causing increased pressure and brain damage), Dementia (group of thinking and social symptoms that interferes with daily functioning), gastrostomy status (tube inserted through the belly that brings nutrition directly to the stomach), dysphagia (swallowing difficulties), hemiplegia and hemiparesis (a condition that causes partial or total paralysis of one side of the body), following cerebral infarction affecting left non-dominant side cerebral infarction (a medical condition where blood flow to the brain is disrupted, causing brain tissue to die due to a lack of oxygen and nutrients), Essential Hypertension (high blood pressure) and neuromuscular dysfunction of bladder with indwelling Foley catheter. Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. Further review revealed Resident #49 needed extensive assistance with ADL care with one staff assistance. Section GG of Resident #49's MDS indicated Resident #49 was dependent (required assistance and was unable to help with activities) with all ADLs and was unable to roll to the left or right. Section M of Resident #49's MDS assessment indicated Resident #49 was at risk for developing pressure ulcers. Record review of Resident #49's care plan with a revision date of 02/10/2025 revealed Resident #49 had the potential to develop pressure ulcers and interventions included to reposition the resident frequently or more often as needed. Record review of Resident #49's weekly wound evaluation and summary report dated 3/6/2025 revealed Resident #49 had no wound on her sacrum (area at the base of the spine). Record review of Resident #49's skin assessment progress notes dated 3/13/25 reflected open to sacral and coccyx measurement was 5cm (Length) x 0.3cm (width). Record review of Resident #49's physician order dated 3/01/2025 revealed Resident #49 should be repositioned every two hours . In an observation on 3/11/2025 at 9:39 a.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/11/2025 at 10:46 a.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/11/2025 at 1:24 p.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation on 3/11/2025 at 4:45 p.m., Resident #49 was observed lying flat on her back with one pillow under her head. No other pillows or wedges (foam wedge used for positioning) were observed in Resident #49's room. Resident #49 was unable to answer questions appropriately. In an observation on 3/12/2025 at 9:35 a.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation on 3/12/2025 at 11:49 a.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an observation of incontinent and Foley catheter care on 03/12/25 at 1:30 PM with CNA H, Resident #49 was lying in bed on her back. While cleaning in-between Resident #49's buttocks with the wet wipes. Resident #49 was grimacing and said ouch, ouch. CNA H then applied Zinc Oxide 20 % cream, a skin protectant. In an observation on 3/12/2025 at 3:00 p.m., Resident #49 was observed in the same position on her back with one pillow under her head. No other pillows or wedges were observed in Resident #49's room. In an interview with C.NA H on 3/12/25 at 3:05PM regarding turning and repositioning Resident #49, CNA H said pressure sores were prevented by rotating or turning the resident every two hours. CNA H stated some residents had extra pillows, and some residents had wedges to use for turning. CNA H stated that if a resident was not turned then sores could develop. Observation on 3/12/25 at 6:23 PM of a skin assessment with Wound Care Nurse revealed Resident #49 was lying on her back in bed. LVN repositioned Resident #49 to her left side and used the wet wipes to clean in-between the buttocks, where the sacral (bone or region at base of spine)and coccyx (tailbone) met, with resident grimacing and hitting the bed. Resident #49 had an open area between sacral and coccyx area about 5cm (length) by 0.2cm (wide) and the Wound Care Nurse was asked to measure the open area. She said the wound doctor does the wound measuring. In an interview with the Wound Care Nurse on 3/12/25 at 6:35 PM, she said she was not aware that Resident #49 had an open area in-between her buttocks and she was going to call the doctor and resident's responsible party to notify them. In an interview on 3/13/2025 at 10:10 a.m., the Wound Care Nurse reported if a resident was bedridden then they were repositioned every one to two hours. The Wound Care Nurse reported they used pillows to help reposition residents, and the nurse was responsible for ensuring residents were repositioned. The Wound Care Nurse stated if residents were not repositioned then it could cause skin breakdown (wounds). The Wound Care Nurse stated Resident #49 was on an air mattress and stated Resident #49 was repositioned every one to two hours . In an interview on 3/13/2025 at 11:55 a.m., the DON reported that dependent (requires assistance) residents should be turned every one and a half to two hours and more frequently if they were in pain. The DON stated pillows or wedges were used for repositioning the residents. The DON reported Resident #49 should still be repositioned every one to two hours. Record review of facility's policy titled, Skin Management Policy, with a revision date of 2/01/2014, revealed If new skin alterations of any type are identified .physician orders are obtained. The patient is reviewed by the interdisciplinary team and a plan of care is initiated. A policy specific to repositioning residents for pressure ulcer prevention was not received at the time of exit.

Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet a resident medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment that described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #49) reviewed for care plans. The facility failed to ensure Resident #49's Dementia and Hypertension diagnoses and medications were addressed in her comprehensive care plan. This failure could place residents at risk of not receiving appropriate care. The findings included: Record review of Resident #49's face sheet last captured 03/14/2025 reflected Resident #49 was a [AGE] year-old female originally admitted on [DATE] and readmitted [DATE]. Her medical diagnoses included Dementia (group of thinking and social symptoms that interferes with daily functioning) and Essential Hypertension (high blood pressure). Record review of Resident #49's quarterly MDS assessment, dated 02/10/25, revealed a BIMS score of 05 indicating severely impaired cognition. She was totally dependent on staff for all efforts for ADLs including eating, oral hygiene, toileting, showering or bathing self, dressing and personal hygiene. Further review revealed Resident #49 needed extensive assistance with ADL care with two staff assistance and the resident was incontinent of bowel and continent of bladder with indwelling Foley Catheter. Record review of Resident #49's care plan dated 2/10/25 revealed the resident had ADL (activity of daily living) self-care performance deficit related to limited impairment to upper and lower extremities with interventions including resident needed extensive assist with two-person assistance with incontinent care. and totally dependent on staff for all efforts for ADLs including eating, oral hygiene, toileting, showering or bathing self, dressing and personal hygiene . Record review of Resident #49's order summary, dated 3/1/25, revealed Physician Orders which included the following: - Catapres TTS-3 Patch Weekly 0.3 MG/24Hr (Clonidine Hcl) Apply 1 patch trans dermally one time a day every Tuesday for with an order date of 12/26/2024 and a start date of 12/31/2024 - Hydrochlorothiazide oral tablet 25mg, Give 25mg via peg-tube (a tube that is passed through the abdominal wall to the stomach for delivering nutrition or medication) one time a day for HTN with order date 12/26/24. - Lisinopril tablet 20 mg, Give 2 tablet via G-tube one time a day for HTN hold for SBP < 110, HR less than 60. Record review of Resident #49's Comprehensive Care Plan initiated 2/20/2024 revealed there were no focus areas addressing the resident's diagnoses of Dementia and Hypertension and no focus areas which indicated her medications including Catapres hypertension patch, hydrochlorothiazide and Lisinopril. In an interview with LVN-MDS D on 03/13/25 at 2:47 PM, LVN-MDS D said she had been working as the MDS nurse for 3 years, and she completed care plans. MDS D said that Resident #49's Comprehensive Care Plan did not address their diagnoses of HTN and Dementia, and did not address their active orders for hypertension medications, but it should have . LVN MDS-D stated these diagnoses and medications were ordered/documented prior to her Care Plan being completed, so should have been included on her Comprehensive Care Plan. LVN MDS-D stated these diagnoses and medications should automatically trigger a Care Area Assessment (CAA) area and she did not know why they were not triggered or why they were missed. LVN MDS-D stated she was responsible for the quarterly and annual assessments of the Comprehensive Care Plan. LVN MDS-D further stated it was important for these diagnoses and medications to be addressed in the Care Plan, so staff had the information needed to meet the resident's specific care needs. Interview with the DON, on 03/13/2025 at 5:05 p.m. revealed the Comprehensive Care Plans needed to address and include all of the residents' nursing, mental and psychosocial needs, and contain the interventions and services the resident would need to meet these needs. The DON said she would be assessing and in-servicing staff to ensure the resident needs were being met to include completion of assessments and Care Plans. Record review of the facility's policy dated 1/20/2021, titled Comprehensive Care Planning, revealed .The interdisciplinary team will continue to develop the plan in conjunction with the RAI (MDS3.0) and CAAS, completing and conducting comprehensive Care Plan Meeting and Reviews by day 21 after admission. The Care Plan is revised every quarter, significant change of condition, annual or as the resident condition changes on an individualized basis. The Care Plan process is an ongoing review process: Procedure: 3. The comprehensive care plan is developed within 21 days of admission .5. The interdisciplinary team will review the healthcare practitioner's notes and orders (e.g., dietary needs, medications, routine treatments) and implement a Comprehensive Care Plan to meet the residents' immediate care needs including but not limited to: a. Initial goals based on an admission include GG section discharge goals. b. Physician orders. i. Specific Care plan on the main reason for Admission to the community, i.e.: Dementia

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 3 residents (Resident#33) reviewed for accidents. -The facility did not provide adequate supervision to prevent Resident # 33 from sustaining a burn to her right hand and right foot from a hot (noodle soup) spill. This failure could place residents at risk for serious injuries and pain. Findings included: Record review of the admission sheet (undated) for Resident # 33 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Her diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, muscle weakness (generalized), contracture, right hand and contracture of muscle, right hand. Record Review of Resident #33's comprehensive MDS assessment, dated 10/07/2022, revealed the BIMS score was 11 out of 15 indicating moderately impaired cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet-use and personal hygiene and supervision with eating. The resident was always incontinent of bowel and bladder. Record Review of the care plan, dated 6/22/22 revised on 12/01/22, reaved the following: Focus: (Resident #33) had an ADL self-care performance deficit r/t R Hemiplegia with Right hand and foot contractures. Goal: (Resident #33) will maintain/improve current level of function in ADLs through the review date. Interventions: EATING: (Resident #33) requires set-up assistance by 1 staff to eat. CONTRACTURES: (Resident #33) have contractures of the (Right hand and Right Foot). Provide skin care every shift to keep clean and prevent skin breakdown. Focus: (Resident #33) has a right lower arm burn. Goal: Right lower Arm Burn will resolve without complications within the review date. Interventions: Wound care consult. Perform treatments per MD orders. Monitor for pain, give med per order, monitor for relief. Record review of Resident #33's physician order, dated 11/30/22, revealed an order for Vaseline Gel (White Petrolatum). Apply to right lower arm burn topically three times a day for burn. Record review of Resident #33's physician order, dated 12/02/22, revealed an order for right forearm: Clean with NS, pat dry, apply silvadene cream and cover with non-adherent dressing one time a day. Record review of Resident #33's physician order, dated 12/02/22, revealed an order for right lateral thigh: Clean with NS, pat dry, apply silvadene cream, cover with non-adherent dressing one time a day. Record review of Resident #33's nurses notes, dated 11/30/2022 at 6:54 pm, written by RN B read in part: .CNA reported that resident had burned herself with hot soup. Patient observed lying in fowler's position on bed holding right arm. Patient reported that she accidentally spilled her hot soup on right forearm while trying to eat it. Assessment done and noted open and non-open blisters to right arm. No other injuries found. Patient complaining of pain and given PRN pain medication. NP notified and received new orders for Vaseline TID to be applied to affected area as well as wound care consult. DON and patient's family member notified. VS 127/76, pulse 60, resp 18, O2 98%, pain 7/10. Will continue to monitor and follow up . Record review of Resident #33's Weekly Skin Assessment, dated 11/30/2022 at 6:19 pm, revealed first degree burn on right forearm from spilling hot soup. An observation and interview on 12/01/22 at 12:35p.m., revealed Resident # 33 was sitting in the dining room eating her lunch. She had a dry dressing, dated 12/01/22, on her right forearm. Resident#33 said she got burned from hot soup when she was transferring noodles soup from the cup to a bowl. She said she often ate noodles in her room because she did not like what they served in the kitchen most of the time for dinner. She said residents were not allowed to get the hot water from the kitchen and she had to ask staff for assistance. She said staff went and make the noodle cup soup in the kitchen. She said it hurt so bad that she placed call light for staff to assess her. Resident said, I yelled out in pain for about 10 to 15 minutes before anybody came in the room. In an interview on 12/01/22 at 2:45p.m., with WCN A, she said this morning Resident #33's nurse and aide told her that she needed to access Resident#33's arms as the resident was burned from cup of noodles. She said, 'I looked at it and took a picture and sent it to the wound care doctor. The doctor asked if it was a burn and gave an order to apply Silvadene. In an interview on 12/01/22 at 2:50p.m. with RN B, she said she helped CNA R pass out dinner trays on Hall 300 and then went to the dining room, as she was the nurse in charge of dining room duty for dinner. She said CNA R came to her and said that Resident #33 burned herself. She said she went to access the resident and Resident #33 said she accidently burned herself. She said resident usually ate noodle soup in the evenings. She said resident had burn blisters, so she called the NP and received an order to apply Vaseline. RN B said Resident#33 required extensive assistance due to right sided weakness. In a telephone interview on 12/01/22 at 3:14p.m., CNA R said Resident # 33 required extensive assistance with all ADLs and set up assistance with meals because of right side weakness. She said she put the water in the noodle soup cup, placed it in the microwave for 3 minutes,and took it to the resident. She said she did not check the temperature. She said she carried the noodle cup to the resident's room; it was not hot for her. She said she heard Resident#33 screaming and her call light was on. She said she went to check on her and the resident said, I dropped noodles on me. Resident had burns on her arm. She said she immediate notified RN B. CNA R said facility provided training online couple of weeks ago. She said she could not recall the exact date. She said the training was about how to handle residents, dealing with their food and getting them up. She said the training did not mention checking food temperatures. In an interview on 12/01/22 at 3:34p.m., with DON, she said the process was for the resident to ask somebody to heat or re-heat their food from the kitchen. She said she was made aware Resident#33 burned herself. She said she went to assess Resident#33 and the resident told her that she was pouring noodle soup from the cup to a bowl. The DON said Resident #33 had a weak side and poured it on self. The DON said she assessed the resident and she had blisters on the right hand and thigh. She said the NP was notified and they received an order for wound care consult. When asked if it was safe for Resident # 33 to be handling hot liquids without adequate supervision, the DON said Resident # 33 was competent. The DON said no in service/education were conducted with staff with handling residents food because the family member had [NAME] Resident#33's food. At that time, the Surveyor shared Resident#33 and CNA R's interview with the DON. The DON said she was not aware staff heated the soup for the resident. The DON said she had seen the resident's family member yesterday (11/30/22) and assumed the family member had brought the soup. The DON said her expectation for staff was for them to check the food temperature before giving it to the resident. She said, I don't know how staff would check the temperature because staff can not physically eat someone's food. I will in-service staff. At that time, a policy on accidents/supervision was requested. In an interview on 12/01/22 at 3:43p.m., DON said the facility had policy on Departmental Supervision but did not have a policy on accidents/supervision.

Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #'s1, 2, and 3) reviewed for supervision. The facility failed to adequately supervise Resident #'s 1 and 2 to prevent eloping from the facility and being found off the premises. The facility failed to provide assistive devices to prevent elopement for Resident #3. When the surveyor arrived one morning neither the receptionist nor other staff member were at the desk monitoring the front door for exit seeking residents. These failures could result in residents not receiving appropriate supervision leading to elopement, injuries, hospitalization , or death. An Immediate Jeopardy situation was identified on 07/12/22 at 1:30 p.m. The Immediate Jeopardy was removed on 07/16/22 at 11:05 a.m. The facility remained out of compliance at a scope of pattern and a severity of no actual harm with potential for more than minimal harm that is not immediate due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. Findings included: Resident #1 Record review of a face sheet dated 07/11/22 indicated Resident #1 was an [AGE] year-old male admitted to the facility on [DATE]. He had diagnoses included Alzheimer's disease and dementia. Record review of an MDS dated [DATE] indicated Resident #1 had minimal difficulty hearing, unclear speech, usually understood others, usually made himself understood, and had adequate vision without corrective lenses; he had severely impaired cognition with a BIMS score of 7 out of 15; he had no behaviors including wandering; and he required supervision assistance with ambulation. Record review of Resident #1's Elopement Risk Assessments indicated: * on 11/29/21 he was low risk; * on 12/29/21 he was high risk; and * on 04/30/22 he was medium risk. Record review of the comprehensive care plan initiated on 12/11/21 indicated there was no care plan for elopement risk. Record review of the Grievances from December 2021 to July 2022, indicated a grievance dated 05/03/22 regarding the elopement process when Resident #1 was not in his room and found outside signed by the administrator. The follow-up included an in-service on Elopement Process, Resident #1 received a wander guard, and Resident #1 was to be monitored every hour for 2 weeks. Record review of a handwritten note dated 04/30/22 by the Administrator indicated Resident #1 was last seen at 04:30 PM lying in his bed watching TV. He was found missing by facility staff at 05:00 PM when passing dinner trays. A facility check was conducted by all staff from 05:00 p.m. until 05:05 p.m. The responsible party (RP), nurse practitioner, and administrator were notified at 05:07 p.m. The RP indicated she was not far from the facility and would assist in the search. Four (4) staff members searched a 2-mile radius around the facility. He was found by RP at 05:23 PM on their way to the facility to join the search for him. According to Weather.gov accessed on 07/12/22 at https://www.weather.gov/wrh/Climate?wfo=hgx, the temperature on 04/30/22 was 88 degrees Fahrenheit. Record review of the April Licensed Nurse MAR indicated staff were monitoring Resident #1's wander guard every shift. During an interview on 07/10/22 at 12:20 p.m. the Administrator said she did not know why Resident #1 took off his wander guard and left the facility but he had not removed the wander guard since and they had had no further incidents since with him. During an observation and interview on 07/11/22 at 11:00 a.m. revealed Resident #1 was in his room. He was wearing a wander guard. He indicated he was doing good. Resident #1 was confused and able to answer appropriately. During an interview on 07/13/22 at 1:15 p.m. the DON said she was not employed at the facility when Resident #1 eloped. During an interview on 07/14/22 at 02:23 p.m. RN D said she was on duty the day of the incident with Resident #1. She said she had checked the wander guard and it was on but he must have removed it before he went out the door. Resident #2 Record review of a face sheet dated 07/10/22 indicated Resident #2 was an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included stroke, elevated blood sugar requiring insulin, and high blood pressure. Record review of an MDS dated [DATE] indicated Resident #2 had minimal difficulty hearing, unclear speech, usually made herself understood, usually understood others, and had adequate vision without corrective lenses; she had moderately impaired cognition with a BIMS score of 11 out of 15; she had no behaviors including wandering; and she required supervision/limited assistance with ambulation utilizing a walker. Record review of the History and Physical dated 04/18/22 indicated Resident #2 had confusion. Record review of Resident #2's Elopement Risk assessment dated [DATE] indicated she was a medium risk. Record review of physician orders from 04/15/22 through 07/04/22 indicated Resident #2 had no order for a wander guard. Record review of the care plan dated 04/15/2022 indicated Resident #2 was an elopement risk with interventions of 1. wander guard placed for resident's safety, bracelet would alert staff if and when resident attempted to exit doors of facility and staff to monitor daily. Resident #2's care plan did not include that she cut off her wander guard before her elopement. Record review of Resident #2's MARs and TARs from April 15, 2022 through July 04, 2022 indicated no documentation of the wander guard. Record review of Provider Investigation Report indicated Resident #2 exited the facility on 07/04/22. Staff discovered she was missing at 05:30 PM. The last time she was seen was at 05:15 PM by a housekeeper. The facility was made aware of Resident #2's location when local police came to the facility at 05:40 PM and reported she was found a block away from the facility and was sent to the hospital for evaluation. There was no indication she was wearing a wander guard. According to Weather.gov accessed on 07/12/22 at https://www.weather.gov/wrh/Climate?wfo=hgx, the temperature on 07/04/22 was 97 degrees Fahrenheit. Record review of Resident #2's Elopement Risk assessment dated [DATE] indicated she was a high risk. Record review of the care plan revised on 07/05/22 indicated Resident #2 was an elopement risk with interventions of resident had a history of removing her wander guard device and new intervention was the resident would be placed on 2-hour visual checks. During an interview on 07/10/22 at 12:20 p.m. the Administrator said the family reported according to the hospital, Resident #2 had no injuries from the elopement. She said they had not had any issues in quite a while of Resident #2 trying to leave the facility. She said family normally came Monday through Friday around dinner time and she was used to the routine but they did not come on the 4th due to holiday and went out of town. During an interview on 07/13/22 at 1:15 p.m. the DON said Resident #2 eloped but she was waiting for her family. She said when Resident #2 returned from the hospital a wander guard was placed on her. She said it was placed on the ankle and the family told her the box contained a family members ashes so she would not remove it again. She did not realize the care plans did not address the exit seeking behaviors. During an observation and interview on 07/13/22 at 2:00 p.m. indicated Resident #2 had returned from the hospital and was in her room with a family member. She was wearing a wander guard. The family member indicated the resident had returned the day before. The family member said Resident #2 did not have a fall but did have something going on with her and that was why she stayed at the hospital. The resident, translated by the family member, indicated she was going to meet her family and left. Resident #3 Record review of a face sheet dated 07/11/22 indicated Resident #3 was an [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included dementia. Record review of Resident #3's MDS dated [DATE] indicated Resident #3 had moderate difficulty hearing and wore a hearing aid, had unclear speech, usually made herself understood, usually understood others, and had impaired vision requiring corrective lenses; she had severely impaired cognition per staff assessment with inattention and disorganized thinking; she had no behaviors including wandering; and she required limited assistance with ambulation utilizing a walker or a wheelchair. Record review of Resident #3's Elopement Risk Assessments indicated: *on 11/24/21 she was high risk; * on 12/20/21 she was high risk; * on 03/20/22 she was high risk; and * on 06/30/22 she was medium risk. Record review of Resident #3's care plan revised on 07/07/22 indicated she had no care plan for elopement risk. During an observation and interview on 07/11/22 at 11:00 a.m. revealed Resident #3 was confused saying she needed to go to work and was observed by the Surveyor headed towards the front door. She had no wander guard on. She made it to the door before Receptionist B could stop her. Receptionist B said the resident had a wander guard on before but it was removed in April 2022 by the resident cutting it off and had not been replaced. A wander guard was placed on Resident #3 at this time by Receptionist B. Record review of Resident #3's Physician's orders dated 07/11/22 revealed Resident #3 had no order for a wander guard or visual observations of the resident. During an observation on 07/10/22 at 9:15 a.m. revealed the Surveyor was let into the facility by a charge nurse. There was no Receptionist at the front area. During an observation and interview on 07/10/22 at 10:20 a.m. revealed the Surveyor noticed the alarm on the front door of the facility was not armed due to a green light indicating it was off to prevent exiting the facility unless using the keypad. The wander guard system was armed because a resident with a wander guard on went by the door and it locked. The MA said it should be armed at all times because if a resident did not have a wander guard on they could exit the building. During an interview on 07/10/22 at 11:30 a.m. the Administrator said they usually left the door unarmed during the day when there were a lot of people coming in and out of the facility. She said there were some residents who liked to go out also and they could not arm the keypad alarm because the facility was not a prison and residents had to right to go outside. She said it was responsibility of the receptionist to monitor. During an observation on 07/10/22 at 4:00 PM revealed the Surveyor noted the door alarm was disarmed due to a green light indicating it was off when she was leaving the facility. The wander guard system was engaged. During an observation on 07/11/22 at 10:45 a.m. revealed the Surveyor noted the door alarm was disarmed due to a green light indicating it was off when she entered the facility. There was a receptionist at the front desk. During an interview on 07/11/22 at 11:25 AM the Receptionist said the maintenance man disarmed the main alarm to the door in the mornings and she reset it when she left at 5:00 PM. Record review of an undated Signal Device (Wanderguard) and Door Alarm Monitoring policy indicated some company facilities did not have secured units and it becomes very important to identify residents who walk or wheel themselves unrestricted and become a threat to leave the facility unattended due to their confusion. The facility must ensure the resident's safety while utilizing the least restrictive means available Record review of a Wandering, Unsafe Resident policy revised August 2014 indicated Policy Statement: The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Policy Interpretation and Implementation: 1. Staff will identify residents who are at risk for harm because of unsafe wandering (including elopement). 2. The staff will assess at-risk individuals for potentially correctable risk factors related to unsafe wandering. 3. The resident's care plan will indicate the resident is a risk for elopement or other safety issues. Interventions to try to maintain safety, such as a detailed monitoring plan will be included Record review of an Elopement Drill policy revised 04/01/18 indicated 4 The entire process of the facility and grounds, from the time the patient/resident is missing will be completed within (30) thirty minutes. 5. If the search fails to locate the missing resident within (30) thirty minutes from the time the patient/resident is found to be missing, then the Administrator and/or designee places a mock phone call to the appropriate community agencies (Police, Local Health Department), Administration, the patient's/resident's legal representative and the attending physician 7.When the Patient/Resident is located, the Charge Nurse Completes a head to toe assessment The Director of Notifies the Administrator/designee and places mock call to the appropriate community agencies, the attending physician, and the patient's/resident's legal representative The Administrator and DON were notified on 07/12/22 at 1:30 p.m., that an IJ situation was identified due to the above failure and the Administrator was provided the IJ template and a POR was requested. The facility's Plan of Removal was accepted on 07/12/22 at 07:22 p.m., and included the following interventions: Immediate Action Resident #1 elopement on 4/30/22. o Wander guard revaluated to ensure working properly on 7/11/22. o Elopement assessment done on 5/3/22, 6/13/22, and 7/12/22. o Staff in-service done on 5/3/22, 7/4/22, and 7/12/22. Topic: Elopement Drill. Instructor: DON. Resident #2 Elopement on 7/4/22. o Replacement of wander guard on 7/11/22 o Resident eloped on 7/4/22 found sitting on ground. o Staff in-service done on 7/5/22, and 7/12/22. Topic: Elopement Drill. Announcement: Code PINK, which signals that an Elopement Drill Procedure is in. progress An immediate and thorough search of the center and surrounding grounds. Including but not limited to a search of the area outside the nearest exit to the patient's/resident's room or the exit where he/she was last seen, and the entire unit where the patient/resident resides or was last seen, the remainder of the facility (all rooms, closets - including storage areas - and bathrooms) and grounds, extending beyond the fence line. The entire search process of the facility and grounds, from the time the patient/resident is missing. If the search fails to locate the missing patient/resident within (30) thirty minutes from the time the patient/resident is found to be missing, then the Administrator and/or designee places a mock telephone call to the appropriate community agencies (Police, Local Health Department), Administration, the patient's/resident's legal representative and attending physician. The search is continued. Two staff members search the surrounding streets by car for a two (2) mile radius around the facility. When the Patient/Resident is located, the Charge Nurse completes a head-to-toe assessment. The Social Service Designee assesses the patient/resident for emotional distress. The Charge Nurse reports any findings to the Director of Nursing. The Director of Nursing notifies Administrator/designee and places mock calls to the appropriate community agencies, the attending physician and patient's/resident's legal representative. The facility's Quality Assurance Committee investigates the incident and implements intervention to prevent reoccurrences. When the missing resident is located, an announcement, Code PINK Clear is made over the PA system. Instructor: DON 100% of all fulltime staff in-serviced 2 staff members on FMLA will be in-serviced once returned to ensure compliance o Wander guard placed on resident upon readmission 7/11/22 o Elopement assessment completed on 7/11/22 after readmission from hospital by DON o Care plan updated on 7/5/22 for behavior of removing wander guard by DON o Readmission care plan 7/11/22 by DON Resident #3: o Wander guard placed on resident 7/11/22. o Elopement assessment completed on 7/11/22. o Care plan updated on 7/11/22 by DON to add the wander guard placement. Facility door works properly; it will not open if a resident wearing a wander guard is within specific range until resident is removed from the area. o Wander guard systems is checked daily by Receptionist. o Last date checked: 7/12/22. o Location of documentation in elopement binder. Receptionist is available on 2 shifts. While on break the Receptionist is relieved by the BOM, EDO, or Admissions Director. The additional management will make sure that the door is always covered to supervise resident at risk of elopement. Weekend Receptionist works Saturday and Sunday and will monitor the door during 12 hour shifts and after shift the inside keypad security lock will be used to let individuals out of the facility. When there is not a receptionist the keypad security system will be used. What is the facility plan if residents remove their wander guards? o Wander guards are checked daily on each shift per MD Order and will put back on if removed based on daily checks. Elopement Residents: o Risk of elopement assessment, care plans and interventions reviewed/revised for all resident at risk of wandering/elopement on 7/12/22 by DCO and RDCO. o Residents observed to ensure placement 7/12/22 by DCO and RDCO. o All procedures documented. Plans to ensure compliance Medical director confirmed receipt of IJ notice on 7/13/22. Elopement binder (binder that documents all resident who have wander guards and contains daily checks of wander guard system). o Wander guard system will be check daily by receptionist. Check that door will not open when resident with wander guard is at the door; all residents with wander guards are checked o Any potential resident identified as having exit seeking behaviors will be discussed Monday - Friday during morning meetings. Elopement in-service o Given by the DON 7/12/22 o All staff must complete in service prior to working next shift and will be added to new hire orientation. Daily wander guard checks done on all residents with wander guards to ensure placement and properly working. o Wander guards are checked daily on each shift per MD Order and will put back on if removed based on daily checks if receptionist is not available a charge nurse will ensure that device is working properly documentation will be located in the elopement binder. Sound alarm upon exit. o Sound alarm will be placed on door which indicates when anyone is exiting the facility. o Sound alarm placed on door 7/13/22. Audit for proper functioning done on 7/13/22. Completed by Maintenance Director. QAPI meeting completed on 7/12/22. o Meetings are done monthly they will review for compliance and follow up identified noncompliance will result in staff re-education Monitoring: On 07/16/22 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Observation on 07/14/22 at 01:10 p.m. revealed an Elopement Risk binder was located at the nursing station with the face sheets of all current residents with wander guards in alphabetical order. Observations on 07/13/22 from 12:30 p.m. to 02:15 p.m., 07/14/22 from 12:30 p.m. to 02:30 p.m., 07/15/22 from 01:15 p.m. to 04:00 p.m., and 07/16/22 from 10:15 a.m. to 11:00 a.m. indicated the facility had placed another device on the door to alert staff when the door was opened so it did not have to be locked all the times, allowing visitors and residents who could safely sit outside without supervision to exit. Someone sat in the receptionist area if the receptionist was gone on break or if not, the front door was locked, and the keypad had to be used to open the door. Resident #'s 1, 2, and 3 had a wander guard either on their wrist or on their ankle. Check of the wander guard system done by the receptionist. During interviews on 07/13/22 through 07/16/22 on the 6a-2p and the 2p-10p shifts and phone interviews for the 10p-6a shift with 34 staff (2 ADONs, 2 RNs, 11 LVNs, 3 MAs, 1 RA, 8 CNA's, 3 Receptionists, and 4 Housekeepers) revealed they were able to appropriately define elopement risk, identify the location of the resident elopement book, provided the procedure for a resident found trying to leave the facility without supervision, they were to notify the nurse and the nurse was to replace with wander guard if it was removed by the resident. The Receptionists said they were to let nursing staff or administrative staff, if available, know when they were going on break. All the receptionists knew to check the wander guard system. The weekend Receptionist said she was to let nursing staff know she was going on break and to lock the door, so the keypad had to be used to let someone out. Record reviews of the charts were completed for Resident #s 1, 2, and 3 and reflected elopement assessments and orders for wander guards. Resident care plans included their elopement status. Wander guard checks were done every shift (6a-2p, 2p-10p, and 10p-6a). Record review of in-services dated 07/13/22 regarding elopement was completed with all full-time staff except for 1 who was out of the country and 1 who was on FMLA. PRN and weekend staff were being in-serviced prior to their shifts. On 07/16/22 at 11:05 a.m. the Administrator was informed the IJ was removed; however, the facility remained out of compliance at a level of no actual harm with potential for more than minimal harm that is not immediate with a scope of pattern due to the facility's need to continue to monitor the effectiveness of their plan of removal.

Based on interview and record review the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for one of six residents (CR #1) reviewed for quality of life. 1. The facility failed to address CR #1's development of suicidal ideation after he stated he wanted to die. 2. the facility failed to ensure CR #1 a recommendation for a psychological consult was communicated to the residents Nurse practitioner or Physician after the resident was transferred to the hospital at his request after making suicidal statements and returned to the facility hours later. 3. The facility failed to assess CR #1 for suicide and properly monitor him after he returned from the hospital which resulted to CR #1 stabbing himself in the arm with a fork two days later . This was determined to be a past non-compliance at the severity level of immediate Jeopardy (IJ) due to the facility initiated and implemented actions that corrected some of the non-compliance prior to the beginning of the survey. These failures placed Resident #1 in an immediate jeopardy (IJ) situation from 10/11/2021 through 10/13/2021. These failures could place residents at risk of decreased mental health, a diminished quality of life and physical harm. Findings include: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's progress notes, dated 10/10/2021 at 8:15 PM written by RN A, revealed, Resident was in the bed during the shift. Noted refusing meals, medications, and all ADLs . Resident continue to say he wants to die. VS BP 137/70, Pulse 80, Resp. 18, Temp.98.2 and O2 sat 95%. Resident stated he wants to go to the hospital. Nurse placed a call to RP, messages left on the voice mail. This community DON was notified and the physician on call was also notified. New order obtained to transfer resident to Hospital ER for evaluation. At 8:30 p.m. resident was transferred to Hospital ER. Record review of CR #1's Skilled Charting, dated 10/11/21 at 4:00 AM completed by LVN B, revealed no changes to mood and behavior were noted the notes reflected, Patient status post [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of CR #1's discharge MDS, dated [DATE], revealed a staff assessment for mental status which indicated his memory was intact and his cognitive skills for daily decision making was moderately impaired. Further review of the MDS revealed he had verbal behaviors directed towards others that occurred 1 to 3 days . Record review of CR #1's care plan, dated 10/13/21, created by the MDS Coordinator revealed in part, .He has repetitive behavior continually request to go to hospital have had multiple admissions has multiple complaints about health now stating, 'that I want to die'. He wants to go home but family want him to remain here in facility complaints about roommates very unhappy, Resident opened up skin using a fork was transferred to hospital for laceration and cuts on 10/13/21 . Further review of care plan area revealed no interventions were listed . Record review of CR #1's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] Record review of CR #1's SBAR, dated 10/13/21, revealed resident noted large blood stain on bed linen and some on the floor, with a cut on his right hand and a fork in his left hand. The condition, symptom, or sign had never occurred before and resident was transferred to the hospital. Record review of CR #1's progress notes, dated 10/13/2021 at 8:39 AM written by LVN C, revealed, Resident found in a pool of blood at 7 AM with a fork in his left hand and a cut about 4 cm long and 1inch deep on his right hand. Verbalized ' I want to die but fork not sharp enough.' Placed resident on one-on-one supervision immediately, all items around and within his reach removed, notified DON, ADON and called 911. Resident transferred to Hospital emergency room , and report given to the police. Notified physician and RP no response, left message to call facility. Record review of CR #1's progress notes, dated 10/13/2021 at 10:00 AM written by LVN C, revealed Follow-up, Blood estimated to be +/- 3-4 oz saturated in linen soiled and multiple drops on the floor at residents' right side. Record review of CR #1's progress notes, dated 10/13/2021 at 1:43 PM written by the DON, revealed Follow-up call with RP, writer was able to talk to him and discuss plan of care, he was in agreement to arrange for psych consult/treatment, stated family is unable to take care of him but did not elaborate what issues they have with resident. He is aware resident is in the hospital. Record review of CR #1's progress notes, dated 10/14/21 at 12:56 PM written by LVN C, revealed, correction of measurement Length: 4.0, Width: 05, depth: 0.5. ( Unknown measures unit meant). Interview on 10/26/21 at 2:00 PM, LVN C said she was the nurse who initiated CR#1's hospital transfer on 10/13/21. LVN C said she was very surprised by what happened with CR #1 and said no one told her he had expressed wanting to harm himself or had displayed signs of depression. LVN C said when she came in for her shift, she went by CR #1's room and greeted him from the door around 6 AM. She said he responded to her how he normally would in a pleasant mood. She said maybe about 30 minutes later CNA B came to her holding a fork that had blood on it. She said she immediately went into CR #1's room and pulled the covers back off of him and she saw all the blood under the covers. She said the resident then stated the fork was not sharp enough and he wanted to kill himself. LVN C said she saw the injuries on his arm where the blood was came from and called 911. LVN C said there was a CNA assigned to sit with him one on one until the ambulance got there. LVN C said she was not told to monitor CR #1 for making suicidal comments and did not know he had made any. Interview on 10/26/21 at 2:10 PM, RN A said CR #1 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said in the past CR #1 had stated he felt like he was dying but on 10/10/21, it was the first time she heard him say he wanted to die. RN A said she never heard CR #1 say anything like that before or display any signs of depression. She said the resident would come up with things to say so they would send him to the hospital, and they would just call the physician and have him sent. RN A said, on 10/10/21, CR #1 stated he wanted to die and told her he wanted to go to the hospital, so she ahead called the NP and told her what he said. She said the NP gave orders to go ahead and send him to the hospital. RN A said CR #1 came back to the facility later that night, but she was already gone when he arrived back at the facility . Interview on 10/26/21 at 3:08 PM, the NP said CR #1 went in and out of the hospital because he preferred to be in the hospital and did not like being in the facility. The NP said if the nurses would not send him then he would call 911 himself. The NP said she was notified on 10/10/21 he wanted to go to the hospital really bad again, she told the facility to go ahead and send him. She said the resident was sent right back later that night with no new orders and she told the nurse to resume all his previous orders. The NP said she was not told anything about CR #1 making suicidal statements or needing a psychological consult and suggested maybe the information was told to another NP. Interview on 10/26/21 at 3:17PM, NP B said she was not told CR #1 had any psychological issues or made statements of wanting to harm himself previous to the incident on 10/13/21. The NP said if some information like that was told to her she would have the resident sent out for a psych consult. Interview on 10/26/21 at 3:20 PM, the physician said he could not recall any situation with CR #1 and said the other physician might could remember more clearly. Interview on 10/26/21 at 3:30 PM, Physician B said he knew about the incident with CR #1 hurting himself with the fork but denied any knowledge of statements CR #1 made on 10/10/21 regarding wanting to die. The physician said in that type of situation they would get the resident a psych consult or maybe transferred to a psych facility for an evaluation depending on assessment of the resident. Physician B said it would typically be the NP's who would be notified of those types of situations, but he had not heard anything from them about CR #1 making statements about hurting himself. Physician B said he would speak to the facility about better communication between them and the physicians . Interview on 10/26/21 at 3:47 PM, the DON said CR #1 always wanted to go out to the hospital and would say or do anything to go to the hospital. The DON said on 10/10/21 he made statement to RN A about wanting to die so she told the NP and they sent him out. The DON said CR #1 returned to the facility later the same night but did not come back with any paperwork or written orders. The night nurse (LVN B) said the hospital had called and said they recommended CR #1 get a psych consult . The DON said CR #1 returned to the facility and had been fine and she worked on getting him the psych consult but said it took a few days to arrange and prepare the paperwork . The DON said they started the process to get him a psych consult on 10/11/21 or 10/12/21. The DON said she did not think the Social Worker got to speak with CR #1 before he was transferred to the hospital on 10/13/21. The DON said while they were arranging the psych consult the facility did close observation on the resident by filling out an internal form to observe his location every 15 minutes . Interview on 10/26/21 at 4:01 PM, the MDS Coordinator said she had created the care plan for CR #1 on 10/13/21 regarding his behavior of harming himself. The MDS Coordinator said the Social Worker would typically create the care plan for that area but the Social Worker was out on leave, so she created it for her in her absence. The MDS Coordinator said she was not aware CR #1 had stated he wanted to die on 10/10/21. The MDS Coordinator said usually herself or administrative staff would update care plans and said if something happened over the weekend, they would pick it up on the care plan the following weekdays. The MDS Coordinator said if the statements CR #1 made were on a Sunday and the Social Worker was not in the facility the following weekdays, then that would explain why the care plan had not been updated. Interview on 10/26/21 at 4:10 PM, the Social Worker said she never knew CR #1 had suicidal behavior until 10/13/21 and she could not remember if she was out on leave during that time. The Social Worker said she just remembered getting to work and CR #1 was already gone to the hospital for hurting himself with the fork . The Social Worker said when a resident made statements about or displayed behaviors of wanting to harm themselves, she would go and assess them first and see if the resident had a plan or means to hurt themselves . Depending on the assessment she would have items removed that he could use to hurt himself and possibly have the resident on one on one supervision while they coordinate getting an outside psych consult. The Social Worker said she would usually arrange a psych consult if a resident needed one . Interview on 10/26/21 at 5:18 PM, CNA D said she went in on 10/13/21 and went into CR #1's room to do her initial round around 6:30 AM - 6:45 AM. She said she walked over to CR #1 and he was covered with the covers and handed her a fork that had blood on it. She said CR #1 stated, I tried to kill myself . CNA D said she went over to the left side of the bed and looked under the covers and saw all the blood under the covers and his hand looked like it had been stabbed with the fork pretty bad. CNA D said she immediately went and got LVN C and she took over caring for CR #1 and called 911. CNA D denied ever hearing CR #1 make suicidal statements or knowing he had in the past. CNA D said she did not know anything about CR #1 being monitored for suicidal behaviors . Interview on 10/26/21 at 5:25 PM, LVN B said CR #1 came back from the hospital on her shift around 4:00 AM on 10/11/21. She said CR #1 returned with no paperwork with him. LVN B said she called the NP to let her know CR #1 had returned and told her he did not return with any paperwork for new orders and she said to continue his previous orders. LVN B said she only knew a psych consult was recommended by the hospital because they called and spoke to the previous shift nurse and told her CR #1 could benefit from a psych consult. LVN B said the previous nurse told her what the hospital said during their shift report but when CR #1 arrived back to the facility on her shift he arrived with no orders. LVN B said the previous nurse was the one who spoke to the hospital so she would have been the person to further communicate the recommendation to the proper personnel to get him one. LVN B said she did not know if staff were informed of the recommendation for psych consult. LVN B said she started the close observation form when CR #1 returned to the facility and said he went to his room and went to sleep and slept through the night with no issues. LVN B said CR#1 slept with the door open so they would walk by the room to make sure he continued to sleep . Interview on 10/26/21 at 5:40 PM, LVN C reiterated she did not know about CR #1 being at risk for harming himself. She stated she did not monitor the resident for risk of suicidal behavior because no one told her to. LVN C reviewed the close one on one monitoring sheet with her initials on it and stated she filled out the form but she was told the form was to be filled out to make sure the resident was in his room because he was at risk for elopement because he had previously tried to leave the facility. LVN C said she was not using the form to monitor him for behaviors. LVN C said she would make sure the resident was in his room and mark it on the form. Interview on 10/26/21 at 5:50 PM, LVN F said she worked the night shift on 10/12/21 - 10/13/21 from 6 AM - 2 PM. LVN F said she heard what happened with CR #1 hurting himself with a fork and said she had no idea he had previously made statements about wanting to die. LVN F denied doing any type of close monitoring on CR #1 but said she did see him throughout the night and said he was sleeping. She said she last saw CR #1 in the morning on 10/13/21 before she left around 6:00 AM and said he was in his bed doing fine. LVN F said she had not filled out a form where she monitored CR #1 every 15 minutes and stated again, she did not know he was supposed to be monitored for any type of psychological reasons. Record review and interview on 10/26/21 at 6:00 PM, the DON said the Quality of Life - Dignity policy was the only policy they had related to Quality of Life. Review of the Quality of Life - Dignity policy (Revised August 2009) revealed it did not address areas of concern listed above . The DON also said there was not a policy she could find that addressed behavioral services. It was determined that these failures placed CR #1 in an immediate jeopardy (IJ) situation from 10/11/2021 through 10/13/2021. The facility took the following actions to correct the noncompliance which were confirmed by the surveyor : Record review of CR #1's discharge MDS, dated [DATE], revealed resident was discharged from the facility on 10/13/2021 . Interview on 10/26/21 at 5:20 PM, the Administrator said the Social Worker was out from 10/8/21 - 10/12/21 and her first day back was 10/13/21 and CR #1 had already been transferred to the hospital. The Administrator said the DON was responsible for getting CR #1 the psych consult in the Social Workers absence and stated the facility had three days to get the paperwork completed for psych consults. The Administrator said while the resident waited for a psych consult, they monitored him every 15 minutes. The Administrator said she heard some of the staff were not aware why CR #1 was being monitored and she said they (administration) did not want CR #1 to know he was being closely monitored because it would upset him. The Administrator said some of the nurses like to talk and they did not want the nurses telling him he was being monitored or why, so they did not tell everyone why . The Administrator explained the monitoring form was a sign off sheet with codes to indicate where the resident was located at that time and what they were doing with the nurse's initials . Record review of CR #1 One on One Monitoring Form revealed form was started on 10/11/21 at 3:45AM by LVN B which indicated he was in his room sleeping throughout the night and had checked his vital signs and administered medications at 4:15 AM and 5:30 AM. Further review of the monitoring sheets revealed they were completed from 10/11/21 - 10/13/21 every 15 minutes. LVN C initialed the monitoring sheet, dated 10/12/21 from 7:00 AM - 2:45 PM and LVN E initialed the monitoring sheets, dated 10/11/21 and 10/12/21 from 11:00PM - 6:45AM. Further review of the monitoring sheet for the night shift (11 PM - 6:45 AM) on 10/12/21 - 10/13/21 revealed LVN E noted CR #1 was in his room sleeping at 6:0 0AM, 6:15 AM, and 6:30 AM. LVN E then noted at 6:45 AM CR #1 was in his room doing activities/reading/TV . Further record review of facility in services revealed facility staff were provided in-serviced on or about 10/12/2021 regarding abuse/neglect and how to identify and act with residents that exhibit phycological behaviors and self-harm as well as on one on one monitoring of the resident until transfer arrangement are secured . This training was completed prior initiating investigation. Staff interviews confirmed understanding of the training and expectations. 4 nurses and CNAs were interviewed from different shifts.

Based on interview and record review, the facility failed to provide an environment that is free from accident for each resident to prevent avoidable accidents for one of six residents (CR #1) reviewed for accidents and supervision. The facility failed to ensure appropriate interventions were in place to prevent CR #1 from self- harm after he expressed desire to die . The facility failed to ensure CR #1 was prevented from having access to a metal fork which he used to stab himself in the arm two days after he returned from hospital. This was determined to be a past non-compliance at the severity level of immediate Jeopardy (IJ) due to the facility initiated and implemented actions that corrected some of the non-compliance prior to the beginning of the survey. These failures placed Resident #1 in an immediate jeopardy (IJ) situation from 10/11/2021 through 10/13/2021. These failures could place residents at risk of decreased mental health, a diminished quality of life and physical harm. Findings include: CR#1 Record review of CR #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included: acute [CONDITION(S)], COVID-19, [CONDITION(S)], [CONDITION(S)], acquired absence of right toe, [CONDITION(S)], cerebral infarction, [CONDITION(S)] and [CONDITION(S)], cognitive communication deficit, [CONDITION(S)], [CONDITION(S)], hypertensive heart and chronic kidney disease with heart failure and with stage 5 chronic kidney disease, peripheral vascular disease, type II diabetes, [CONDITION(S)], hypertension and acute ischemic heart disease . Record review of CR #1's progress notes, dated 10/10/2021 at 8:15 PM written by RN A, revealed, Resident was in the bed during the shift. Noted refusing meals, medications, and all ADLs . Resident continue to say he wants to die. VS BP 137/70, Pulse 80, Resp. 18, Temp.98.2 and O2 sat 95%. Resident stated he wants to go to the hospital. Nurse placed a call to RP, messages left on the voice mail. This community DON was notified and the physician on call was also notified. New order obtained to transfer resident to Hospital ER for evaluation. At 8:30 p.m. resident was transferred to Hospital ER. Record review of CR #1's Skilled Charting, dated 10/11/21 at 4:00 AM completed by LVN B, revealed no changes to mood and behavior were noted the notes reflected, Patient status post readmission from ER at 3:45 AM with order for psych consult. Record review of CR #1's discharge MDS, dated [DATE], revealed a staff assessment for mental status which indicated his memory was intact and his cognitive skills for daily decision making was moderately impaired. Further review of the MDS revealed he had verbal behaviors directed towards others that occurred 1 to 3 days . Record review of CR #1's care plan, dated 10/13/21, created by the MDS Coordinator revealed in part, .He has repetitive behavior continually request to go to hospital have had multiple admissions has multiple complaints about health now stating, 'that I want to die'. He wants to go home but family want him to remain here in facility complaints about roommates very unhappy, Resident opened up skin using a fork was transferred to hospital for laceration and cuts on 10/13/21 . Further review of care plan area revealed no interventions were listed . Record review of CR #1's physician orders revealed no orders were entered for psychological consult as of this review date 10/26/2021 Record review of CR #1's SBAR, dated 10/13/21, revealed resident noted large blood stain on bed linen and some on the floor, with a cut on his right hand and a fork in his left hand. The condition, symptom, or sign had never occurred before and resident was transferred to the hospital. Record review of CR #1's progress notes, dated 10/13/2021 at 8:39 AM written by LVN C, revealed, Resident found in a pool of blood at 7 AM with a fork in his left hand and a cut about 4 cm long and 1inch deep on his right hand. Verbalized ' I want to die but fork not sharp enough.' Placed resident on one-on-one supervision immediately, all items around and within his reach removed, notified DON, ADON and called 911. Resident transferred to Hospital emergency room , and report given to the police. Notified physician and RP no response, left message to call facility. Record review of CR #1's progress notes, dated 10/13/2021 at 10:00 AM written by LVN C, revealed Follow-up, Blood estimated to be +/- 3-4 oz saturated in linen soiled and multiple drops on the floor at residents' right side. Record review of CR #1's progress notes, dated 10/13/2021 at 1:43 PM written by the DON, revealed Follow-up call with RP, writer was able to talk to him and discuss plan of care, he was in agreement to arrange for psych consult/treatment, stated family is unable to take care of him but did not elaborate what issues they have with resident. He is aware resident is in the hospital. Record review of CR #1's progress notes, dated 10/14/21 at 12:56 PM written by LVN C, revealed, correction of measurement Length: 4.0, Width: 05, depth: 0.5. ( Unknown measures unit meant). Interview on 10/26/21 at 2:00 PM, LVN C said she was the nurse who initiated CR#1's hospital transfer on 10/13/21. LVN C said she was very surprised by what happened with CR #1 and said no one told her he had expressed wanting to harm himself or had displayed signs of depression. LVN C said when she came in for her shift, she went by CR #1's room and greeted him from the door around 6 AM. She said he responded to her how he normally would in a pleasant mood. She said maybe about 30 minutes later CNA B came to her holding a fork that had blood on it. She said she immediately went into CR #1's room and pulled the covers back off of him and she saw all the blood under the covers. She said the resident then stated the fork was not sharp enough and he wanted to kill himself. LVN C said she saw the injuries on his arm where the blood was came from and called 911. LVN C said there was a CNA assigned to sit with him one on one until the ambulance got there. LVN C said she was not told to monitor CR #1 for making suicidal comments and did not know he had made any. Interview on 10/26/21 at 2:10 PM, RN A said CR #1 had a history of wanting to go to the hospital and if you wouldn't send him, he would call 911 himself. She said in the past CR #1 had stated he felt like he was dying but on 10/10/21, it was the first time she heard him say he wanted to die. RN A said she never heard CR #1 say anything like that before or display any signs of depression. She said the resident would come up with things to say so they would send him to the hospital, and they would just call the physician and have him sent. RN A said, on 10/10/21, CR #1 stated he wanted to die and told her he wanted to go to the hospital, so she ahead called the NP and told her what he said. She said the NP gave orders to go ahead and send him to the hospital. RN A said CR #1 came back to the facility later that night, but she was already gone when he arrived back at the facility . Interview on 10/26/21 at 3:08 PM, the NP said CR #1 went in and out of the hospital because he preferred to be in the hospital and did not like being in the facility. The NP said if the nurses would not send him then he would call 911 himself. The NP said she was notified on 10/10/21 he wanted to go to the hospital really bad again, she told the facility to go ahead and send him. She said the resident was sent right back later that night with no new orders and she told the nurse to resume all his previous orders. The NP said she was not told anything about CR #1 making suicidal statements or needing a psychological consult and suggested maybe the information was told to another NP. Interview on 10/26/21 at 3:17PM, NP B said she was not told CR #1 had any psychological issues or made statements of wanting to harm himself previous to the incident on 10/13/21. The NP said if some information like that was told to her she would have the resident sent out for a psych consult. Interview on 10/26/21 at 3:20 PM, the physician said he could not recall any situation with CR #1 and said the other physician might could remember more clearly. Interview on 10/26/21 at 3:30 PM, Physician B said he knew about the incident with CR #1 hurting himself with the fork but denied any knowledge of statements CR #1 made on 10/10/21 regarding wanting to die. The physician said in that type of situation they would get the resident a psych consult or maybe transferred to a psych facility for an evaluation depending on assessment of the resident. Physician B said it would typically be the NP's who would be notified of those types of situations, but he had not heard anything from them about CR #1 making statements about hurting himself. Physician B said he would speak to the facility about better communication between them and the physicians . Interview on 10/26/21 at 3:47 PM, the DON said CR #1 always wanted to go out to the hospital and would say or do anything to go to the hospital. The DON said on 10/10/21 he made statement to RN A about wanting to die so she told the NP and they sent him out. The DON said CR #1 returned to the facility later the same night but did not come back with any paperwork or written orders. The night nurse (LVN B) said the hospital had called and said they recommended CR #1 get a psych consult . The DON said CR #1 returned to the facility and had been fine and she worked on getting him the psych consult but said it took a few days to arrange and prepare the paperwork . The DON said they started the process to get him a psych consult on 10/11/21 or 10/12/21. The DON said she did not think the Social Worker got to speak with CR #1 before he was transferred to the hospital on 10/13/21. The DON said while they were arranging the psych consult the facility did close observation on the resident by filling out an internal form to observe his location every 15 minutes . Interview on 10/26/21 at 4:01 PM, the MDS Coordinator said she had created the care plan for CR #1 on 10/13/21 regarding his behavior of harming himself. The MDS Coordinator said the Social Worker would typically create the care plan for that area but the Social Worker was out on leave, so she created it for her in her absence. The MDS Coordinator said she was not aware CR #1 had stated he wanted to die on 10/10/21. The MDS Coordinator said usually herself or administrative staff would update care plans and said if something happened over the weekend, they would pick it up on the care plan the following weekdays. The MDS Coordinator said if the statements CR #1 made were on a Sunday and the Social Worker was not in the facility the following weekdays, then that would explain why the care plan had not been updated. Interview on 10/26/21 at 4:10 PM, the Social Worker said she never knew CR #1 had suicidal behavior until 10/13/21 and she could not remember if she was out on leave during that time. The Social Worker said she just remembered getting to work and CR #1 was already gone to the hospital for hurting himself with the fork . The Social Worker said when a resident made statements about or displayed behaviors of wanting to harm themselves, she would go and assess them first and see if the resident had a plan or means to hurt themselves . Depending on the assessment she would have items removed that he could use to hurt himself and possibly have the resident on one on one supervision while they coordinate getting an outside psych consult. The Social Worker said she would usually arrange a psych consult if a resident needed one . Interview on 10/26/21 at 5:18 PM, CNA D said she went in on 10/13/21 and went into CR #1's room to do her initial round around 6:30 AM - 6:45 AM. She said she walked over to CR #1 and he was covered with the covers and handed her a fork that had blood on it. She said CR #1 stated, I tried to kill myself . CNA D said she went over to the left side of the bed and looked under the covers and saw all the blood under the covers and his hand looked like it had been stabbed with the fork pretty bad. CNA D said she immediately went and got LVN C and she took over caring for CR #1 and called 911. CNA D denied ever hearing CR #1 make suicidal statements or knowing he had in the past. CNA D said she did not know anything about CR #1 being monitored for suicidal behaviors . Interview on 10/26/21 at 5:25 PM, LVN B said CR #1 came back from the hospital on her shift around 4:00 AM on 10/11/21. She said CR #1 returned with no paperwork with him. LVN B said she called the NP to let her know CR #1 had returned and told her he did not return with any paperwork for new orders and she said to continue his previous orders. LVN B said she only knew a psych consult was recommended by the hospital because they called and spoke to the previous shift nurse and told her CR #1 could benefit from a psych consult. LVN B said the previous nurse told her what the hospital said during their shift report but when CR #1 arrived back to the facility on her shift he arrived with no orders. LVN B said the previous nurse was the one who spoke to the hospital so she would have been the person to further communicate the recommendation to the proper personnel to get him one. LVN B said she did not know if staff were informed of the recommendation for psych consult. LVN B said she started the close observation form when CR #1 returned to the facility and said he went to his room and went to sleep and slept through the night with no issues. LVN B said CR#1 slept with the door open so they would walk by the room to make sure he continued to sleep . Interview on 10/26/21 at 5:40 PM, LVN C reiterated she did not know about CR #1 being at risk for harming himself. She stated she did not monitor the resident for risk of suicidal behavior because no one told her to. LVN C reviewed the close one on one monitoring sheet with her initials on it and stated she filled out the form but she was told the form was to be filled out to make sure the resident was in his room because he was at risk for elopement because he had previously tried to leave the facility. LVN C said she was not using the form to monitor him for behaviors. LVN C said she would make sure the resident was in his room and mark it on the form. Interview on 10/26/21 at 5:50 PM, LVN F said she worked the night shift on 10/12/21 - 10/13/21 from 6 AM - 2 PM. LVN F said she heard what happened with CR #1 hurting himself with a fork and said she had no idea he had previously made statements about wanting to die. LVN F denied doing any type of close monitoring on CR #1 but said she did see him throughout the night and said he was sleeping. She said she last saw CR #1 in the morning on 10/13/21 before she left around 6:00 AM and said he was in his bed doing fine. LVN F said she had not filled out a form where she monitored CR #1 every 15 minutes and stated again, she did not know he was supposed to be monitored for any type of psychological reasons. Record review and interview on 10/26/21 at 6:00 PM, the DON said the Quality of Life - Dignity policy was the only policy they had related to Quality of Life. Review of the Quality of Life - Dignity policy (Revised August 2009) revealed it did not address areas of concern listed above . The DON also said there was not a policy she could find that addressed behavioral services. It was determined that these failures placed CR #1 in an immediate jeopardy (IJ) situation from 10/11/2021 through 10/13/2021. The facility took the following actions to correct the noncompliance which were confirmed by the surveyor : Record review of CR #1's discharge MDS, dated [DATE], revealed CR#1 was discharged from the facility on 10/13/2021 . Interview on 10/26/21 at 5:20 PM, the Administrator said the Social Worker was out from 10/8/21 - 10/12/21 and her first day back was 10/13/21 and CR #1 had already been transferred to the hospital. The Administrator said the DON was responsible for getting CR #1 the psych consult in the Social Workers absence and stated the facility had three days to get the paperwork completed for psych consults. The Administrator said while the resident waited for a psych consult, they monitored him every 15 minutes. The Administrator said she heard some of the staff were not aware why CR #1 was being monitored and she said they (administration) did not want CR #1 to know he was being closely monitored because it would upset him. The Administrator said some of the nurses like to talk and they did not want the nurses telling him he was being monitored or why, so they did not tell everyone why . The Administrator explained the monitoring form was a sign off sheet with codes to indicate where the resident was located at that time and what they were doing with the nurse's initials . Record review of CR #1 One on One Monitoring Form revealed form was started on 10/11/21 at 3:45AM by LVN B which indicated he was in his room sleeping throughout the night and had checked his vital signs and administered medications at 4:15 AM and 5:30 AM. Further review of the monitoring sheets revealed they were completed from 10/11/21 - 10/13/21 every 15 minutes. LVN C initialed the monitoring sheet, dated 10/12/21 from 7:00 AM - 2:45 PM and LVN E initialed the monitoring sheets, dated 10/11/21 and 10/12/21 from 11:00PM - 6:45AM. Further review of the monitoring sheet for the night shift (11 PM - 6:45 AM) on 10/12/21 - 10/13/21 revealed LVN E noted CR #1 was in his room sleeping at 6:0 0AM, 6:15 AM, and 6:30 AM. LVN E then noted at 6:45 AM CR #1 was in his room doing activities/reading/TV . Further record review of facility in services revealed facility staff were provided in-serviced on or about 10/12/2021 regarding abuse/neglect and how to identify and act with residents that exhibit phycological behaviors and self-harm as well as on one on one monitoring of the resident until transfer arrangement are secured . This training was completed prior initiating investigation. Staff interviews confirmed understanding of the training and expectations. 4 nurses and CNAs were interviewed from different shifts.

Based on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 3 residents reviewed for accidents. (Resident #84) -The facility did not provide adequate supervision to prevent Resident # 84 from sustaining a burn to her left thigh from hot water spill, causing her to yell in pain. This failure affected one resident and placed her at risk for serious injury from hot water. Findings include: Resident# 84: Record review of the admission sheet for Resident # 84 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Record Review of Resident #84's comprehensive MDS assessment dated [DATE] revealed the BIMS score was 12 indicating intact cognitive skills. Further review of the MDS revealed that she required extensive assistance from staff for dressing, toilet use and personal hygiene and supervision with eating. Resident was always incontinent of bowel and bladder. Record Review of the Care Plan dated 4/12/19 revealed Resident # 84 had impaired cognitive function/dementia or impaired thought processes r/t Dementia AEB BIMS score of 13. Goal: the resident will improve current level of cognitive function through the review date. The resident will be able to communicate basic needs on a daily basis through the review date. Intervention: ask yes/no questions in order to determine the resident's needs. Keep the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Monitor/document/report PRN any changes in cognitive function, specifically changes in : decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. Reminisce with the resident using photos of family and friends. Resident # 84 had an incident on 7/9/19. Resident spilled hot water on her lap. Redness to the left thigh. Intervention: staff assist resident with handling hot liquids. Wound consult. Resident # 84 is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t Physical Limitations. Resident # 84 have an ADL self-care performance deficit r/t Activity Intolerance, Dementia, Impaired balance. Intervention: eating: the resident requires (x) 1 staff to eat with set up. Record review of nurses note dated 7/9/2019 read in part: .revealed notified by CNA and Charge Nurse that the resident had spilled hot water on her legs. This writer with ADON and Charge Nurse assessed Resident #84's legs. No redness or injury seen. Resident states that her left anterior lower leg and top of left foot felt tender to touch. Resident states that she had her thermos of hot water and it slipped out of hands and fell in her lap. Discussed with resident that we will continue to monitor her legs for redness and potential injury from the hot water . Record review of Resident #84's nurses note dated 7/9/2019 revealed in part: .this afternoon, the patient spilled hot water on her Left Lower Extremity. Pants were immediately removed. No redness noted to site. Patient states that her left foot is tender to touch. No blistering noted to Lower extremity. MD made aware. MD stated to monitor for changes in that leg . Record review of the in service dated 7/10/19 presented by DON revealed Resident #84 must have staff assistance when pouring hot water. Record review of Resident #84's physician's orders [REDACTED]. Record review of Resident #84's nurses note dated 7/14/2019 revealed patient remains in the bed during the shift, easily aroused and alert. Total care requires with all ADLs. Cont. to apply [MEDICATION NAME] to bilateral thighs s/p hot water spill. Noted bilateral thighs with some tracks of redness. Area sensitive to touch as patient does not want pressure on her thighs. Continue on Tylenol as ordered for pain. Will cont. to monitor and F/U. Record review of Resident #84's nurses note dated 7/15/2019 revealed on follow up assessment of resident's thigh post hot water spill, noted abrasion to left inner thigh that measures 6.8x2cm(clustered) with no drainage. Order received for xeroform dressing every 2 days. Treatment done and well tolerated. No complaints of pain noted. Will continue to monitor. Record review of Resident #84's physician's orders [REDACTED]. One time a day every 2 day(s) for hot water spill abrasion. Record review of Resident #84's physician's orders [REDACTED]. Record review of Resident #84's Wound evaluation and management summary dated 7/24/19 read in part: . at the request of the referring provider, a through wound care assessment and evaluation was performed today. She had a burn wound of the left thigh for at least 12 days duration. There is exudate. Prior healing wound has improved and requires confirmation of current clinical status and evaluation with preventive recommendations to prevent recurrence . Observation on 7/30/19 at 12:00pm, CNA T provided incontinent care to Resident #84. The resident had brown streak marks to bilateral thigh and left upper lateral leg. In an interview on 7/30/19 at 12:30pm Resident # 84 said she got burned from hot water when she was making her noodles soup. She said she often ate noodles in her room because she did not like what they serve in the kitchen most of the time. Resident # 84 pointed at the blue thermos sitting on top of the drawer and said residents were not allowed to get the hot water from the kitchen and have to ask staff for assistance. She said staff would go and get the hot water from the kitchen for her soup. She said she was sitting on her wheelchair with the bedside table nearby. She said the CNA that brought the water did not close the thermos lid properly and she spilled water on herself. She said it hurt so bad that she yelled out in pain and staff came in to assess her. In an interview on 7/31/19 at 1:50 pm with DON and the regional nurse, the DON said the process was for the resident to ask somebody to get hot liquids from the kitchen. She said Resident # 84 kept a thermos in her room and CNA's would get the water from the kitchen. When asked if it was safe for Resident # 84 to be handling hot liquids without adequate supervision, the DON said Resident # 84 was competent, was her own responsible party and had eaten noodles many times in her room. The DON said the resident was assessed after the incident and it did not appear to be burn. Resident # 84 said she spilled hot water on herself. She said after this incident, she in serviced staff that Resident #84 has to be assisted when handling hot fluids. The Regional nurse asked the DON what was documented in the incident report. The DON said it was documented that Resident # 84 spilled water on her legs from the thermos. She said Resident # 84 did not mention the thermos was not closed properly. In an interview on 8/1/19 at 9:10am CNA I, said she was in serviced less than a month ago on Resident # 84 requiring assistance when handling hot fluids. She said Resident # 84 required total assistance with all ADLs. She said Resident #84 liked for staff to fill her thermos with hot water, so she could make noodle soup. She said Resident #84 liked drinking coffee in the morning so she made sure to hand the coffee with the lid and straw, so resident does not get burn again. A policy on accidents/supervision was requested from the DON on 07/31/19 at 1:50 pm, but was not provided before exit.

Based on observation, interview and record review the facility failed to ensure 1 of 19 residents (Resident #8) reviewed for quality of care received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care in that: -Resident #8 had pressure ulcers and contractures and her pain was not effectively controlled. This failure affected 1 resident whose pain was uncontrolled and placed 47 residents on pain management at risk of not receiving adequate assessments, medical care and services which could have a negative impact on their health and well-being. Findings: Record review of Resident #8's face sheet revealed a re-admitted [DATE] with an original admission date of [DATE]. Her [DIAGNOSES REDACTED]. She was [AGE] years old. Record review of Resident #8's Quarterly MDS dated [DATE] revealed under Speech Clarity: she was coded as having unclear speech. Her BIMS (Brief Interview for Mental Status) score was 10 out of 15 which indicating moderate impaired cognition. Under Functional Status: she required extensive assistance with 2 persons physical assist in bed mobility, transfer and toilet use. She was totally dependent on staff for dressing, eating, personal hygiene and bathing. Under Functional Limitation in Range of Motion: Resident #8 had impairment on both sides of upper and lower extremities. Under Pain Management: in the last 5 days Resident #8 had not received scheduled pain medication regimen, had not received PRN pain medication OR was offered and declined, and she had not received non-medication intervention for pain. Under Pain Presence: Resident #8 was coded as "no" for having had pain or hurting at any time in the last 5 days. On section J1100: Resident #8 had not experienced any shortness of breathing. On Swallowing/Nutritional Status: Resident #8 had a feeding tube. Under Other Ulcers, Wounds and Skin Problems: Resident #8 had open [MEDICAL CONDITION] other than ulcers, rashes and cuts. Record review of Resident #8's Daily Monitoring of Pain for April 2014 revealed that her pain scale was 4 (on a scale from 1 to 10) on 4/7/14. On 4/8/14 and 4/9/14, her pain scale was 5. Record review of facility's "Comparative Pain Scale" printed at the back of the Daily Monitoring of Pain revealed that a pain scale of 4 was described as "Distressing" and further described as "Strong, deep pain, like an average toothache, the initial pain from a bee sting, or minor trauma to part of the body, such as stubbing your toe real hard. So strong you notice the pain all the time and cannot completely adapt .... " A pain scale of 5 was described as "Very Distressing" which was further described as "strong, deep, piercing pain, such as sprained ankle when you stand on it wrong, or mild pack pain. Not only do you notice the pain all the time, you are now so preoccupied with managing it that you normal lifestyle is curtailed. Temporary personality disorders are frequent." Record review of Resident #8's Daily Monitoring of Pain for May 2014 revealed that Resident #8 was marked as having no pain for the whole month of May. Record review of Resident #8's Physician's progress report dated 6/3/14 revealed that Resident #8 had severe contractures and drooling. Under assessment and plan, Resident #8 was documented as being total care and was tube fed. "New Knee Pressure Sore and chronic upper back pressure sore. Recently in the hospital (2 weeks) [MEDICAL CONDITION]. Uses Hoyer Lift. Family goal is for patient to be comfortable and no further hospital transfers ... " Record review of Resident #8 ' s Physician ' s progress report dated 6/24/14 revealed " as per LVN patient with evidence of pain " . Resident #8 had " Pain (multiple joints) " . Record review of Resident #8's physician order [REDACTED]. -Start [MEDICATION NAME] 5/325 1 tab peg every 4 hours around the clock and every 2 hours as needed for pain. Record review of Resident #8's Nurse's notes dated 6/25/14 at 8:00 pm revealed that Resident #8 was yelling out in pain. Record review of Resident #8's Daily Monitoring for Pain on 6/25/14 revealed that Resident #8 was documented as having no pain in all shifts. Record review of Resident #8's Pain Evaluation dated 4/2/14 and 7/2/14 revealed the following evaluation: -Resident #8 did not demonstrate any signs of the following that may impede her ability to report pain: she had no cognitive impairment, no sensory impairment and no communication difficulties. -Under Pain Profile, the origin of pain was blank. Resident #8 was not currently in pain and was not at risk for pain. -Under "Indicate which of the following interventions have been used and its effectiveness: " , Prescription medications, over-the-counter medications including herbal, non-med therapy list, Resident #8 was coded as "N/A" (Not Applicable) on 7/2/14 and not filled up on 4/2/14. -Under "List and Profile all current locations of pain. Review at each evaluation. If applicable, incorporate most recent MDS information", the form was blank. Record review of Resident #8's summary of physician's orders [REDACTED]. -Clean left back with normal saline, pat dry apply [MEDICATION NAME] and dry dressing daily -Clean left lateral knee wound with wound cleanser, pat dry, apply Calcium Alginate and cover with dry dressing every 3 days. -Clean left knee with normal saline, pat dry, apply alginate and foam dressing daily. -clean right back wound with normal saline, pat dry, apply Santyl and Calcium Alginate cover with foam dressing daily. Record review of Resident #8's physician orders [REDACTED]. -Clean right buttocks with normal saline, pat dry. Apply Duoderm dressing every 3 days. -Clean left buttocks with normal saline, pat dry. Apply Duoderm dressing every 3 days. Record review of Resident #8's care plan dated 8/8/12 revealed "I have chronic pain" with the following interventions: -Observe and report changes in usual routine, sleep patterns, decrease in functional abilities, decrease ROM, withdrawal or resistance to care. Observation of Resident #8 on 7/10/14 at 9:37 am revealed that she was lying in bed on her right side. She had contractures of all extremities. Her upper extremities were flexed with contracted fingers. Her lower extremities were contracted with the right leg stiff and extended and the left leg flexed. She was connected to a feeding tube. She did not respond to any questions from the surveyors. Her eyes were closed. LVN P was observed doing wound care. He did not assess Resident #8 for pain before starting the wound care. He started by cleaning Resident #8's wounds on the upper back. Resident #8 had facial grimacing, her brows were wrinkled and her face was flushed while LVN P was cleaning the wound bed with normal saline . The resident was breathing through her mouth. LVN P was asked about the resident's respiration. He counted the respirations to 30 breaths per minute. LVN P was asked why Resident #8 had facial grimacing and increased respiration, LVN P replied, "maybe an indication of pain". LVN P said that Resident #8 was pre-medicated with pain medication 30 minutes prior to wound care. LVN P proceeded with the wound care to the left knee. LVN P pulled the old dressing to the left knee which revealed a large wound. LVN P measured the wound as 7.2 cm x 6.5 cm x .3 cm. There was drainage and yellow slough to the wound bed. Resident #8's eyes started blinking, she had facial grimacing, wrinkled brows and she started panting. The surveyor asked LVN P about Resident #8 grimacing and panting. LVN P counted the resident's respiration and said they were "50 something, I can't continue treatment for [REDACTED]. Two RN surveyors were in the room observing the wound care. Record review of the facility's "Assessing Pain in the Elderly" attached to the Resident #8's MAR indicated [REDACTED] -Non- verbal clues to pain: -Facial Expressions: --Slight frown, sad, frightened face --Grimacing, wrinkle forehead --Closed or tightened eyes --Any distorted expression --Rapid blinking -Verbalizations/Vocalizations: --Sighing, moaning, groaning --Grunting, chanting, calling out --Noisy breathing -Respiratory: --Decreased respiratory flow and volume In an interview with LVN P at the time of the wound care observation on on 7/10/14 at 9:37 am revealed that Resident #8 had "Bullous ulcers (acute or chronic [DIAGNOSES REDACTED] skin disease, involving the formation of blisters at the space between the skin layers epidermis and dermis), an [DIAGNOSES REDACTED] disease". He said that the pressure ulcers were caused by the [DIAGNOSES REDACTED] disease. He said the interventions were to reposition resident every 2 hours to relieve pressure, protein supplements, Vitamin C, MVI, Zinc Sulfate, Calcium Alginate with silver. He said that Resident #8 had Bullous ulcers to right upper back, left upper back, right buttocks, left buttocks and left knee. LVN P said that the wounds on the sacral area were new. In an interview with RN B on 7/10/14 at 10:10 am revealed that the last time Resident #8 had pain medication was at 7:30 am. In an interview with LVN P on 7/10/14 at 10:46 am revealed that Resident #8 was "a little better". He said that he went back to check Resident #8 and her respiration was 28. In an interview with CNA FF on 7/10/14 at 2:50 pm said Resident #8 did not always talk. She said that she knew when Resident #8 was in pain because she will have facial grimace, "you will see it in her face". In an interview with the Director of Staff Development on 7/11/14 at 10:36 am revealed that the nurses were in serviced on how to assessed for pain. They should look for facial grimace, moaning, groaning and increased in respiration which was a sign of discomfort. She said that during wound care, when a resident had a possible pain, the nurse should stop and assess and check when was the last pain medication was ordered. In an interview with LVN P on 7/11/14 at 10:39 am revealed that the incident that happened "yesterday, does not usually happen". He said that Resident #8 was out of bed a lot that morning, maybe the stress of going in and out of bed added to the pain. LVN P said that a good sign not to continue the wound care with Resident #8 "yesterday" was when she was having "tachypnea trying to compensate for breathing. She was panting". In an interview with ADON B on 7/11/14 at 10:55 am said residents should be assessed for pain daily and documented on the "pain sheets". She said that the focus during wound care should be making sure that the residents are "comfortable". ADON B said that the wound care should have been stopped when Resident #8 was seen with a facial expression. In an interview with the DON on 7/11/14 at 11:24 am said LVN P should have assessed Resident #8 before he started with the wound care. She said that Resident #8 should be assessed before the wound care, during the wound care and after the wound care for pain, grimacing, restlessness, agitation, change of respiration. She said that during the wound care, if Resident #8 was in pain, the wound care should have stopped and determine if there was a need to continue or not. She said Resident #8 had so many things going on prior to the wound care. She said that Resident #8 had a shower that morning and she was transferred to the Gerichair and was transferred again to the bed for wound care. She said that LVN P probably did not know that Resident #8 had been up several times prior to wound care that morning. Record review of the facility's policy and procedure on Pain - Clinical Protocol dated April 2007 revealed, read in parts, "Assessment: 1. The physician and staff will identify individuals who have pain or who are at risk for having pain ... Monitoring: 1. The staff will reassess the individual's pain and consequences of pain at regular intervals; at least each shift for acute pain or significant changes in levels of chronic pain at least weekly in stable chronic pain ..." Review of the facility's CMS 2567 revealed that there were 48 residents on pain management.