Every finding on record at Gold City Health and Rehab

Based on staff interviews, record review, and review of the facility policy titled, Functional Impairment-Clinical Protocol, the facility failed to ensure that one of three sampled residents (R) (R1) was assessed for use of a medical device (Broda (specialized seating designed for individuals with mobility challenges, physical disabilities, or those requiring enhanced postural support) chair) prior to its use. This deficient practice placed R1 at risk for use of medical equipment without assessment to determine appropriateness, need, and safe use.Findings include:A policy regarding assessment of residents prior to the use of mobility devices was requested but not provided.Review of the facility's policy titled Functional Impairment - Clinical Protocol, dated September 2012 under the section Assessment and Recognition, stated, Upon admission to the facility, at any time a significant change in condition occurs, and periodically during a resident's stay, the physician and staff will assess the resident's physical condition, functional decline, and risk for additional functional decline . The policy further stated: . 3. The physician should order consultations and professional evaluations appropriate to the resident's condition. 6. The physician and staff will review the results and implications of these evaluations and use them to guide subsequent care planning. 7. A physician, nurse, or therapist may initiate screening for the potential to benefit from rehabilitative services, such as physical or occupational therapy. 8. Following the screening, the therapist will document whether the resident may benefit from a more detailed rehabilitation evaluation or from unskilled therapy.A review of the electronic medical record (EMR) revealed that R1 was admitted to the facility with diagnoses including but not limited to Down syndrome, cerebral palsy unspecified, type 2 diabetes mellitus congestive heart failure, chronic atrial fibrillation, epilepsy, benign prostatic hyperplasia, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy and presence of urogenital implants.Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that R1 was assessed with a Brief Interview for Mental Status (BIMS) score of 99 (not conducted, able to complete). The resident was assessed as having severely impaired short- and long-term memory and severely impaired cognitive skills for daily decision-making. Section GG, Functional Ability, indicated no impairment in upper or lower extremity function, and the resident utilized a manual wheelchair for mobility. Section P, Restraints and Alarms, indicated that bed rails, trunk, limb, or other restraints, bed alarms, and chairs that prevent rising were not in use.Review of R1's care plan dated 12/02/2025 revealed limited mobility, requiring staff supervision to ambulate up to 10 feet and use of a wheelchair for locomotion. The care plan addressed fall risk and safety concerns, with goals focused on maintaining safety and preventing falls. Interventions included staff supervision, environmental safety measures, and fall precautions.In an interview with LPN AA on 02/03/2026 at 3:30 PM, when asked whether R1 had been assessed for use of the Broda chair prior to its use, Licensed Practical Nurse (LPN) AA stated he had not.In an interview with a Restorative Certified Nursing Assistant (CNA) II on 2/4/2026 10:30 am, she stated revealed she was not aware of R1 using a Broda chair, as he is using a regular wheelchair, stating that R1 is able to stand and prefers to stand.In an interview with a Physical Therapy Assistant (PTA) JJ on 02/05/2026 at 11:54 AM, she stated that when use of a Broda chair was being considered, nursing staff were expected to submit a referral to physical therapy (PT) for an assistive device evaluation. She stated that PT would complete the evaluation to determine whether a Broda chair was appropriate and provide recommendations to nursing staff. She reported that R1 did not have a referral for PT, was currently using a regular wheelchair, and that she had never observed R1 using a Broda chair. She further stated that nursing staff may initiate use of a Broda chair if they believed it was in the resident's best interest; however, a PT referral was still required for assessment. She stated that without an evaluation, it was difficult to determine whether R1 would be able to independently transfer out of a Broda chair, noting this would depend in part on the degree of recline.During a joint interview with the Infection Preventionist, MDS nurse, and Administrator on 02/05/2026 at 12:55 PM, LPN AA stated they used a Broda chair for comfort and not as a mobility device, but they should have sent a referral to PT to see if it was appropriate. We should have initiated a PT referral then, but it was not done. When asked whether discussing the use of a Broda chair with the family and including it in the resident's care plan was sufficient without an assessment, Registered Nurse (RN) EE stated that even if it was used for comfort and positioning rather than mobility, this was not sufficient and that an assessment should have been completed, if that is what the policy states. The Administrator agreed with RN EE that a therapy assessment should have been initiated.

Based on staff interviews, record review, and review of the facility policies titled, Compliance with Reporting Allegations of Abuse/Neglect/Exploitation and Use of Restraints, the facility failed to report an allegation of abuse timely involving one of three sampled residents (R) (R1) to the State Survey Agency. This deficient practice resulted in delayed investigation, placing facility residents at risk for continued or unaddressed abuse.Findings include:A review of the facility's policy dated 12/19/2022 titled Compliance with Reporting Allegations of Abuse/Neglect/Exploitation revealed under Policy: .all allegations of abuse/neglect.are reported immediately to the Administrator of the facility and to other appropriate agencies in accordance with current stated and federal regulations within prescribed timeframes.A review of the facility's policy dated April 2017 titled Use of Restraints revealed under Policy Interpretation and Implementation: 1. Physical Restraints are defined as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one's body. 2.If the resident cannot remove a device in the same manner in which the staff applied tit given that resident's physical condition(i.e., side rails are put back down, rather than climbed over), and this restricts his /her typical ability to change position or place, that device is considered a restraint. 3. Examples of devices that are /may be considered physical restraints include leg restraints, arm restraints, hand mitts, soft ties or vest, wheelchair safety bars, geri-chair geriatric chair), and lap cushions and trays that the resident cannot remove. 4. Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted including: . c. placing a resident in a chair that prevents the resident from rising. A review of the electronic medical record (EMR) for R1 revealed admission to the facility with diagnoses including but not limited to Down syndrome, cerebral palsy unspecified, type 2 diabetes mellitus congestive heart failure, chronic atrial fibrillation, epilepsy, benign prostatic hyperplasia, chronic kidney disease stage 3, anxiety, restlessness and agitation, lumbar compression fractures, abdominal distension, obstructive uropathy and presence of urogenital implants.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that R1 was assessed with a Brief Interview for Mental Status (BIMS) score of 99 (could not be conducted). The resident was assessed as having severely impaired short- and long-term memory and severely impaired cognitive skills for daily decision-making. Section GG, Functional Abilities) indicated no impairment in upper or lower extremity function, and the resident utilized a manual wheelchair for mobility. Section P, Restraints and Alarms, indicated that bed rails, trunk, limb, or other restraints, bed alarms, and chairs that prevent rising were not in use.Review of the care plan for R1 dated 12/02/2025 revealed that R1 has limited mobility, requires staff supervision to ambulate up to 10 feet, uses a wheelchair for locomotion, and requires staff assistance with documentation as needed.Review of the Facility-Reported Incident (FRI) documentation, the police report, medical records, and staff interviews, the following sequence of events was identified:On 10/26/2025 at approximately 5:00 AM, two day shift Dietary Staff members FF and GG observed R1 reclined in a Broda chair at the nurses' station and the resident appeared to be secured at the wrists and feet. However, they did not recognize this observation as a reportable allegation of abuse at that time.At approximately 06:45 AM, Infection Control Licensed Practical Nurse (LPN) AA observed R1 resting in a Broda chair and instructed night shift staff that the chair could be considered a restraint and that the resident should be transferred to his personal wheelchair. No wrist or ankle restraints were observed at that time.On 10/28/2025, Dietary Staff FF and GG reported their concerns to the Dietary Manager during the morning meeting and were instructed to submit written statements and report to administration.On 10/28/2025 at 10:30 AM, the Administrator was notified. At 11:43 AM, on the same date, the Administrator reported the Facility-Reported Incident to the State Agency.The Administrator initiated an internal investigation, notified the resident's family, physician, and the police, and interviewed the involved staff. Based on the investigation, it was determined that restraints were not used. Night shift staff stated the Broda chair was used for resident comfort and that no wrist or ankle restraints were applied.On 10/29/2025, the Interdisciplinary Team (IDT) was unable to determine whether restraints had been used.On 11/04/2025, a police investigator interviewed all involved staff and reported the case to the State Agency.During an interview with the Administrator on 02/03/2026 at 4:00 PM, the Administrator was asked to have Certified Nursing Assistant (CNA) HH, who was involved in the incident, contact the surveyor. The Administrator also stated that LPN II, who had provided care to R1, was no longer employed by the facility. Attempts to contact the facility on 02/03/2026 at 08:00 PM and 08:30 PM to reach CNA HH were unsuccessful. On 02/04/2026 at 09:30 AM, the Administrator stated the facility was experiencing intermittent internet and phone issues and was unable to explain why the calls were not answered.During an interview with Dietary Staff member GG on 02/04/2026 at 10:04 AM, she stated that she typically arrived at work around 05:00 AM. She reported that upon arrival at the facility to clock in, she observed R1 seated in a medical chair. She stated the resident asked her for tea and appeared to have immobile arms. She stated she believed the resident's hands were secured at the wrists with Velcro; however, she could not state this with certainty due to dim lighting at the time. She reported the resident was wearing disposable underwear, with his waist covered by a sheet. When asked why she did not immediately report the observation to administration, she stated that she was not aware at the time that the practice observed was not considered normal at the facility, explaining that she was not medical staff and worked in the kitchen. She further stated that she reported her observations on 10/28/2025, when she shared the information with her Dietary Supervisor. Upon receiving the report, the Dietary Supervisor instructed her to provide a written statement and immediately reported the concern to the Administrator.In an interview with Dietary Aide FF on 02/04/2026 at 10:30 AM, she stated that she typically arrived at work around 04:50 AM. She reported observing R1 reclined in a chair near the nurses' station and covered with a white blanket. She stated the resident appeared unable to move his arms or legs and that only his head was moving forward. She reported the resident stated, I am done, I am done. When asked why she did not immediately report the observation to administration, she stated she reported her observations to nursing staff, who informed her that the resident had not slept that night, had been awake throughout the night, and would remain in the chair for a bit.In an interview with the Infection Control LPN AA on 02/03/2026 at 3:30 PM, she stated that when she arrived at work on 10/26/2025 at approximately 06:45 AM, she observed R1 reclined in a Broda chair with his feet elevated. She stated she understood that a reclined Broda chair may be considered a restraint and instructed LPN II to assist the resident to his regular wheelchair. She stated that she did not observe R1 to be restrained or in distress.During an interview with Physical Therapy Assistant (PTA) JJ on 02/05/2026 at 11:54 AM, she explained that a regular wheelchair was designed to allow independent mobility and repositioning, whereas a Broda chair was a positioning chair intended to provide postural support for residents with poor sitting posture. She further stated that, unlike a standard wheelchair, a Broda chair may limit a resident's ability to rise without assistance and could function as a restraint.During a joint interview on 02/05/2026 at 12:55 PM with LPN AA, the MDS Coordinator-Registered Nurse (RN), Interim Director of Nursing (DON) EE, and the Administrator, LPN AA stated that use of a recliner may be considered a restraint if a resident was unable to get out of it independently. She stated she could not confirm with certainty whether R1 would be able to independently propel himself out of the Broda chair. LPN AA further stated that staff were expected to immediately report any allegations of potential abuse, including the use of restraints, to their supervisors and/or the Abuse Coordinator. She stated that this reporting should have occurred immediately. The Administrator confirmed she served as the Abuse Coordinator and was available 24/7 (24 hours a day, 7 days per week); if unavailable, the DON was the designated point of contact. She further stated that all staff, including nursing and non-nursing staff, were trained in the reporting process and were expected to immediately report any suspected abuse or restraint, even if uncertain.

Based on interviews, record review, and facility policy review, the facility failed to prevent resident to resident abuse for one of three residents (Resident (R)10) reviewed in a total sample of 20. This failure resulted in R9 having unsupervised access to R10 providing opportunity for R9 to pull R10's arm inappropriately and attempt to kiss R10's hands. Findings include:Review of the facility's policy Abuse, Neglect and Exploitation with an implementation date of 12/19/2022, provided by the facility indicated under Definitions: Definition of sexual abuse is non-consensual sexual contact of any type with a resident. Under III. Prevention of Abuse, Neglect and Exploitation-The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves: A. Establishing a safe environment that supports, to the extent possible, a resident's consensual sexual relationship and by establishing policies and protocols for preventing sexual abuse. This may include identifying when, how, and by whom determinations of capacity to consent to a sexual contact will be made and where this documentation will be recorded; and the resident's right to establish a relationship with another individual, which may include the development of or the presence of an ongoing sexually relationship.Review of R9's admission Record found under the Profile tab of the electronic medical record (EMR) revealed diagnoses of Alzheimer's disease, dementia, hypertension, anxiety disorder, major depressive disorder, and high-risk heterosexual behavior.Review of R9's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/8/2025 found under the MDS tab of the EMR indicated that R9 Brief Interview for Mental Status (BIMS) score was 3 of 15, indicating R9 had severe cognitive impairment. The MDS indicated physical behavior, directed toward others one to three days, other behavioral symptoms - occurred one to three days.Review of R9's Care Plan found under the Care Plan tab of the EMR with a revised date of 7/3/2025, revealed that R9 had a care plan for a behavior problem related to inappropriate sexual behavior toward other residents with interventions to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and monitor behavior episodes and attempt to determine underlying cause. Review of R10's admission Record found under the Profile tab of the EMR diagnoses of Alzheimer's disease, dementia, restlessness and agitation, chronic pain, spinal stenosis, and hypertension.Review of R10's admission MDS with an ARD of 3/24/2025 found under the MDS tab of the EMR indicated that R10's BIMS was not assessed, no score was entered. Review of R10's Care Plan found under the Care Plan tab of the EMR with a revised date of 8/19/2025 revealed that R10 had a care plan for self-care deficit, verbal and physical aggression when redirected, wandering, resistive to care, and impaired cognitive function/dementia or impaired thought processes related to Alzheimer's disease. Review of R10's Progress Note, dated 8/21/2025 found in the Progress Notes tab of the EMR, authored by Licensed Practical Nurse (LPN)1 revealed LPN1 witnessed R9 holding onto R10's hand and attempting to kiss his hands and arms. R10 attempted to disentangle himself without success. LPN1 separated R10 and R9. Another staff member assisted R10 away from the area at this time. No apparent injuries or distress noted at this time. Placed on 30-minute checks for R10's safety.Review of a Facility Incident Report Form provided by the facility dated 8/22/2025 indicated an incident on 8/21/2025 involving R9 touching R10's arm and kissing his hand while R10 was attempting to pull away. During an interview on 8/29/2025 at 3:26 PM, LPN1 stated that the incident occurred at shift change. LPN1 stated that she had just left her office and as she entered the area around the nurses' station, she saw R9 and R10. R9 was holding R10's arm and R9 attempted to pull away but was unable. R9 was seated in a wheelchair facing R10 who was standing. R9 attempted to pull on R10's arm which created a back-and-forth motion as R10 attempted to pull his arm back. LPN1 stated that R9 attempted to kiss R10's hand but was unsuccessful. LPN1 stated the certified nurse aides (CNAs) were making rounds and no staff member was at the nurses' station. R9 became upset when R10 was escorted to his room and attempted to follow R10. LPN1 stated that she stood between R9 and the entrance to R10's hallway at the double doors so that R9 could not follow R10.During an interview on 8/29/2025 at 5:30 PM, the Administrator stated that her expectations of staff were to meet the basic needs of residents, know their characteristics and behaviors, strategize their interventions, and talk to family members to glean more clues about resident interventions. The Administrator stated she would educate staff, hold impromptu care plan meetings, and provide an individualized supervision approach in the care and protection of the residents.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to develop a comprehensive person-centered care plan that included specific interventions to ensure psychosocial well-being and safety for one of three residents (Resident (R) 4) reviewed in a sample of 20 residents.Findings include: Review of the facility policy titled, Comprehensive Care Plans with an implementation date of 4/1/2025 indicated under Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs and ALL services that are identified in the resident's comprehensive assessment and meet professional standards of quality.Review of R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed an admission date to the facility on [DATE] with diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, paraplegia, Review of R4's admission Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/25/2024 indicated a Brief Interview for Mental Status (BIM) score of 15, which indicated R4 was cognitively intact.Review of R4's Care Plan revised on 06/15/25 and located in the EMR under the Care Plan tab revealed a plan for a behavior problem related to having auditory and visual hallucinations at time and has a history of suicidal ideations and suicidal attempts. Interventions initiated on06/16/2025 were to perform 15-minute resident safety checks, resident to have only plastic silverware, resident moved to a room with a roommate, and the room was cleared of items that are potentially harmful.Review of Progress Note dated 5/20/2025 indicated the R4 called out to the nurse tearfully and stated that she was suicidal and drank hand sanitizer.Review of a Progress Note, dated 6/3/2025, authored by Licensed Practical Nurse (LPN)3 indicated that LPN3 found R4 with a plastic bag over her head loosely and stated she was trying to kill herself. Observation on 8/26/2025 at 4:05 PM revealed R4 in her electric wheelchair attempting to get an item from inside the personal refrigerator that was on the floor. Observed clear trash liners in R4's roommate's trash can and in R4's trash can.In an interview on 8/26/2025 at 4:45 PM Certified Nurse Aide (CNA)1 stated that it would be ok to have a trash liner in the trash can if it was not in reach of the resident. In an interview on 8/26/2025 at 4:49 PM CNA2 stated that it would be ok the have a trash liner in the trash can.In an interview on 8/29/2025 at 5:30 PM, when asked about specific care plan interventions and how to communicate those interventions to staff, the Administrator stated it didn't matter what the changes were, they should document the specific interventions that relate to the situation, and then ensure they monitor for effectiveness. The Administrator stated going forward, all care plans would have to be reviewed and triaged regarding negative potential impact on residents.

Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure a resident was evaluated for appropriate bed rail use and that alternative measures were attempted prior to installation of bed rails for one of one resident (Resident (R) 4) reviewed for bed rails out of a total sample of 20. The lack of alternate bed rail measures had the potential to lead to safety concerns related to bed rail use. Findings include:Review of the facility's policy titled Bed Safety and Bed Rails, provided by the facility, with a revision date of August 2022 indicated, Use of Bed Rails.The use of bed rails or side rails (including temporarily) raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent.Review of R4's admission Record, found in the Profile tab of the electronic medical record (EMR) revealed diagnoses of cerebral palsy, schizoaffective disorder, bipolar disorder, major depressive disorder, anxiety disorder, suicidal ideations, and paraplegia, Review of R4's admission Minimum Data Set (MDS) located in the MDS tab in the EMR with an Assessment Reference Date (ARD) of 11/25/2024 indicated a Brief Interview for Mental Status (BIM) score of 15, which indicated R4 was cognitively intact.Review of R4's Care Plan dated 11/14/2024 and located in the EMR under the Care Plan tab revealed an Activity of Daily Living self-care performance deficit related to cerebral palsy care plan with a side rail intervention initiated on 1/28/2025. Quarter rails up on both sides to assist with bed mobility. Observe for injury or entrapment related to side rail use. Reposition as necessary to avoid injury. Review of R4's medical record did not reveal an initial bed rail assessment; documented alternatives tried prior to consideration of bed rail or a consent for bed rails.Observation on 8/25/2025 at 5:30 PM revealed a bedrail in the lowered position on the right side of the bed and the bed pushed against the wall on the left side.During an interview on 8/26/2015 at 2:15 PM, Licensed Practical Nurse (LPN)2 acknowledged that there was a bed rail on R4's bed and stated that she had not seen R4 use it.In an interview on 8/29/2025 at 10:00 AM, the Administrator confirmed that R4's bed rail evaluation, consent for use, and alternatives tried before installing the bed rail were not done.In an interview on 8/29/2025 at 5:30 PM, the Administrator and Director of Nursing (DON) stated that they did not know how the alternatives tried documentation, assessment by nurses and interdisciplinary (IDT) review and documentation were missed. The Administrator stated that her expectations going forward would be for more communication between nurses, IDT members and herself prior to installing bed rails to ensure that they were appropriate for resident use and safety.

Based on staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to maintain Registered Nurse (RN) coverage for eight consecutive hours seven days a week on 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024. This failure had the potential to render all 68 residents without the necessary medical assistance that only an RN could provide, leading to adverse outcomes. Findings include: Review of the Daily Nursing Staff Report(s), dated 8/10/2024, 8/11/2024, 8/24/2024, and 8/25/2024 that was provided by the Administrator, indicated the absence of RN coverage during each shift of each day listed. The form revealed, report contains nursing staff directly responsible for resident care. The form continued, daily posting of this information is required for nursing homes participating in Medicare and Medicaid programs. During an interview on 8/28/2024 at 11:25 am, the Administrator [interim since July 2024, but familiar with facility] verified that there should have been RN coverage for at least eight consecutive hours every day of the week. She acknowledged that not having an RN during each day had the potential for negative outcome situations.

Based on observation, staff interviews, record review, and review of the facility's policies titled Dishwashing and Temperature Log Guidelines, the facility failed to ensure the chemical level of the low temperature dishwasher was maintained at a level that would sanitize the soiled dishes with the potential to affect 68 of 68 residents. The deficient practice had the potential to result in the spread of infections/viruses and food borne illness. Findings include: Review of the facility's undated policy titled, Dishwashing revealed the low temperature dishwasher rinse temperature should be in the temperature range of 120 degrees Fahrenheit (F) to 150 degrees F and the chlorine should be 50 part per million concentration minimum to 100 PPM concentration maximum. Review of the facility's undated policy titled, Temperature Log Guidelines revealed the dish machine log should have been completed three times daily to ensure the temperatures and the sanitizer levels were properly maintained and controlled. During an observation on 8/25/2024 at 7:04 pm, Dietary Aide (DA) 3 was observed running the dishes from the evening meal through the dishwasher. DA3 stated the dishwasher was a low temperature dishwasher. The sanitizer level of the rinse water of the dishwasher was checked and when the test strip was placed in the rinse water of the dishwasher it did not change color indicating it was at zero (0) parts per million (PPM) concentration level of chlorine. DA3 stated she probably needed to prime the machine. She pushed the primer button three times, ran the dishwasher repeatedly, and it tested at zero PPM. The sanitizer was checked a third time while she continually pushed the primer button throughout the wash and rinse cycles and the sanitizer was still measuring zero parts per million. She continued to wash the dishes without telling anyone about the dishwasher not dispensing any sanitizer into the rinse cycle of the dishwasher with DA2 continuing to remove the dishes from the racks on the clean end of the dishwasher and putting them away in the kitchen. During continued observation on 8/25/2024 at 7:29 pm, the sanitizer was checked for a fourth time and was zero PPM. DA3 stated she had worked a double shift and the last time she checked the sanitizer level of the dishwasher was at 8:14 am that morning and the test strip turned purple indicating it was between 50 and 100 PPM of chlorine sanitizer. When queried about what she was supposed to do if the sanitizer was not testing at the correct level, she stated she was supposed to tell the Dietary Manager (DM). When asked when she would be telling the DM, she stated in the morning after the DM arrived at work. She stated they were supposed to check the levels three times a day and write it down on the temperature log. The temperature logbook located on a shelf in the dishwasher room was provided by DA2. The book contained instructions for testing the level of the sanitizer and a log titled Dishwasher Temperature. The log had a space for the temperature and the sanitizer levels. Review of the log revealed it was not completed for 8/22/2024, 8/23/2024, lunch and dinner on 8/24/2024 and 8/25/2024. A document in the book used to write sanitizer levels titled, Test for Chlorine Sanitizer revealed the sanitizer should have been 50 PPM. During an interview on 8/25/2024 at 7:57 pm, the Dietary Manager (DM) stated she shook the sanitizer container and then primed it, and she got it to 100 PPM. She was informed it was zero PPM and verified it should have been at 50 PPM and if it was not, the staff should not have been using the dishwasher.

03115 Based on observation, staff and resident interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, and Abuse, Neglect, Exploitation and Misappropriation Prevention Program, the facility failed to protect the residents' right to be free from mental/verbal abuse for four of 13 residents (R) (R53, R11, R122, and R71) and free from physical abuse for one of one resident (R48) reviewed for abuse out of a total sample of 43 residents. Specifically, R19 verbally harassed R53 and verbally insulted R11. Also, R16 verbally harassed R53 and verbally disrespected R122 and R71. This failure had the potential to cause psychosocial harm to the residents. Findings include: Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 12/19/2022, revealed, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . The policy continued, . the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated 4/2021, revealed, . residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms 1. Review of R19's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 9/29/2023 and located under the MDS tab of the electronic medical record (EMR), revealed R19 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicating no cognitive decline; and had diagnoses that included diabetes and acute kidney failure. Review of R19's Misc (Miscellaneous) tab, located in the EMR revealed a Care Plan, initiated on 1/3/2019 related to behaviors. Interventions included not arguing with R19 and for Social Services to visit with R19 as needed. Review of R53's annual MDS, located under the MDS tab and with an ARD of 5/22/2024, revealed R53 had severely impaired cognitive skills; had long-term and short-term memory problems; was dependent on a wheelchair for mobility; and had diagnoses which included dementia with behavioral disturbances, cognitive communication deficit, and Alzheimer's disease. Review of the Facility Incident Report Form, dated 10/24/2023 and provided by the facility, revealed on 8/30/2024, R19 was talking to R53 and accusing her of stealing. R19 tried to move away when their wheelchairs became interlocked. R19 then began accusing R53 of stealing again, and R53 then struck R19 in the face with magazines. There were no injuries noted to R19. The immediate steps taken to prevent further incidents were the facility separated the residents, the police were called, the State, physician, Ombudsman, and resident representatives were notified, and the abuse coordinator initiated an investigation. The follow-up investigation revealed the facility substantiated an incident between R53 and R19. Review of a post-incident Behavior PAR (Patient at Risk) Tracking Documentation form, dated 10/26/2023 and provided by the facility, revealed R19 was having his behavior tracked due to taunting other residents causing another resident (R53) to hit him. The Intensity of Behavior section was filled with typically severe. The Goals section was filled with to monitor and redirect negative behaviors. R19 was monitored for five weeks post incident with the following indications: Week One: No changes in medications per pharmacy and R19 was informed that it was not good behavior to taunt other residents. Week Two: R19 was making fun of another resident in the dining room. Week Three: R19 had a mellow week. Week Four: R19 continued to make upsetting comments to residents. Week Five: No aggressive or demeaning comments. Review of a [Name of psychiatric services] Subsequent Medication Evaluation report, dated 11/20/2023 and located under the Misc tab in the EMR, revealed R19's behavior was recorded as appropriate, with the report summary stating there was nothing new reported, R19 was stable, no medication side effects were noted, and a gradual dose reduction (GDR) of medications were not indicated. There were no Care Plan updates for the 10/24/2023 incident with R53. The CP was reviewed and continued on 11/23/2023, and no new interventions were identified or implemented related to R19's behaviors. Review of R11's quarterly MDS, with an ARD of 10/17/2023 and located under the MDS tab of the EMR, revealed R11 was admitted to the facility on [DATE] and had a BIMS score of 99, which indicated staff was unable to assess the resident's cognitive status. Review of the Facility Incident Report Form, dated 12/19/2023 and provided by the facility, revealed on 12/19/2023, R19 entered the room of R11 and made inappropriate remarks related to R11's body, not knowing a staff member was behind the curtain in the room. The staff member asked R19 to leave the room. The immediate steps taken to prevent further incidents were the facility separated the residents, the police were called, the State, physician, Ombudsman, and resident representatives were notified, R19 refused to be sent to the hospital for evaluation, and the abuse coordinator initiated an investigation. The follow-up investigation revealed the facility substantiated an incident between R19 and R11. The facility followed time frames and requirements for incident. Review of R11's Progress Note, dated 12/20/2023 and located under the Prog tab of the EMR, R19 had wheeled himself into R11's room and made inappropriate comments related to R11's body. R19 did not notice the staff in the room and was immediately confronted about what he said, and R19 tried to quickly change the subject. R19 was escorted from the room, and incident protocol was initiated. Review of a Behavior PAR Tracking Documentation form, dated 12/21/2023 revealed R19 was having his behavior tracked due to making sexually inappropriate comments to R11. The Frequency of Behavior section was filled with often (multiple times weekly), and the Intensity of Behavior section was filled with typically severe. The Goals section was filled with to monitor and redirect, educate resident on inappropriate statements, and to have [psychiatric services] re-evaluate R19. R19 was monitored for four weeks post incident with the following indications: Week One: sexually inappropriate comments. Week Two: continued to slander facility, staff, and other residents because of the reported incident with R11. Week Three: continued to make negative comments towards other residents. Week Four: Negative behaviors continued. Review of a [Name of psychiatric service] Subsequent Medication Evaluation report, dated 2/5/2024 and located under the Misc tab of the EMR, revealed R19's behavior was indicated to be appropriate and R19's weight was discussed, but not his behaviors. There were no Care Plan updates for the 12/20/2023 incident with R11, and no new interventions were identified or implemented related to R19's behaviors. Interview on 8/27/2024 at 11:30 am with Licensed Practical Nurse (LPN) 4 stated that R16 and R19 have not liked R53 for a long time. LPN4 stated R16 and R19 will say things quietly, thinking the staff are not aware and so only R53 can hear them, just to get her to react. LPN4 added that R16 and R19 go around to other residents saying that R53 is a thief trying to turn the residents against R53. LPN4 added R53 is normally calm and sweet until R16 and R19 instigate something. During a Resident Council meeting on 8/27/2024 at 2:00 pm, no resident raised concerns related to fear or distrust of other residents. R16 and R19 were present during the Resident Council meeting and were antagonistic towards the Resident Council President for praying before the meeting. Interview on 8/28/2024 at 12:45 pm with the Administrator, who started July 2024, verified R19's care plan had not been updated with new interventions each time R19 was involved in an inappropriate behavior situation. The Administrator stated she was not sure why ([psychiatric) Services evaluation forms indicated R19 was stable on most of his encounters, with no behavioral issues brought to the physician's attention and stated she would contact [psychiatric service]. On 8/28/2024 at 1:30 pm, the ADON was asked for any documented behavior monitoring or 15-minute checks for R19. The documentation was not received before the end of the survey. 2. Review of R16's Face Sheet, located in the EMR under the Profile tab, revealed R16 was admitted to the facility on [DATE] with diagnoses which included tobacco use, psychosis, restlessness and agitation, major depressive disorder, and generalized anxiety disorder. Review of R16's quarterly MDS, with an ARD of 8/8/2024 and located under the MDS tab of the EMR, revealed R16 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact. Review of R16's paper Plan of Care, provided by the facility, dated 3/14/2017, and last reviewed 5/9/2024, revealed R16 had a problem with displaying verbally aggressive behaviors at times. The care plan problem recorded, .I make inappropriate comments to other residents and staff members during smoke breaks. I have been educated on my behaviors . Under the approach section of the care plan, the care plan recorded to remove R16 from public areas when the behavior was disruptive and unacceptable. An entry, dated 03/03/24, in the approach section of the plan of care recorded the resident continued to be verbally abusive to other residents. Review of R53's annual MDS, located under the MDS tab of the EMR and with an ARD of 5/22/2024, revealed R53 had severely impaired cognitive skills; had long-term and short-term memory problems; was dependent on a wheelchair for mobility; and had diagnoses which included dementia with behavioral disturbances, cognitive communication deficit, and Alzheimer's disease. Review of a complaint summary, completed by the former Administrator, titled [Name of the Facility], dated 7/19/2023 and provided by the Administrator, revealed the document was a follow up to the self-reported incident #202306917. The document recorded that on Wednesday 7/12/2023 at approximately 2:25 pm, LPN8 and the Social Service Director (SSD) came to the Abuse Coordinator/Administrator and informed him that LPN6 reported to them that she overheard R16 asking R53 multiple times if she wanted to get raped. According to the report, it was reported to the Department of Health, police, physician, ombudsman, and the responsible party. According to the written statement from LPN6 on 7/12/2023 at 2:00 pm, she was in the dining room passing medications when she heard R16 ask R53 twice if she knew Kyane [NAME] and R53 did not respond and then ask her if she knew Bow-Wow twice and again R53 did not respond. Then R16 stated yeah you know Bow-Wow he got raped, 'Do you want to be raped?' and then she repeated it and said to her again do you want to be raped so they can suck your face. According to the statement, LPN6 told R16 that was not the kind of thing to say and to not say it again. R16 told LPN6 that R53 knew all the rappers and LPN6 told R16 that R53 did not and to not repeat it again. The complaint summary stated they were immediately separated. According to the report and attached documents, the police questioned R16, and she admitted to police that she asked R53 if she wanted to be raped and should not have said it and apologized. The report concluded there was a verbal altercation between the two residents and R16 did speak inappropriately to R53. The facility obtained a new consultation for psychiatric services for R16. Review of R16's Care Plan revealed no new interventions were identified or implemented related to the resident's behaviors. Interview on 8/27/2024 at 12:58 pm, with the SSD via telephone revealed, the incident was reported to her by an agency nurse, and R53 did not seem bothered by it. She stated she did consider it to be verbal abuse, and R16 had a history of vulgar behavior. During an interview on 8/27/2024 at 5:44 pm, LPN4 stated she had heard R16 speak inappropriately to other residents and at times try to irritate other residents. She stated when she saw it, she immediately redirected and separated them and reported it to the SSD and the charge nurse. Review of R122's annual MDS, with an ARD of 4/18/2024 and located under the MDS tab of the EMR, revealed R122 was admitted to the facility on [DATE] and had a BIMS score of 13 out of 15, which indicated he was cognitively intact. According to the admission/discharge record, located in the Profile tab of the EMR, R122 was discharged from the facility on 6/21/2024. Review of R71's annual MDS, with an ARD of 4/12/2024 and located under the MDS tab of the EMR, revealed R71 was admitted to the facility on [DATE] and had a BIMS score of 15 out of 15, which indicated she was cognitively intact. According to the admission/discharge record, located in the Profile tab of the EMR, R71 was discharged from the facility on 6/21/2024. Review of a Resident Incident Report, dated 2/21/2024 at 3:00 pm and provided by the Administrator, revealed the SSD had reported to the Administrator that R122 had reported that R16 was being verbally abusive to him and R71 on 2/20/2024 at approximately 7:00 pm to 8:00 pm. Review of the abuse summary titled, [Name of the Facility] dated 2/28/2024 and provided by the Administrator, revealed that on 2/21/2024 at approximately 3:00 pm, it was reported to the SSD and then to the previous Administrator/Abuse Coordinator that on 2/20/2024 between approximately 7:00 pm and 8:00 pm, R16 allegedly called R122 queer and R71 a lesbian. Review of R122's Progress Note, dated 2/21/2024 at 3:34 pm, written by LPN7, and located under the Prog Note tab of the EMR, revealed R122 reported to LPN7 that on 2/20/2024 around 7:30 pm that he and R71 were sitting in the hall when R16 rolled up to them and spoke verbal insults to them, including calling him a queer and R71 gay. According to the note, R16 denied it happened. Review of R16's Care Plan revealed no new interventions were identified or implemented related to the resident's behaviors. On 8/28/2024 at 12:24 pm, a telephone interview was conducted with LPN7. LPN7 stated she did not witness the incident. She stated R122 reported it to her the next day. She stated she felt R16 had a history of saying a lot of inappropriate comments to other residents but she had a history of being discreet about it so there were no witnesses. 3. Review of the Facility Incident Report Form dated 8/30/2023 and provided by the facility revealed at 3:45 pm on 8/30/2023 R53 struck R48 on the arm with a very thin lightweight green plastic plate. There were no injuries noted on R48 and she denied any pain. The immediate steps taken to prevent further incidents were the facility separated the residents, the police were called, R53 was sent to the hospital for observation, the State, physician, Ombudsman, and resident representatives were notified, and the abuse coordinator initiated an investigation. The follow-up investigation revealed R53 was by the bingo prize table during activities when R48 came up to her and told R53 that she [R53] could not have any prizes. R53 then hit R48 with the plastic plate in the arm. The facility followed time frames and requirements for incident. Review of the Census tab located in the electronic medical record (EMR) revealed R48 was admitted on [DATE]. Review of the Med Diag [Medical Diagnoses] tab located in the EMR revealed R48 had diagnoses including post-stroke affecting the right dominant side and aphasia. Review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/11/2023 revealed R48 had a Brief Interview for Mental Status (BIMS) score of eight out of 15 indicating a moderate decline in cognition. Review of the Prog Note [Progress Note] tab of the EMR revealed a historical note dated 8/30/2023 that stated bingo had ended in activities and R48 began telling R53 to get away from the prize table and that she [R53] could not have anything. R53 then took a plastic plate and hit R48 in the arm. Review of the Census tab located in the EMR revealed R53 was admitted on [DATE]. Review of the Med Diag tab located in the EMR revealed R53 had diagnoses including Alzheimer's disease with late onset, cognitive communication deficit, and dementia. Review of the quarterly MDS with an ARD of 8/23/2023 located in the EMR revealed R53 had a BIMS score of 99 out of 15 indicating the interview could not be completed due to R53's cognitive decline. Review of the Misc [miscellaneous] tab located in the EMR revealed a Care Plan (CP) with a concern related to negative behaviors initiated on 5/16/2022 with interventions including redirection, observation for root cause, and behavior documentation. Review of the Prog Note tab located in the EMR revealed a note dated 9/1/2023 that stated R53 had hit R48 in the arm with a plastic plate during activities. During a Resident Council meeting on 8/27/2024 at 2:00 pm, no resident raised concerns related to fear or distrust of other residents.

Based on staff interviews, record review, and review of the facility policy Abuse, Neglect, and Exploitation, the facility failed to provide adequate supervision to prevent accidents for four of four residents (R) (R6, R3, R23, and R36) reviewed for supervision out of a total sample of 43. Specifically, R6 had diagnoses of severe dementia, delusions, and paranoid schizophrenia and exhibited aggressive behaviors towards R3, R23, and R36. As a result of this deficient practice the residents in the facility had the potential for harm from the aggressive behaviors from R6. Findings include: Review of the facility policy Abuse, Neglect, and Exploitation, dated 12/19/2022 revealed, The identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect . Identifying, correcting and intervening in situations in which abuse, neglect, . with the deployment of trained and qualified, registered, licensed, and certified staff on each shift in sufficient numbers to meet the needs of the residents, and assure that the staff assigned have knowledge of the individual residents' care needs and behavioral symptoms. 1. Review of facility incident reports revealed a resident-to-resident altercation occurred between R6 and R3 on 11/22/2023. Review of R6's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6 had diagnoses that included Alzheimer's disease, vascular dementia, paranoid schizophrenia, delusional disorder, unspecified dementia with behavioral disturbances, and major depressive disorder. Review of R6's Care Plan, located in the EMR under the Misc (Miscellaneous) tab and dated 8/11/2023, revealed, . [R6] have [sic] negative behaviors. [R6] can be combative at times. The interventions included, . Observe for wander/elopement behavior I am physically aggressive towards staff members at times I am verbally aggressive at times I enjoy coffee and books to help me when [R6 is] angry . Review of R6's annual Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 9/22/2023, revealed R6 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated staff was unable to assess his cognitive status. It was recorded R6 was severely cognitively impaired and rarely/never makes decisions. Review of R3's Admission Record, located in the EMR under the Profile tab, revealed diagnoses that included major depressive disorder, unspecified intellectual disabilities, and seizures. Review of R3's quarterly MDS, located in the EMR under the MDS tab and with an ARD of 9/22/2023, revealed R3 had a BIMS score of 6 out of 15, indicating R3 was severely cognitively impaired. Review of R6's Patient at Risk (PAR), flow sheet, provided by the facility and dated 11/10/2023, revealed R6 had been agitated since some medications were reduced and taken away, and had exhibited some behaviors of kicking another resident's wheelchair. It was recorded that the medications were added back due to agitation and aggressive behaviors. Review of R6's Progress Note, provided by the facility and dated 11/22/2023 at 12:45 pm, revealed, . resident witnessed having altercation with [R3] in the dining room during lunch. Witness saw [R6] with tray cover [used to keep food warm] in hand and very upset, hitting [R3] and other residents in the dining room stated that R6 hit R3 on the top of the head. Review of R3's Progress Note, provided by the facility and dated 11/22/2023 at 2:43 pm, revealed, [R3] in dining room for lunch at 12:45 another resident [R6] took his tray lid and hit resident over the head three times. No apparent injury. No c/o [complaint of] of [sic] pain just scared. [R3] was removed from the dining room to prevent any further contact . Review of R6's Care Plan, located in the EMR under the Misc tab, revealed no new interventions were identified or implemented after the incident on 11/22/2023. 2. Review of facility incident reports revealed there was a resident-to-resident altercation between R6 and R23 on 4/26/2024. Review of R23's Admission Record, located in the EMR under the Profile tab, revealed an admitted [DATE] with medical diagnoses that included anxiety and dementia. Review of R23's annual MDS, located in the EMR under the MDS tab and with an ARD of 3/25/2024, revealed R23 had a BIMS score of 99, which indicated staff was unable to assess R23's cognitive status. It was recorded R23 was severely cognitively impaired and rarely/never makes decisions. Review of R23's Progress Note, provided by the facility and dated 4/26/2024 at 3:18 pm, revealed, It was reported to this nurse that in the dining room, shortly after lunch [R23] ran into another resident [R6] with her w/c [wheelchair]. [R6] then struck [R23] in the face. [R23] redirected and assessed for injury. No apparent [injury]. During an interview on 8/28/2024 at 9:59 am, the Activities Director (AD) recalled the incident between R6 and R23 had happened so fast. The AD stated R23 propelled her wheelchair backwards. The AD stated she saw R23 was going to run into R6, and she jumped up right then but was not quick enough to prevent the incident. The AD stated she should have been able to stop the incident. 3. Review of facility incident reports revealed there was a resident-to-resident altercation between R6 and R36 on 4/27/2024. Review of R36's Admission Record, located in the EMR under the Profile tab, revealed R36 had diagnoses that included bipolar disease, seizures, schizophrenia, and vascular dementia. Review of R36's annual MDS, located in the EMR under the MDS tab and with an ARD of 2/20/2024, revealed R36 had a BIMS score of 5 out of 15, indicating R36 was severely cognitively impaired. Review of R36's Progress Notes, provided by the facility and dated 4/27/2024 at 3:20 pm, revealed, . reported to staff that a male resident had entered the room sometime during the night, seated in a wheelchair, began touching [R36] all over, pulling off her blankets and yelling at [R36] to get up. [R36] roommate stated it was about 6:00 am, when this occurred . Review of R6's Progress Notes, provided by the facility and dated 4/27/2024 at 3:57 pm, documented R6 was assessed and sent to the local medical center for evaluation. Review of R6's Care Plan, located in the EMR under the Misc tab and updated 4/27/2024, revealed, . Monitor behaviors. On Q [every]15-minute check x 72 hours. Notify [psychiatric services] of current behaviors . Review of R6's Progress Notes, provided by the facility and dated 4/28/2024 at 1:11 am, revealed, . [R6] was returned to the facility, placed in room B 14B with no new orders. Will continue 15-minute checks and continue to monitor . During an interview on 8/26/2024 at 10:52 am, the Business Office Manager (BOM) confirmed the room change for R6 occurred on 4/27/2024, and R6 was moved from room A 10B to room B 14B. During an interview on 8/27/2024 at 5:34 pm, Licensed Practical Nurse (LPN) 2 explained R6 did enter the room for R36 and began feeling around the bed, removing the covers, and saying get out. LPN2 explained R6 had recently changed rooms and was on the wrong hallway looking for his room. LPN2 stated R6 was confused, on the wrong hallway, went into a room he thought was his, and thought that someone else was in his bed. LPN 2 confirmed R6 should have been monitored and redirected to the correct hallway after the room change. On 8/27/2024 at 3:00 pm, the facility was asked to provide the [psychiatric services] consultation report following the resident-to-resident interaction on 4/27/2024. The report was not provided by the end of the survey. 4. Review of facility incident reports revealed there was a resident-to-resident altercation between R6 and R23 on 5/11/2024. Review of R23's Progress Notes, dated 5/11/2024 at 2:30 pm, revealed R23 was propelling backwards in the wheelchair in the front lobby when the chair ran over the foot of R6, who then hit R23 on the shoulder with a closed fist. Review of R23's Progress Notes, dated 5/11/2024 at 3:44 pm, revealed, . this nurse was walking out of another resident's room when the receptionist notified me, she witnessed [R23] wheelchair ran over the foot of [R6] and then [R6] punched [R23] in the left shoulder. Both residents were separated and assessed for injury. No injury was found . Review of R6's Care Plan, located in the EMR under the Misc tab and updated 5/11/2024 revealed, . Monitor behaviors. On Q [every] 30-minute check x 72 hours . Review of R6's PAR flow sheet, provided by the facility and dated 5/17/2024, revealed, . recently had an altercation where he hit another resident after being bumped into [with a wheelchair]. [R6] will be redirected and monitored to try to prevent altercations . During an interview on 8/28/2024 at 11:50 am, the Assistant Director of Nursing (ADON) confirmed the facility needed to provide monitoring of R6 all the time. The ADON stated staff were aware of R6's behaviors and were on alert to monitor R6 when he came out of his room. The ADON stated after the incident on 4/27/2024, every 15-minute monitoring should have remained in place until the [psychiatric services] consultation was completed.

Based on staff interview, record review, and review of the facility's policy titled, Antipsychotic Medication Use, the facility failed to monitor for adverse consequences and behaviors related to antidepressant use for one of five residents (R) (R24) reviewed for unnecessary medications out of a total sample of 43. The deficient practice had the potential to place the resident at risk of untreated adverse consequences to the medication. Findings include: Review of the facility's policy titled, Antipsychotic Medication Use dated July 2022 revealed, . The staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: a. General anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation. b. Cardiovascular: orthostatic hypotension, arrhythmias. c. Metabolic: increase in total cholesterol triglycerides, unstable or poorly controlled blood sugar, weight gain; or d. Neurologic: akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke, or TIA [transient ischemic attack] . Review of R24's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed an admitted [DATE] with diagnoses that included bipolar disorder and generalized anxiety disorder. Review of R24's admission Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 7/29/2024, revealed R24 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating R24 was cognitively intact. Review of R24's Physician Order, located under the Orders tab in the EMR and dated 7/22/2024, revealed R24 was to receive sertraline HCl (Zoloft, an antidepressant) 100 milligram (mg) orally every day for depression. Review of R24's Care Plan, located under the Care Plan tab in the EMR and dated 8/2/2024, revealed, . The resident uses psychotropic medications [related to] Bipolar . Interventions included, . Monitor/document/report PRN (as needed) any adverse reactions of psychotropic (antidepressant) medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person . Review of R24's Medication Administration Record (MAR), Treatment Administration Record (TAR), and the TASKS tab (information completed by the certified nursing assistants (CNAs) of the EMR revealed no documentation of adverse consequence or behavior monitoring for R24. During an interview on 8/28/2024 at 10:40 am, the Assistant Director of Nursing (ADON) confirmed R24 was prescribed an antidepressant and, after reviewing the EMR, the ADON confirmed there was no documentation the resident was being monitored for behaviors or adverse consequences. The ADON confirmed the monitoring should be documented.

Based on staff interview, record review, and review of the facility's policy titled Advanced Directives, the facility failed to ensure one of 43 sampled residents (R) (R16) reviewed for advanced directives had a medical record that accurately reflected her request to not have cardiopulmonary resuscitation (CPR) in the event she should experience cardiopulmonary failure. The deficient practice had the potential to result in the resident receiving CPR against her wishes. Findings include: The facility's policy titled, Advanced Directives, dated [DATE] revealed, the resident had a right to formulate an advance directive. The policy revealed the resident's wishes were communicated to the residents' direct care staff and physician by placing the advanced directive documents in a prominent, accessible location in the medical record. Review of R16's the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] and located in the MDS tab of the electronic medical record (EMR) revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated she was cognitively intact. Review of the Diagnosis tab of R16's EMR revealed diagnoses which included unspecified psychosis, personal history of transient ischemic attack and cerebral infarction, transient cerebral ischemic attack, and subarachnoid hemorrhage affecting left side. Review of R16's EMR revealed it was documented that she was a FULL CODE, meaning to attempt CPR in the event of cardiopulmonary failure, in capital letters on the dashboard section of the EMR. Review of R16's Admission Record, dated [DATE] and located in the paper record, identified her as a full code. Review of R16's paper record/chart revealed a sticker located on the inside of the chart cover that read DNR (Do Not Resuscitate) and a document titled, Do Not Resuscitate for Resident with Decision Making Capacity, signed and dated by the resident on [DATE] and located at the front of the chart, revealed CPR was not to be initiated in the event of cardiopulmonary failure. In addition, the Advanced Directive Checklist, signed by the resident on [DATE] had DNR order check marked. Review of physician's orders located under the Orders tab of the EMR revealed she had a current physician's order with a start date of [DATE] for DNR. During an interview on [DATE] at 1:28 pm, the Assistant Director of Nursing (ADON) verified the dashboard in the EMR and the Admission Record in the paper chart were inaccurate. She stated in the event the resident experienced cardiorespiratory failure the staff would know not to start CPR because they would have checked the advanced directive paper in the paper chart.

Based on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect, and Exploitation, the facility failed to ensure an allegation of abuse was reported within two hours of occurrence for two of 12 residents (R) (R6 and R36) sampled for abuse out of a total sample of 43. The deficient practice had the potential for timely intervention to not be implemented for the protection of the residents. Findings include: Review of the facility's policy titled Abuse, Neglect, and Exploitation, dated 12/19/2022 revealed, Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: a. Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Review of R6's Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed R6 had diagnoses that included Alzheimer's disease, vascular dementia, paranoid schizophrenia, delusional disorder, unspecified dementia with behavioral disturbances, and major depressive disorder. Review of R6's annual Minimum Data Set (MDS), located in the EMR under the MDS tab and with an Assessment Reference Date (ARD) of 7/25/2024, revealed R6 had a Brief Interview for Mental Status (BIMS) score of 99, which indicated staff was unable to assess his cognitive state. It was recorded R6 was severely cognitively impaired and rarely/never made decisions. Review of R36's Admission Record, located in the EMR under the Profile tab, revealed R36 was readmitted to the facility on [DATE] with diagnoses that included bipolar disease, seizures, schizophrenia, and vascular dementia. Review of R36's annual MDS, located in the EMR under the MDS tab and with an ARD of 2/20/2024, revealed R36 had a BIMS score of 5 out of 15, indicating R36 was severely cognitively impaired. Review of a Progress Note for R36, provided by the facility and dated 4/27/2024 at 3:20 pm, revealed . reported to staff that a male resident had entered the room sometime during the night, seated in a wheelchair, began touching [R36] all over, pulling off her blankets and yelling at [R36] to get up. [R36] roommate stated it was about 6:00 am when this occurred . Review of a Progress Note, for R36, provided by the facility and dated 4/27/2024 at 3:57 pm, revealed, . it was reported to this nurse [Licensed Practical Nurse (LPN) 2] at approximately 11:00 am on 4/27/2024 by the dayshift CNA [Certified Nurse Aide] that a female resident [R36] reported [R6] had been in her room at approximately 6:00 am on 4/27/2024. [R36] reported to the night shift CNA that [R6] entered her room and wheeled himself over to her bedside. [R36] stated that [R6] began feeling around on her blanket and touched her and he started yelling at her to get out of bed . During an interview on 8/27/2024 at 5:34 pm, LPN2 stated that at approximately 11:00 am on 4/27/2024, CNA7 reported to her that R6 had went into R36's room about 6:00 am on 4/27/2024, propelled himself to R36's bed, and began feeling around on the bed, pulling off the covers, and demanding R36 get out of the bed. LPN2 stated she then reported the incident to the Assistant Director of Nursing (ADON). LPN2 confirmed the incident should have been reported earlier. LPN2 stated the incident was not included in the change of shift report the day it occurred. Review of the facility's investigation of the incident revealed a handwritten document by CNA7, dated 4/27/2024 at 7:26 pm, who was present at the time of the incident and removed R6 from the room of R36. The statement recorded, . at approximately 6:30 am, I heard yelling coming from A hall, A 3 bed B, [R36] was yelling 'stop, don't touch me' and I found [R6] touching her. My first instinct was to pull [R6] out of her room. After that I went back to make sure [R36] was okay. I asked her what happened. [R36] told me that he was touching her legs and arms and yelled at her to 'get out of his bed.' Around 6:40-6:45 am, I went to the nurse's station to tell the charge nurse because I thought [R6] was under her care. I did not make sure the nurses heard me and that was my mistake. I just wanted to be sure [R36] was okay and charted the actions [R6] made. I am not sure who heard my statement this morning. During an interview on 8/27/2024 at 11:54 am, the Administrator confirmed the incident on 4/27/2024 between R6 and R36 was not reported to the abuse coordinator until five and one-half hours after the incident occurred. The Administrator confirmed there was a delay in reporting and that the incident should have been reported when it occurred.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Abuse, Neglect and Exploitation, the facility failed to thoroughly investigate an allegation of staff to resident abuse involving one of 12 residents (R) (R68) reviewed for abuse out of a total sample of 43. This failure increased the risk of ongoing staff to resident abuse. Findings include: Review of the facility's policy titled, Abuse, Neglect and Exploitation, dated 12/19/2022, revealed, . Written procedures for investigations include . Providing complete and through documentation of the investigation . Review of R68's Admission Record, located in the Profile tab of the electronic medical record (EMR), revealed admission to the facility on [DATE] with diagnoses including type 2 diabetes, monoplegia of lower limb, and depression. Review of R68's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 8/8/2024 and located in the MDS tab of the EMR, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated the resident was cognitively intact. Review of R68's nursing Progress Note, dated 6/7/2024 and located under the Notes tab of the EMR, revealed R68 had reported to the Certified Nursing Aide (CNA) staff that the night shift CNA was rough with her. It was recorded R68 stated that CNA2 pushed her wheelchair out of reach and that she made her lie in her own urine in bed. It was recorded R68 stated CNA2 shoved her, and this was immediately reported to the abuse coordinator and a police report was made. It was recorded R68 was assessed for injury, with scratches on her wrists and bruising to her shins noted. It was recorded that the incident was under investigation. Review of the facility's investigative file for the incident, provided by the Administrator, revealed: An interview with R68, dated 6/7/2024, that recorded, Interview with [R68] on 6/7/2024, abuse coordinator along with the police officer interviewed [R68]. [R68] stated 'the CNA on my hall at night was very rude and pushed me around.' The police officer asked if she knew the CNA and she stated, '[CNA 2], the skinny black girl.' When asked how she pushed her around she stated, 'She was just rude, and she pushed my chair on the other side of the room so I could not get up.' There was no documentation R63 was asked about the scratches on her wrists or the bruising on her shins. An investigation summary conclusion, dated 6/6/2024, recorded, The facility investigated the incident, and abuse could not be substantiated. [CNA2] was suspended immediately while investigation underway. [CNA2] was informed of her suspension and quit without notice via text message shortly after. [R68] was assessed for injuries, a few bilateral scratches to her wrist and bilateral bruise to shins probably occurred while attempting to self-ambulate in her room as she is non-compliant at times. Nursing completed skin assessments on all residents on hall with no concerns noted. A follow-up interview with R68, dated 6/11/2024, recorded, On 6/11/2024 the abuse coordinator/administrator, along with the social worker went to interview [R68] and [R68] stated 'CNA' was very rude to me, pushed me down in the bed and pushed my wheelchair to the other side of the room and then left the room and said you are my responsibility. Review of R68's interview did not reveal any documentation that R68 was asked about the scratches on her wrists or the bruising on her shins. Review of facility's investigation revealed no documentation R68 was asked about the scratches on her wrists or the bruising on her shins. During an interview on 8/26/2024 at 3:11 pm, R68 stated CNA2 was rough while assisting her to bed one night. R68 stated after she was placed in bed, CNA2 moved her wheelchair to the opposite side of the room so she could not reach it. R68 stated it was a while ago, and she could not recall the whole incident. R68 stated CNA2's employment was terminated, and she had no other abuse or neglect concerns since. R68 denied any marks or bruises currently and could not remember scratches related to the incident. During an interview on 8/26/2024 at 5:52 pm, the Administrator stated she was not employed during the abuse investigation for R68. The Administrator stated she felt that R68 should have been asked about the scratches and bruises that were documented as being observed during the investigation.

Based on resident and staff interviews, record review, and review of the facility's policy titled, Transfer and Discharge, the facility failed to provide the resident and the responsible party with notice of the transfer and the reasons for the transfer in writing and in a language and manner they understand for one of two residents (R) (R4) reviewed for hospitalization out of a total sample of 43. The deficient practice had the potential to result in the resident and/or responsible party not knowing the resident was transferred to the hospital and the reasons for the transfer. Findings include: Review of the facility's policy titled, Transfer and discharge date d 12/19/2022, revealed a transfer notice would be provided to the resident and representative when a discharge was initiated by the facility for medical reasons to an acute care setting such as a hospital. Review of R4's Face Sheet, located under the Profile tab of the electronic medical record (EMR), revealed R4 was readmitted to the facility on [DATE] with diagnoses that included acute respiratory failure with hypoxia, psychosis, chronic kidney failure, intellectual disabilities, and lobar pneumonia. Review of R4's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 7/24/2024 and located under the MDS tab of the EMR, revealed he had a Brief Interview for Mental Status (BIMS) score of eight out of 15, which indicated the resident had moderately impaired cognition. During an interview on 8/25/2024 at 8:48 pm, R4 was asked if he had been hospitalized in the past six months. He stated, Yes, but he could not remember any details related to the hospitalization or if he received any written notices. Review of the Prog (Progress) Notes tab of the EMR, dated 6/12/2024 at 10:32 am, revealed R4 was discharged to the hospital emergency roiagnom on [DATE] at 8:20 am after he had problems breathing and his oxygen levels dropped. A progress note, dated 6/17/2024 at 6:33 pm, revealed he returned to the facility on [DATE] at 5:30 pm. Review of the EMR and hard chart revealed no transfer/discharge notices. During an interview on 8/28/2024 at 5:52 pm, the Business Office Manager (BOM) stated they did not send a written transfer/discharge notice with the resident or to the resident's responsible party; however, the ombudsman was notified of the transfer.

Based on observation and staff interviews, the facility failed to ensure that one of three medication carts (B Hall) was secure when left unattended and out of the site of the nursing staff. The deficient practice had the potential to allow residents and/or visitors unauthorized access to medications. Findings include: Review of the facility's policy titled, Security of Medication Cart dated April 2007 under the section titled Policy Interpretation and Implementation revealed, 4. Medication carts must be securely locked at all times when out of the nurse's view. Observation on 8/27/2024 at 12:20 pm revealed a medication cart on the B hallway between rooms B5 and B78. The cart was out the sight of the nurse. The medication cart was unlocked, and inside the drawer were residents' liquid medications and vials of residents' insulin. The drawers to the cart were easily accessible to anyone walking down the hall. R56 and R61 and were both within 2-3 feet of the unlocked cart. The cart remained unlocked until 12:37 pm, when the Assistant Director of Nursing (ADON) was observed locking it. During an interview on 8/27/2024 at 1:11 pm, Licensed Practical Nurse (LPN) 2 stated she was moving too fast and forgot to lock the cart before proceeding to another hall. LPN2 stated R61 notified her that the surveyor opened the cart and that it was left unlocked. LPN2 stated it was important to ensure that the medication cart remained locked so that residents were safe. During an interview on 8/27/2024 at 1:28 pm, the Director of Nursing stated she expected medication carts to be locked and secured when not in sight or being used. The DON stated nursing staff had been educated on keeping the medication carts locked, but she did not know the last time.

Based on staff interview and review of the facility provided form titled Daily Nursing Staff Report(s), the facility failed to indicate the daily census in the space provided on the daily posted form. This failure had the potential for resident family, friends, or other visitors to not know the ratio of nursing staff to residents causing uncertainty of ability and availability of the staff for residents' needs. The facility census was 68 residents. Findings include: Review of the Daily Nursing Staff Report(s) from 7/29/2024 through 8/26/2024 that was provided by the Administrator, presented a space, but the facility census information was not filled in. The form revealed, report contains nursing staff directly responsible for resident care. The form continued, daily posting of this information is required for nursing homes participating in Medicare and Medicaid programs. During an interview on 8/28/2024 at 11:25 am, the Administrator [interim since July 2024, but familiar with facility] verified that the Daily Nursing Staff Report(s) posted daily in the front of the facility should have had the census indicated in the space provided.

Based on observations, staff interviews, and a review of the facility policy titled, Infection Control and Prevention, the facility failed to ensure infection control practices were maintained during incontinence care for 1 of 3 residents (R) (#1) observed receiving incontinence care. This failure had the potential of exposing patients to infections due to cross contamination. Findings included: A review of the facility policy titled, Infection Control and Prevention with a revision date of 2018 revealed that an infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 11. Prevention of Infection; (3) educating staff and ensuring that they adhere to proper techniques and procedures. Observation on 04/25/2023 at 10:04 a.m. R#1 was lying in their bed. The Certified Nursing Assistant (CNA) #7 without first doffing gloves, conducting hand hygiene, and donning a clean pair of gloves, CNA #7 placed a clean brief on the resident. While wearing the same gloves, CNA #7 touched the resident's clothing, privacy curtain, and some magazines lying on the resident's bed. Interview on 04/25/2023 at 2:15 p.m. with CNA #7 revealed that she did not realize she had touched items in the resident's room with soiled gloves. Post survey interview on 5/11/2023 at 12:00 p.m. with the Director of Nursing revealed that the facility is currently providing competencies regarding infection control for proper donning and doffing and hand hygiene. The DON stated her expectation for all staff is to maintain infection control precautions from contact precautions through airborne.

Based on staff interviews, record review, and a review of the facility policy titled, Abuse, Neglect, and Exploitation, and Wandering and Elopements, the facility failed to complete a thorough investigation related to an allegation of abuse for one of six residents (R) (#1) reviewed for abuse. In addition, the facility failed to complete a thorough investigation related to neglect for one of one resident (R) (#7) reviewed for the elopement of the facility without staff knowledge. Findings included: A review of the facility's policy titled, Abuse, Neglect and Exploitation, with an implementation date of 11/28/2016, indicated, Each resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy indicated, Investigation of Alleged Abuse, Neglect and Exploitation. - When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: a. Interview the involved resident, if possible, and document all responses. If a resident is cognitively impaired, interview the resident several times to compare responses. b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. Obtain witness statements, according to appropriate policies, all statements should be signed and dated by the person making the statement. 1.Review of the most recent quarterly Minimum Data Set (MDS) for R#1 dated 03/16/2023, revealed the resident had short-term and long-term memory problems and moderately impaired cognitive skills for daily decision making based on the Staff Assessment for Mental Status. The MDS indicated that the resident did not have behavioral symptoms directed toward others. Record review of the care plan for R#1 dated 03/29/2023, indicated the resident had a self-care deficit. Approaches directed staff to check for incontinence every two hours and as needed (PRN) and provide incontinence care per the protocol and after each incontinent episode. A review of a Facility Incident Report, dated Monday, 03/20/2023 at 7:45 p.m., revealed the activities director had reported to the abuse coordinator that he/she witnessed an agency certified nursing assistant (CNA) allegedly forcefully bump Resident #1 on the arm, with the back of their hand. The report indicated that the facility reported the incident to the state agency, ombudsman, physician, and responsible party. A five-day follow-up report to the self-reported incident, dated 03/27/2023, indicated the agency CNA who allegedly bumped R#1's arm finished her shift and left the building before the incident was reported. The CNA was flagged as DNR, meaning do not return, by the facility. The report indicated that the agency that employed the CNA was contacted online. The abuse coordinator interviewed the activities director concerning the reported incident. The activities director stated they walked by the door to R#1's room, and the resident had been incontinent, and it was all over the floor. The activities director stated they went to find a CNA to clean up R#1. The activities director stated that the CNA was very rude to them and then forcefully bumped R#1 on the arm with the back of her hand. A skin assessment was completed by the interim Director of Nursing, and no concerns were noted. The report indicated that during the investigation, the activities director was asked for a written statement but quit without notice before submitting the statement. The facility abuse coordinator also interviewed the charge nurse, who stated she did not recall any of the events that allegedly occurred on 03/20/2023, she only remembered that R#1 was changed without incident. The conclusion to the five-day follow-up report indicated that the facility could not substantiate that the incident occurred. The five-day report was submitted to the state agency on 03/27/2023. A review of the statement written by the charge nurse who had been on duty at the time of the alleged incident, dated 03/27/2023, revealed, This nurse was never notified of any resident not being cleaned or taken care of by the activity director. This nurse also never saw any resident in D hall that was not taken care of on Monday, March 20, 2023. R#1 was changed without incident. A review of the facility's investigation revealed that no other staff or residents were interviewed during the investigation regarding the allegation of abuse. Interview on 04/28/2023 at 6:42 p.m. with Administrator stated that staff should have followed the facility abuse/neglect policy and additional staff and residents should have been interviewed. 2. A review of the facility policy titled, Wandering and Elopements, with a revision date of March 2019, indicated, The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Record Review of the most recent annual Minimum Data Set (MDS) for R#7 dated 01/27/2023, did not indicate the resident had wandering behavior and did not indicate the resident was at risk of getting to dangerous places or intruding on the privacy of others. The MDS indicated the resident had no functional limitations in range-of-motion in the upper or lower extremities and did not use mobility devices. Record review of the care plan for R#7 dated 03/29/2023, revealed the resident was at risk for wandering and elopement due to leaving grounds. Approaches instructed staff to provide distraction/redirection as indicated, provide simple commands and prompting, assess the resident for changes in mental status, and promptly check all exit doors if an alarm is sounding. The Care Plan indicated that on 03/29/2023, R#7 walked to a store off grounds and called the facility for someone to come get them. The Care Plan indicated that no injury was noted, and the incident was investigated according to facility policy. Record review of an Elopement Risk Assessment, dated 07/25/2022, indicated that R#7 was not at risk for elopement. A review of a five-day follow-up report to a self-reported incident, dated 04/03/2023, revealed that on 03/29/2023 at 3:30 p.m., it was reported to the abuse coordinator that R#7 had called the facility and asked the Business Office Manager (BOM) to come pick them up. R#7 provided their location, which was 1.3 miles away. The report revealed that during the investigation, it was determined that R#7 frequently sat on the front porch of the facility, and the resident left frequently with their family. After investigating the incident, the facility substantiated that the incident had occurred. The five-day follow-up report and an investigation did not contain information regarding interviews with staff, other residents, or the resident's family or responsible party related to the root cause of R#7's elopement. A thorough investigation was not conducted to determine how the resident left the facility without the knowledge of the staff. Interview on 04/27/2023 at 9:05 a.m. with Administrator and BOM both reported that R#7 had not eloped from the facility prior to this incident or since that time, and he left the facility daily with family or sat on the porch in a rocking chair. The Administrator and BOM both revealed that the facility had locks on the doors and a code was required to open them. They did not know who opened the door on 03/29/2023 so the resident could sit on the porch. A continued interview with the BOM on 4/27/2023 at 9:05 a.m. revealed that on 03/29/2023, the resident was sitting on the porch, and at about 3:30 p.m., she received a call from the resident's cell phone from the resident to come pick them up. The BOM stated that the resident was at the grocery store down the road and did not want to walk back up the hill to get back to the facility. The BOM further revealed that R#7 reported they left the facility unattended to clear their head, and when they returned to the facility, R#7 was assessed and instructed to take a staff member with them if they were going outside. A continued interview with the Administrator on 4/27/2023 at 9:05 a.m. revealed that the staff received education on the emergency response procedures for elopement and code yellow drills and the resident's care plan was updated after the incident. The Administrator stated that the resident did not know the door code, and staff had been instructed not to open the door and let the resident go outside unaccompanied by staff. The Administrator further revealed that the resident was added to the elopement precautions binder kept at the nurses' station; the binder contained a face sheet and photo. Interview on 04/28/2023 at 6:42 p.m. with Administrator revealed he had not interviewed additional staff and other residents and did not feel it was necessary at the time.

Based on observation, staff interviews, record review, and a review of the facility policy titled, Nursing Standards of Care, and Urinary Continence and Incontinence Management, the facility failed to ensure thorough incontinence care was provided for 1 of 3 dependent residents (R) (#1) reviewed for incontinence care. Findings included: A review of a facility policy titled, Nursing Standards of Care, with a review date of April 2023, indicated, Incontinent residents will be checked every two to three hours for episodes of incontinence. They will receive incontinent [incontinence] care with each incontinent occurrence. A review of a facility policy titled, Urinary Continence and Incontinence Management, with a revision date of August 2022, indicated, The staff and practitioner will appropriately screen for, and manage, individuals with urinary incontinence. Management of incontinence will follow relevant clinical guidelines. Although requested, no policy was provided that described the procedure for incontinence care. Record review of the most recent quarterly Minimum Data Set (MDS), for R#1 dated 3/16/2023, revealed that the resident required extensive assistance with toilet use. The MDS indicated R#1 was occasionally incontinent of bowel and bladder. Record review of the care plan for R#1 Care Plan dated 03/29/2023, indicated the resident had a self-care deficit. Approaches directed staff to check for incontinence every two hours and as needed (PRN) and provide incontinence care per protocol after each episode of incontinence. Observation on 04/25/2023 at 10:04 a.m. R#1 was observed lying in their bed. Licensed Practical Nurse (LPN) #1 was observed checking the resident for incontinence. The resident's adult brief was soiled with urine. Incontinence care was provided by Certified Nursing Assistant (CNA) #7. CNA #7 donned gloves and pulled down the front of the resident's brief, obtained pre-moistened cloths, and wiped the resident's anterior perineal area and genitals. CNA#7 did not clean the area behind the genitals or the buttocks where the soiled brief had been in contact with the resident's skin. CNA #7 then placed a clean brief on the resident and assisted the resident with dressing. On 04/25/2023 at 2:15 p.m., CNA #7 was interviewed and reported completing Resident #1's incontinence care according to her training. After the observation was reviewed with the CNA, CNA #7 stated she did not complete incontinence care as trained. CNA #7 was unable to recall the date of her last skills training for incontinence care. Interview on 04/28/2023 at 6:22 p.m. with the Director of Nursing (DON) she stated there were plans to provide competency testing and skills training for staff related to incontinence care. Interview on 04/28/2023 at 6:42 p.m. with the Administrator revealed that staff were trained in incontinence care when initially hired and annually. The Administrator stated he planned to work with the new DON to provide additional staff training.

Based on observations, interviews, record review, and policy review, the facility failed to ensure the call light was placed within reach to enable the resident to call for assistance, for one resident (R) (R#61) of 21 sampled residents. Findings included: Review of the policy titled, Call System, Residents, copyright 9/2022, revealed residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Review of the policy titled, Answering the Call Light, copyright 9/2022, revealed under General Guidelines number 5. Ensure that the call light is accessible to the resident when in bed, from the toilet, from the shower or bathing facility and from the floor. Review of the clinical record revealed R#61 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with behavioral disturbance and age-related physical debility. The resident's most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) was coded as 5, which indicated severe cognitive impairment. The MDS indicated the resident required extensive assistance with bed mobility, transfer, and toilet use and required limited assistance with locomotion. Observation on 1/30/2023 at 9:35 a.m., R#61 was observed lying in bed on their right side, facing the wall. The call light was lying on the mattress at the foot of the bed, out of the resident's reach. Observation on 1/30/2023 at 12:54 p.m., R#61 was observed lying in bed on their back. The call light remained at the foot of the bed, out of the resident's reach. Observation on 1/31/2023 at 8:51 a.m., R#61 was observed sitting in a wheelchair next to the bed. The call light remained on the foot of the bed, out of the resident's reach. Interview on 1/31/2023 at 12:55 p.m., Certified Nursing Assistant (CNA) AA stated R#61 could and did use the call light if it was within the resident's reach. CNA AA observed and confirmed the call light was not within the resident's reach at this time. She indicated she usually kept the call light within the resident's reach when the resident was in bed. Interview on 1/31/2023 at 1:15 p.m., Licensed Practical Nurse (LPN) BB indicated the resident could use the call light if it was close to the resident's hands. LPN BB stated the resident's call light should be placed near the resident's hands when the resident was in bed so the resident could access and use it. Interview on 2/2/2023 at 11:10 a.m., Director of Nursing (DON) indicated R#61 should have the call light placed within her reach so she could use it to call for help. The DON confirmed R#61 could use the call light if it was within the resident's reach. Interview on 2/2/2023 at 4:10 p.m., Administrator indicated there was no excuse for a resident's call light not being within their reach. During further interview, the Administrator stated if the resident could not use the traditional call light, the facility needed to get the resident a touch pad call light or some type of system the resident could use.

Based on interviews, record review, and review of the policies titled Abuse, Neglect and Exploitation and Abuse Prevention Program, the facility failed to ensure that a significant medication error was reported to the State Survey Agency (SSA) in a timely manner for one of 16 sampled residents (R)(R#1). On 9/9/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Regional Administrator and onboarding facility Administrator, and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on 9/9/22 at 2:31 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 8/26/22. A removal plan (Credible Allegation of Compliance) was received on 9/13/22, related to F609: 483.12(c)(1)-Reporting of Alleged Violations (Scope/Severity[S/S]: J.); F610: 483.12(c)(2)-Investigate Alleged Violations (Scope/Severity[S/S]: J.); F726: 483.35(a)(3)-Competent Nursing Staff (Scope/Severity[S/S]: J.); F760: 483.45(f)(2)-Free from Significant Medication Errors (Scope/Severity[S/S]: J.); F835: 483.70 - Administration (Scope/Severity[S/S]: J.). Based on observations, interviews, record review, and review of the facility policies as outlined in the removal plan, it was validated that the corrective action plans and the immediacy of the deficient practice as removed on 9/14/22. The facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures governing medication administration, reporting and investigating allegations, administration and competent nursing staff. Findings include: Review of the policy titled Abuse, Neglect and Exploitation dated 11/28/16 revealed: Number 9. Response and Reporting-anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect, or exploitation is suspected, the Licensed Nurse should; a. responds to the needs of the resident and protect them from further incident (document); b. notifies the Director of Nursing and Administrator (document); c. initiates an investigation immediately d. Notify the attending physician, resident's family/legal representative and Medical Director; e. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately; f. contacts the State Agency and local Ombudsman off to report the alleged abuse; g. Monitor and document the resident's condition, including the response to medical treatment or nursing interventions; h. document actions taken in steps above in the medical record. Number 10. The facility must annually notify covered individuals' obligation to comply with the following reporting requirements: b. each covered, individual shall report immediately, but not later than two hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies. Facility administration should report to the state nurse aid registry or nursing board, any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service. Review of the Facility Incident Report Form dated 8/29/22, revealed the type of incident was reported as other specified as medication error. Details of the report revealed the date and time of the incident was 8/26/22 at 9:45 a.m. Details of the incident are resident received wrong medication during 9:00 a.m. med pass. Treatment required revealed resident sent to emergency room (ER) for evaluation and treatment due to low pulse rate. Steps taken by the facility to prevent further incidents: in-service completed with nurse on five rights of Med Pass. Nurse required to participate in additional med-pass orientation. The report to the State Survey Agency (SSA) was dated 8/29/22 and the date of the incident was 8/26/22, reflecting the incident was not report within the two-hour timeframe. Review of the follow-up to the self-reported incident 8661, addressed to the state agency dated 9/6/22, revealed that on 8/26/22, R#1 received medications not prescribed to him by LPN AA. The follow-up indicated that the investigation revealed that LPN AA inadvertently administered R#1's roommates' medication to him. R#1 received [MEDICATION(S)] 400mg, [MEDICATION(S)] 300mg, [MEDICATION(S)] 20mg, [MEDICATION(S)] 20mg, [MEDICATION(S)] 25mg, [MEDICATION(S)] 40mg, and [MEDICATION(S)] 50mg. The Physician was notified with orders received to monitor blood pressure and heart rate every two hours. R#1 was noted to have an irregular heart rate and sent to the emergency department for evaluation and treatment. R#1 returned from the hospital to the facility on [DATE]. LPN AA received education on 8/26/22 related to medication errors, significant medication related errors and adverse consequences. Interview on 9/6/22 at 3:30 p.m., Administrator stated he was out of town and the Director of Nursing (DON) was in charge and oversaw the building in his absence. He stated that he received a call from the Regional Nurse Consultant (RNC) QQ on 8/26/22 after 4:00 p.m. regarding a medication error. He revealed that he was unaware the resident was sent to the hospital. He further stated he expects the DON to keep him informed of residents going to the hospital or questionable occurrences in the facility. During further interview, he stated the DON has his email and cell phone number but did not contact him regarding the incident. Interview on 9/7/22 at 1:30 p.m. with the RNC QQ, revealed she was notified of the medication error late in afternoon on 8/26/22 around 4:00 p.m. The RNC QQ stated she instructed the DON to fill out a medication error report and to take LPN AA off the medication cart and provide education on the five rights of medication administration. During further interview, RNC QQ revealed notifying the Administrator of the medication error the same day after 4:00 p.m. Cross reference F760

Based on record review, interviews, and review of facility policies, the facility failed to conduct a thorough investigation for a significant medication error that occurred on 8/26/22, for one of 16 sampled residents, (R)(R#1). On 9/9/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Regional Administrator and onboarding facility Administrator, and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on 9/9/22 at 2:31 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 8/26/22. Findings include: Review of the undated policy titled Abuse Prevention Policy revealed facility conducts an investigation of alleged violations, suspected abuse, neglect, or misappropriation of property and provides notification to the proper authorities according to state and federal regulation, including unusual occurrences. Unusual occurrences refer to accidents/incidents that are unusual in nature and are reportable occurrences in the facility. The Department of Health requests that unusual occurrences or situations that might result in quality of care and services be reported. F. Investigation Procedures-after identifying an alleged violation, the facility will thoroughly investigate the incident. All reports are due within five working days to manager/administrator and the state survey agency on aging. Review of the policy titled Abuse, Neglect, and Exploitation, dated 11/28/2016 revealed number 7. Investigation of alleged abuse, neglect and exploitation-when suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include a. interview the involved resident, if possible, and document all responses; c. interview all witnesses separately. Include roommates, and staff members in the area. Obtain witness statements, according to appropriate policies. All documents should be signed and dated by the person making the statement; d. document the entire investigation chronologically. If a staff is accused of abuse by a resident/family member or another staff person, that staff member is suspended pending investigation. If it is determined the allegation is unsubstantiated through investigation, then the staff member is brought back to work; educated as to preventions, identification, reporting of abuse and allowed to continue to work. Staff observation and monitoring for this staff member will occur through the licensed nurse on duty for a time determine by the Administrator to ensure alleged staff follows Freedom of Abuse policies. If through investigation the staff member is found to be guilty of abuse, then the progressive discipline process will be initiated. 1. On 8/26/22 a medication error report was completed with the following: Corrective action: Contacted physician, sent wrong list of medications to residents, vitals taken, orders to start every two-hour blood pressure check for 24 hours. Measures taken to prevent a reoccurrence of similar errors: in-service on five rights of medication pass. 2. Initial Facility reported incident on 8/29/22; incident occurred on 8/26/22 3. Five-day follow-up report to the State on 9/6/22 No further investigation into the incident until identification made by Surveyors on 9/7/22. Interview on 9/6/22 at 3:30 p.m., with the Administrator, he stated being off work and out of town. The Administrator stated receiving a call from the Regional Nurse Consultant after 4:00 p.m. on 8/26/22 regarding a medication error. The Administrator revealed being unaware the resident was sent to the hospital. The Administrator revealed that the Director of Nursing (DON) oversaw the building in his absence. The Administrator further stated he expects the DON to keep him informed of residents going to the hospital or questionable occurrences in the facility. He stated the DON has his email and cell phone number but did not contact him. The Administrator stated that the Quality Assurance Performance Improvement (QAPI) Committee was made aware of the occurrence on 8/29/22 when the Administrator reported the incident to the State. The QAPI committee met on 9/9/22 to discuss residents being free from medication errors, timely reporting, and quality of care. Interview on 9/7/22 at 1:30 p.m. with the Regional Nurse Consultant (RNC) QQ, revealed being notified of the medication error late in afternoon on 8/26/22 around 4:00 p.m. The RNC QQ instructed the DON to fill out a medication error report and to take LPN AA off the medication cart and provide education on the five rights of medication administration. RNC QQ further revealed notifying the Administrator the same day after 4:00 p.m. of the medication error. Cross reference F760

Based on record review, interviews, and policy review, the facility failed to ensure direct care nursing staff were adequately trained and evaluated for competency for medication administration for one Licensed Practical Nurse (LPN) who administered incorrect medications to resident (R) R#1 out of 16 sampled residents. On 9/9/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Regional Administrator and onboarding facility Administrator, and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on 9/9/22 at 2:31 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 8/26/22. A removal plan (Credible Allegation of Compliance) was received on 9/13/22, related to F609: 483.12(c)(1)-Reporting of Alleged Violations (Scope/Severity[S/S]: J.); F610: 483.12(c)(2)-Investigate Alleged Violations (Scope/Severity[S/S]: J.); F726: 483.35(a)(3)-Competent Nursing Staff (Scope/Severity[S/S]: J.); F760: 483.45(f)(2)-Free from Significant Medication Errors (Scope/Severity[S/S]: J.); F835: 483.70 - Administration (Scope/Severity[S/S]: J.). Based on observations, interviews, record review, and review of the facility policies as outlined in the removal plan, it was validated that the corrective action plans and the immediacy of the deficient practice as removed on 9/14/22. The facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures governing medication administration, reporting, and investigating allegations, administration, and competent nursing staff. The findings include: Review of the policy titled Administering Medications revised 4/19, revealed medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation number 9. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Methods of identifying the resident include a. Checking identification band; b. Checking photograph attached to medical record; c. If necessary, verifying the resident identification with other facility personnel. Number 2. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Number 4. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been oriented to the medication administration system used by the facility. Number 5. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three days to ensure established procedures are followed and proper resident identification methods are learned. R#1 is a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/26/22 a significant medication error occurred at approximately 8:45 a.m. during the 9:00 a.m. medication pass when LPN AA failed to correctly identify R#1 and administered to him, his roommate's 9:00 a.m. medications including [MEDICATION(S)] (medication to treat [CONDITION(S)] and shingles) 400 milligrams (mg), [MEDICATION(S)] ER (medication used to treat high blood pressure) 300 mg, [MEDICATION(S)] (medication used to treat fluid retention or swelling) 20 mg, [MEDICATION(S)] (medication used to treat high blood pressure) 20 mg, [MEDICATION(S)] (medication used to treat high blood pressure) 25 mg, [MEDICATION(S)] (medication used to treat depression) 40 mg, and [MEDICATION(S)] (medication used to treat severe pain) 50 mg. Within two hours R#1 had a decline in condition, jeopardizing his health, requiring aggressive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services (EMS) was called, and the resident was transferred at approximately 11:38 a.m. to a local ER. ER records revealed the patient became more bradycardic and hypotensive, received calcium and [MEDICATION(S)], a whole bowel irrigation and was airlifted to a larger Medical Center ICU for a higher level of care where he remained for seven days with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview on 9/6/22 at 10:30 a.m. with the Director of Nursing (DON), revealed she was doing morning medication pass training with LPN AA. However, the DON was unable to recall if she was completing medication competency check with LPN AA. The DON did not provide competency documentation performed on the 9/6/22 morning medication pass. Interview on 9/9/22 at 11:35 a.m. with LPN CC, revealed she was asked to come in and fill out competency check sheets for medication administration and was asked to back date the competencies for 8/29/22, 8/30/22, and 8/31/22 to indicate the days LPN AA observed her do medication passes. The competency sheets were noted that these days were observation only and were not signed by LPN AA. There was no evidence of demonstration of skills performed By LPN AA. Interview on 9/9/22 at 12:00 p.m. with LPN AA revealed on the morning of 8/26/22 during the 9:00 a.m. medication pass, she was training with the DON on the D Hall. She stated the DON left her unattended to correct an order. LPN AA stated while the DON was gone, she administered to R#1 his roommate's medication. During further interview, she stated she realized she had just given R#1 his roommates medications and went to the DON to let her know she gave the wrong medications. LPN AA revealed she had observed other nurses give medications for a few hours on different days, but this was the first time she had been assigned to a medication cart and was giving medications to residents on D Hall. Continued interview with LPN AA revealed she has not completed any medication administration training prior to 8/26/22. She stated she continued to pass morning medication unattended, after the DON reviewed the Five rights of Medication Administration with her. Cross reference F760

Based on observations, record review, staff interviews, and review of facility policies, the facility failed to ensure one resident (R) (R#1) was free from a significant medication error which resulted in a decline in condition, requiring a transfer to the hospital and then airlifted to an Intensive Care Unit (ICU) for seven days. In addition, the facility failed to store medications in a locked area inaccessible to unauthorized individuals. During medication administration, preset medications were observed on top of medication cart A unattended by licensed staff, and accessible to wandering residents. The census was 84. On 9/9/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Regional Administrator and onboarding facility Administrator, and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on 9/9/22 at 2:31 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 8/26/22. A removal plan (Credible Allegation of Compliance) was received on 9/13/22, related to F609: 483.12(c)(1)-Reporting of Alleged Violations (Scope/Severity[S/S]: J.); F610: 483.12(c)(2)-Investigate Alleged Violations (Scope/Severity[S/S]: J.); F726: 483.35(a)(3)-Competent Nursing Staff (Scope/Severity[S/S]: J.); F760: 483.45(f)(2)-Free from Significant Medication Errors (Scope/Severity[S/S]: J.); F835: 483.70 - Administration (Scope/Severity[S/S]: J.). Based on observations, interviews, record review, and review of the facility policies as outlined in the removal plan, it was validated that the corrective action plans and the immediacy of the deficient practice as removed on 9/14/22. The facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures governing medication administration, reporting and investigating allegations, administration and competent nursing staff. Findings include: Review of the policy titled Administering Medications, revised April 2019 revealed the policy statement as medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation number 5. A medication error is defined as the preparation or administration of drugs or biologicals which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Number 9. The individual administering medications verifies the resident's identity before giving resident his/her medications. Methods of identifying the resident include a. checking identification band; b: checking photograph attached to medical record; and c. if necessary, verifying resident identification with other facility personnel. Number 10. The individual administering the medication checks the label three times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. Number 29. New personnel authorized to administer medications are not permitted to prepare or administer medications until they have been orientated to the medication administration system used by the facility. Number 30. The Charge Nurse must accompany new nursing personnel on their medication rounds for a minimum of three (3) days to ensure established procedures are followed and proper resident identification methods are learned. Review of the policy titled Adverse Consequences and Medication Errors revised April 2014 revealed under Policy Interpretation and Implementation number 5. A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Number 6. Examples of medication errors include a. Omission, b. Unauthorized drug- a drug is administered without a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Wrong route of administration, e. Wrong dosage form, f. Wrong drug, g. Wrong time; h. and/or failure to follow manufacturer instructions and/or accepted professional standards. 1. R#1 is a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 8/26/22 a significant medication error occurred at approximately 8:45 a.m. during the 9:00 a.m. medication pass when Licensed Practical Nurse (LPN) AA failed to correctly identify R#1 and administered to him, his roommate's 9:00 a.m. medications including [MEDICATION(S)] (medication to treat [CONDITION(S)] and shingles) 400 milligrams (mg), [MEDICATION(S)] ER (medication used to treat high blood pressure) 300 mg, [MEDICATION(S)] (medication used to treat fluid retention or swelling) 20 mg, [MEDICATION(S)] (medication used to treat high blood pressure) 20 mg, [MEDICATION(S)] (medication used to treat high blood pressure) 25 mg, [MEDICATION(S)] (medication used to treat depression) 40 mg, and [MEDICATION(S)] (medication used to treat severe pain) 50 mg. Within two hours R#1 had a decline in condition, jeopardizing his health, requiring aggressive treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Emergency Medical Services (EMS) was called, and the resident was transferred at approximately 11:38 a.m. to a local ER. ER records revealed the patient became more bradycardic and hypotensive, received calcium and [MEDICATION(S)], a whole bowel irrigation and was airlifted to a larger Medical Center ICU for a higher level of care where he remained for seven days with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the progress note dated 8/26/22 at 11:12 a.m. revealed writer was approached by the DON to notify MD of medication error on resident. Resident received roommates 9:00 a.m. medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Most recent vitals are BP 122/68 and HR 49. Family notified and MD, transferring to [hospital] ER for eval and treatment. Review of the August 2022 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Situation, Background, Assessment, Request (SBAR) dated 8/26/2022 at 12:23 p.m. revealed under Situation as medication error and residents' pulse dropping, resident sent to the emergency room at 9:45 a.m.; Background revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Overload of BP meds; Request MD notified at 9:30 a.m. by DON. Review of Medication Error Report dated 8/26/22 revealed the Director of Nursing (DON) and the Physician were notified that R#1 was given another residents' 9:00 a.m. medications. Physician ordered for resident's vitals to be taken every two hours. Further review revealed the resident was sent to the ER for low pulse rate. Interview on 9/6/22 at 10:30 a.m. with the DON stated that LPN AA was a seasoned nurse with [AGE] years of experience and was hired on 8/14/22 to be a Unit Manager (UM). The DON revealed she was working with LPN AA on the medication cart on 8/26/22. She stated she stepped away from LPN AA to tend to another task. The DON revealed LPN AA approached her and said, I am so embarrassed no one will ever trust me again, I just gave R#1 the wrong medicine. She explained she had given R#1 the wrong medication, that she had given him his roommate's 9:00 a.m. medications. She stated the Physician was notified of the significant medication error and ordered to monitor R#1's vital signs. During further interview, she revealed R#1 had a considerable decline in his condition, his vital signs dropped, and he was sent to the emergency room (ER) for evaluation. Interview on 9/9/22 at 12:00 p.m. with LPN AA revealed she has been very upset about what happened to R#1 and has prayed daily for him to recover from her mistake. She revealed on the morning of 8/26/22 she was training with the DON during the 9:00 a.m. medication pass. She stated the DON left her alone to tend to another task and while she was gone, she gave R#1 his roommate's medication. She stated she realized that she had administered the wrong medications to R#1 when she started to prepare R#1's medication and realized she had just given him medication. She stated she informed the DON that she gave R#1 the wrong medicine, that she gave him his roommates medication. She revealed she has been a nurse for almost [AGE] years, and stated she was not familiar with the medication system used by this facility and became frustrated and confused and gave the wrong meds. During further interview, she revealed she had observed nurses give medications for a few hours a couple of days, but this was her first time assigned to a medication cart and was administering medications to residents on D Hall. LPN AA stated she completed the morning med pass for D Hall unsupervised, and stated that if she had questions, she had to go find the DON, because she did not stay with her, or help her complete the medication pass. 2. Review of the policy titled Administrating Medications version 2.0 revised April 2019 revealed the policy statement is medications are administered in a safe and timely manner, and as prescribed. Policy Interpretation and Implementation includes Number 19. During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse or aide. It may be kept in the doorway of the resident's room, with open drawers facing inward and all other sides closed. No mediations are kept on top of the cart. The cart must be clearly visible to the personnel administering medications, and all outward sides must be inaccessible to residents or others passing by. Observation on 9/14/22 at 9:09 a.m. of LPN BB on A Hall revealed a medication cart outside room A8, with six medication cups on the top of the cart labeled with resident first and/or last names. The nurse on the cart preparing the medications revealed she prepares multiple resident medication cups for administration and labels them with the resident's name so that she doesn't become confused. During further interview, she revealed this is the way she usually prepares her medications and stated she prepares medicine cups for several residents at the same time. Observation on 9/14/22 at 9:24 a.m. LPN BB on A Hall left the medication cart unattended for approximately four minutes while she went to administer medications to residents in room [ROOM NUMBER]A. There were two medication cups containing pills left on top of the cart when she entered room [ROOM NUMBER]A. Two residents were observed wandering on A Hall. One of the two wandering residents walked up to the cart with the two cups of medication unattended. Interview on 9/14/22 at 9:28 a.m. LPN BB confirmed she left the medication cart unattended with two cups of medications on top. She stated, I guess I am going to get dinged for that one, and I probably did something wrong, but that is how I usually fix my cups for med pass''. Competency check for LPN BB was requested on 9/14/22 at 2:25 p.m. The Infection Control Preventionist (ICP) presented documents for medication administration review, and each had staff members first name only with no signature of the nurse completing the competency check. The sheets revealed oral meds were administered with no details, no additional routes of administration observed, or any details of the skills observed. The Competency check was not signed by the staff member who was being checked off for. Interview on 9/14/22 at 2:35 p.m. with ICP, she stated she observed the nurses administer medications without their knowledge. She confirmed that LPN BB had competency check completed. During further interview the ICP stated the facility does not have a Staff Development Coordinator and confirmed that there were no competency checks completed during the year 2022. Interview on 9/15/22 at 10:20 a.m. with the ICP revealed medications should never be prepared for multiple residents prior to administration and should never be left unattended. Interview on 9/15/22 at 11:00 a.m. with RNC OO revealed it is her expectation that medications be properly stored at all times in locked carts and never left on the top of the medication cart unattended. Interview on 9/15/22 at 2:45p.m. with LPN EE revealed medications should be prepared for one resident at a time and medications should never be left unattended.

Based on record review, resident, family, and staff interviews, review of the job description for the Administrator, the facility failed to ensure administration provided oversight of the competency of the nursing staff to prevent an incident of significant medication error; also failed to ensure incident was reported to the State Agency (SA) timely and that a thorough investigation of a significant medication error was complete for one resident (R#1). The sample size was 16. On 9/9/22 a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had the likelihood to cause serious injury, harm, impairment, or death to residents. Regional Administrator and onboarding facility Administrator, and Interim Director of Nursing were informed of the Immediate Jeopardy (IJ) on 9/9/22 at 2:31 p.m. The noncompliance related to the Immediate Jeopardy was identified to have existed on 8/26/22. A removal plan (Credible Allegation of Compliance) was received on 9/13/22, related to F609: 483.12(c)(1)-Reporting of Alleged Violations (Scope/Severity[S/S]: J.); F610: 483.12(c)(2)-Investigate Alleged Violations (Scope/Severity[S/S]: J.); F726: 483.35(a)(3)-Competent Nursing Staff (Scope/Severity[S/S]: J.); F760: 483.45(f)(2)-Free from Significant Medication Errors (Scope/Severity[S/S]: J.); F835: 483.70 - Administration (Scope/Severity[S/S]: J.). Based on observations, interviews, record review, and review of the facility policies as outlined in the removal plan, it was validated that the corrective action plans and the immediacy of the deficient practice as removed on 9/14/22. The facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures. In-service materials and records were reviewed. Observations and interviews were conducted with staff to ensure they demonstrated knowledge of the facility's policies and procedures governing medication administration, reporting and investigating allegations, administration and competent nursing staff. R Findings include: Review of the document titled Administrator Job Description revealed a hire date of 8/15/22. The document revealed the summary is to lead and direct overall operation of the facility in accordance with resident needs, government regulations, and company policies to maintain care for the residents while achieving the facility's business objectives by performing the following duties personally or through subordinate supervisors. Facility Management Functions: Maintain a working knowledge and ensure compliance with all governmental regulations. Safety and Job Hazards Functions: Report all accidents and incidents. 1. The facility administration failed to ensure one resident was free of significant medication errors. R#1 had a decline in condition that jeopardized the resident's health requiring him to be cared for in the ICU for seven days. 2. The facility administration failed to report an incident of significant medication error on 8/26/22 that occurred during the 9:00 a.m. medication pass, by LPN AA. The incident was not reported timely within the mandated two-hour time frame. 3. The facility administration failed to conduct a thorough investigation of a significant medication error that occurred on 8/26/22 during the 9:00 a.m. medication pass. R#1 had a decline in condition, requiring transport a higher level of care and remained in intensive care unit (ICU) for seven days. LPN AA was allowed to continue to work, unsupervised, without an investigation into the incident. 4. The facility administration failed to provide training and validate competencies for the nursing staff to ensure the nursing staff administer medications, by using the Five Rights of Medications to prevent significant medication errors. The interim DON failed to complete a medication administration competency for LPN AA and allowed LPN AA to continue administering medications after a significant medication error occurred during the remainder of LPN AAs 12-hour shift. Interview on 9/6/22 at 3:30 p.m., Administrator stated he was out of town and the Director of Nursing (DON) was in charge and oversaw the building in his absence. He stated that he received a call from the Regional Nurse Consultant (RNC) QQ on 8/26/22 after 4:00 p.m. regarding a medication error. He revealed that he was unaware the resident was sent to the hospital. He further stated he expects the DON to keep him informed of residents going to the hospital or questionable occurrences in the facility. During further interview, he stated the DON has his email and cell phone number but did not contact him regarding the incident. Interview on 9/6/22 at 5:35 p.m. with the DON revealed Licensed Practical Nurse (LPN) AA informed her that she had administered R#1 the wrong medications. She stated she then contacted the RNC QQ, who instructed her to provide one on one training with LPN AA on the Five Rights of Medication Administration and all the staff who were present. Interview on 9/9/22 at 12:00 p.m. with LPN AA, revealed she was upset about what happened to R#1 and was praying daily for him to recover from her mistake. LPN AA stated that on the morning of 8/26/22, during the 9:00 a.m. medication pass, she was training on the medication cart with the DON. She stated the DON left her unattended to take care of another task. During the absence of the DON, LPN AA continued to prepare and administer medications, and she gave R#1 his roommate's medication. She stated that while preparing R#1's medications, she realized he had just received medications. She state she reported the mistake to the DON that she just gave R#1 his roommates medication. LPN AA stated that she did not fill out any paperwork regarding the incident or provide a written statement about the incident. She stated the DON provided education for her about the Five Rights of Medication Administration and gave her an in-service paper to sign with a printed copy of the education. During further interview, LPN AA stated she completed the morning med pass for D Hall D by herself and was unsupervised.

Based on observation, record review and interviews, the facility failed to provide a safe and medication free environment for two (2) residents (#12 and #10) from a total sample of fourteen (14) residents. The failure to administer medications caused actual harm to one (1) resident (#12) when the facility administered a non-prescribed medication to the resident. Resident #12, became lethargic and had to be admitted to an acute care facility for treatment of [REDACTED]. Findings include: 1.) Resident #12 was originally admitted to the facility on [DATE] and readmitted [DATE] with a [DIAGNOSES REDACTED]. Review of the Nurse's Note dated 10/6/15 at 11:00 a.m., revealed that resident was observed leaning to the right side in the wheelchair with slurred speech with right side weakness. Continued review revealed that the resident was placed on bed for evaluation, oxygen started, and Emergency Medical System (EMS) was notified for transport to the hospital. Resident's responsible party was notified of the current condition and transport to the hospital. Review of the preprinted December 2015 Physician order [REDACTED]. Review of the October 2015, preprinted monthly orders reflected on the Medication Administration Record (MAR) for resident #12, revealed that on October 6, 2015 the resident received the following medication at 9:00 a.m.: [MEDICATION NAME] 5 mg, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] 0.5 mg. Review of the Hospital History and Physical dated 10/6/15 revealed that resident #12 was sent to the hospital with stroke-like symptoms and Altered Mental Status (AMS). Continued review revealed a positive urine drug screen for Benzodiazepines, in which there was no evidence of a physician order [REDACTED].#12, might have a medication overdose. In the emergency room , resident #12 was administered Flumazenil, (a medication used to reverse the effects of Benzodiazepines). After the administration of the Flumazenil, resident #12 began to respond and admitted to the acute care facility for continued observation, which included treatment with intravenous (IV) fluids to flush out the Benzodiazepines. Review of the Hospital Chemistry Laboratory report dated 10/6/15 revealed a positive Benzodiazepine result. Review of the Hospital Discharge Summary Report dated 10/7/15 revealed, resident #12, admitted to the acute care facility with a [DIAGNOSES REDACTED]. Review of the Medication Error Report dated 10/6/15 revealed that resident #12 was transferred to an acute care facility for symptoms of a [MEDICAL CONDITIONS] at 11:00 a.m.; however, at 3:00 p.m., the acute care facility notified the facility that the resident was being admitted , after testing positive for Benzodiazepines. Continued review revealed that the nurse notified the Administrator and the Physician. Review of the Educational Moment Form dated 10/6/15 for Medication Administration Procedure Verbal and Return Demonstration Five (5) Rights revealed that eighteen (18) of the facility's nurses on all three (3) shifts were educated, including the agency nurse that administered the medication to resident #12. Review of agency nurse's witness statement dated 10/6/15 revealed that approximately 9:30 a.m., resident #12, was up in her wheelchair asking for someone to roll her over and over and the nurse asked if she was ready for her medications, the resident replied yes. Continued review revealed that the nurse gave the resident her morning medication, which included [MEDICATION NAME] 5 mg, [MEDICATION NAME] 500 mg, and [MEDICATION NAME] 0.5 mg after confirming her room number and name on arm band and MAR. The nurse gave resident #12 some chocolate pudding with her medication, which she swallowed without any issues and the resident went onto an activity in the dining room. Interview with Licensed Practical Nurses (LPN) AA and BB on 11/30/15 at 11:40 a.m., revealed that they had been recently inserviced on medications and when giving medications, to check pictures and/or arm bands. Interview with the Administrator on 12/7/15 at 11:30 a.m., revealed that the facility never really knew how resident #12 tested positive for the Benzodiazepine. Continued interview revealed that in the morning meeting we talked about how another resident could have possibly given the medication to resident #12, but we were not really sure. A medication error report and education on all nurses, including agency nurse was completed. The Administrator stated that the agency nurse was passing medication that particular day on A-hall and an inservice was completed on that day (10/6/15), including agency, along with a completed narcotic audit for the A-hall and an audit for the MAR room number and picture without any issues. This went into the Quality Assurance (QA) Program on 10/7/15 due to this particular reason and that there had been some alert and oriented residents stating that they had not been getting their medications in a timely manner. Continued follow up done on a daily basis with alert and oriented residents and now it is done randomly, with the last being completed on 11/25/15. Another interview at 2:40 p.m., revealed that this has been the only concern in the facility of this nature. 2.) Resident #10 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Resident #10 was discharged from the facility on September 3, 2015. Review of the Physician admission orders [REDACTED]. Review of the Admission physician progress notes [REDACTED].#10 is to continue with current medication as prescribed and follow up with neurologist as needed. Review of the July, August and September 2015 preprinted Physician order [REDACTED]. Review of the July 2015 MAR revealed no evidence of medication administered as follows: 1.) [MEDICATION NAME] 25/100 two (2) tablets: 7:00 p.m. on 7/7, 7/13, and 7/23/15 2.) [MEDICATION NAME] 25/100 two (2) tablets: 7:00 a.m. on 7/6/15 3.) [MEDICATION NAME] 25/100 one (1) tablet: 7:00 a.m. on 7/13/15 4.) [MEDICATION NAME] 25/100 one (1) tablet: 4:00 p.m. on 7/3/15 5.) [MEDICATION NAME] 25/100 one (1) tablet: 7:00 p.m. on 7/6, 7/7, 7/8, 7/9, 7/13, and 7/23/15 6.) [MEDICATION NAME] 25/100 one (1) tablet: 10:00 p.m. on 7/14, 7/18, 7/28, and 7/29/15 For a total of sixteen (16) omitted doses during the month of July 2015. Review of the August 2015 MAR, revealed no evidence of medication administered as follows: 1.) [MEDICATION NAME] 25/100 one (1) tablet: 4:00 p.m. on 8/18/15 2.) [MEDICATION NAME] 25/100 one (1) tablet: 10:00 p.m. on 8/26/15 For a total of two (2) omitted doses during the month of August 2015. Review of the September 2015 MAR, revealed no evidence of medication administered as follows: 1.) [MEDICATION NAME] 25/100 one (1) tablet: 7:00 p.m. and 10:00 p.m. on 9/2/15 For a total of two (2) omitted dose during the month of September 2015. Interview with the Assistant Director of Nursing (ADON) on 12/7/15 at 1:20 p.m., revealed the procedure for withholding a medication is to circle the dose on the MAR and indicate the rational for omission. Continued interview the ADON confirmed the missing medications on the MAR's. Telephone interview on 12/22/15 at 10:45 a.m., during the post survey QA Process, with the Minimum Data Set (MDS) Coordinator revealed that resident #10 was admitted to the facility receiving the above medication, which was ordered by a community neurologist. Observation on 11/25/15 between 8:10 a.m. and 9:27 a.m., revealed four (4) nurses, on four (4) halls (A, B, C, and D) with five (5) residents (#1, #2, #3, #4, and #5), for a total of thirty-four (34) opportunities, resulting in a zero percent (0%) medication error rate.