Every finding on record at Grandview Rehabilitation and Healthcare Center

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for medication administration, the facility failed to ensure a medication was administered in accordance with the six (6) rights of medication administration. The facility failed to ensure the correct methadone bottle and dose were verified prior to administration, resulting in Resident #1 being given another resident's methadone dose of 120 milligrams (mg) instead of 10 mg ordered for Resident #1. This incident represented the second such occurrence in a six month period and placed Resident #1 at risk for significant adverse effects including respiratory depression, decreased level of consciousness, and cardiovascular compromise. This resulted in the finding of Immediate Jeopardy. The findings include:Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), opioid dependence, adjustment disorder and anxiety disorder. A physician's order dated 2/13/26 directed to administer Methadone concentrate 10 milligrams (mg) per milliliter (mL), give 10 mg orally one time a day for Methadone Maintenance Therapy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14). The Resident Care Plan dated 5/26/26 identified Resident #1 was at increased risk for pain due to a history of substance use disorder and was at risk for substance use disorder related to a history of substance and/or alcohol addiction and utilized Methadone for treatment. Interventions included anticipating the resident's need for pain relief and responding immediately to any complaints of pain, monitoring/recording/reporting to the licensed nurse the resident's complaints of pain or request for pain treatment and communicating and complying with the contracted agency's (Root Center) contract and needs for the resident's continued involvement in the treatment plan. The facility Reportable Event form dated 8/1/26 identified at 5:30 AM the nursing supervisor, Registered Nurse (RN) #1, called the Director of Nursing (DON) to report he had administered Resident #2's methadone dose of 120 mg to Resident #1. Resident #1 had an order for methadone 10 mg daily and received 120 mg in error. RN #1 reported when Resident #1 poured the methadone dose into his/her mouth, Resident #1 realized it was too much liquid and spit it out. The report indicated the Advanced Practice Registered Nurse (APRN) #1, was notified and a new order was obtained to not administer Resident #1's ordered methadone dose of 10 mg to him/her for 8/1/26. Review of progress note dated 8/1/26 failed to reflect documentation detailing the mediation error and that a nursing assessment had been completed. A late entry APRN note created on 8/3/26 at 4:16 PM by APRN #1 for 8/1/26 at 1:16 PM identified she was asked to evaluate Resident #1 after a reported medication administration error involving methadone. The note indicated per nursing, Resident #1 was inadvertently administered an incorrect dose of methadone and immediately spit out the medication upon recognizing it was not his/her usual dose. The note identified at the time of the evaluation, Resident #1 stated he/she felt well, denied any concerns, and Resident #1 remained clinically stable following the reported medication error. Interview with Resident #1 on 8/4/26 at 10:40 AM identified on 8/1/26, a nurse (RN #1) gave him/her a bottle of methadone and did not ask him/her their name or methadone dose. Resident #1 identified he/she also did not read the label on the bottle but once he/she poured the liquid into his/her mouth, he/she identified immediately that it was too much liquid. Resident #1 reported he/she may have swallowed some but spit a majority of the liquid out back into the bottle and reported to RN #1 that he/she was given the incorrect bottle of methadone. Interview with the Director of nursing (DON) on 8/4/26 at 10:50 AM identified RN #1 should have ensured the bottle of methadone that he brought to Resident #1 was intended for Resident #1, was the correct dose and RN #1 should have verified with Resident #1 his/her name and dose of methadone at the bedside prior to handing the bottle to Resident #1. The DON identified through her investigation it was determined the methadone proof-of-use (documentation that tracks the handling, transfer, and storage of methadone from receipt to administration or disposal to ensure accountability and prevent diversion) if RN #1 had LPN #1 verify the labeled methadone bottle matched Resident #1's proof-of-use sheet before cosigning, the error would not have occurred. The DON indicated both RN #1 and LPN #1 should have been verifying the methadone inside the intended resident's room and not in the hallway at LPN #1's medication cart while LPN #1 was actively pouring medications. Interview with APRN #1 on 8/4/26 at 12:12 PM identified the DON notified her at around 7:00 AM of the medication error, reporting Resident #1 received the wrong dose of methadone and Resident #1 refused transfer to the Emergency Department. APRN #1 explained she evaluated Resident #1 later in the day on 8/1/26, again on 8/2/26 and Resident #1 was at baseline with no concerns or changes identified, Resident #1 continued to report feeling fine following the incident. APRN #1 reported the error was a significant medication error that could have caused respiratory depression and slowed/shallow breathing, drowsiness, confusion, decreased heart rate and blood pressure and unresponsiveness. Interview with LPN #1 on 8/4/26 at 12:30 PM identified on 8/1/26 she was in the middle of her morning medication pass when RN #1 approached her at the medication cart and requested that she cosign methadone for Resident #2. LPN #1 identified RN #1 had the binder containing the methadone proof-of-use sheets open, requested that she sign it, and although she should have, she reported she did not look at the sheet to compare the bottle of methadone RN #1 was holding and the proof-of-use sheet were for Resident #1. LPN #1 identified she was preoccupied and just signed the methadone proof-of-use sheet the book was open to and went back to her medication pass. LPN #1 indicated she was made aware that RN #1 had given Resident #1 Resident #2's methadone by the DON. LPN #1 explained had she verified that both the methadone bottle and the proof-of-use sheet matched and observed RN #1 entering the correct room, the methadone medication error may have been prevented. Review of RN #1's statement dated 8/1/26 identified he was not sure how the methadone medication error occurred, as he took the bottle of methadone to another nurse (LPN #1) to verify the resident and methadone dose matched. Although attempted, an interview with RN #1 was not obtained. Review of the Methadone for Opioid Addiction policy dated 2/24/26 directed, in part, the shift RN Supervisor will hand the methadone bottle to the resident for self-administration after completing the Rights of Medication Administration: Right patient, right dose, right drug, right route, right time and right documentation. The resident will open the methadone bottle and validate that the seal is intact and is dated and labeled correctly. If the seal is not intact, or the dose is improperly dated, the dose will not be given and the DON, Administrator, MD/APRN and the methadone-associated clinic will be notified. In addition, an incident report of possible diversion and/or potentially omitted dose will be completed. The resident will self-administer the appropriately dated and labeled methadone. Review of the Medication Administration policy (undated) directed, in part, to ensure that the six rights of medication administration are followed to include: right resident, right drug, right dosage, right route, right time and right documentation. Compare medication source with the Medication Administration Record to verify the resident's name medication name, form, dose, route and time. Observe resident consumption of medication. Sign MAR after administered. If medication is a controlled substance sign the narcotic book. Correct any discrepancies and report to the nurse manager. A Plan of Correction for past non-compliance with a compliance date of 8/3/26 was submitted and accepted by the state agency during an on-site visit on 8/4/26: Immediate Corrective Actions:The medication error was immediately investigated, and the resident was assessed. No adverse outcome was identified.The Medical Director was notified of the incident and the corrective actions implemented.The licensed nurse involved (RN #1) received immediate re-education regarding the facility's Methadone administration policy and safe medication administration practices. Appropriate disciplinary action was initiated. RN #1's employment was subsequently terminated effective 08/03/2026.All licensed nursing staff received mandatory education on the facility's revised Methadone administration procedure, which includes the following required steps: The Methadone cart must accompany the nurse during medication administration.Only one resident's Methadone bottle may be removed from the secured storage area at any time. Multiple bottles shall never be out simultaneously.Two licensed nurses must independently verify the correct resident, medication, dose, route, date, and time at the resident's bedside prior to administration.Both nurses will sign the Methadone Administration Record (ROOT documentation) verifying completion of the independent double-check. The administering nurse will identify the resident and state: Hello Mr./Ms. [Resident Name], I have your Methadone. Please review the label and verify your name, dose, and today's date.If the resident is unable to read the medication label, the resident will verbally confirm their prescribed Methadone dose whenever possible.The information provided by the resident will be compared with the medication label and the Methadone Administration Record before administration.Medication will not be administered until all required identifiers have been verified.Staff will directly observe ingestion of the medication in accordance with facility policy.Documentation will be completed immediately following administration in both the ROOT documentation and the electronic medical record (PCC).Identification of Other Residents at Risk:All residents receiving Methadone are considered to have the potential to be affected by this deficient practice.Systemic Corrective Measures:1. Random weekly audits of Methadone administration will be conducted for four (4) consecutive weeks by the Director of Nursing and/or designee to verify compliance with the required bedside independent double verification process.2. Audit elements will include verification that: Only one Methadone bottle is removed at a time. Two licensed nurses independently verify the resident, medication, dose, route, date, and time at the bedside.Required documentation is completed immediately following administration.Facility Methadone administration procedures are consistently followed. 3. Following successful completion of four consecutive weekly audits demonstrating compliance, audits will transition to monthly monitoring until substantial compliance is achieved.4. Audit findings, trends, corrective actions, and opportunities for improvement will be reviewed during the facility's quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings until substantial compliance has been achieved.Date of Compliance: 08/03/2026

Based on clinical record reviews, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1), the facility failed to ensure a licensed nurse (RN #1) completed and documented a nursing assessment following a significant medication error involving the administration of 120 milligrams (mg) of methadone to Resident #1, instead of the prescribed 10 mg dose. This failure placed Resident #1 at risk for serious adverse effects including respiratory depression, slowed breathing, decreased heart rate and blood pressure, and unresponsiveness. The findings include:Resident #1's diagnoses included Chronic Obstructive Pulmonary Disease (COPD), opioid dependence, adjustment disorder and anxiety disorder. A physician's order dated 2/13/26 directed to administer Methadone concentrate 10 milligrams (mg) per milliliter (mL), give 10 mg orally one time a day for Methadone Maintenance Therapy. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 was cognitively intact (Brief Interview for Mental Status (BIMS) score of 14). The Resident Care Plan (RCP) dated 5/26/26 identified Resident #1 was at risk for substance use disorder related to a history of substance and/or alcohol addiction and utilized Methadone for treatment. The RCP identified Resident #1 had Emphysema/COPD related to smoking and utilizes oxygen therapy related to ineffective gas exchange. Interventions included monitoring for signs and symptoms of acute respiratory insufficiency and reporting to the provider as needed including anxiety, confusion, restlessness, shortness of breath at rest, cyanosis and somnolence; monitoring respirations, pulse oximetry and heart rate; administering oxygen via nasal cannula at two (2) Liters Per Minute (LPM) at rest/sleep and three (3) LPM with activity to maintain an oxygen saturation of 90 percent (%) or higher. The facility Reportable Event form dated 8/1/26 identified at 5:30 AM the nursing supervisor, Registered Nurse (RN) #1, called the Director of Nursing (DON) to report he had administered Resident #2's methadone dose of 120 mg to Resident #1. Resident #1 had an order for methadone 10 mg daily and received 120 mg in error. RN #1 reported when Resident #1 poured the methadone dose into his/her mouth, Resident #1 realized it was too much liquid and spit it out. The report indicated the Advanced Practice Registered Nurse (APRN) #1, was notified and a new order was obtained to not administer Resident #1's ordered methadone dose of 10 mg to him/her for 8/1/26. Review of progress note dated 8/1/26 failed to reflect documentation detailing the mediation error and that a nursing assessment had been completed. Review of the clinical record identified Resident #1's vital signs were not documented following the medication error on 8/1/26 at 5:30 AM until 8:25 AM (approximately three (3) hours later) by the 7:00 AM to 3:00 PM charge nurse, LPN #2. A late entry APRN note created on 8/3/26 at 4:16 PM by APRN #1 for 8/1/26 at 1:16 PM identified she was asked to evaluate Resident #1 after a reported medication administration error involving methadone. The note indicated per nursing, Resident #1 was inadvertently administered an incorrect dose of methadone and immediately spit out the medication upon recognizing it was not his/her usual dose. The note identified at the time of the evaluation, Resident #1 stated he/she felt well, denied any concerns, and Resident #1 remained clinically stable following the reported medication error. The APRN note identified the examination was without evidence of adverse medication effects, there was no acute respiratory or cardiac distress noted, and Resident #1 will continue to be monitored closely. Interview with the DON on 8/4/26 at 4:01 PM identified once RN #1 called her to report the methadone error, she arrived at the facility within forty-five (45) minutes. The DON indicated RN #1 should have completed a full RN assessment to include a respiratory and cardiac assessment and vital signs immediately following the incident, but she was unable to find documentation that an assessment had been conducted and RN assessments are to be documented in the clinical record prior to the RN leaving. A late entry nurse's note created on 8/4/26 at 11:56 AM by the DON identified, in part, on 8/1/26 at 8:00 AM RN #1 notified her that an incorrect methadone dose had been given to Resident #1, receiving Resident #2's methadone dose of 120 mg instead of Resident #1's prescribed dose of 10 mg. The DON indicated she interviewed staff and Resident #1 and Resident #1 was alert and oriented, in no acute distress, had no visible signs of respiratory depression or distress and respirations were even and unlabored with a rate of 18 breaths per minute. The APRN was notified of the incident and new orders were received to monitor vital signs every four (4) hours. Although attempted, an interview with RN #1 was not obtained. Review of the Incidents and Accidents policy (undated) directed, in part, in the event of an incident or accident, immediate assistance will be provided. Any injuries will be assessed by the licensed nurse or practitioner, and the affected individual will not be moved until safe to do so. Documentation in the resident medical record should include the date, time, nature of the incident, location, initial findings, notifications and any orders obtained. Complete all associated tools/assessments in the electronic medical record. Although requested, policies on medication errors/significant medication errors were not provided.

Based on clinical record review, observation, review of facility documentation, review of policy and staff interviews for 1 of 2 residents ( Resident #114) reviewed for Activities of Daily Living (ADL), the facility failed to ensure a resident was offered ancillary services when a change in provider occurred. The facility also failed to ensure podiatry services were provided for a resident with excessively long toenails. The findings include: Resident #114's diagnosis included visual loss, atherosclerosis of both legs and reduced mobility. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #114 had severe vision loss and mild cognitive impairment. The care plan dated 3/17/2026 indicated Resident #114 had a deficit in completing activities of daily living. An intervention includes providing the assistance of 1 staff member for all care due to visual limitation. An observation on 5/11/2026 at 11:55 AM identified Resident #114's toenails were excessively long, all 10 nails past the ends of the toes and both toenails thickened. The Assistant Director of Nursing Services (ADNS) came into Resident #114's room to see the resident at which time Resident # 114 informed the ADNS about her/his toenails. Resident # 114 indicated she/he had not seen the podiatrist for months. The Advanced Practice Registered Nurse (APRN) indicated Resident #114 would be placed on the list for a podiatry visit. An interview and observation with the Director of Nursing Services (DNS) on 5/13/2026 at 1:27 PM identified there was a change in the provider for ancillary services on 12/2025 and Resident #114 had not been offered enrollment for the new provider yet. An observation of Resident #114's toenails with the DNS who agreed the resident's toenails were excessively long. The DNS explained to Resident #114 the rationale for the need to be enrolled in the current ancillary provider program to ensure a podiatry appointment. On 5/14/2026 at 10:53 AM an interview, clinical review and facility document and policy review with the DNS identified the last podiatry visit for Resident #114 was provided on 7/02/2025 for treatment of thickened and elongated toenails secondary to the resident was unable to trim them his/herself. The DNS indicated Resident #114 was now enrolled in the program and on the podiatrist list for June 2026 to ensure Resident # 114 could be seen as soon as possible. Review of the facility policy for podiatry services with the DNS identified there are no staff members trained to trim resident toenails and the facility depends on an outside podiatry provider to provide the care.The Facility Policy labeled Podiatry services indicated residents who have complicated disease process foot care will be referred to a qualified professional including a podiatrist.

Based on observations, policy review and staff interviews for 1 of 4 medication rooms (South 2) reviewed for medication storage and labeling, the facility failed to store medications and biologicals per professional standards and facility policy. The findings include:Observation on 5/12/26 at 12:28 PM identified 2 Nurse Aides (NA) walking down the unit past the nurse's station of an unlocked medication room.Observation and interview with Licensed Practical Nurse (LPN # 2) on 5/12/26 at 12:34 PM identified LPN # 2 walking down the hallway (out of vision sight of the medication room) stating she just went to the restroom. LPN #2 indicated the facility policy directs that a medication room is locked at all times when not in use, for which she was responsible for that shift. LPN #2 could not identify why she did not close the medication room door all the way. Review of the medication room identified an unlocked treatment cart containing medicated lotions, powders and treatment supplies, and 2 cabinets containing over the counter medications (in part containing ibuprofen, melatonin, aspirin, acetaminophen, laxatives and vitamins) as well as a box of auto shield needles used for insulin administration.Interview with the Registered Nurse Supervisor (RN # 2) on 5/13/26 at 8:48 AM identified the nurse on the unit was responsible for keeping the medication room door closed and locked all times. Additionally, RN #2 identified there were residents on unit South 2 that tended to take things due to their cognitive status.The Medication Storage Policy directed in part that all medications housed on premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, separation and security. Additionally, all drugs and biologicals, will be stored in locked compartments (examples: medication carts, cabinets, drawers, refrigerators and medication room).

Based on clinical record review, observations, staff interviews, and review of facility policy for 1 of 3 residents for (Resident #54) reviewed for infection control, the facility failed to ensure staff wore appropriate Personal Protective Equipment (PPE) when providing care to a resident with an indwelling urinary catheter and a history of colonization with a multidrug-resistant organism. The findings included:Resident #54 was admitted with diagnoses that included stroke, neuromuscular dysfunction of the bladder, and carrier or suspected carrier of methicillin-resistant Staphylococcus aureus (a bacterium resistant to certain antibiotics).The quarterly MDS assessment dated [DATE] identified Resident #54 had severe cognitive impairment and required substantial/maximal assistance for toileting, personal hygiene, bathing, and lower body dressing. The MDS assessment also identified Resident #54 had an indwelling urinary catheter.A nursing note dated 5/4/2026 indicated that urine was noted to be leaking around the suprapubic catheter site.A physician's order dated 5/6/2026 directed the implementation of enhanced barrier precautions related to colonization of Methicillin- Resistant Staphylococcus Aureus (MRSA ) a bacterium resistant to certain antibiotics in the urine.A nursing care plan revised on 5/6/2026 indicated Resident #54 was at risk for infection related to indwelling medical devices and a history of multidrug-resistant organisms. Interventions included following enhanced barrier precautions per facility protocol. An undated nursing aide care card also identified the resident had a urinary catheter and was on enhanced barrier precautions. On 5/11/2026 11:30AM, an observation during resident screening identified that when the surveyor entered Resident#54's room, the resident's curtain was closed. However, through the room's mirror on the opposite side of the wall from the head of the bed, NA#1 and NA#9 were observed dressing Resident #54 including raising the resident's pants. NA#9 went around the curtain and indicated that the resident was being given morning care, and they were going to transfer the resident out of bed. Neither NA#1 nor NA#9 were observed wearing an isolation gown.On 5/11/2026 at 11:35AM, an interview and observation of the precautions sign on the door frame of Resident #54's room with LPN#6 identified Resident #54 was on enhanced barrier precautions and that gloves and gowns should be worn with care.On 5/11/2026 at 11:45 AM, an interview with NA#9 identified she could not identify why she was not wearing a gown when providing morning care. NA#1 indicated that they were wearing gowns but had taken the gowns off in the room after providing care. An observation with NA#9 and NA#1 of the room failed to identify a garbage pail or garbage bag that contained discarded gowns or gloves.A review of the facility policy for Enhanced Barrier Precautions indicated that personal protective equipment for enhanced barrier precautions was only necessary when performing high-contact care activities. The policy further identified high-contact care activities, which included dressing, bathing, transferring, providing hygiene, changing linens, and assisting with toileting.

Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two residents (Resident #1) reviewed for smoking, the facility failed to ensure the resident was treated with respect and dignity and the resident's rights were honored, and failed to ensure the resident was not prevented from leaving the facility for a Leave of Absence (LOA) and LOA time was not limited. The findings include: Resident #1 was admitted with diagnoses that included schizoaffective disorder, dementia, bipolar, nicotine dependence, anxiety, and a history of substance abuse. Record review identified Resident #1 had a court appointed conservator. A quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental Status (BIMS) score of 14 indicated alert and oriented), had no behavioral symptoms, no wandering, and was independent with personal hygiene and walking. A resident care plan (RCP) dated 2/16/2026 identified Resident #1 exhibited noncompliance with care, was a smoker, and was independent with ambulation with a rolling walker. Interventions directed to protect rights of resident and others, independent to smoke on leave of absence unsupervised, allow resident to express emotions and provide resident with meaningful activities. An APRN note dated 3/6/2026 identified Resident #1's cognitive capacity for treatment decisions remained intact for routine care. Baseline dementia was noted but not significantly impacting medication adherence with facility support. Gait maintained with rolling walker assistance; balance adequate, no acute neurological deficits, speech fluent, mood stable, thought process logical and judgement intact. A physician's order dated 3/6/2026 directed Resident #1 may go on leave of absence (LOA) for one (1) hour. An APRN note dated 3/23/2026 indicated an evaluation for competency that identified thought processes were logical, goal directed, speech fluent and clear, and fine motor coordination was intact. Resident #1 was cooperative and engaged. Resident #1 demonstrated understanding of medical condition and need for ongoing care, judgement appeared intact for routine decisions, no concerns with impulse control. The note indicated, based on clinical assessment, Resident #1 demonstrated adequate cognitive capacity to participate in decision-making discussions. No acute psychiatric symptoms or cognitive impairment was noted that precluded participation in advanced care planning. Baseline cognitive function appeared preserved with ability to understand and express preferences regarding medical care. Cognitive capacity for healthcare decision making intact with appropriate orientation, logical thinking and ability to understand medical information. A nursing note dated 4/17/2026 at 7:13 PM identified the conservator was updated that the resident was on LOA from 2:30 and did not return till 7 PM. Conservator expressed that resident is not to exceed no more than and hour. Stated that if resident acts up can send out and that any further behaviors can hold LOA till comes in Tuesday to speak to him/her. Resident is made aware of the situation and what can happen. Record review failed to identify additional information regarding limitations on Resident #1's resident rights and his/her ability to leave the facility for an LOA. A nursing note dated 4/19/2026 at 6:25 PM identified Resident #1 fell while outside the facility while on LOA and upon notification to the conservator, the conservator clarified that the one-hour LOA was meant to be one (1) hour daily, not multiple one (1) hour LOAs. (in one day). A physician order dated 4/19/2026 directed Resident #1 may go on LOA for one (1) hour once daily. Record review failed to identify additional information regarding limitations on Resident #1's resident rights and his/her ability to leave the facility for an LOA. A physician order dated 4/29/2026 directed to discontinue Resident #1 may go on LOA for one (1) hour daily. Interview with LPN #3 on 4/30/2026 identified she had cared for Resident #1 regularly and was his/her nurse on 4/17 and 4/18/2026. LPN #3 stated Resident #1 was very independent and took frequent independent smoke breaks but was only allowed per the conservator to go on LOA for one (1) hour at a time. Resident had signed out for an LOA on 4/17/2026 at 2: 30 PM. Resident #1 notified her when he/she returned to the facility and indicated he/she was delayed returning to the facility within the one (1) hour required due to shopping at a local supermarket. LPN #3 stated that was not the first time Resident #1 had exceeded the one (1) hour LOA time limit. Then on 4/18/2026, Resident #1 reported to LPN #3 that while he/she was on an LOA, he/she had smoked marijuana and drank two (2) beers. The conservator and the APRN were notified. The APRN gave new orders to hold medications that potentially would cause sedation. Interview with psychiatric APRN #1 on 4/30/2027 at 2:07 PM identified she evaluated Resident #1 on 4/17/2026 for behaviors dealing with noncompliance to smoking policy at the facility and noncompliance with LOA time limit. There was no safety concerns noted at the time and no psychotic symptoms. APRN #1 indicated the focus was on behavior accountability and impulse control with Resident #1 actively participating. APRN #1 stated she evaluated Resident #1 on 4/23/2026 per facility request, for sleep issues and medication for sleep (Ambien). Resident #1 reported anxiety and sleep deprivation but cognition was unchanged from previous evaluations. Interview with SW #1 on 4/30/2026 at 12:50 PM identified SW #1 stated when any resident signs out on LOA, they are responsible for themselves and they do not need supervision. Resident #1's LOA order was modified on 4/19/2026 per request of the conservator due to Resident #1 not complying with the one (1) hour limitation when on LOA shopping; Resident #1 was on LOA for approximately 5 hours. SW #1 was unsure when the one (1) hour limit was initially placed on Resident #1's right to leave the facility on an LOA. SW #1 stated Resident #1 was known to be non-compliant at times, but was cognitively alert and oriented. SW #1 stated, with the conservator approval and recommendation, the one (1) hour LOA time limit was implemented due to poor decision making. Interview and review of medical record with psychiatric APRN #2 on 4/30/2026 at 1:00 PM identified that she followed up with Resident #1 on 4/20/2026 after Resident #1's self-report of substance abuse on LOA. APRN #2 stated Resident #1's insight was fair, and Resident #1 had expressed some remorse and stated the intent not to repeat behaviors. Resident #1 was redirectable but continued to demonstrate poor choices while on LOA. Resident #1 was alert, anxious at times, cooperative and easily engaged with no signs of psychosis or changes in mood, and stated due to Resident #1's history of opioid use disorder, drug seeking behaviors could occur. APRN #2 stated Resident #1 was not considered a danger to self or others. She evaluated Resident #1 again on 4/29/2026 to address ongoing behavioral concerns by staff, and stated Resident #1 had no significant changes to mentation. APRN #2 stated changes to Resident #1's LOAs were completed due to facility request per facility policy, not per her recommendations. Interview with RN #1 on 4/30/2026 at 1:15 PM identified on 4/28/2026 an episode dealing with LOA privileges had resulted in police intervention when Resident #1 was unable to be re-directed and had increased agitation. Resident #1 refused to go to the hospital and was able to be calmed by EMS. RN #1 stated, upon notification to the conservator, the conservator requested that the independent LOAs be discontinued. Nursing note dated 4/29/2026 at 3 PM identified Resident #1 did not return from an LOA and when Resident #1 returns to the facility, his/her independent LOA will be restricted per resident conservator. Record review failed to identify why the right for LOAs was taken away from Resident #1. Interview with the Director of Nurses (DON) on 4/30/2026 at 2:00 PM identified that Resident #1's LOA orders were based on recommendations from the conservator and the conservator was responsible for medical and financial decisions for Resident #1. The DON stated changes to Resident #1's LOA orders were completed based on the conservator's directions with collaboration by the medical team. The DON identified that on 4/30/2026, the conservator had directed Resident #1 not be allowed to go on LOAs and that the conservator would decide for how long, as Resident #1 was not abiding by the one (1) hour independent LOAs by staying out past the time limits. When Resident #1 asked how long the limits would be in place, the conservator replied that they would revisit it a few days later. The DON stated the facility was were following the conservator's direction for the LOA restrictions. Interview failed to identify why the facility did not honor Resident #1's rights. APRN #3 was unavailable for interview during survey. Although requested the facility did not provide a policy for Leave of Absence for surveyor review during the survey. The facility's Resident [NAME] of Rights dated 1/8/2023 directed in part, that residents have the right to be informed of and participate in, his or her treatment plan including the right to establish goals and outcomes of care, the type, amount, frequency and duration of care including the right to request or refuse treatment. The resident had the right to exercise his or her rights and be supported by the facility to exercise their rights. The resident had the right to a dignified existence and self-determination. The facility must promote and facilitate resident's self-determination through support of residents' choice.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled resident reviewed for medication administration the facility failed to ensure Resident #1, who was prescribed a controlled substance (Methadone) for substance use disorder (SUD) was administered Methadone per physician's order when the licensed nurse removed two (2) residents Methadone from the lock box at the same time, stored the Methadone on the top of the medication cart and then administered Resident #1 another resident's Methadone which was a 1100 percent (%) higher dose than prescribed subsequently leading to a significant medication error which required hospitalization. The findings include: Resident #1's diagnoses included opioid dependence, adjustment disorder, anxiety disorder, Chronic Obstructive Pulmonary Disorder (COPD) and deviated nasal septum (one side of the nose is wider and the other side is narrower altering the pattern of airflow through the nose). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10)and was independent with Activities of Daily Living (ADLs), bed mobility, transfers and ambulation. The Resident Care Plan (RCP) dated 12/08/25 identified Resident #1 was at increased risk for pain due to a history of SUD and utilized Methadone for treatment. Interventions included anticipating the resident's need for pain relief and responding immediately to complaints of pain, monitoring/recording/reporting to the licensed nurse complaints of pain or request for pain treatment and communicating and complying with the facility's contracted agency for the resident's continued involvement in the treatment plan. A physician's order dated 2/13/26 directed to administer Methadone concentrate 10 milligrams (mg) per milliliter (mL), give 10 mg orally one time a day for Methadone Maintenance Therapy. A nurse's note by LPN #1 dated 2/19/26 at 7:01 AM identified Resident #1 was transferred to the hospital related to a medication administration error. The nursing supervisor (RN #1) administered 120 mg of Methadone instead of the prescribed 10 mg dose. The error was identified after administration. Resident #1 was immediately assessed, and his/her vital signs were within normal limits. The note identified Resident #1 was monitored for signs of opioid overdose, including respiratory depression and decreased level of consciousness, and due to the excessive dose and potential for adverse effects, Emergency Medical Services (EMS) was activated, and Resident #1 was transferred to the hospital for further evaluation and monitoring. A nurse's note by RN #1 dated 2/19/26 at 7:09 AM identified at approximately 6:10 AM, while administering morning medications, she inadvertently selected the wrong bottle of Methadone for Resident #1. Resident #1 received Methadone 120 mg by mouth rather than the prescribed 10 mg dose. The APRN was notified immediately of the error, and an order was received to transfer Resident #1 to the Emergency Department (ED) for evaluation and monitoring due to significant overdose risk. The hospital Discharge summary dated [DATE] identified Resident #1 was admitted from the facility due to an accidental Methadone overdose (given 120 mg rather than 10 mg). Resident #1 required an Intensive Care Unit (ICU) stay with a Narcan drip (used to reverse the effects of Methadone). The Narcan drip was weaned off in the early morning of 2/20/26 and Resident #1 was restarted on Methadone 10 mg daily. Resident #1 was discharged back to the facility on 2/22/26. Interview with Resident #1 on 2/24/26 at 12:14 PM identified on 2/19/26, RN #1 went to administer his/her Methadone and the bottle containing the Methadone contained an unusually large amount of liquid. Resident #1 asked RN #1 if she was sure that was his/her dose to which she reported, yes. Resident #1 reported he/she drank the Methadone as instructed and then shortly after, RN #1 returned to his/her room and reported he/she was correct in questioning the Methadone dose and she administered someone else's Methadone bottle, and he/she was subsequently overdosed. Resident #1 identified he/she was then told he/she would be transferred to the ED and reported he/she could not recall anything after entering the ambulance on 2/19/26 until the day he was transferred back to the facility on 2/22/26, further stating he/she blacked out. Interview with RN #1 on 2/24/26 at 1:09 PM identified on 2/19/26, she opened the locked Methadone cart and removed Resident #1 and Resident #2's Methadone bottles, along with the associated Methadone Chain of Custody Records (Documentation that tracks the handling, transfer, and storage of methadone from receipt to administration or disposal to ensure accountability and prevent diversion). and placed them on top of the medication cart. She reported she had the cart positioned in the doorway of Resident #1's room and asked Resident #1 his/her name and Methadone dose and verified the bottle and the record were correct. She then turned and picked up the Methadone bottle without verifying she had the correct Methadone bottle for Resident #1 and handed it to him/her. After Resident #1 drank the liquid from the Methadone bottle, he/she asked if RN #1 was sure she gave him/her the right dose because there was a lot of liquid in the bottle and he/she usually had a small amount. RN #1 identified she immediately checked the bottle and realized she gave Resident #1, Resident #2's bottle of Methadone, which was a significantly higher dose. She immediately notified Resident #1 that she administered the wrong dose, notified the APRN and transferred Resident #1 to the ED. She reported she should not have removed two (2) residents Methadone doses out of the lock boxes at the same time and should have verified she handed Resident #1 the correct Methadone bottle. She identified Resident #1 was highly nervous and anxious following the incident. Interview with APRN #1 on 2/24/26 at 1:34 PM identified Resident #1 had a history of respiratory issues therefore was at risk for respiratory depression and sedation. Interview with the DON on 2/24/26 at 2:20 PM identified RN #1 should not have removed the Methadone from the lock boxes in the medication cart for two (2) residents at the same time and should not have left one (1) of the Methadone bottles on top of the medication cart unattended while delivering Resident #1 his/her Methadone. The DON identified RN #1 should have ensured the bottle of Methadone she brought to Resident #1 was intended for Resident #1 and was the correct dose and should have verified with Resident #1 his/her name and dose of Methadone at the bedside prior to handing the bottle to Resident #1 to administer. The DON reported RN #1 continued to administer Methadone to residents following the incident and stated she worked an additional shift after the incident where she administered Methadone to residents in the facility. Review of the Medication Administration policy (undated) directed, in part, to ensure that the six rights of medication administration are followed to include: right resident, right drug, right dosage, right route, right time and right documentation. Compare medication source with the Medication Administration Record to verify the resident's name medication name, form, dose, route and time.

Based on review of clinical records, facility documentation and interviews for five (5) of twelve (12) residents (Resident #2, #8, #9, #10 and #11) reviewed for physician's orders, the facility failed to ensure provider orders were reviewed and signed by the physician following resident admissions to the facility and monthly. The findings include:1. Resident #12 was admitted to the facility on [DATE].Review of physician orders identified orders were not reviewed and signed on 1/14/26 or 2/1/26 in accordance with facility practices.2. Resident #10 was admitted to the facility on [DATE].Review of physician orders identified orders were not reviewed and signed on 1/20/26 or 2/1/26 in accordance with facility practices.3. Resident #9 was admitted to the facility on [DATE].Review of physician orders identified orders were not reviewed and signed on 1/21/26 or 2/1/26 in accordance with facility practices.4. Resident #2 was admitted to the facility on [DATE].Review of physician orders identified orders were not reviewed and signed on 2/6/26 in accordance with facility practices.5. Resident #8 was admitted to the facility on [DATE].Review of physician orders identified orders were not reviewed and signed on 2/18/26 in accordance with facility practices.Interview with the DON on 3/2/26 at 9:00 AM identified the admitting physician was responsible for reviewing and signing orders when completing the initial history and physical within 48 to 72 hours of admission to the facility and then monthly. The DON was unaware that the orders were not consistently signed.Interview with the Medical Director (MD #1) on 3/2/26 at 10:17 AM identified when a resident is newly admitted , the admitting physician is responsible for signing the admission orders within 72 hours of admission to the facility when completing the history and physical and then monthly thereafter. He reported that when the clinical record is accessed, there is no prompt to sign the orders, and unsigned orders must have been missed.Although requested, the facility was unable to provide a policy detailing the frequency that physician's orders were to be reviewed.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #6) reviewed for accidents, the facility failed to ensure a complete and accurate clinical record when a physician's order directed Resident #6 was to be on every fifteen (15) minute checks and the checks were not completed but were later documented as completed. The findings include:Resident #6's diagnoses included vascular dementia without behavioral disturbances, alcohol dependence, opioid dependence, generalized anxiety disorder, depressive episodes and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation. The MDS identified Resident #6 had no wandering behaviors.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #6 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, encephalopathy (disease of the brain that alters brain function or structure), a history of Traumatic Brain Injury (TBI), poor impulse control, a history of altercations with another resident, utilized psychoactive drugs, was a fall risk, had a history of alcohol abuse and was at risk for disorientation, confusion, unsteady gait and slurred speech. Interventions included monitoring/documenting/reporting changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, cueing, reorienting and supervising as needed, monitoring for clinical and behavioral changes, maintaining a safe environment and placing the resident on every fifteen (15) minute monitoring. A physician's order dated 1/23/26 directed Resident #6 was on every fifteen (15) minute observations every shift.A nurse's note written by RN #3 on 1/23/26 at 10:04 AM identified Resident #6 expressed a desire to leave the facility and was subsequently placed on every fifteen (15) minute checks.A nurse's note by LPN #2 on 2/25/26 at 1:55 PM identified when she returned to the unit at 1:55 PM the NA (NA #1) and Housekeeper (Housekeeper #1) on the unit notified her that Resident #6 was not in his/her room or on the unit. The note identified she immediately checked the resident's room and unit and a call was placed to the Nursing Supervisor to report the resident was not in his/her room and possibly left the building. All rooms on three (3) units were checked and a call was placed to notify the DON and ADON. The DON was later notified that the resident was located and was headed back to the unit. The note identified the last time she observed the resident was at 1:00 PM. Interview with the DON on 2/27/26 at 12:04 PM identified after watching the camera footage, Resident #6 was seen at 12:36 PM looking around in the hallway to ensure no one was around and then approached the keypad and exited the secured door through the unit stairwell and down 4.5 flights of stairs. She reported the camera at the ambulance entrance did not capture the resident so Resident #6 must have exited through an unsecured door at the bottom of the stairwell onto the sidewalk. The 'every 15-minute check sheet' dated 2/25/26 identified NA #2 signed the sheet every 15- minutes from 7:00 AM through 1:15 PM although Resident #6 was seen on camera exiting the unit via the stairwell at 12:36 PM. The sheet identified Resident #6 was in the hallway at 12:45 PM, 1:00 PM and 1:15 PM when Resident #6 was outside of the facility. Interview with NA #2 on 3/2/26 at 12:35 PM identified although she was not assigned to Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26, and had not completed any 15 minute checks on Resident #6 that shift, the ADON approached her after Resident #6 was unable to be located inside the building and directed her to fill out the sheet although she had not completed the every 15 minute checks for Resident #6. NA #2 reported she knew she should not have documented incorrectly but identified that the ADON demanded that the 'every 15-minute check sheet' was completed and she was afraid she would lose her job if she did not do what was directed. Additionally, she identified she was unsure when Resident #6 had last been seen and estimated the time, which is why she signed off at 12:45 PM, 1:00 PM and 1:15 PM.The February 2026 Documentation Survey Report for Resident #6 identified that NA #3 had documented on Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26.Interview with NA #3 on 3/2/26 at 12:29 PM identified although her initials indicate that she documented on Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26, she did not complete any of the 15 minutes checks on Resident #6 per the plan of care that shift. She identified that she had a very heavy assignment and was busy Interview with LPN #2 on 3/2/26 at 12:44 PM identified she last observed Resident #6 between 12:30 PM and 12:45 PM on 2/25/26, she then went on break. She identified when she returned from her break, NA #1 communicated they were unable to locate Resident #6, so she (LPN #2) notified RN #2 (nursing supervisor) who immediately went to search for Resident #6 outside. LPN #2 identified the ADON went to the unit, and they discovered that the 'every 15-minute check sheet' had not been filled out the entire 7:00 AM to 3:00 PM shift and the ADON told both NA #2 and LPN #2 that they needed to figure out how to complete it. She reported NA #2 was hesitant on filling in the 'every 15-minute check sheet' for Resident #6 but eventually completed it. Interview with the ADON on 3/2/26 at 1:37 PM identified when she was made aware on 2/25/26 that Resident #6 was unable to be located, she went to the unit and discovered the 'every 15 minute check sheet' had not been filled out for Resident #6 for the entire shift so she directed NA #2 and LPN #2 to complete it. The ADON further identified the 'every 15-minute check sheet' should have been filled out at the time of the observation and not completed afterwards.Interview with the DON on 3/2/26 at 1:15 PM identified the clinical record should have been complete and accurate and the every 15 minute checks should have been filled out at the time of the observations and not afterwards. The ADON should not have directed NA #2 and LPN #2 to fill out the 'every 15 minute check sheet' after Resident #6 was unable to be located. The DON reported Resident #6 was off the unit at 12:45 PM, 1:00 PM and 1:15 PM so the documentation was inaccurate on the 'every 15-minute check sheet'.Review of the Documentation in the Medical Record policy (undated) directed, in part, each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Documentation shall be factual, objective and resident centered and false information shall not be documented. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #6) reviewed for a change in condition, the facility failed to notify the provider timely of the resident's change in behavior and cognition resulting in a delay of treatment. The findings include:Resident #6's diagnoses included vascular dementia without behavioral disturbances, alcohol dependence, opioid dependence, generalized anxiety disorder, depressive episodes and chronic pain.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation. Additionally, it identified that the resident had no wandering behaviors.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #6 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, encephalopathy (disease of the brain that alters brain function or structure), a history of Traumatic Brain Injury (TBI), poor impulse control, a history of altercations with another resident, utilized psychoactive drugs, was a fall risk, had a history of alcohol abuse and was at risk for disorientation, confusion, unsteady gait and slurred speech. Interventions included monitoring/documenting/reporting as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, cueing, reorienting and supervising as needed, monitoring for any clinical and behavioral changes, maintaining a safe environment for the resident and placing the resident on every fifteen (15) minute monitoring. A physician's order dated 1/23/26 directed every fifteen (15) minute observations every shift. A nurse's note by RN #3 on 1/23/26 at 10:04 AM identified Resident #6 expressed a desire to leave the facility and was subsequently placed on every fifteen (15) minute checks. A nurse's note by LPN #3 on 1/24/26 at 2:21 PM identified Resident #6 was confused, exit seeking, going into other residents' rooms and attempting to get to the elevator.A nurse's note by LPN #4 on 1/29/26 at 6:36 AM identified exit seeking behaviors and identified Resident #6 stated he/she would leave the facility and not return and further identified Resident #6 did not have on a Wanderguard (a wearable tracking device that triggers an automated security response when a resident at risk for exit seeking approaches an exit door).A psychiatric evaluation and consultation note written by MD #2 on 2/4/26 identified Resident #6 had a functional and cognitive decline that remained evident.Review of the clinical record from 1/23/26 through 2/10/26 failed to identify that a provider had been notified of increased confusion, wandering or exit seeking.A psychiatric APRN note dated 2/11/26 identified he was asked to see the resident after an incident in the dining room where Resident #6 threw something in frustration. The note identified Resident #6 was on every 15-minute checks for exit seeking behavior. No new recommendations were made.A nurse's note by LPN #3 on 2/12/26 at 11:50 PM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A nurse's note by LPN #4 on 2/13/26 at 6:39 AM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A psychiatric APRN note dated 2/13/26 identified she was asked to see Resident #6 for exit seeking behavior, increased confusion and agitation. The note reported education was provided regarding the nature and progression of vascular dementia, however, Resident #6 demonstrated limited insight. The note identified a new order for hydroxyzine 25 milligrams (mg) every twelve (12) hours as needed for anxiety/restlessness.A nurse's note by LPN #3 on 2/17/26 at 12:30 AM identified increased confusion, wandering and trying to get to the elevator.A nurse's note by LPN #5 on 2/17/26 at 6:19 AM identified confusion and wandering the hallways the majority of the shift.A psychiatric APRN note dated 2/20/26 identified she met with Resident #6 to follow-up on medication management. Resident #6 reported confusion at night and staff reported continued confusion, worsening at night, sundowning, wandering and exit-seeking. The note identified evidence of cognitive decline and directed a new order for trazodone 50 mg daily at bedtime for insomnia. A nurse's note by LPN #3 on 2/20/26 at 11:34 PM identified increased confusion, wandering the halls and into other residents' rooms.A nurse's note by LPN #3 on 2/22/26 at 11:08 PM identified wandering and continuously checking the elevator attempting to exit.A nurse's note by LPN #6 on 2/23/26 at 7:40 AM identified confusion, wandering, exit seeking and searching for family members most of the night.A nurse's note by LPN #2 on 2/25/26 at 1:55 PM identified when she returned to the unit at 1:55 PM the NA (NA #1) and Housekeeper (Housekeeper #1) on the unit notified her that Resident #6 was not in his/her room or on the unit. The note identified she immediately checked the resident's room and unit and a call was placed to the Nursing Supervisor to report the resident was not in his/her room and possibly left the building. All rooms on three (3) units were checked and a call was placed to notify the DON and ADON. The DON was later notified that the resident was located and was headed back to the unit. The note identified the last time she observed the resident was at 1:00 PM.Interview with the psychiatric APRN on 2/27/26 at 3:35 PM identified she had not been notified by staff of Resident #6's increased confusion, wandering or exit seeking until 2/13/26. She identified that once she was made aware she evaluated Resident #6 immediately and started him/her on medication to treat anxiety, restlessness and insomnia. She identified that upon interview, Resident #6 communicated he/she was aware of the increased confusion at night and the psychiatric APRN reported that if the facility notified her when the symptoms developed around 1/23/26, she could have treated the resident sooner which could have prevented the incident on 2/25/26 when Resident #6 exited the building unbeknownst by staff.Interview with the Medical Director on 3/2/26 at 10:17 AM identified he was not notified of Resident #6's initial change in cognition. The change in condition was discussed during the interdisciplinary teams weekly 'At Risk' meeting, but he did not believe the increased confusion and behaviors were due to an acute medical issue but more a psychiatric change. He reported a psychiatric provider should have been notified by nursing of the change at the time it was identified so Resident #6 could have been treated for the symptoms immediately. He identified Resident #6 displays poor judgement and if a psychiatric provider had been notified timely, a neuro cognitive evaluation could have been ordered to determine the plan of care.Interview with the DON on 3/2/26 at 9:00 AM identified nursing should have immediately notified the psychiatric APRN when it was identified Resident #6 was increasingly confused, wandering and exit seeking. She reported had the psychiatric APRN been notified timely, Resident #6 could have been treated sooner.Review of the Notification of Changes policy dated 1/18/24 directed, in part, the facility must inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there is a change requiring notification. Circumstances requiring notification include: Significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status, circumstances that require a need to alter treatment and a change in resident rights.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for high-risk medications, the facility failed to ensure a baseline Resident Care Plan (RCP) was developed for a resident receiving a high-risk controlled substance. The findings include:Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for high-risk medications, the facility failed to ensure a baseline Resident Care Plan (RCP) was developed for a resident receiving a high-risk controlled substance. The findings include:Resident #2's diagnoses included long term use of opiate analgesic and wedge compression fracture of the first lumbar vertebrae (the front part of the lower spinal vertebra collapses into a wedge shape due to excessive pressure, causing severe back pain).The admission Evaluation dated 2/3/26 identified Resident #2 was alert and oriented to person, place, time and situation and required limited assistance with transfers and was independent with bed mobility.The Methadone Chain of Custody Record dated 2/4/26 for Resident #2 identified Resident #2 received Methadone 120 mg per mL from 2/5/26 through 2/24/26.A physician's order dated 2/7/26 directed to administer Methadone concentrate 120 mg per mL, give 120 mg orally one time a day for Methadone Maintenance Therapy.Review of the clinical record failed to identify an RCP had been developed for the use of Methadone for Methadone Maintenance Therapy.Interview with the DON on 2/25/26 at 10:40 AM identified Methadone is considered a high-risk medication and an RCP should have been developed prior to Resident #2 receiving the medication. She identified nursing is responsible for initiating the RCP, but the MDS Coordinator is responsible for reviewing the RCPs and should have identified at the 72-hour care plan meeting and while completing the 2/9/26 admission Minimum Data Set (MDS) assessment, that an RCP had not been developed for Methadone use.Interview with the MDS Coordinator (RN #4) on 2/25/26 at 11:07 AM identified Methadone is considered a high-risk medication, and a baseline RCP should have been developed by nursing prior to Resident #2 starting Methadone. She identified a 72-hour care plan meeting was held on 2/5/26 and she was responsible for reviewing the RCPs. She did not realize an RCP had not been developed for the use of Methadone at that time. She reported she was responsible for reviewing the RCP with the MDS assessment dated [DATE], and that although she signed the RCP as complete on 2/16/26, an RCP for Methadone use had still not been developed.Subsequent to surveyor inquiry, an RCP was initiated on 2/24/26 identifying that Resident #2 is at risk for substance use disorder with a history of substance use and utilized Methadone. Interventions included communicating with and complying with the prescribing clinic's contract/needs for continued involvement in the treatment plan.Review of the Baseline Care Plan policy (undated) directed, in part, that the facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will be developed within 48 hours of a resident's admission and include the minimum healthcare information necessary to properly care for a resident including, but not limited to: Initial goals based on admission orders, physician orders, dietary orders, therapy services, social services and PASARR recommendations if applicable. The admitting or supervising nurse on duty shall gather information from the admission physical assessment, hospital transfer information and physician orders. Interventions shall be initiated that address the resident's current needs including: Any health and safety concerns to prevent decline or injury and any special needs. A supervising nurse shall verify within 48 hours that a baseline care plan has been developed.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of three (3) sampled residents (Resident #6 and #7) reviewed for wandering behaviors, the facility failed to ensure a Wander Risk Evaluation was completed according to facility policy. The findings include:1. Resident #6's diagnoses included vascular dementia without behavioral disturbances, alcohol dependence, opioid dependence, generalized anxiety disorder, and depressive episodes.A Wander Risk Evaluation dated 2/4/25 identified Resident #6 was a low risk for wandering.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation. The MDS identified Resident #6 had no wandering behaviors.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #6 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, encephalopathy (disease of the brain that alters brain function or structure), a history of Traumatic Brain Injury (TBI), poor impulse control, a history of altercations with another resident, utilized psychoactive drugs, was a fall risk, had a history of alcohol abuse and was at risk for disorientation, confusion, unsteady gait and slurred speech. Interventions included monitoring/documenting/reporting as needed any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, cueing, reorienting and supervising as needed, monitoring for clinical and behavioral changes, maintaining a safe environment and placing the resident on every fifteen (15) minute monitoring.A nurse's note by RN #3 on 1/23/26 at 10:04 AM identified Resident #6 expressed a desire to leave the facility and was subsequently placed on every fifteen (15) minute checks.Review of the clinical record from 2/5/25 through 2/27/26 failed to identify further Wander Risk Evaluations had been completed for Resident #6.Interview with the DON on 2/27/26 at 12:04 PM identified Wander Risk Evaluations should be completed in entirety at least quarterly and was unable to explain why Resident #7's Wander Risk Evaluation dated 11/12/25 was not completed, why a subsequent Wander Risk Evaluation had not been completed or why Resident #6 had not had a Wander Risk Evaluation completed since 2/4/2025. Additionally, the DON identified that on 1/23/26, when Resident #6 communicated a desire to leave the facility and was subsequently placed on every 15-minute checks, a Wander Risk Evaluation should have been completed by licensed nursing staff.2. Resident #7's diagnoses included dementia without behavioral disturbances, altered mental status and a history of falls.A physician's order dated 5/29/25 directed Resident #7 had a Wanderguard (a wearable tracking device that triggers an automated security response when a resident at risk for exit seeking approaches an exit door) applied to the right wrist and to check placement and function every shift.A Wander Risk Evaluation dated 11/12/25 identified Resident #7 was a low risk for wandering/elopement. The assessment was not completed with only one (1) out of eight (8) questions answered.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #7 had severely impaired cognition, had short-term and long-term memory problems and required supervision assistance for bed mobility and transfers.The Resident Care Plan (RCP) dated 12/22/25 identified Resident #7 was at risk for wandering and/or elopement. Interventions included a Wanderguard was applied to Resident #7's right wrist.Review of the clinical record failed to identify a Wander Risk Evaluation was completed following the 11/12/25 evaluation.Review of the Schedule of Evaluations policy dated 7/22/24 directed, in part, the facility will utilize evaluations and/or other tools to collect and analyze specific data in order to aid facilities in the development of resident-centered care plans. Elopement/Wander Risk evaluations are to be conducted on admission, readmission, quarterly, annually, and with a significant change in condition.Review of the Elopements and Wandering Residents policy (undated) directed, in part, that residents will be assessed for risk of elopement and unsafe wandering upon admission and throughout their stay by the interdisciplinary team.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #2) reviewed for medication administration, the facility failed to ensure a physician's order was in place prior to the resident receiving a high-risk controlled medication. The findings include:Resident #2's diagnoses included long term use of opiate analgesic and wedge compression fracture of the first lumbar vertebrae (the front part of the lower spinal vertebra collapses into a wedge shape due to excessive pressure, causing severe back pain).The admission Evaluation dated 2/3/26 identified Resident #2 was alert and oriented to person, place, time and situation and required limited assistance with transfers and was independent with bed mobility.The Methadone Chain of Custody Record dated 2/4/26 for Resident #2 identified Resident #2 received Methadone 120 mg per mL from 2/5/26 through 2/24/26.A physician's order dated 2/7/26 directed to administer Methadone concentrate 120 mg per mL, give 120 mg orally one time a day for Methadone Maintenance Therapy (after Resident #2 had already received two (2) doses of Methadone).Interview with the DON on 2/25/26 at 10:40 AM identified medications should not be administered without a physician's order and reported she was unaware that Resident #2 did not have a physician's order for the Methadone until 2/7/26, after receiving doses on both 2/5/26 and 2/6/26. She identified the facility utilized the Methadone Chain of Custody Record as the Methadone Administration Record, but a physician's order should have been entered into the electronic medical record.Review of the Residents Receiving Methadone for Opioid Addiction policy dated 7/18/24 directed, in part, the attending physician and pharmacy will be notified of the resident's participation in the Methadone Maintenance program, and an order will be obtained for the resident to self-administer Methadone after successfully completing a self-administration evaluation.Review of the Medication Administration policy (undated) directed, in part, to ensure that the six rights of medication administration are followed to include: right resident, right drug, right dosage, right route, right time and right documentation. Compare medication source with the Medication Administration Record to verify the resident's name medication name, form, dose, route and time.

Based on review of the clinical record, facility documentation, facility policy, observation, and interviews, for one (1) of three (3) residents (Resident #6) reviewed for accidents, the facility failed to provide adequate supervision for a resident who was identified as a fall risk, had a provider documented cognitive decline with ongoing exit-seeking behaviors, and had a provider order directing every fifteen (15) minute safety checks. The facility failed to ensure effective monitoring and environmental safeguards, which resulted in the resident accessing a secured stairwell door without staff awareness, descending approximately 4.5 flights of stairs, and exiting the building to a main roadway and walking approximately 0.5 miles away from the facility without staff knowledge. The findings include: Resident #6's diagnoses included generalized muscle weakness, lack of coordination, chronic pain, polyneuropathy (malfunction of many peripheral nerves throughout the body causing numbness, tingling, burning pain and muscle weakness), vascular dementia without behavioral disturbances, alcohol dependence, opioid dependence, generalized anxiety disorder and depressive episodes.A Fall Risk Evaluation dated 2/23/24 identified Resident #6 was at a moderate risk for falling.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation.A nurse's note dated 1/10/26 at 5:51 AM identified Resident #6 was observed on the floor between two (2) beds and sustained a small contusion (soft tissue injury) under his/her left eye but that no other injuries were observed.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #6 had a history of falls and was at risk for falls related to confusion, unawareness of safety needs, psychoactive drug use, a sedative/hypnotic medication for insomnia, a history of alcohol abuse increasing his/her risk for disorientation, confusion, falls with associated injury, slurred speech and unsteady gait, has impaired cognitive function/dementia or impaired thought processes related to altered mental status, encephalopathy (disease of the brain that alters brain function or structure), a history of Traumatic Brain Injury (TBI), and poor impulse control. Interventions included maintaining a safe environment, anticipating and meeting needs, placing the resident on every fifteen (15) minute monitoring, monitoring for clinical and behavioral changes, monitoring/documenting/reporting changes in cognitive function.The Interdisciplinary Plan Meeting documentation dated 1/22/26 identified Resident #6 was a fall risk.A physician's order dated 1/23/26 directed Resident #6 was on every fifteen (15) minute observations every shift.A nurse's note by RN #3 on 1/23/26 at 10:04 AM identified Resident #6 expressed a desire to leave the facility and was subsequently placed on every fifteen (15) minute checks.A nurse's note written by LPN #3 on 1/24/26 at 2:21 PM identified Resident #6 was confused, exit seeking, going into other residents' rooms and attempting to get to the elevator. A nurse's note written by LPN #4 on 1/29/26 at 6:36 AM identified exit seeking behaviors and identified Resident #6 stated he/she would leave the facility and not return and further identified Resident #6 did not have on a Wanderguard (a wearable tracking device that triggers an automated security response when a resident at risk for exit seeking approaches an exit door). A psychiatric evaluation and consultation note written by the psychiatric physician, MD #2 on 2/4/26 identified Resident #6 had a functional and cognitive decline that remained evident.A psychiatric APRN note dated 2/11/26 identified he was asked to see the resident after an incident in the dining room where Resident #6 threw something in frustration. The note identified Resident #6 was on every 15-minute checks for exit seeking behavior. A nurse's note by LPN #3 on 2/12/26 at 11:50 PM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A nurse's note by LPN #4 on 2/13/26 at 6:39 AM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A psychiatric APRN note dated 2/13/26 identified she was asked to see Resident #6 for exit seeking behavior, increased confusion and agitation. The note reported education was provided regarding the nature and progression of vascular dementia, however, Resident #6 demonstrated limited insight. The note identified a new order for hydroxyzine 25 milligrams (mg) every twelve (12) hours as needed for anxiety/restlessness.A nurse's note by LPN #3 on 2/17/26 at 12:30 AM identified increased confusion, wandering and trying to get to the elevator.A nurse's note by LPN #5 on 2/17/26 at 6:19 AM identified confusion and wandering the hallways the majority of the shift.A psychiatric APRN note dated 2/20/26 identified she met with Resident #6 to follow-up on medication management. Resident #6 reported confusion at night and staff reported continued confusion, worsening at night, sundowning, wandering and exit-seeking. The note identified evidence of cognitive decline and directed a new order for trazodone 50 mg daily at bedtime for insomnia. A nurse's note by LPN #3 on 2/20/26 at 11:34 PM identified increased confusion, wandering the halls and into other residents' rooms.A nurse's note by LPN #3 on 2/22/26 at 11:08 PM identified wandering and continuously checking the elevator attempting to exit.A nurse's note by LPN #6 on 2/23/26 at 7:40 AM identified confusion, wandering, exit seeking and searching for family members most of the night.A nurse's note by LPN #2 on 2/25/26 at 1:55 PM identified when she returned to the unit at 1:55 PM the NA (NA #1) and Housekeeper (Housekeeper #1) on the unit notified her that Resident #6 was not in his/her room or on the unit. The note identified she immediately checked the resident's room and unit and a call was placed to the Nursing Supervisor to report the resident was not in his/her room and possibly left the building. All rooms on three (3) units were checked and a call was placed to notify the DON and ADON. The DON was later notified that the resident was located and was headed back to the unit. The note identified the last time she observed the resident was at 1:00 PM.Observation of the stairwell door on the North-2 unit on 2/27/26 at 12:04 PM identified a pin pad secured door and 4.5 flights of stairs leading to an exit door that led to the street. The exit door was unsecured.Interview with Resident #6 on 2/27/26 at 12:09 PM identified on 2/25/26 he/she was upset with RN #3 because she would not give him/her her badge to open the elevator, so he/she went into the hallway and watched staff at the secured stairwell until he/she was able to see the code entered and when staff were in other rooms, he/she entered the code to the door, and with difficulty went down the stairs, exited a door to the street, and walked into downtown.Interview with RN #3 on 2/27/26 at 12:52 PM identified that since Resident #6's room was changed on 1/8/26, Resident #6 had been searching for a way out of the facility by pacing the hallways, going in and out of other residents' rooms and hovering by the elevator searching for exit doors. She reported that although the resident had been on every 15-minute checks, staff could not constantly have an eye on the resident. She identified that on the morning of 2/25/26, Resident #6 expressed wanting to leave the facility, but she told him/her that he/she could not leave because he/she did not have a Leave of Absence (LOA) order. RN #3 identified Resident #6 appeared to accept her explanation but then several hours later she was notified Resident #6 was unable to be located and she went outside to search for him/her. RN #3 identified Resident #6 was a fall risk and she located him/her about 0.5 miles away from the facility on the sidewalk of a main street and Resident #6 reported he/she wanted to go find women and alcohol. She identified Resident #6 was unharmed and was brought back to the facility without incident but Resident #6 was not safe to be outside in the winter unsupervised, and staff were unaware he/she had exited the building.Interview with the DON on 2/27/26 at 12:04 PM identified after watching the camera footage, Resident #6 was seen at 12:36 PM looking around in the hallway to ensure no one was around and then approached the keypad and exited the secured door through the unit stairwell and down 4.5 flights of stairs. She reported the camera at the ambulance entrance did not capture the resident so Resident #6 must have exited through an unsecured door at the bottom of the stairwell onto the sidewalk. She identified it had snowed earlier in the day, Resident #6 was a fall risk, and it was unsafe for him/her to have gone down the stairwell, outside and walked about 0.5 miles away without staff knowledge. Resident #6 had a physician's order for every 15-minute monitoring for safety. Additionally, she identified the pin pad code remained the same after the incident, as they were unsure how to change it. She indicated Resident #6 had a decline in mentation but no further cognitive testing had been performed. The DNS identified that following the incident, a one-to-one staff observation was initiated and was still in place for safety. Further, she identified that a missing person (Dr. Hunt) code had never been called by staff and due to her not being made aware of the incident until around 2:15 PM, after Resident #6 had already been located, law enforcement was not notified, and the facility's policy was not followed. The 'every 15-minute check sheet' dated 2/25/26 identified NA #2 signed the sheet every 15- minutes from 7:00 AM through 1:15 PM although Resident #6 was seen on camera exiting the unit via the stairwell at 12:36 PM. The sheet identified Resident #6 was in the hallway at 12:45 PM, 1:00 PM and 1:15 PM when Resident #6 was outside of the facility. Interview with NA #2 on 3/2/26 at 12:35 PM identified although she was not assigned to Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26, and had not completed any 15 minute checks on Resident #6 that shift, the ADON approached her after Resident #6 was unable to be located inside the building and directed her to fill out the sheet although she had not completed the every 15 minute checks for Resident #6. NA #2 reported she knew she should not have documented incorrectly but identified that the ADON demanded that the 'every 15-minute check sheet' was completed and she was afraid she would lose her job if she did not do what was directed. Additionally, she identified she was unsure when Resident #6 had last been seen and estimated the time, which is why she signed off at 12:45 PM, 1:00 PM and 1:15 PM.The February 2026 Documentation Survey Report for Resident #6 identified that NA #3 had documented on Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26.Interview with NA #3 on 3/2/26 at 12:29 PM identified although her initials indicate that she documented on Resident #6 on the 7:00 AM to 3:00 PM shift on 2/25/26, she did not complete any of the 15 minutes checks on Resident #6 per the plan of care that shift. She identified that she had a very heavy assignment and was busy and could not recall Resident #6 being on her assignment.Interview with LPN #2 on 3/2/26 at 12:44 PM identified she last observed Resident #6 between 12:30 PM and 12:45 PM on 2/25/26, she then went on break. She identified when she returned from her break, NA #1 communicated they were unable to locate Resident #6, so she (LPN #2) notified RN #2 (nursing supervisor) who immediately went to search for Resident #6 outside. LPN #2 identified the ADON went to the unit, and they discovered that the 'every 15-minute check sheet' had not been filled out the entire 7:00 AM to 3:00 PM shift and the ADON told both NA #2 and LPN #2 that they needed to figure out how to complete it. She reported NA #2 was hesitant on filling in the 'every 15-minute check sheet' for Resident #6 but eventually completed it.Interview with the ADON on 3/2/26 at 1:37 PM identified when she was made aware on 2/25/26 that Resident #6 was unable to be located, she went to the unit and discovered the 'every 15 minute check sheet' had not been filled out for Resident #6 for the entire shift so she directed NA #2 and LPN #2 to complete it. The ADON further identified the 'every 15-minute check sheet' should have been filled out at the time of the observation and not completed afterwards.Re-interview with the DON on 3/2/26 at 9:00 AM and 1:15 identified nursing should have immediately notified the psychiatric APRN when it was identified Resident #6 was increasingly confused, wandering and exit seeking. She reported had the psychiatric APRN been notified timely, Resident #6 could have been treated sooner, interventions could have been put into place, and potentially prevented Resident #6 from exiting the building without staff knowledge on 2/25/26. Additionally, she reported that Resident #6's clinical record should have been complete and accurate and the every 15 minute checks should have been filled out at the time of the observations and not afterwards, nor should the ADON have directed NA #2 and LPN #2 to fill out the 'every 15 minute check sheet' after Resident #6 was unable to be located. The DON reported Resident #6 was off the unit at 12:45 PM, 1:00 PM and 1:15 PM so the documentation was inaccurate on the 'every 15-minute check sheet' and staff should have supervised Resident #6 as directed.Interview with the Medical Director on 3/2/26 at 10:17 AM identified a psychiatric provider should have been notified of Resident #6's change of cognition and increased behaviors at the time they were identified so Resident #6 could have been treated for the symptoms immediately. He identified Resident #6 had poor judgement and his/her LOA order was revoked for returning to the facility intoxicated. He identified that if a psych provider had been notified timely, a neuro cognitive evaluation could have been ordered to determine the plan of care. The Medical Director reported that staff should have ensured Resident #1 was monitored at least every 15-minutes per physician's order for safety and identified Resident #6 was not safe to have descended 4.5 flights of stairs to the sidewalk and walked approximately 0.5 miles into downtown.Review of the Fall Prevention Program Policy directed in part that each resident be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. High Risk protocols include a fall prevention indicator on the door, and interventions including but not limited to assistive devices, increased rounds, a sitter, medication regimen review, low bed, alternate call system, scheduled ambulation, family/caregiver education and therapy services referral.Review of the Documentation in the Medical Record policy (undated) directed, in part, each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate and timely documentation. Documentation shall be factual, objective and resident centered and false information shall not be documented. When documentation occurs after the fact, outside acceptable time limits, the entry shall be clearly indicated as late entry. Although requested, a policy on every 15 minute checks was not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #6) reviewed for wandering behaviors, the facility failed to provide social service support to the resident and failed to obtain a repeated Brief Interview for Mental Status (BIMS) evaluation following a documented change in cognition. The findings include:Resident #6's diagnoses included vascular dementia without behavioral disturbances, alcohol dependence, opioid dependence, generalized anxiety disorder, depressive episodes and chronic pain.A Wander Risk Evaluation dated 2/4/25 identified Resident #6 was a low risk for wandering.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #6 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 12), and was independent with bed mobility, transfers and ambulation. The MDS additionally identified that the resident had no wandering behaviors.The Resident Care Plan (RCP) dated 1/22/26 identified Resident #6 had impaired cognitive function/dementia or impaired thought processes related to altered mental status, encephalopathy (disease of the brain that alters brain function or structure), a history of Traumatic Brain Injury (TBI), poor impulse control, a history of altercations with another resident, utilized psychoactive drugs, was a fall risk, had a history of alcohol abuse and was at risk for disorientation, confusion, unsteady gait and slurred speech. Interventions included monitoring/documenting/reporting changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status, cueing, reorienting and supervising as needed, monitoring for clinical and behavioral changes, maintaining a safe environment and placing the resident on every fifteen (15) minute monitoring.A nurse's note by RN #3 on 1/23/26 at 10:04 AM identified Resident #6 expressed a desire to leave the facility and was subsequently placed on every fifteen (15) minute checks.A nurse's note by LPN #3 on 1/24/26 at 2:21 PM identified Resident #6 was confused, exit seeking, going into other residents' rooms and attempting to get to the elevator.A nurse's note by LPN #4 on 1/29/26 at 6:36 AM identified exit seeking behaviors and identified Resident #6 stated he/she would leave the facility and not return and further identified Resident #6 did not have on a Wanderguard (a wearable tracking device that triggers an automated security response when a resident at risk for exit seeking approaches an exit door).A psychiatric evaluation and consultation note written by MD #2 on 2/4/26 identified Resident #6 had a functional and cognitive decline that remained evident.A psychiatric APRN note dated 2/11/26 identified he was asked to see the resident after an incident in the dining room where Resident #6 threw something in frustration. The note identified Resident #6 was on every 15-minute checks for exit seeking behavior. No new recommendations were made.A nurse's note by LPN #3 on 2/12/26 at 11:50 PM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A nurse's note by LPN #4 on 2/13/26 at 6:39 AM identified increased confusion, wandering, looking for family members, attempting to enter the elevator and exit seeking behaviors.A psychiatric APRN note dated 2/13/26 identified she was asked to see Resident #6 for exit seeking behavior, increased confusion and agitation. The note reported education was provided regarding the nature and progression of vascular dementia, however, Resident #6 demonstrated limited insight. The note identified a new order for hydroxyzine 25 milligrams (mg) every twelve (12) hours as needed for anxiety/restlessness.A nurse's note by LPN #3 on 2/17/26 at 12:30 AM identified increased confusion, wandering and trying to get to the elevator.A nurse's note by LPN #5 on 2/17/26 at 6:19 AM identified confusion and wandering the hallways the majority of the shift.A psychiatric APRN note dated 2/20/26 identified she met with Resident #6 to follow-up on medication management. Resident #6 reported confusion at night and staff reported continued confusion, worsening at night, sundowning, wandering and exit-seeking. The note identified evidence of cognitive decline and directed a new order for trazodone 50 mg daily at bedtime for insomnia. A nurse's note by LPN #3 on 2/20/26 at 11:34 PM identified increased confusion, wandering the halls and into other residents' rooms.A nurse's note by LPN #3 on 2/22/26 at 11:08 PM identified wandering and continuously checking the elevator attempting to exit.A nurse's note by LPN #6 on 2/23/26 at 7:40 AM identified confusion, wandering, exit seeking and searching for family members most of the night.A nurse's note by LPN #2 on 2/25/26 at 1:55 PM identified when she returned to the unit at 1:55 PM the NA (NA #1) and Housekeeper (Housekeeper #1) on the unit notified her that Resident #6 was not in his/her room or on the unit. The note identified she immediately checked the resident's room and unit and a call was placed to the Nursing Supervisor to report the resident was not in his/her room and possibly left the building. All rooms on three (3) units were checked and a call was placed to notify the DON and ADON. The DON was later notified that the resident was located and was headed back to the unit. The note identified the last time she observed the resident was at 1:00 PM. Review of the clinical record from 1/23/26 through 2/25/26 failed to identify social services had met with or assessed Resident #6 following the 1/23/26 change in cognition.Review of the clinical record from 1/23/26 through 3/1/26 failed to identify a repeat BIMS had been completed for Resident #6.Interview with the Director of Social Services on 3/2/26 at 11:47 AM identified he was aware Resident #6 had a decline in cognition and had been increasingly confused and wandering the unit since January 2026. He identified he did not meet with Resident #6 or reassess his/her BIMS as required with a change in cognition.Interview with the DON on 3/2/26 at 9:00 AM identified social services should have met with and evaluated Resident #6 as soon as it was determined there was a change in behavior and/or cognition and that with any change in cognition, a repeat BIMS evaluation should be completed.Review of the Dementia Care policy directed, in part, it is the policy of the facility to provide the appropriate treatment and services to every resident who displays signs of, or is diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being. The care plan goals and interventions will be monitored on an ongoing basis for effectiveness and will be reviewed and revised as necessary. Appropriate referrals will be made if current interventions are ineffective or resident shows a decline in psychosocial, mood or behavioral status (i.e. physician, mental health provider, licensed counselor, pharmacist, social worker).Although requested policies on change in cognition and BIMS evaluations were not available.

Based on review of the clinical record, facility documentation, facility policy and interviews for two (2) of five (5) residents (Resident #1 and Resident #2) reviewed for medication administration, the facility failed to ensure self-administration of medication evaluations were completed by licensed nursing staff prior to the residents self-administering the first dose of a controlled substance according to facility policy. The findings include:1. Resident #1's diagnoses included opioid dependence, adjustment disorder and anxiety disorder.The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had moderately impaired cognition (Brief Interview for Mental Status (BIMS) score of 10) and was independent with Activities of Daily Living (ADLs), bed mobility, transfers and ambulation.The Resident Care Plan (RCP) dated 12/08/25 identified Resident #1 was at increased risk for pain due to a history of substance use disorder (SUD) and utilized Methadone for treatment. Interventions included anticipating the resident's need for pain relief and responding immediately to complaints of pain, monitoring/recording/reporting to the licensed nurse complaints of pain or request for pain treatment and communicating and complying with the facility's contracted agency for the resident's continued involvement in the treatment plan.A. Review of the clinical record identified Resident #1 was discharged to the hospital on 2/11/26 and readmitted to the facility on [DATE].A physician's order dated 2/13/26 directed to administer Methadone concentrate 10 milligrams (mg) per milliliter (mL), give 10 mg by mouth one time a day for Methadone Maintenance Therapy and Resident #1 was approved for supervised self-administration.The Methadone Chain of Custody Record dated 2/14/26 identified Resident #1 received Methadone 10 mg per mL from 2/14/26 through 2/18/26.A nurse's note by RN #1 dated 2/19/26 at 7:09 AM identified at approximately 6:10 AM, while administering morning medications, she inadvertently selected the wrong bottle of Methadone for Resident #1. Resident #1 received Methadone 120 mg by mouth rather than the prescribed 10 mg dose. The APRN was notified immediately of the error, and an order was received to transfer Resident #1 to the Emergency Department (ED) for evaluation and monitoring due to significant overdose risk.Review of the clinical record identified that a Medication Self-Administration Evaluation had not been completed since 7/18/25.B. Review of the clinical record identified Resident #1 was discharged to the hospital on 2/19/26 and readmitted to the facility on [DATE].The Methadone Chain of Custody Record dated 2/22/26 for Resident #1 identified Resident #1 received Methadone 10 mg per mL on 2/23/26 and 2/24/26.A Medication Self-Administration Evaluation was completed on 2/24/26 at 11:38 AM (2 days after readmission and after 2 doses had already been received) indicating Resident #1 may self-administer medications with supervision. 2. Resident #2's diagnoses included long term use of opiate analgesic and wedge compression fracture of the first lumbar vertebrae (the front part of the lower spinal vertebra collapses into a wedge shape due to excessive pressure, causing severe back pain).The admission Evaluation dated 2/3/26 identified Resident #2 was alert and oriented to person, place, time and situation and required limited assistance with transfers and was independent with bed mobility.The Methadone Chain of Custody Record dated 2/4/26 for Resident #2 identified Resident #2 received Methadone 120 mg per mL from 2/5/26 through 2/24/26.A physician's order dated 2/7/26 directed to administer Methadone concentrate 120 mg per mL, give 120 mg orally one time a day for Methadone Maintenance Therapy and noted Resident #2 was approved for supervised self-administration.Review of the clinical record failed to identify a Medication Self-Administration Evaluation had been completed until 2/24/26 at 12:40 PM (20 days after starting on Methadone and after 20 doses had already been received).The Resident Care Plan (RCP) dated 2/24/26 identified Resident #2 is at risk for substance use disorder (SUD) with a history of substance use and utilized Methadone. Interventions included communicating with and complying with the prescribing clinic's contract/needs for continued involvement in the treatment plan.Interview and clinical record review with the DON on 2/25/26 at 10:40 AM identified the Medication Self-Administration Evaluation is to be completed on admission and readmission to the facility for all residents on Methadone and upon initiation of all new Methadone orders. She reported residents on Methadone must be able to self-administer the medication and identified that the Medication Self-Administration Evaluation should have been completed prior to any resident self-administering the medication. The DON identified the Medication Self-Administration Evaluation should have been completed for Resident #1 on both the 2/13/26 and 2/22/26 readmissions to the facility and for Resident #2 on 2/8/26 when the Methadone was first initiated. She identified that it is the responsibility of either the charge nurse or the nursing supervisor to ensure the evaluation is completed when the Methadone order is entered.Review of the Residents Receiving Methadone for Opioid Addiction policy dated 7/18/24 directed, in part, an order will be obtained for the resident to self-administer Methadone after successfully completing a self-administration evaluation. Prior to the first administration of Methadone, a Methadone self-administration evaluation will be completed.Review of the Self Medication policy (undated) directed, in part, that a resident must be physically capable of handling medication containers, including the opening and closing of the container, using locked storage boxes and pouring the dose. A resident must be able to communicate clearly with nursing staff regarding administration problems, errors and cooperate with monitoring and accountability practices. Residents must be cognitively capable of understanding administration directions and of accepting responsibility for protocol implementation. Upon admission and periodically, each resident is assessed by interdisciplinary team members for capacity to participate in the self-medication program. If the resident is deemed a candidate for self-medication, and should the resident wish to participate, a physician's order for self-medication will be maintained and will include the drug name, dose, frequency, route and self-medication approval.Review of the Schedule of Evaluations policy dated 7/22/24 directed, in part, for all residents at the time of admission, at the time a resident desires to exercise their right to self-administer their medications, quarterly, annually and change in condition for any resident who wishes to self-administer their medication or when there is a change in his/her ability to safely self-administer.

Based on review of the clinical records, interviews, facility documentation and facility policy for 1 of 3 (Resident #68) sampled residents reviewed for bowel and bladder, the facility failed to ensure Resident #68 was assessed by a Registered Nurse (RN) when bleeding was experienced. Resident #68 was admitted to the facility in October 2024 with diagnoses that included schizoaffective disorder, overactive bladder with incontinence, and urinary tract infections.The quarterly Minimum Data Set assessment dated [DATE] identified Resident #68 was cognitively intact and required supervision/set up for activities of daily living including toileting. The Resident Care Plan dated 11/7/25 identified Resident #68 had episodes of incontinence and required assistance with toileting. Interventions included to provide adult briefs as needed, assistance with toileting, clean peri area with each incontinence episode, notify of changes of decline in incontinence and refer to therapy as needed. Interview with Resident #68 on 12/2/25 at 10:58 AM identified that Resident #68's menstrual cycle had restarted after not experiencing a menses for many years and was experiencing bleeding. Resident #68 indicated that it was reported to the nursing staff, but he/she could not recall when it was reported. Interview with LPN #2 on 12/2/25 at 11:00 AM indicated that she was made aware from shift to shift nursing report on 12/2/25 that Resident #68 had reported bleeding, but she had not checked Resident #68 for any bleeding. LPN #2 indicated that she told Resident #68 we can look later if you go to the bathroom. Interview and review of facility documentation with LPN #2 on 12/3/25 at 9:30 AM noted that she had not checked Resident #68 for any bleeding on 12/2/25 because Resident #68 had not called her when he/she went to use the bathroom. The Advanced Practice Registered Nurse (APRN) #1's concern binder revealed that Resident #68 bleeding issue had been entered into the log on 12/2/25 but failed to identify the time and person who entered the concern in the log. According to LPN #2 on 12/3/25 at 9:30 AM she was unaware if APRN #1 had assessed Resident #68 on his visit on 12/2/25.Nursing notes from 12/1/25 through 12/3/25 failed to reflect an RN assessed Resident #68 for bleeding (total of 5 nursing notes with no RN assessment) and there was no documentation that the peri-area or adult brief was observed by the LPN. Furthermore, there was no documentation that APRN #1 had assessed Resident #68 on 12/2/25. Interview and review of the clinical record with the DNS on 12/3/25 at 10:30 AM failed to reflect an RN assessment note from 12/1/25 through 12/3/25. Nursing notes revealed that Resident #68's the Nurse Aide (NA) reported blood on Resident #68's brief on 12/1/25 on the 3:00 PM to 11:00 PM shift. The nursing note lacked an evaluation of the peri area by the LPN and failed to identify the LPN reported the bleeding to the RN or RN supervisor. The DNS indicated that an RN assessment and nursing note should have been completed when Resident #68 reported bleeding. Furthermore, the DNS indicated that the LPN should have evaluated the area. The DNS was unsure of the reason there was not an RN assessment documented for Resident #68 as it was standard of practice for the RN to assess and document any changes of condition.Interview with APRN #1 on 12/3/25 at 10:45 AM revealed that he had not checked Resident #68 on 12/2/25 because he could not locate the resident. APRN #1 indicated that an RN assessment should have occurred and been documented in Resident #68's clinical record. In addition, APRN #1 stated that licensed nursing staff should be checking Resident #68 for any bleeding in the peri-area. Subsequent to surveyor inquiry, a physician's order dated 12/3/25 by APRN #1 directed to monitor Resident #68 for bleeding for 3 days. If bleeding was observed, ensure RN visually evaluated and report results to provider (order initiated 3 days after initial report of bleeding).Although a policy on RN assessment was requested, the facility was unable to provide a policy.The Documentation in Medical Record Policy dated 1/18/2024 directed, in part, that each resident's medical record shall contain an accurate representation of the actual experience of the resident. Licensed staff shall document all assessments, observations, and services in the medical record.

Based on observations, review of facility documentation, facility policy and interviews for 1 of 2 residents (Resident #3) reviewed for activities of daily living (ADL's), the facility failed to provide nail care for a resident with a hand contracture. The findings include: Resident #3 diagnoses included hemiplegia (paralysis) and hemiparesis (weakness) following a cerebral infarction (stroke) affecting the left non-dominant side, pain in the left arm and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #3 was severely cognitively impaired and dependent with toileting, bed mobility and transfers. The MDS also indicated Resident #3 had an upper and lower extremity impairment on one side. The Resident Care Plan (RCP) dated 10/17/25 identified Resident #3 had an alteration in musculoskeletal status and a history of a cerebral vascular accident (stroke). The RCP included an ADL self-care performance deficit with interventions that included application of a left-hand contracture splint and keeping fingernails short. The Nurse Aide (NA) Assignment sheet (a pre-printed assignment given to the NA) directed Resident #3's shower days were Monday and Thursday on the 3:00 PM to 11:00 PM shift. The NA care card (Individualized Resident Assignment posted in the resident's closet) for Resident #3 directed shower days as Monday and Thursday on the 3:00PM to 11:00PM shift. Observation and interview with Physical Therapist (PT) #1 on 12/4/25 at 10:27 AM identified Resident #3's left hand fingernails were untrimmed, lengthy, and pressing into the palm of the resident's hand. PT#1 indicated Resident #3 had a left-hand contracture with hemiparesis and due to that his/her nails should be kept trimmed and short or they could dig into the residents' skin and compromise the skin integrity. PT #1 noted Resident #3's fingernails on the right hand were trimmed and short and proceeded to assist Resident #3 with opening his/her left-hand contracture and observed inside the palm of the resident's hand was a small amount of yellow, brownish debris with intact skin. PT #1 identified it was the responsibility of the nursing staff to regularly maintain and trim Resident #3's fingernails and that she would let the nurse know to trim them. Interview and observation with NA #5 on 12/4/25 at 11:01 PM identified although Resident #3's fingernails on the right hand were trimmed and short the left-hand fingernails were untrimmed and lengthy. NA #5 indicated the residents left hand fingernails should not be that way because nails that long can cut into the skin with the hand like that. NA #5 identified she was unsure about trimming resident's fingernails because she had not received any training on it and was not sure where to find nail clippers. NA #5 indicated she would need to check with the nurse and ask her to trim them. Interview and observation on 12/4/25 at 11:07 AM with LPN #6 identified although Resident #3's fingernails on the right hand were trimmed and short, the left-hand fingernails were untrimmed and lengthy. LPN #6 indicated Resident #3's left hand fingernails should not be that way because with the hand contracted the fingernails can start digging into the skin. LPN #6 identified it was the responsibility of the nurse or NA to keep the resident's fingernails trimmed and short and she would attempt to trim them now. Interview and observation on 12/4/25 at 11:08 AM with RN #1 identified a resident's fingernails should be trimmed by the NA on shower days, as needed or requested by the resident. RN #1 indicated Resident #3's fingernails on his/her left hand were too long, should have been trimmed and kept short, especially because of the resident's contracture and risk to his/her skin integrity. RN #1 identified she was not sure of the reason Resident #3's left-hand fingernails were not trimmed but she would get them trimmed. Another interview with RN #1 on 12/4/25 at 1:00 PM indicated she attempted to trim Resident #3's fingernails on the left hand earlier and the resident refused. RN #1 indicated she would reapproach the resident after lunch and trim the fingernails of his/her left hand. Interview with NA #8 on 12/5/25 at 10:06 PM identified she was assigned Resident #3 on the 3:00 PM to 11:00 PM shift on 12/1/25 (which would have been Resident #3's shower day) but was not aware the resident was scheduled for a shower that evening. NA #8 indicated although she missed giving the resident a shower, she did wash Resident #3's hands and checked his/her fingernails but did not trim them. NA #8 identified it was her responsibility to shower the resident and trim fingernails on shower days but had made a mistake and did not notice that Resident #3's shower was listed on her assignment. Interview with the DNS 12/5/25 at 10:30 AM identified Resident #3's fingernails should have been trimmed if needed on shower days and if a shower was not done the resident should still have had his/her fingernails trimmed. The DNS indicated the NA was responsible for showers and nail trimming and nursing should have made sure that showers were being done. The DNS identified she would need to meet with the nursing staff to go over the shower schedule and review nail care of the residents. A subsequent observation on 12/5/25 at 11:00 AM identified Resident #3 was seated in a wheelchair with his/her left-hand contracture splint in place and his/her left-hand fingernails were trimmed and short.Review of the facility policy, Activities of Daily Living (ADL's), undated, directed care and services will be provided for grooming and a resident who is unable to carry out activities of daily living will receive the necessary services to maintain good grooming and personal hygiene.

Based on the clinical record, observation, interviews and facility policy for 1 of 5 sampled residents (Resident #101) reviewed for medication administration, the facility failed to follow physician's orders to perform mouth checks every shift after medication administration. The findings included: Resident #101 was admitted in September 2023 with diagnoses that included dementia, psychosis, and anxiety disorder. The annual Minimum Data Set assessment dated [DATE] identified that Resident #101 was severely cognitively impaired, with a short/long term memory problem. Resident #101 required minimum assistance with activities of daily living, ambulated independently and was able to self-feed. Physician orders dated 9/10/25 directed to administer Fluvoxamine (medication for obsessive compulsive disorder) 150 mg (milligrams), give (3) 50 mg tabs for hoarding tendencies at bedtime.The Resident Care Plan dated 9/20/25 identified Resident #101 was at risk for exhibiting non-compliance with activities of daily living. Interventions included allowing the resident to make decisions related to daily care, educate on the importance of compliance with daily care, re-approach when refusing care, offer bed bath if refuses shower and allow time to express feelings and concerns. Observation on 12/1/25 at 10:00 AM with LPN #1 identified a Fluvoxamine 50 mg tab on the floor by Resident #101's bedside chair near the window. LPN #1 was unable to explain what night the medication may not have been administered. LPN #1 notified the supervisor immediately regarding the medication being found on the floor of Resident #101's room. Subsequent to finding medication on the floor in Resident #101's room, a new physician's order was obtained on 12/1/25 to perform mouth checks every shift after medication administration.Observation of LPN #2 administering medications to Resident #101 on 12/3/25 at 8:33 AM noted a mouth check was not conducted after medications were administered. LPN #1 stated in an interview on 12/3/25 at 9:00 AM that she was made aware from the nursing shift report on 12/3/25 that there was a new order for mouth checks to be performed. LPN #2 indicated that she should have asked Resident #101 to open his/her mouth and move his/her tongue to ensure Resident #101 had swallowed all of his/her medications. LPN #2 acknowledged that she did not ask Resident #101 to open his/her mouth to ensure medication was swallowed check and was unable to explain the reason she did not follow this procedure. The Medication Administration Record (MAR) dated 12/3/25 indicated that LPN #2 signed off that a mouth check was performed on Resident #101 on the 7:00 AM to 3:00 PM shift (despite observations noting a mouth check was not completed after medication administration).Interview with the DNS on 12/3/25 at 10:30 AM identified that LPN #2 should have followed physician's orders and performed a mouth check by having Resident #101 open his/her mouth and inspect it to ensure there was no pocketing of medications in the mouth. The DNS was unaware if there was a facility policy on performing a mouth check.Although requested, the facility did not have a policy on conducting mouth checks after medication administration.

Based on observations, review of the clinical record, facility documentation, facility policy and interviews for the only sampled residents (Resident #3) reviewed for positioning and mobility, the facility failed to apply left upper and lower extremity splints per the physician's order, for a resident with contractures. The findings include: Resident #3 diagnoses hemiplegia (paralysis) and hemiparesis (weakness) following cerebral infarction (stroke) affecting the left non-dominant side, pain in the left arm and muscle weakness. The quarterly Minimum Data Set (MDS) assessment dated [DATE], identified Resident #3 was severely cognitively impaired and dependent with toileting, bed mobility and transfers. The MDS indicated Resident #3 had an upper and lower extremity impairment on one side but failed to indicate the use of orthotics. A physician's order dated 10/16/25 directed a left-hand splint application schedule of on after AM care and off after PM care daily. The Resident Care Plan (RCP) dated 10/17/25 identified Resident #3 had an alteration in musculoskeletal status related to a contracture of the left leg and a history of a cerebral vascular accident (stroke). The RCP indicated a potential impairment to skin integrity related to decreased mobility. Interventions included a left knee orthotic splint and a left-hand splint both to be put on after AM care and taken off after PM care daily. An Occupational Therapy (OT) Discharge summary dated [DATE] identified Resident #3 remained compliant with wearing prescribed left hand Leeder grip splint (resting hand splint) as part of an ongoing tone management and joint protection program and staff were educated on the purpose of the splint, donning/doffing (application and removal) techniques and signs and symptoms to monitor with no issues reported at that time. A physician's order dated 10/22/25 directed a left knee orthotic application schedule of on after AM care and off after PM care daily. A Physical Therapy (PT) Discharge summary dated [DATE] directed discharge recommendations of splinting with the left knee orthotic had been handed to nursing who will continue to monitor. Observations on 12/1/25 at 12:40 PM, 12/2/25 at 12:00 PM and 12/3/25 at 12:30 PM noted Resident #3 without the benefit of the left hand and the left leg splint in place. Observation, interview, and review of the clinical record with LPN #5 on 12/3/25 at 1:01 PM identified Resident #3 was in bed and without the benefit of his/her left-hand splint or left leg splint on. LPN #5 indicated Resident #3 should have had both splints in place and the Nurse Aide (NA) should have checked the care plan, but the NA was from a nursing agency. LPN #5 identified Resident #3 did not refuse application of the splints and proceeded to put the splints on for the resident. Review of the Treatment Administration Record (TAR) with LPN #5 on 12/3/25 at 1:01 PM identified although she had signed for application of the left arm splint and left knee splint she had made a mistake and failed to ensure the splints had been put on Resident #3 as ordered prior to signing off on the TAR. Interview, observation, and review of facility documents with NA #7 on 12/3/25 at 1:03 PM identified although his assignment indicated placement of a left arm splint and a left leg splint for Resident #3, he failed to put the splints on during AM care because LPN #5 did not tell him to put them on. NA #7 indicated he did not check the NA care card (Individualized Resident Assignment) for Resident #3 and failed to notice the splint photos and directions (which were on the resident's closet with the NA care card) when he provided AM care. NA #7 proceeded to observe LPN #5 while she applied Resident #3's left arm and left leg splint. Review of the NA care card with NA #7 indicated placement of both a left arm and left leg splint for Resident #3 to be put on in the AM and off in the PM. Interview, observation, and review of facility documents with the Director of Rehab (PT #1) on 12/4/25 at 10:27 AM identified Resident #3 was seated in a wheelchair in the dining room with the left arm and left leg splints in place. PT #1 indicated both splints were needed for the residents left hand and left leg contractures and if the resident did not have the splints applied as ordered (daily after AM care), his/her contractures would worsen. PT #1 identified she had provided education to the nursing staff for the left arm and left leg splints for Resident #3 and posted the splint photos and directions for the staff inside of the resident's closet (below the NA care card). PT #1 indicated the resident did not refuse application of the splints and she was going to provide further education to the nursing staff to ensure the splints were being applied daily after AM care as ordered. Interview with the DNS on 12/5/25 at 10:30 AM identified it was the responsibility of the nursing staff to donn (put on) and doff (take off) Resident #3's left arm and left leg splints daily as ordered. The DNS indicated if the NA failed to put the splints on, it would have been the responsibility of the charge nurse to ensure the splints were in place before signing the TAR. The DNS was unsure why the splints were not being applied and indicated she would need to speak to the charge nurse and provide further education for the nursing staff. Review of the facility policy, Contracture Management and Prevention Program, dated 8/26/25, directed it is the policy of the facility that the nursing and rehabilitation departments provide the necessary care and services for the prevention and management of contractures by use of positioning devices, splints, braces. When a positioning device is assessed as appropriate rehab will issue the device with a wearing schedule and daily application of the assistive devices can be applied by either rehab or nursing.

Based on interviews, review of clinical records, review of documentation, and facility policy for 1 of 8 sampled residents (Resident #58) reviewed for abuse, the facility failed to protect the residents' right to be free from verbal abuse. The findings include:Resident #58's diagnoses included fracture of the left arm humerus, fracture of the left femur, displaced fracture of the right tibia, and acute pain due to trauma. Review of a Grievance form dated 7/1/2025 (written in response to an allegation that occurred on 6/28/2025) identified Resident #58 had reported to the facility that a staff member referred to him/her as the N-word. The Grievance form further identified that the facility made him/her aware that the incident was under investigation and the facility would adhere to the facility policy. The grievance form stated that the staff member was educated but continued to demonstrate an inability to adhere to policies, exhibited insubordination, and was non-compliant. Additionally, the staff member lacked adequate customer service skills, and, as a result, their employment was terminated. (later identified that NA #6 was not terminated as an employee but made a Do Not Return to the facility from the staffing agency). The Grievance form was signed by the facility's Administrator on 7/4/2025. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #58 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, did not experience episodes of delusions or verbal behavioral symptoms towards others, and was dependent for his/her personal hygiene and rolling left and right in bed.The Resident Care Plan (RCP) in effect from 5/15/2025 through 7/20/2025 identified Resident #58 required assistance with activities of daily living and had a history of refusing care and medications. Interventions included encouraging the resident to participate in his/her care and praising all efforts at self-care. The RCP failed to include any allegation of verbal abuse.Interview on 7/16/2025 at 10:03 AM with Resident #58 identified on 6/28/2025 Nurse Aide (NA) #6 called her a F***ing N-word and he/she reported feeling abused to a Social Worker (SW). Resident #58 further identified since the incident of verbal abuse he/she had difficulty sleeping due to being afraid of retaliation by other staff for reporting the abuse, and he/she was not sure what people will do these days.Review of nursing notes for June 2025 and July 2025 failed to identify any documentation in Resident #58's Electronic Medical Record (EMR) or in the paper chart, that there was an allegation of verbal abuse that had occurred on 6/28/2025. Review of physician notes for June 2025 and July 2025 failed to identify any documentation of Resident #58's allegation of verbal abuse or that any verbal altercation had occurred or been reported for the grievance dated 6/28/2025. Review of social service notes written by Social Worker (SW) #3 identified that wellness checks had been performed with Resident #58 on 6/30/2025 and 7/1/2025. The notes indicated he/she was in a good mood, was alert and oriented, and that SW would continue to conduct 1:1 visits as needed. The notes failed to identify the reason wellness checks were being conducted with Resident #58. Review of a Psychiatric Advanced Practice Registered Nurse (APRN) note dated 6/30/2025 identified that Resident #58 was seen for a previous allegation of verbal abuse (called a bitch) which occurred on 5/16/2025. Although the APRN had seen Resident #58 for the previous allegation, the note failed to address the grievance dated 6/28/2025 (2 days prior to the visit). The APRN note indicated that during the 6/30/2025 visit, Resident #58 was alert, pleasant, and engaging. The resident presented in good spirits, no agitation or restlessness was noted and Resident #58 denied a depressed mood or anxiety.Interview on 7/18/2025 at 9:50 AM with Social Worker (SW) #1 identified that he was made aware through a daily report that a staff member used the N-word directed toward Resident #58 but did not indicate on what date. SW #3 collected information on the incident but did not perform an investigation into the allegation nor was he a part of the investigation, stating it was the Nursing Department's responsibility to conduct any investigation. SW #1 indicated that social work did perform wellness checks on Resident #58 as use of the N-word could cause pain and he wanted to be certain the resident was safe. SW #1 failed to document the details of the wellness check within the EMR or paper chart. SW #1 stated he did not report the incident of abuse to administration because they were already aware. Interview on 7/18/2025 at 10:23 AM with SW #3 identified that Resident #58 notified her during rounds, on the day after the incident (6/29/2025) that a Nurse Aide (NA) called him/her the N-word, that the racial slur made him/her feel uncomfortable, and he/she requested not to receive care from that NA going forward. SW #3 stated she notified her supervisor (SW #1) and the DNS of the allegation of abuse, and she was not involved with completing an investigation as the DNS and her supervisor (SW #1) were responsible for investigations. Interview on 7/18/2025 at 10:33 AM with the Director of Nursing Services (DNS) identified that she was made aware of the abuse allegation, by a social worker, that Resident #58 was called the N-word, but failed to identify the date or social worker's name. Subsequently, a team meeting was held and it was decided to place NA #6 on the Do Not Return. The DNS stated that she did not conduct an investigation and believed that social work had completed the investigation. The DNS further identified that the incident of abuse was documented as a grievance and not reported to the State Agency (SA) per a directive from the facility Administrator. The DNS stated that the NA calling Resident #58 the N-word constituted verbal abuse.An interview and review of Resident #58's grievance form on 7/18/2025 at 11:15 AM with the Administrator identified that he was notified of the allegation of verbal abuse towards Resident #58 by SW #1. Further, he identified he signed the Grievance form, and he believed the use of the N-word was said in Resident #58's presence but was not said directly to him/her. The Administrator disagreed that a NA referring to a resident as a f***ing N-word in the presence of that resident was an allegation of verbal abuse. According to the grievance form, the Administrator, Social Services and Nursing Departments were made aware of the allegation on 7/1/2025, and the Administrator did recall that he had signed the form. During an interview on 7/21/2025 at 12:36 PM with NA #6, she stated she was falsely accused of calling Resident #58 the N-word. NA #6 further identified she called Resident #58 mean and stated the resident was throwing small sized things at her. She indicated the incident with Resident #58 was witnessed by Registered Nurse (RN) #9. Further NA #6 indicated that after speaking with the DNS, the DNS indicated she could continue to work at the facility but not be assigned to Resident #58's unit.Interview on 7/22/2025 at 1:40 PM with the nurse scheduler identified that NA #6 was placed on the Do Not Return list because she called Resident #58 the N-word. The Nurse Scheduler further identified it was either social service or the DNS who provided her with the reason for placing NA #6 on the Do Not Return list.Interview on 7/22/2025 at 1:40 PM with Person #1 from NA #6's staffing agency identified the facility informed him/her that NA #6 had called a resident the N-word and she was placed on a Do Not Return List. Person #1, however, stated that NA #6 continued to work at the facility after the incident even though she was told by Person #1 not to go back to the facility.Interview on 7/23/2025 at 10:12 AM with RN #9 identified he was not present and did not witness NA #6's interaction of verbal abuse involving Resident #58 and did not witness Resident #58 throw anything at NA #6.Review of the facility's Abuse, Neglect, and Exploitation policy identified, in part, that 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 definition of abuse was indicated as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff-to- resident abuse. Abuse also includes the deprivation by any individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective an any mental or physical condition, cause physical harm, pain, or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on observation, review of the clinical record, facility policy, and interviews for 1 of 8 sampled residents (Resident #3) reviewed for abuse, the facility failed to ensure a resident was not involuntarily secluded and had access to all facility locations. The findings include:Resident #3's diagnoses included encounter for orthopedic aftercare (cervical laminectomy), type 2 diabetes, and schizoaffective disorder bipolar type.Observation and interview on 7/16/2025 at 12:38 PM identified that Resident #3 was not visible from the doorway. He/she was observed behind a privacy curtain, lacked any engaging activities such as television, radio, or personal activity, and lay in bed silently. Resident #3 stated he/she wanted to go outside but was told by staff that he/she could not leave the floor without a staff member and most times there was no staff to assist with outdoor privileges. Further, Resident #3 stated he/she was told he/she could only go outside when the smokers went out, but he/she did not smoke, and was upset due to seeing other residents leave the floor during non-smoking times when he she could not, stating It's not fair. Resident #3 indicated that he/she felt stuck on his/her unit and that it was like being in prison. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #3 had a Brief Interview of Mental Status (BIMS) score of 15 indicating intact cognition, did not exhibit the behavior of wandering, required substantial assistance with chair/bed-to-chair transfers, and was independent in wheeling 50 feet with 2 turns in a manual wheelchair.The Resident Care Plan (RCP) in effect 3/13/2025 through 7/22/2025 identified Resident #3 preferred to pursue independent leisure activities as he/she was at the facility for short term rehab. Interventions included encourage independent leisure activities, and assist the resident as needed/requested by facilitating self-directed activities of interest.Interview on 7/22/2025 at 12:01 PM with Licensed Practical Nurse (LPN) #7 and Advanced Practice Registered Nurse (APRN) #1 identified that LPN #7 has never let Resident #3 off the floor nor has she ever seen him/her leave the floor as there were no Leave of Absence (LOA) orders in place that would allow him/her to leave the floor. APRN #1 identified that he was responsible for evaluating residents for LOA orders and he had not placed any orders for Resident #3 to leave the floor. Further he indicated the reason Resident #3 had no LOA privileges was because his/her conservator did not want him/her outside or leaving the building.Interview on 7/22/2025 at 12:07 PM with Person #2 (Resident #3's conservator) identified that no one from the facility had ever contacted him/her or asked him/her if Resident #3 could leave the floor or go outside. Person #2 further identified that Resident #3 had told him on multiple occasions that he/she asked staff to leave the floor, and the nurses tell him/her no. Person #2 stated he/she would like Resident #3 to be able to go outside in the courtyard area near the gazebo when he/she wanted to as it would do him/her good to get out into the fresh air to get some sunshine and Vitamins('s). A second observation of Resident #3 on 7/22/2025 at 12:32 PM identified he/she was independently locomoting up and down the hallway in a manual wheelchair. Resident #3 watched 3 other residents (Resident #27, Resident #68, and Resident #75) get badged out, off the floor, into the elevator to go outside independently. Resident #3 was noted to frown and wheeled his/herself back down the hallway to his/her room.Interview on 7/23/2025 at 8:54 AM with the Director of Nursing (DNS) identified that she brought up, in May, to the Director of Recreation, the issue of Resident #3 not being allowed outside to the resident area. The DNS stated that there is a resident-maintained garden, and she requested chairs be placed outside in that resident area to sit outside and enjoy the weather. Further, the DNS indicated she was aware that Resident #3 could only go outside if he/she smoked and believed it was unfair that smokers could go outside 4 times a day and non-smokers could not. The DNS stated she had previously brought up, during morning meeting, the subject of residents wanting to go outside and not being allowed to, and that staff needed to be educated. She further indicated that she was aware when Resident #3 had not been allowed off the floor or outside to the resident area, the resident was being involuntary secluded. Additionally, other residents wanted to leave the floor to go to the resident area and staff had not allowed this to occur.Interview on 7/23/2025 at 10:41 AM with the Director of Recreation identified that she was notified by the DNS in May to place chairs outside for the residents to sit outside in the fresh air. She submitted a concern form to the Maintenance Department and told maintenance verbally in June to place chairs outside. Further, she identified she was notified by Resident Council that they also wanted to go outside, and they requested a cover from the facility to provide shade. The Director of Recreation indicated she had never taken Resident #3 outside and does not want to use the gazebo as shade, as the area near the gazebo may smell like smoke, but all residents were allowed outside to the gazebo area once a month for a picnic. Review of the facility's Abuse, Neglect, and Exploitation policy identified in part, that instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Although a definition of involuntary seclusion was included in the Abuse, Neglect, and Exploitation policy, the facility failed to include in the policy how non-agitated residents would be protected from involuntary seclusion.

Based on review of the clinical record, facility documentation, facility policy and interviews for 1 (one) of 3 (three) residents (Resident #1) reviewed for abuse, the facility failed to ensure the resident was free from abuse from a staff member. The findings include: Resident #1's diagnoses included anxiety disorder and hypertension (high blood pressure). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #1 had a Brief Interview for Mental status (BIMS) of fifteen (15) indicative of intact cognition, exhibited no behaviors and required supervision for activities of daily living and was independent with transfers and ambulation. A Resident Care Plan (RCP) dated 9/10/24 identified Resident #1 is a current smoker with interventions that included to educate the resident on safe smoking, educating the resident that smoking materials must be held by the facility staff and to offer smoking cessation. Review of the facility Accident and Investigation (A&I) dated 9/18/24 identified Resident #1 was outside for a scheduled smoke break when the resident became upset with the brand of cigarettes, he/she was given and confronted Nurse Aide (NA) #1. Resident #1 then went back inside, and NA #1 followed him/her to the elevator, where NA #1 was observed yelling at the resident to open the doors. Staff immediately intervened and brought NA #1 to the Director of Nurse's (DNS) office. Review of facility statement written by Licensed Practical Nurse (LPN) #4 identified that she worked 7:00 AM to 3:00 PM on 9/18/24 and as she was approaching the afternoon smoke break, she observed the NA on duty (NA #1) to be visibly irritated and NA #1 then stated to the residents, nobody talk to me on smoke break. She reported that when smoke break had concluded, Resident #1 came back inside and was very upset reporting that NA #1 talked to and treated him/her poorly. Review of a Social Service note dated 9/18/24 identified that the resident had an altercation with a staff member, support was provided, and a referral was made to psychiatric services to follow up with the resident. Review of psychiatric progress notes identified that the resident was seen on 9/18, 9/19 and 9/25/24 for support regarding the verbal altercation with a staff member, he was able to recall the incident and was upset with the staff member. Interview with Resident #1 on 10/9/24 at 10:45 AM identified that he/she recalled the incident with NA #1, reporting that NA#1 was yelling at him/her and trying to lunge and get at him/her in the elevator after the resident approached her about receiving the wrong cigarettes at smoke break. Resident #1 reported that NA #1 had a threatening presence and reacted towards him/her like she was trying to fight him/her on the streets, identifying that it made him/her feel angry and upset with how they were treated. Interview with LPN #1 on 10/9/24 at 10:53 AM identified that around 2:30 PM on 9/18/24, Resident #1 was getting on the elevator and NA #1 came running down the hall after the resident, yelling profanities at and using derogatory language towards the resident. She reported that the elevator door had started to shut, and NA #1 began hitting the door with closed fists and demanding that Resident #1 open the elevator door, appearing that she was trying to fight the resident. She identified that Resident #1 continued in the elevator, and she was able to convince NA #1 to move away from the door, reporting that LPN #2 then came to assist her and called the nursing supervisor to notify them of the incident while she notified the DNS. Additionally, she identified that Resident #1 was shaken up following the incident and reported to her that NA #1 was crazy and acting like a man. Interview with RN #1 (Nursing Supervisor) on 10/9/24 at 2:05 PM identified that she was walking to her office on the first floor towards the end of the 7:00 AM to 3:00 PM shift and saw Resident #1 waiting at her door, which was surprising to her because the resident does not usually complain. She reported that the resident was very upset, stating that NA #1 was trying to fight me. The resident reported that when he/she was getting into the elevator, NA #1 had her her hands balled up into fists and tried getting onto the elevator with him/her while yelling at him/her. Interview with RN #3 (also a Nursing Supervisor) on 10/9/24 at 2:37 PM identified that LPN #2 called her regarding the incident involving NA #1 and Resident #1. She reported that she immediately went to speak with the resident, who was visibly upset and reported that NA #1 was loud, speaking disrespectfully to him/her and had bad mannerisms. Interview with the DNS on 10/9/24 at 12:38 PM identified that the interaction between NA#1 and Resident #1 was inappropriate. Subsequent to the incident the staff immediately brought NA #1 to his office, ensuring she was not able to interact with any other residents. He reported that he requested that the NA write a statement regarding the incident to which she refused, and subsequently resigned. Although attempted, an interview with NA #1, Social Worker #1 and LPN #4 were unable to be obtained. Review of the Abuse, Neglect and Exploitation policy dated 1/18/24 directed, in part, that abuse means the willful infliction of injury, intimidation or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse. It includes verbal abuse, sexual abuse, physical abuse and mental abuse. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written and will provide complete and thorough documentation of the investigation.

Based on clinical record review, review of facility policy, and interviews for one of three sampled residents (Resident #101) reviewed for facility acquired pressure ulcers, the facility failed to ensure interventions and treatments to prevent the development of a pressure wound were put in place and failed to ensure the wound was assessed appropriately and in a timely manner to prevent the worsening of a pressure ulcer/injury. The findings include: Resident #101 was admitted to the facility on [DATE] with diagnoses that included dementia, anemia, heart failure, thrombocytopenia, malignant neoplasm of the rectum, and presence of ileostomy. The physician's order dated 7/23/24 directed to complete skin monitoring and observation weekly. The skin assessment dated [DATE] identified Resident #101 had intact skin. The Braden scale assessment (used to predict risk for development of pressure ulcer/injury) dated 7/23/24 identified Resident #101 had a score of 16 which is indicative of the resident being at risk for the development of a pressure ulcer. The Resident Care Plan (RCP) dated 7/24/24 identified Resident #101 was at risk for the potential for skin breakdown related to decreased mobility, ileostomy, and incontinence. Care plan interventions included: follow facility protocol for treatment of injury, keep skin clean and dry, and staff to provide frequent incontinence care. The admission MDS assessment dated [DATE] identified Resident #101 had severe cognitive impairment, did not display behaviors, required extensive assistance with toileting, bed mobility, hygiene, dressing, and transfers. The assessment further identified Resident #101 was non-ambulatory, utilized a wheelchair for mobility, did not have range of motion deficits, was frequently incontinent of bladder and had an ileostomy in place for bowel function. It further noted the resident was at risk for the development of pressure ulcers, but did not currently have a pressure ulcer, and had a pressure reducing device to the bed. The assessment did not identify that the resident was on a turning and repositioning program or that the resident had a pressure reducing device to the wheelchair. The nurse's note dated 8/2/24 at 11:13 PM written by LPN #1 identified that the assigned nurse's aide and Resident #101's responsible party reported the resident had a small open wound to the coccyx, Resident #101 denied pain and/or discomfort, and the nursing supervisor was notified. Further review of the nurse's note failed to identify any further documentation about the wound such as a description, measurements, the presence or absence of an odor Review of the clinical record failed to identify that the wound to Resident #101's coccyx was assessed and/or that a treatment order was put in place. Review of the clinical record failed to identify that the weekly skin monitoring and observation for the week of 8/9/24 was completed as ordered by the physician. The nurse's note dated 8/16/24 at 4:32 PM written by LPN #2 (wound nurse) identified Resident #101 had two small open wounds to the coccyx. The first wound size was documented as 0.8 centimeters (cm) in length by 0.5 cm in width and 0.1 cm in depth and the second wound size was documented as 1.0 cm in length by 0.8 cm in width and 0.1 cm in depth. The APRN was updated, and new orders obtained that directed to cleanse the wound with normal saline followed by the application of Calcium Alginate and cover with a dry clean dressing. The wound bed was noted with 100 percent granulation (wound bed characteristics described as red and/or pink in color) and a scant amount of serosanguineous drainage was also noted. Resident #101 denied pain and/or discomfort during the treatment. The resident's responsible party was notified and updated. The physician's order dated 8/16/24 directed to apply pressure reducing air mattress to the bed and check function every shift per resident's weight and comfort. The revised RCP dated 8/16/24 identified Resident #101 had an unstageable pressure ulcer. Care plan interventions directed to check mattress for function every shift and mattress setting adjusted in accordance with patient weight, RN will assess wound and provide appropriate wound treatment per physician orders, and staff will provide frequent incontinent care ensuring bedding and skin remain dry. APRN #1's (wound specialist) initial wound progress note dated 8/19/24 at 7:58 AM identified Resident #101 had a new unstageable pressure ulcer and/or injury to the coccyx related to pressure. The wound size was documented as 0.5 cm in length by 1.5 cm in width and 0.2 cm in depth. The wound bed was covered with 100 percent slough (a yellow and/or white material dead cell that accumulates in the wound bed) and with moderate amount of serosanguineous drainage. The treatment plan directed to apply Santyl (chemical wound debridement) ointment followed by calcium alginate daily and as needed, to follow facility pressure ulcer prevention protocol, apply pressure redistribution mattress per facility protocol, wheelchair pressure redistribution cushion per facility protocol, offload pressure wound and reposition patient every two hours. The physician's order dated 8/19/24 directed to cleanse coccyx wound with normal saline, apply nickel thick layer of Santyl ointment followed by Calcium Alginate and cover with dry clean dressing. The weekly physician's wound progress note dated 8/26/24 at 4:35 PM identified Resident #101 continued with unstageable pressure injury to the coccyx. The wound bed remains with 100 percent slough and the wound size was documented as 0.8 cm in length by 0.5 cm in width and 0.2 cm in width and with small amount of serosanguineous drainage. The treatment plan was to continue to cleanse the wound with normal saline and apply Santyl ointment at the base of the wound and cover with dry clean dressing. The weekly APRN#1 wound progress note dated 9/2/24 at 8:06 AM identified the unstageable wound to the coccyx had worsened. The wound size was documented as 0.5 cm in length by 1.5 cm in width and 0.2 cm in depth and the wound bed remained at 100 percent slough with moderate amount of serosanguineous drainage noted. The treatment plan noted to apply Santyl ointment followed by Calcium Alginate and cover with dry clean dressing daily. The social services progress note dated 9/6/24 at 9:41 AM identified Resident #101 was discharged to the community with rehabilitation and nursing services. Interview with LPN #1 on 9/9/24 at 12:30 PM identified the NA reported Resident #101 had a new open wound to the coccyx on 8/2/24. She could not recall who the Na was that reported the wound to the coccyx. She identified that she visualized Resident #101's coccyx and noted an open wound to the coccyx. She did not measure the open coccyx wound, nor did she call the physician to obtain a treatment, but she immediately reported the open coccyx wound to the nursing supervisor. She further identified that she was an agency staff nurse, and it would be the nursing supervisor's responsibility to assess the coccyx wound, to call the physician and to obtain a treatment order. She further noted that she did not receive any further instruction from the nursing supervisor related to Resident #101 coccyx wound. Interview with RN #1 (nursing supervisor) on 9/9/24 at 1:30 PM identified that she could not remember whether there was a reported open wound to Resident #101's coccyx. She identified that she would document the wound assessment in the nursing progress notes and/or wound documentation, call the physician and obtain treatment orders, and update the wound nurse. Interview with LPN #2 (7-3 charge nurse) on 9/9/24 at 2:00 PM identified that the charge nurse is responsible for checking and documenting the resident skin weekly on their shower day. She identified that she signs off in the TAR (treatment administration record) to indicate that the skin check is completed and completes the weekly skin monitoring assessment under the evaluation. Additionally, LPN #2 could not verify whether she did a skin check for Resident #101 because there was no weekly skin monitoring assessment completed and she did not sign off in the TAR. She further noted that she would report to the nursing supervisor immediately when there is a new wound. Interview with LPN #3 (wound nurse) on 9/9/24 at 2:30 PM identified that she was responsible for monitoring the wounds weekly and also identified that the nursing supervisor or the DNS would assess the wound with her when there is a new onset of wound reported. On 8/16/24, she identified that the charge nurse on the unit reported that Resident #101 had open wound to the coccyx. She identified Resident #101 had 2 small open wound to the coccyx and she measured both wounds. When she referred Resident #101 to the APRN #1 (wound specialist) the following week, the 2 open wounds combine into one open wound to the coccyx. She was not made aware of Resident #101 open coccyx wound that was first noted on 8/2/24. She identified she would expect the physician to be notified, and a treatment to be initiated at the time of discovery to prevent the wound from worsening and the wound should be assessed weekly. Interview with APRN #1 (wound specialist) on 9/9/24 at 2:45 PM identified that her initial consultation with Resident #101 was on 8/19/24 during her wound rounds. She identified that Resident #101 had an unstageable wound to the coccyx because the wound bed was covered with 100% slough. She also noted that the cause of the wound to the coccyx was related to pressure because of the wound's location. She identified that Resident #101 was at risk for pressure injury because of his/her dementia, decreased mobility, and anemia. She was not made aware of the wound to the coccyx on 8/2/24 and it would be the facility's responsibility to let her know when there is a new onset of a wound that needed to be evaluated. She further noted on her wound consult dated 9/2/24 that Resident #101 pressure wound to the coccyx had worsened because the measurement of the wound became larger from the previous wound assessment and the wound bed continued to be covered with 100% slough. She further identified that a pressure ulcer/injury could worsen quickly without a timely assessment and appropriate treatments and interventions provided. Interview with the DNS on 9/10/24 at 11:20 AM identified that he would expect the nurse to assess the wound promptly and call the physician to obtain and implement the treatment immediately. He also was aware that any pressure wound and/or injury could worsen without immediate intervention and treatment. He identified that the weekly skin check needed to be documented under the evaluation of weekly skin monitoring and done weekly. He was not made aware that Resident #101 had a new open wound to the coccyx on 8/2/24. He further identified the coccyx wound should have been assessed by a nurse and documented in a nurse's note that included the wound measurement, description and/or pressure wound stage, call to the physician and obtain and implement treatment, and the wound should have been monitored weekly from the time it developed. Interview with RN #2 (interim ADNS) on 9/10/24 at 11:50 AM identified that she assessed the coccyx wound with LPN #2 on 8/16/24. She identified that she was newly hired and was not aware that the wound nurse was an LPN. She further identified that she agreed with LPN #2's documentation of the wound. The Prevention and Management of Wounds policy identified that residents receive appropriate treatment for skin issues based on the type of wound. The policy noted that staff provides treatments and interventions for skin issues. Review of the policy for procedures noted the nurse would identify the impairment and stage when applicable and is responsible for identifying the appropriate treatment and interventions through collaboration with the wound specialist and wound nurse. The policy directs staff to document physician's orders and transcribe them into the treatment administration record in the electronic medical record, indicate interventions on the resident care plan and recognize factors contributing to pressure, resident needs and behaviors.

Based on a review of clinical records, facility documentation, facility policy, and interviews for three (3) of six (6) residents reviewed for abuse, the facility failed to protect two resident (#3 and #4) from one resident (#2) who exhibited aggressive behaviors resulting in injury and failed to ensure that a resident (#5) was free from physical abuse from a staff member. The findings include: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses that included altered mental status and bipolar disorder. The admission nursing assessment dated [DATE] identified Resident #2 was alert to person and required limited assistance with activities of daily living (ADL). A wandering assessment was completed on 11/27/23 and identified the resident was at low risk for wandering. The care plan dated 11/27/23 identified Resident #2 had a behavior problem and psychotic disturbances related to dementia associated with alcoholism. Interventions included administer medications as ordered and to anticipate and meet Resident #2's needs. Review of APRN #2's (Psychiatric APRN) assessment dated [DATE] identified Resident #2 was alert, confused and staff reported continued wandering into other resident's rooms and sometimes became agitated with redirection. APRN #2 ordered Trazadone (antidepressant and sedative) 50 milligrams (mg) every 12 hours as needed for 14 days for restlessness and anxiety. a. Resident #3 had diagnoses that included dementia and anxiety. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident #3 had moderately impaired cognition, no documented behaviors, and was independent with ADL's. The care plan dated 10/25/23 identified Resident #3 had impaired cognitive function/dementia related to dementia. Interventions included to engage the resident in simple, structured activities that avoid overly demanding tasks, to keep the residents routine consistent, and try to provide consistent care givers as much as possible in order to decrease confusion. Review of the accident and incident report (A & I) dated 11/30/23 identified at 2:10 PM staff responded to yelling coming out of Resident #3's room, Resident #2 was standing facing Resident #3 who was on the floor crying and yelling (visably upset). Resident #2 had hit and pushed him/her down. Resident #2 was immediately removed from the room, 911 was called and the resident was placed on one-to-one supervision while awaiting transport. The nurses note dated 11/30/23 at 4:53 PM identified Resident #3 complained of pain to the right side of the head with noted discoloration to area. Resident #3 was sent to the hospital at the request of the Conservator. Review of the nurses note dated 11/30/23 at 11:36 PM identified the resident had been struck in the face, fell and hit his/her head, trauma work-up in the emergency room was unremarkable. The resident returned to the facility at 8:25 PM. The nurses note dated 12/1/23 at 11:58 AM identified the resident ending up having bruising on the right side of the temple after an interaction with another resident. Resident #2 had a physician's order dated 11/30/23 that directed every fifteen-minute checks for wandering and the care plan was revised to identify patterns of wandering, document wandering behavior and attempted diversional interventions in the behavioral log. Resident #2 had a nurse's note dated 12/1/23 that identified at approximately 4:05 AM the resident returned to the facility with a no harm letter. Nurse's note dated 12/3/23 and 12/4/23 identified that Resident #2 had a bowel movement on the floor of h/her room and the resident was sent to the emergency roiagnom on [DATE] for evaluation of behaviors. A nurses note on 12/11/23 at 3:00 PM identified that Resident #2 was readmitted to the facility at 2:55 PM with a letter stating the resident was not a harm to self or others. A physician's order dated 12/11/23 directed to administer Trazadone 50 mg at bedtime related to bipolar disorder (may repeat one time as needed). A physician's order dated 12/11/23 directed to administer Trazadone 50 mg every 24 hours as needed (prn) for bipolar disorder (may repeat one time at bedtime). A wandering assessment dated [DATE] identified Resident #2 was at risk of wandering with interventions in place. b. Review of Resident #4's clinical record identified the resident had diagnoses that included dementia and adjustment disorder, had severely impaired cognition, ambulated with the assistance of one staff with use of a rolling walker, and shared a room with Resident #2. Review of LPN #3's nurses note dated 12/14/23 at 6:38 AM identified during the shift Resident #2 wandered the hallways, dining room, in other resident's room, disturbed the peace of the unit, and was redirected several times with some effect. Resident #2 was observed in another resident's room naked and was redirected without issue. Resident #2 attempted to wander naked into the same room a second time and was redirected back to his/her room. Resident #2 appeared to lack understanding of personal space and boundaries. Review of the medication administration record (MAR) dated 12/14/23 during the 11:00 PM-7:00 AM shift failed to identify Trazadone was administered as needed in accordance with the physician's order. Review of LPN #4'a nursing note dated 12/14/23 at 2:57 PM identified Resident #2 was restless and pacing throughout the halls during the shift. Resident #2 needed redirection throughout the shift on keeping his/her clothes on, personal space/boundaries and inappropriate touch. Resident #2 did not accept redirection well. Review of the MAR dated 12/14/23 during the 7:00 AM-3:00PM shift failed to identify Trazadone was administered as needed in accordance with the physician's order. An APRN assessment dated [DATE] identified Resident #2 continued behavior dysregulation while at the facility including disrobing and sexually inappropriate behaviors with frequent redirection. Resident #2 was sent to the hospital on 12/4/23 for combative behaviors at which time his/her Seroquel, Namenda and Cymbalta were discontinued. Staff reported Resident #2 was up all night and had some episodes going into other resident's rooms and as needed Trazadone was not used. APRN #2 encouraged as needed medication use as appropriate. Review of LPN #3 nurses note dated 12/14/23 at 8:56 PM identified at 7:50 PM Resident #4 was observed entering his/her own room and then was pushed hard by his/her roommate, (Resident #2), causing him/her to fall and slide halfway out of the room, landing on his/her right side. Review of the (MAR) dated 12/14/23 during the 3:00 PM-11:00 PM shift failed to identify Trazadone was administered as needed in accordance with the physician's order. Review of the A & I report dated 12/14/23 at 7:50 PM identified Resident #2 was seen pushing his/her roommate, (Resident #4), causing Resident #4 to fall to the floor. Resident #2 was placed on one-to-one supervision until the EMT's arrived and then transferred to the hospital. Resident #4 had complained of pain to the right wrist, an x-ray was ordered which identified a fracture of the distal ulna. Resident #4 was transferred to the hospital and returned with splint in place. Interview with NA #6 on 1/2/24 at 1:37 PM identified she last provided care to Resident #2 around 7:00 PM on 12/14/23. She identified Resident #2 was undressing the bed, taking his/her brief off multiple times, and taking his/her clothes off. She identified when she last saw Resident #2 walking down the hallway about 10 minutes before Resident #2 pushed Resident #4 to the floor. Interview with LPN #3 on 12/18/23 at 12:50 PM identified she was Resident #2's nurse on 12/14/23/23 during the 3:00 PM - 11:00 PM. Resident #2 was wandering in and out of other resident's rooms and disrobing prior to the incident with Resident #4. She further identified that she did not medicate the resident with the as needed Trazadone because this was the residents baseline behavior. Interview with LPN #1 on 12/18/23 at 1:50 PM identified she was Resident #2's nurse on 12/13/23 - 12/14/23 during the 11:00 PM - 7:00 AM shift. She identified Resident #2 would wander into other resident's rooms but was easy to redirect. She identified she had not given Resident #2 the as needed (prn) Trazadone for his/her behaviors on 12/14/23 because she had administered the scheduled Trazadone at 9:00 PM and the order identified every 24 hours. LPN #1 failed to administer the Trazadone as needed in accordance with physician orders (order directed may repeat Trazadone dose one time). Interview with APRN #1, psychiatric practitioner, on 12/19/23 at 11:55 AM identified Trazadone would help with Resident #2 's behaviors and she would expect staff to administer the Trazadone. She identified Resident #2 had a history of disrobing at night and told staff to administer the Trazadone as needed when the resident was exhibiting behaviors. Review of the clinical record failed to identify that the facility had medicated the resident with the as needed Trazadone, although exhibiting behaviors, or notify the physician of the behaviors prior to the incident with Resident #4 on 12/14/23. Interview with the DNS on 12/19/23 at 1:00 PM identified the facility was doing the best they could to care for Resident #2 with the resources they had. The DNS identified that the nurses should have medicated Resident #2 with the as needed Trazadone for the resident's behaviors. Subsequent to the event on 12/14/23, Resident #2 was placed on 1:1 upon return from hospital on 12/15/23 until discharged to a psychiatric facility on 12/15/23. 2. Resident #5 was admitted to the facility with diagnoses that included stroke, dementia and mood disorder. The quarterly MDS assessment dated [DATE] identified Resident #5 had severely impaired cognition, had physical behavioral symptoms that occurred for 1 to 3 days during the time frame of a week, was incontinent with bladder and bowel and required assistance of one staff for ADL's. The care plan dated 10/23/23 identified Resident #5 had a diagnosis of dementia with interventions that included to assist with ADL's, cue, reorient and supervise as needed, keep Resident #5's routine consistent and to provide one thought, idea, question and command at a time. The psychiatric note dated 12/11/23 identified Resident #5 occasionally refused care, but it was not an ongoing problem and otherwise had been stable at his/her baseline. A nursing note dated 12/13/23 at 10:25 PM identified a NA reported on 12/12/23 between 7:00 PM - 8:00 PM she witnessed NA #4 being a little rough while guiding Resident #5's feet when putting the resident to bed. Resident #5 kicked NA #4 who in turn slapped Resident #5's right forearm with an open hand. Review of the A & I dated 12/13/23 identified that at 4:30 PM, NA #3 reported on 12/12/23 between 7:00 PM and 8:00 PM, while orienting on the floor with NA #4, she witnessed NA #4 hit Resident #5 on the hand/arm after Resident #5 kicked her. NA #4 was immediately removed from the floor and was terminated. Resident #5 had no recollection of the event. Review of NA #4's undated written statement identified on 12/12/23 she was orienting NA #3 and they were putting Resident #5 to bed. Resident #5 kicked NA #4 and she pushed his/her foot away from her. The psychiatric note dated 12/13/23 identified Resident #5 had an altercation with staff and did not remember the incident. Resident #5 stated he/she would not hurt anyone and was not considered a danger to self or others. Interview with NA #3 on 12/19/23 at 10:12 AM identified on 12/12/23 it was her first day orienting on the floor with another NA. She identified when NA #4 was caring for Resident #5 before bed, she did not explain what she was doing and was working at a fast pace fast. She identified NA #4 lifted Resident #5's legs and dropped them quickly. Resident #5 then kicked NA #4 and NA #4 smacked Resident #5 with an open hand on his/her forearm. NA #3 further identified she was scared to tell anyone because it was her first day training on the floor, however, was educated during orientation on reporting abuse as soon as witnessed. She identified she reported her observation on 12/13/23 because the event stuck with her and she was previously in shock as to what she witnessed on 12/12/23. Although multiple attempts were made, an interview with NA #4 was unsuccessful. Interview with the DNS on 12/19/23 at 1:00 PM identified he was not aware of the incident that occurred on 12/12/23 until 12/13/23 at 4:30 PM and subsequently NA #4 was removed from the floor and was terminated. He identified NA #3 was a new NA but would still have expected her to report the incident immediately. He further identified NA #4 should have left the resident and re-approached the resident when being combative. Review of the abuse prevention policy directed to maintain the rights of all residents to be free from abuse, neglect and mistreatment. Review of the Residents [NAME] of Rights directed that the resident has the right to be treated with consideration, respect and recognition of his/her dignity and individuality.

Based on observations, clinical record review, facility policy and interviews for 1 of 3 sampled residents (Resident #83), identified at risk for pressure ulcers, the facility failed to ensure appropriate settings for low air loss (LAL) mattress. The findings include: Resident #83 diagnoses included: heart failure, dementia, diabetes, chronic kidney disease, history of non-pressure chronic ulcers, history of deep tissue injury (DTI), and an open wound to lower extremity. The Quarterly MDS assessment dated [DATE] identified Resident #83 cognitively impaired, with no current pressure ulcers, required total assistance of two for transfers, extensive assistance of two for bed mobility. The Resident Care Plan dated 10/17/23 identified Resident #83 as having a pressure reducing air mattress for the treatment and prevention of pressure injuries and friction/shear injuries, resident is at very high risk for skin/connective tissue injuries. Interventions directed treatment per MD order, monitoring healing, use of an air mattress, and a goal of resident not developing any further skin/connective tissue injuries resulting from friction and shear. Additionally, the care plan identified the resident has the potential for pressure ulcer development related to decreased mobility/immobility. Interventions included educating resident/family/caregivers on causes of skin breakdown, including positioning requirements and frequent repositioning, with a goal of resident having intact skin, free of redness, blisters, or discoloration. The Resident care plan additionally, indicated diabetic ulcers dated 3/23/23, last revised on 6/29/23 with a goal of resident's skin remaining free form breakdown and resolved care planned item dated 10/27/22 indicating a history of a DTI. A Treatment Administration Record dated 3/24/22 indicates Low Air Loss - Static Pressure mattress - check function and setting every shift (keep settings at 250 pounds per resident's weight and comfort). A physician's order dated 3/24/22 directed low air loss static pressure mattress, check function and settings every shift (keep settings at 250 per resident's weight and comfort every shift). A physician's order dated 9/13/22 directed skin prep to bilateral heels every 8 hours, every shift related to other skin changes. A nurse's aide care card last updated 5/3/23 indicated air mattress at proper setting. A Braden Scale Evaluation dated 9/7/23 indicated the resident at high risk of skin breakdown. A Wound Physician Progress Note dated 9/12/23 indicated resident had a cluster of dry scabs at dorsum of left foot with no acute signs of infection and directed to apply skin prep and keep dry. Observation and interview on 10/30/23 at 11:05 AM with LPN #1 identified that the resident's mattress was set at about 270 pounds, close to 280 pounds and that the resident did not weigh 280 pounds. She indicated that it is the responsibility of the aide and the nurse, but ultimately the nurse to ensure mattress is set correctly. A weight summary report indicated on 11/1/23 the resident's weight was 152.6 pounds. Review of the manufacturer's operating instructions for Proactive Medical Products for the Protekt Aire 2000 pump and overlay system indicates in Step #6 to determine the patient's weight and set the control knob to that weigh setting on the control unit. Review of the facility Support Surface Guidelines Level II dated 9/2013, annual review dated 2023 indicates the purpose is to provide guidelines for the assessment of appropriate pressure reducing and relieving devices for residents at risk of skin breakdown. General Guidelines #1 redistributing support surfaces are to promote comfort for all bed- or chairbound residents, prevent skin breakdown, promote circulation, and provide pressure relief or reduction. Guidelines for selecting the appropriate pressure-relieving devices, item #2 indicates use of a pressure ulcer risk scale such as the Braden Scale to help determine the need for and appropriate type of pressure-relieving devices. Refer to bed selection algorithm for support surface selection.

Based on clinical record reviews, review of facility's documentation, review of policy and interviews for two of six sampled residents reviewed for abuse/neglect for (Resident # 210), the facility failed to protect the resident from mistreatment and for (Resident #31), the facility failed to assist the resident with meal consumption and The findings included: 1. Resident #210's diagnoses included type 2 diabetes with polyneuropathy, metabolic encephalopathy, adjustment disorder, end stage renal disease, anemia, end stage renal disease, osteomyelitis to right ankle and foot, congestive heart failure, convulsions, and cerebral infarction. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #210 had no cognitive impairment and had verbal behavioral symptoms directed towards others and at times reject care. The MDS further identified Resident #210 was independent with eating and required extensive assistance or was totally dependent for help with ADLs. The Resident Care Plan dated 3/22/2023 identified Resident #210 had exhibited episodes of negative verbalization toward staff and or residents and Resident #210 had the potential to be verbally aggressive related to ineffective coping skills and poor impulse control. Interventions included assisting Resident #210 to develop more appropriate methods of coping and interacting and encouraging the resident to express feelings appropriately, if Resident #210 became agitated intervene before agitation escalates, guide away from source of distress and engage calmly in conversation. If response is aggressive, staff should walk calmly away and re-approach later, refer for psych evaluation as needed and give Resident as many choices as possible about care and activities. A nurse's note dated 4/08/2023 at 8:48 PM identified Resident #210 called the supervisor's phone and reported his/her supper tray was taken away before he/she had eaten. The resident's concern was discussed with the charge nurse who stated Resident #210 had been yelling at staff, swearing, and had refused his/her tray. The charge nurse was advised to follow up with Resident # 210 and call the kitchen to see if they could make something else for him/her. Approximately 20 minutes later, as this supervisor (RN #3) walked onto the unit, there was yelling coming from the direction of Resident #210's room. A staff member (NA#8) was standing in the doorway having an aggressive verbal altercation with the resident. NA # 8 was removed from area and left the building willingly. In to assess resident following the incident. Resident # 210 appeared at baseline, states Oh I don't care about that in reference to the altercation and proceeds to discuss how upset he/she was about not getting his/her meal tray. Resident #210 identified that sandwiches were brought up from the kitchen, but he/she was not satisfied with this option and declined all options offered. The local police department was notified of incident and informed the facility they would be out later this evening to complete case. The Reportable Event report dated 4/08/2023 identified Resident #210 was allegedly given his/her dinner and refused it, as well as the alternate menu option available. The report further indicated Resident # 210 allegedly called the supervisor and reported that he/she did not receive a dinner tray. When the supervisor went to the unit NA#8 was heard saying loudly this is why you're in that bed he/she then walked out the room and said, I'm leaving. the police was notified NA#8 voluntarily terminated his/her employment. A nurse's note dated 4/08/2023 at 11:04 PM identified the writer RN #3(nursing supervisor) checked on Resident #210 following the allegation. Resident #210 was eating his/her meal. Resident#210 was advised the staff member involved in the altercation would not be working with him/her going forward. Resident #210 voiced his/her concerns regarding threats NA # 8 made. The writer advised Resident # 210 the police was notified. Resident #210 verbalized that he/she was happy with that resolution. The social service note dated 4/10/23 2:10 PM identified the Social Worker went to speak to Resident # 210 about an incident that occurred between him/her and NA. Resident # 10 verbalized the NA ( NA# 8) was being disrespectful calling him/her a by his/her gender and that is why s/he was in this bed. Resident #210 stated NA # 8 proceed to take his/her dinner tray out and brought in 2 sandwiches and he/she stated I do not want this s**t . The resident stated he/she was ok and was trying not to let staff get to him/her. A psychiatric assessment note following incident dated 4/11/2023 identified on assessment Resident #210 presented as withdrawn with flat affect and depressed mood with irritability and agitation. Anxiety was elevated at times, however, stable on assessment that day. The note further identified Resident #210 was not a danger to self or others. An interview with Resident #210 on 4/26/2023 at 9:40 AM identified NA #8 came into the room during supper time and placed a tray on his/her bed, before he/she could move the cover to see the meal, the NA #8 quickly took the tray away then returned later with sandwiches. Resident #210 identified he/she had originally ordered a hot meal and did not like sandwiches. Resident # 210 further identified he/she did not like sandwiches, was upset and threw the sandwiches on the floor. NA #8 then called him/her a mother f *** and told him/her he/she was going to get his/her boyfriend to f*** him/her up. Resident # 210 was upset by NA# 8 threatening statement that he/she believed he/she needed to have his/her family protect him/her from NA # 8 An interview with RN #3 weekend shift supervisor (7:00 AM to 7:00 PM) on 4/27/23 at 12:18 PM identified on 4/08/2023 during the evening around super time he/she was called to the unit due to shouting heard between Resident #210 and NA #8. RN #3 further identified as he/she was entering the unit NA #8 was seen coming out of Resident #210's room then returned standing in the doorway yelling 'that's why you are in that bed, that's why you are in that bed.' RN #3 identified that he/she was unable to hear what Resident #210 was saying at the time and was unable to get an actual statement from Resident #210 because he/she did not want to talk about it at that time (Resident #210 was very upset). He/she identified that after yelling NA #8 then stormed toward him/her saying he/she was clocking out and left the building. RN #3 identified that NA #8 showed up for his/her shift the next day and was advised he/she could not to return to work until investigation into incident had been completed. NA #8 was very upset and refused to give statement regarding incident. NA #8 was terminated related to incident. Efforts to contact NA #8 for interview during survey via telephone were unsuccessful. Interview with RN #6 Independent Nurse Consultant hired by the facility on 5/01/2023 at 3:39 PM identified NA #8's behavior was very unusual on the day of the incident. During the investigation Resident #210 expressed NA #8 was usually very helpful. RN #6 further identified that the facility had no tolerance for this kind of behavior and had terminated NA #8 as a result. RN #6 identified NA #8 was very upset about termination and had been refusing up to date to provide statement. An interview with former DNS on 5/02/2023 at 11:50 AM identified he/she was not working during the incident and did not participate in completing investigation. Review of the facility's abuse policy directed the facility prohibits the mistreatment, neglect, and abuse of residents/ patients. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The policy further stated that the facility had designed and implemented processes which strive to ensure the prevention and reporting of abuse, neglect, or mistreatment. The policy's definition of abuse included the willful infliction of injury, deprivation of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial wellbeing. Neglect was defined as failure to provide goods and services necessary to avoid physical harm mental anguish, or mental illness. The policy further defined verbal abuse as the written, oral, or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance to describe resident, regardless of their age ability to comprehend or disability. Mental abuse included but was not limited to humiliation, harassment, and threats of punishment. 2. Resident #31's diagnoses included hereditary ataxia, severe protein-calorie malnutrition, blind, spasmodic torticollis, and depression. The dietician note dated 3/3/23 identified Resident # 31 review of likes and dislikes for meals, noted the resident requires meal set up and feeding assistance and identified no weight loss. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #31 had no cognitive impairment, mood or behavior issues and required extensive assistance with all ADLs. The MDS further identified Resident #31 had adequate hearing, clear speech, severely impaired vision, no swallowing or dental issues and received a therapeutic mechanically altered diet. The Resident Care Plan dated 3/14/2023 identified Resident #31 had an ADL self-care performance deficit related to ataxia. The care plan further identified Resident #31 required supervision of one to one and extensive assistance for eating. The care plan also identified the Resident had an ADL self-care performance deficit related to a progressive neurological disease process and blindness. Interventions directed Resident #31 to have Speech Language Pathology evaluation for recommendations and noted that Resident #31 required one to one supervision during meals. A review of facility's grievance file dated 3/19/23 identified Resident #31 reported to nursing supervisor he/she was not fed breakfast. Further review of the grievance file identified on 3/24/2023 Resident #31 had also reported to the supervisor s/he was not fed dinner. The facility's documentation of investigation of the allegation identified the assigned Nurse Aide (NA) did not know Resident #31 required assistance with feeding and indicated she lost her paper assignment. Staff spoke to resident, and s/he indicated she has been eating well and have been fed consistently prior to these events. Additionally, the facility investigation identified that as a resolution Resident #31 would no longer be assigned nurses from the agency and noted the supervisor will check in daily on Resident # 31. A review of Resident #31's percentage of meal consumption dated 2/1/23 to 3/18/23 identified the resident consumed 60-100 percentage of the meal when assisted by staff. A review of Resident #31's bedside Kardex during the investigation report identified Resident #31 required extensive assistance of one person when eating. A psychiatric evaluation note dated 3/01/2023 for a follow up evaluation of Resident #31's mood and behavior was completed, and no acute psychomotor agitation or intellectual challenges were seen. There were no delusions or paranoia noted. Medications were reviewed during the visit and Resident #31 was cooperative. A review of psychiatric evaluation notes for Resident #31 dated 4/02/2023 identified Resident#31 was alert and oriented, had no psychiatric concerns noted in progress notes, staff nurse reported occasional confusion and complaints about care from Resident #31. Resident #31 denied any increased depression or change in sleep pattern or appetite. Resident # 31 denied increase in anxiety and did not present as anxious or agitated, Resident #31 reported no change in sleep pattern and did not present as fatigued or lethargic. A physician's order dated back since 8/23/2022 to 4/2023 directed Resident #31 to provide one to one assistance with all oral intakes. An interview with Resident #31 on 4/25/2023 at 10:05 AM identified he/ she was not fed dinner on 4/22/2023 and indicated the staff did not bring a dietary tray to his/ her room. Resident # 31 indicated when s/he was not fed on 3/19/22 and 3/24/23 s/he was hungry and had to eat snacks therefore s/he felt the need to file a grievance about not being fed. Resident #31 identified because he/she was blind, nursing staff at facility would tell him/ her incorrect names and let him/her feel like he/she did not know what he/she was talking about when he/she had to report a concern. Resident #31 identified he/she felt very helpless and undermined and wanted to leave the facility, but felt facility was not giving enough help so he/she could leave. Resident #31 identified that over the years he/she had been at facility this is the worst, and it felt like he/she was living through a horror movie. He/ she further identified that the supervisors were assigned to perform checks, but this only lasted a few days, and the facility was not following through with the directive. A review of Resident #31's percentage of meal consumption dated 3/19/23 to 4/22/23 identified the resident consumed 60-100 percentage of the meal when assisted by staff. An interview with RN #3 weekend shift supervisor (7:00 AM to 7:00 PM) on 4/27/23 at 12:32 PM identified on 4/22/2023 when he/she performed a check in on Resident #31 at about 6:30 PM, Resident #31 identified he/she had told the NA who that tried to feed the resident away. RN #3 further identified he/she did not follow-up with the NA to investigate what happened and he/she could not recall the name of the NA because he/she was from the agency. All NAs on facility's schedule for 4/22/2023 on the 3:00 PM to 11:00 PM shift assigned to Resident #31's unit was interviewed, none of the NA could recall being sent away by Resident #31 or assisting Resident #31 with his/her supper meal. Facility staff neglected to provide the one-to-one assistance on two occasions for Resident #31 who required one to one assistance causing the resident to express that she /he was in a horror movie but could not leave the facility. The facility's Abuse Policy notes the facility prohibits the mistreatment, neglect, and abuse of residents/ patients. The facility prohibits any exploitation of the mentally and physically disabled resident in the facility. The policy further stated that the facility had designed and implemented processes which strive to ensure the prevention and reporting of abuse, neglect, or mistreatment. The policy's definition of abuse included the willful infliction of injury, deprivation of goods and/or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Neglect was defined as failure to provide to provide goods and services necessary to avoid physical harm mental anguish, or mental illness. The policy further defined verbal abuse as the written, oral, or gestured language that willfully included disparaging and derogatory terms to residents or their families or within hearing distance to describe resident, regardless of their age ability to comprehend or disability. Mental abuse included but was not limited to humiliation, harassment and threats of punishment or deprivation or abuse that is facilitated or caused by nursing home staff taking or using camera/cellphone that would demean or humiliate resident/s.

Based on clinical record reviews, facility documentation, facility policy and interviews for two of three sampled resident for (Resident # 41), reviewed for pressure ulcer, the facility failed to monitor resident's Circulation, Motion and Sensory (CMS) and skin integrity during the utilization of removable left leg surgical boot for potential skin impairment and pressure ulcer development and for (Resident # 12) reviewed Pressure Ulcers, the facility failed to ensure wound assessment staging and documentation was completed per standards of practice and the facility policy and for . The findings included: 1. Resident # 41's diagnoses included pyogenic arthritis, diabetes mellitus with diabetic neuropathy, infection, and inflammatory reaction due to internal joint prothesis and chronic pain. The Resident Care Plan (RCP) dated 6/9/22 identified Resident # 41 had severely limited mobility and very high risk for skin and connective tissue injury. Interventions directed staff to provide frequent incontinent care, air mattress as ordered, to ensure air mattress device was properly plugged into power outlet and Registered Nurse (RN) would assess wound and provide appropriate wound treatment as ordered by physician and as needed. The annual Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 41 had a Brief Interview for Mental Status (BIMS) score of 14 out of 15, indicative of no cognitive impairment and required extensive assist with 2 persons for bed mobility, transfer, toileting, hygiene and non-ambulatory. The hospital discharge summary dated 9/23/22 identified Resident # 41 underwent a surgery for left lengthening achilles tendon. Resident # 41 discharge summary instructions directed for non-weight bearing to the left lower extremity and splint, to elevate the affected extremity to help with pain and swelling, to keep splint/bandage clean and dry until first postoperative visit, do not get bandage or dressing wet and replace dressing with dry sterile bandage if it became dirty or wet. The nurse's note dated 10/17/22 at 7:41 PM identified Resident # 41 has a cast to left lower extremity that was removed and replaced by a boot. No new orders were identified. The physician consultation recommended weight bearing as tolerated to left leg while using the left surgical boot. The physician's order dated 9/23/22 through 10/26/22 failed to reflect orders to care for a non-removable splint related to status post left foot surgery. The Treatment Administration Record (TAR) dated 9/23/22 through 10/26/22 failed to reflect that the nursing staff had monitored Resident # 41's CMS during the utilization of the non-removable splint. The nurse's notes from 9/23/22 through 10/26/22 failed to reflect evidence the nursing staff provided CMS related to non-removable splint. The nurse's notes from 10/17/22 through 10/26/22 failed to reflect evidence the nursing staff consistently provided CMS and observed the resident's skin integrity underneath the removable left boot. The nurse's note dated 10/26/22 at 7:34 PM identified Resident #41 was evaluated by a wound specialist related to Deep Tissue Injury (DTI) to the left heel, left second toe and left third toe with new order to apply skin prep every shift. Additionally, recommended that the resident not wear boot while in the bed. The wound specialist's progress note dated 10/26/22 at 9:22 PM identified Resident #41 had DTI to the left heel, left second toe and left third toe related to the use of removable left surgical boot. The physician's order dated 10/26/22 directed to apply skin prep to DTI to the left heel, left second toe and left third toe every shift. The wound specialist's progress note dated 11/2/22 at 11:05PM identified Resident #41 had new onset of DTI to left medial great toe. Interview with RN #8 (nursing supervisor) on 4/27/23 at 9:15 AM identified she would reconcile the resident medications and treatment orders prescribed on admission. RN # 8 would then transcribe to the physician orders. She identified the license nurse should check the resident's CMS and skin integrity every shift when resident using a removable boot. RN # 8 could not provide a reason why the orders for the left boot care was not added to the physician's orders because she was not supervisor at that time. Interview with Resident #41 on 4/27/23 at 11:00 AM identified he/she had been using the left boot related to the left leg surgery. Resident # 41 indicated the nursing staff was not removing the strap of the left boot to check his/her skin. He/she further indicated that after the wound develop to his/her left foot then the nurse started to remove the left boot. Interview with License Practical Nurse (LPN #2 wound nurse) on 4/27/23 at 11:40 AM identified she was responsible for monitoring resident's wound and rounding with the wound specialist weekly. She identified Resident # 41 had a developed a new DTI to the left heel, left second toe and left third toe on 10/26/22. She indicated that the wound specialist had seen Resident # 41 DTI to the left heel, left second toe and left third toe related to the use of the left boot. She also indicated she was not aware Resident #41 was using a removable left boot prior to the newly develop pressure wound to the left heel, left second toe and left third toe. She further indicated that the nursing staff should had been monitoring the skin integrity every shift and documented in the clinical chart. Interview with LPN #5 on 4/27/23 at 12:20 PM identified she remembered that Resident # 41 used an orthopedic boot to the left leg. She indicated she would check the resident CMS and skin integrity at least once a shift and would document in the clinical chart. She could not remember whether she took care of Resident # 41 when he/she was using the left orthopedic boot. Interview with Director of Nursing Services (DNS) on 4/27/23 at 12:30 PM identified she expected the nursing staff to check CMS and skin integrity every shift for any residents who using a splint or boot. She indicated the nursing staff would document the care provided in the Treatment Administration Record (TAR) or nurse's note related to the care of a splint or boot. Interview with LPN #4 on 5/1/23 at 11:30 AM identified Resident #41 came back from the orthopedic appointment and the cast to the left leg was removed. She also identified that Resident # 41 had a removable left boot to the left leg. She could not identify whether she checked Resident #41 skin integrity to the left leg related to use of medical device. LPN # 4 indicated she only document in the resident's clinical notes when there was a change from the resident baseline condition. Interview and review of the clinical record with MD #1 (wound specialist) on 5/1/23 at 12:40 PM identified she received a request for a consultation for Resident # 41's DTI to the left heel, left second toe and left third toe. MD #1 indicated the removable left boot hard surface was the cause of the DTI to the left heel, left second toe and left third toe. Clinical record review of MD # 1's progress note dated 10/26/22 identified the DTI to left heel, left second toe, and left third toe caused by Resident # 41 left boot. The left heel initial wound encounter measurement was 1.5 CM length by 2 CM width by 0 CM depth with an area of 3 square CM and described with persistent non-blanchable deep red, maroon/purple discoloration. The left second toe initial wound encounter measurement was 0.5 CM length by 1.5 CM width by 0 CM depth with an area of 0.75 square CM and described with persistent non-blanchable deep red, maroon/purple discoloration. The left third toe initial wound encounter measurement was 0.5 CM length by 0.5 CM width by 0 CM depth with an area of 0.25 square CM and described with persistent non-blanchable deep red, maroon/purple discoloration. Clinical record review of MD #1 progress note date 11/2/22 MD # 1 identified a new onset of DTI to left medial great toe. The left medial great toe initial wound encounter measurement was 0.8 CM length by 0.7 CM by 0 CM depth with an area 0.56 square CM and the wound was noted with persistent non-blanchable deep red, maroon/purple discoloration. MD #1 further indicated she recommended that the nursing staff have a discussion with the orthopedic team about keeping the left boot off while in bed. MD #1 identified the pressure wound was un-avoidable related to the use of the left leg boot, but it should had been identified at the earlier stage rather than DTI. MD #1 also indicated s/he expected the nursing staff to remove the resident's left leg boot and check the skin integrity of the left foot related to the use of medical device. The facility failed to consistently assess the resident's CMS and skin integrity during the utilization of left leg boot to prevent the development of a pressure ulcer. 2 Resident # 12's diagnosis' included Fibromyalgia, polyneuropathy, muscle weakness and diabetes mellitus. The resident was readmitted to the facility on [DATE]. The RCP dated 4/3/23 for resident has a pressure ulcer or potential for pressure ulcer development related to decrease mobility. Intervention included to assess/record/monitor wound healing, measure length, width and depth where possible, assess and document status of wound perimeter , wound bed and healing process, to follow facility policy /protocols for the prevention and treatment of skin breakdown, to teach resident and family the importance of changing positions for prevention of pressure ulcer and to encourage small frequent position changes. A physician's order dated 4/2023 directed a pressure relieving mattress be applied to the bed and to be set to the resident's weight and to check the functions every shift. A physician's order dated 4/2023 directed to reposition Resident #12 every 2 hours and to provide frequent incontinent care every shift. A review of the hospital summary paperwork dated 4/4/2023 indicated after two days in the hospital Resident #12 developed a stage 2 pressure ulcer. The resident was noted with stage 2 pressure ulcers noted on buttocks and areas on both ears. The hospital discharge summary dated 4/4/2023 indicated discharge diagnosis of unstageable pressure ulcer of the right buttock unstageable pressure ulcer of skin and tissue and dermatitis with moisture from urinary and stool incontinence. The hospital transfer Intra-Agency dated 4/4/23 identified Resident #12 had indicated that on 4/4/23 at 8:00 AM(date of readmission to the facility) the Left Gluteal area had moisture. The resident was assessed and noted with associated skin damage(MASD) and possibly an early Deep Tissue Injury which was initially noted on 3/17/2023. On 4/4/23 at 8:00 AM( the day before readmission to the facility) the resident was noted with the right buttocks extending into the coccygeal area and down towards the ischium(3 areas in total) unstageable area first noted on 3/17/2023. On 4/4/2023 at 8:00 AM the resident's right and left ears had unstageable pressure injuries initially noted on 3/17/2023. The facility Admit/readmit evaluation(N) V-1 dated 4/5/2023 completed by and the RN indicated in part identified\ bruising on the coccyx, 5 CM long x 2.5 CM wide x 0 CM deep. The Right buttock indicated a stage 2 pressure ulcer that measured 3.2 CM long x 3.2 CM wide x 0.1 CM deep. A weekly skin monitoring form dated 4/5/2023 at 5:46 PM indicated in part a 3.2 CM stage 2 open area of the skin on the right buttocks. The Braden Scale Evaluation dated 4/5/2023 indicated Resident #32 was a moderate risk for developing a pressure ulcer. The treatment Kardex dated 4/6/2023 at 7:00 AM directed to apply Calmoseptine to the moisture associated skin disorder (MASD) on bilateral buttocks. A wound physician's note dated 4/11/2023 indicated a wound clinician signed off on Resident #12 without a visit to with an assessment and indicated no reason why an assessment had not been conducted. The weekly skin monitoring form dated 4/12/2023 at 4:25 PM indicated right and left ear abrasions, superficial on bilateral earlobes from the oxygen tubing. The physician's order dated 4/12/23 directed cushions to the oxygen tubing after applying skin prep to the ears and the physician's note indicated scratches on the resident's ear. The weekly skin assessment dated [DATE] at 1:24 PM indicated no new skin issues. The weekly skin assessment dated [DATE] at 11:31 AM indicated no new concerns. The Resident Care Card last updated on 5/1/2023 indicated Resident #12 is non ambulatory, requires the assistance of two persons with the use of a mechanical lift and the resident required the assistance of two persons for bed mobility and directed staff to reposition and provide toileting every 2 hours. An observation of Resident #12 on 5/2/2023 at 9:20 AM identified Resident #12 lying on his/her back in bed asleep. Observation was made that a pressure relieving mattress was on the bed with the machine and controls at the foot of the bed on the bed board. Interview on 5/2/2023 with RN #4 at 9:40 AM indicated all the nurses complete the care planning which is a work in progress. RN #4 was unable to identify any documentation and or evidence of Resident # 12's coccyx buttocks pressure ulcers upon readmission to the facility. RN # 4 further indicated she would have expected a description, measurements, and a progress note written weekly for wound rounds. She also indicated on 4/12/23 the clinical record identified a wound physician consultation, but the consult did not indicate the resident was seen by the wound physician. RN #4 consulted with the wound nurse who indicated the physician did see the resident indicated but he does not follow residents who have MASD. RN #4 was unable to produce evidence of documentation regarding the wound status of the stage 2 pressure ulcer that identified on admission (unstageable pressure ulcer in the hospital) or a physician's order which identified that a stage 2 area was assessed and deemed MASD and not a stage 2 pressure ulcer based on the history of the hospital diagnosis. On 5/2/2023 at 10:20 AM the DNS, RN#4, RN# 6, and the surveyor observed Resident # 12's buttocks and coccyx and ears. Observation noted that the skin on the bilateral ears were intact without redness or skin breakdown. The Coccyx and buttock skin observation identified the skin was intact with a pinpoint red area on the left medial buttock with surrounding skin and coccyx intact and pink. An interview on 5/2/2023 at 10:30 AM with RN #4 and the DNS identified staff failed to conduct ongoing monitoring of Resident # 12's skin conditions and pressure ulcer staging with assessment and documentation in accordance to facility practice. They also indicated the skin monitoring and documentation should have been completed. The facility policy labeled Avoidable verses Unavoidable Wounds dated 10/18/2021 notes in part ongoing weekly skin assessments should be documented to identify existing skin integrity status and when pressure ulcers are identified to provide prompt care planning as well as notifying the physician and family. The policy further indicated that the physician and nursing notes should illustrate a coordinated plan of oversite, treatment and consistent follow up. 46117

Based on clinical record review, observation , review of facility documentation and interviews for one of two residents reviewed for Activities of Daily Living for (Resident # 101), the facility failed to ensure that a resident who required device for ambulation received the device timely to promote the resident's independence in mobility . The findings include: Resident #101 was admitted to the facility on [DATE]. The resident's diagnoses included Cellulitis, Sepsis, Hyponatremia, venous stasis ulcer, left leg cellulitis, normocytic anemia, hypoalbuminemia and osteonecrosis and acute osteomyelitis. The hospital discharge summary dated 12/16/21 with an admitted d 12/7/21 to the hospital. The resident primary diagnosis included for discharge left leg cellulitis with osteomyelitis. The resident received surgery for amputation of below the knee secondary to chronic non-healing ulceration to left foot and ankle. Resident reported chronic drainage from this ulceration along with pedal edema despite multiple courses of antibiotics. Resident was admitted to surgical service and started on IV antibiotics with plan to proceed with knee amputation on 12/9/21. Postoperatively patient was evaluated by prosthetic vendor and received an ample shield prior to discharge. At time of discharge pain was well controlled. Additionally directed to follow up with orthopedic in one week. The RCP dated 12/17/21 for resident has an ADL self-care performance deficit related to limited mobility. Interventions included: independent for transfers at wheelchair level, assist of one with ambulation with rehabilitation staff only, to encourage resident to participate to fullest extent possible with each interaction, to praise all efforts at self-care and to provide Physical Therapy ( PT) and Occupational Therapy ( OT) evaluation and treatment per Medical Doctor ( MD) orders. The physician's order dated 12/16/21 to start on 12/17/21 directed prosthetic sock for Below Knee Amputation (BKA) one time a day. Additionally, directed daily pain assessment every shift for pain. The admission MDS assessment dated [DATE] identified the resident was severely cognitively impaired, required supervision with bed mobility, limited assistance one person with transfers, for walking in room, toileting and personal hygiene required extensive one person assistance. The quarterly MDS assessment dated [DATE] identified the resident's cognition and memory were intact, required supervision with bed mobility, independent / supervision with ambulation and supervision for toileting and personal hygiene. The physician's order dated 2/3/23 directed independent with bed mobility and transfers at wheelchair level. Assist of one for short distance hopping for right lower extremity with rolling walker. Observation and interview with Resident # 101 on 4/27/23 at 12:30 PM identified Resident # 101 in the wheelchair groomed appropriately without the benefit of an amputation device. Resident # 101 verbalized to surveyor s/he has not received his/her prosthetic device since he/she was measured for the device by vendor after admission in January 2022. Resident # 101 was also noted with a sock device on left BKA and indicated although s/he can get around from bed to wheelchair the prosthetic device would make the transfer easier. Resident # 101 became tearful and upset while speaking to the surveyor regarding the prosthetic device and indicated he/she had roommate who he/she watch receive a prosthetic device and be discharged while he/she has been waiting months for the device and received no communication from the facility why the device had not been delivered by the vendor from January 2022 to present . Resident # 101 further indicated to surveyor do you how this makes me feel while looking down. A review of the clinical record on 5/1/23 failed to reflect a consultation note from the prosthetic vendor in the clinical record from January 2022. Interview with the DNS and RN# 4 on 5/2/23 at 12:00 PM identified they could not find the prosthetic vendor consultation sheet after the resident's admission in 12/ 2021 but would call the vendor to obtain the consultation. They also indicated they could not explain why Resident # 101 had not received his/her prosthetic device from the vendor to assist with ambulation and thought it may have been related to insurance not covering or the resident could not pay for the device. Both the DNS and RN# 4 indicated they would follow up the consultation sheet and prosthetic device today. Interview with RN # 4 (Corporate Nurse) further indicated she was unaware that Resident # 101 needed a prosthetic device. Interview with the Rehabilitation Director on 5/2/23 at 12:15 PM identified she was told the resident did not have prosthetic device secondary with conservatory ship and insurance problems. However, when she reviewed the resident's clinical record today from 12/21 to 1/18/23, she could not find any documentation from a vendor regarding a prosthetic device and indicated she reached out to the vendor to provide the documentation. The Rehabilitation Director further indicated she would follow up with Resident # 101 today to inform him/her she will be following up on his/her prosthetic device. Interview with RN # 4 on 5/2/23 at 1:30 PM identified there was no concerns regarding the resident's ability to pay for prosthetic device because the resident had adequate funds.

Based on clinical record review, facility documentation review, facility policy review, and interviews for 1 of 6 residents (Resident # 41) reviewed for accidents, the facility failed to ensure the resident was transferred with a [NAME]-lift sling pad in good working condition as specified by manufacture's recommendations prior to transferring the resident to prevent an accident and for two of six sampled residents (Resident #25 and #68) reviewed for accidents, the facility failed to ensure that equipment for resident use was maintained and used in a safe manner. The findings include: 1. Resident # 41's diagnoses included pyogenic arthritis, diabetes mellitus with diabetic neuropathy, infection, and inflammatory reaction due to internal joint prothesis and chronic pain. A physician's order dated 1/30/23 directed to transfer using a [NAME]-lift with 2 people and noted the resident was non-ambulatory. The Resident Care Plan (RCP) dated 8/31/21 and reviewed on 2/8/23 identified Resident # 41 was at risk for fall related to deconditioning, gait, balance problem and history of femur fracture. Interventions directed staff to anticipate and meet the resident's need, to have the call light within reach, ensure resident/family was educated on safety reminders, ensure the resident was wearing proper footwear and directed Physical Therapy (PT) evaluate and treat as needed. Review of Morse scale fall risk assessment dated [DATE] identified Resident # 41 had a score of 15 out of 45 which indicates a low risk for fall. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident # 41 had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicative of no cognitive impairment and required extensive assist with 2 people for bed mobility, transfer, toileting, hygiene, and non-ambulatory. The nurse's note dated 3/29/23 at 3:35 PM identified the Nursing Assistant (NA) alerted the nurse at 3:05 PM that while s/he was transferring Resident # 41 from the chair to the bed using a [NAME]-lift one of the straps of the [NAME]-lift broke off causing the resident to be assisted back to the chair. Resident # 41 complained of left thumb tenderness. The Accident and Incident report dated 3/29/23 identified Resident #41 had an accident with the [NAME]-lift when one of the straps broke off. The investigation noted staff was educated in recognizing a deteriorated sling and an in-house audit was conducted on all slings used in the facility. The audit identified 5 deteriorated slings at which time was removed from the facility. The nurse's notes dated 3/29/23 at 5:35 PM identified Resident # 41's had a transfer status change from [NAME] lift to mechanical lift. Additionally, the notes identified educated that the [NAME] lift does not lift body weight but assist with transfers. Resident # 41 verbalized understanding and agrees with transfer change. The nurse's note dated 4/2/23 at 11:22 AM identified Resident # 41 complained of pain to the left thumb. The left thumb joint area was slightly more prominent compared to the right thumb. An X-Ray for left thumb was ordered secondary to an acute injury. The nurse's note dated 4/3/23 at 8:30 PM identified Resident #41 X-Ray results 20 indicated an acute fracture to the first distal phalanx. A physician's order dated 4/4/23 directed to obtain orthopedic consult for fracture thumb. The physician's progress note dated 4/4/23 identified left thumb distal and recommended splinting of the left thumb and follow up with orthopedics on Friday. Interview with Resident #41 on 4/27/23 at 10:30 AM identified s/he had been using the [NAME]-lift to transfer for several months before the accident happen on 3/29/23. Resident # 14 indicated at the time of the incident the [NAME]-lift strap broke off when the NA #5 and NA #6 tried to transfer him/her from chair to bed. He/she indicated the [NAME]-lift sling looked old and worn out. Resident # 41 further indicated that he/she would alert the staff if he/she was not standing up straight while using the [NAME]-lift. Interview with NA #6 on 4/27/23 at 1:15 PM identified Resident # 41 used [NAME]-lift for transfer. She also identified there was no visible damage to the [NAME]-lift sling pad when she used it to transfer the resident. She identified Resident #41 was leaning more against the [NAME]-lift sling pad when one of the straps that hook onto the [NAME]-lift broke off and Resident # 41 was hanging from his/her side while she assisted him/her back to the chair. NA #4 further indicated there was no change in resident transfer status or condition at the time of the accident. Interview with License Practical Nurse (LPN #6) on 5/1/23 at 10:00 AM identified the accident happen during the change of shift when NA #5 and NA #6 were assisting Resident #41 back to bed. She also indicated that one of the straps that connected to the [NAME]-lift broke off when Resident #41 was being transfer. LPN # 6 further indicated she did not know the condition of the [NAME]-lift sling pad prior to being used to transfer the resident. Interview with Physical Therapist (PT #1) on 5/1/23 at 11:45 AM identified Resident #41 had been using a [NAME]-lift for transfer prior to the accident. She also identified Resident #41 was safe and able to use a [NAME]-lift for transfer because Resident #41 was capable of bearing weight to his/her bilateral lower legs. She indicated she was not aware of any change in resident transfer status prior to the accident. PT # 1 identified Resident #41 continue to work with physical therapy to get him/her back to using a [NAME]-lift. She further indicated that the [NAME]-lift strap should had not broken off despite Resident # 41 leaning more weight against the [NAME]-lift pad. Interview with RN #7 (Former DNS) on 5/2/23 at 11:50 AM identified it was an interdisciplinary team that investigate the [NAME]-lift accident. She indicated NA #6 had a written statement that Resident #41 was putting more weight on the [NAME]-lift sling pad when one the straps broke off. She also indicated that although she did not witness the condition of the [NAME]-lift sling pad used for transfer, the facility conducted an audit of all slings used in the facility. She further indicated that 5 worn slings were removed from the facility after the audit was completed. Attempt to interview NA #5 was unsuccessful during the survey. Review of facility policy title [NAME]-Lift dated 8/16/22 and revised on 10/22/22 identified the facility [NAME]-lift is used by trained staff for lifting and transferring residents only when assessed as safe by physical therapist and as included in the plan of care. The resident must be able to bear weight and have adequate shoulder movement and follow simple directions. The Invacare Reliant 350 stand-up lift manufacturer guideline in part notes that using slings that are bleach, torn, cut, frayed, or broken is unsafe, and their use could result in injury and to discard any sling that meet these criteria immediately. 2. Resident #25's diagnoses included end stage renal disease, weakness and syncope and collapse. A physician's order dated 1/13/2023 directed that Resident #25 attend medical appointments 3 times a week utilizing a wheelchair. The quarterly Minimum Data Set (MDS) dated [DATE] identified Resident #25 had no cognitive impairment and was dependent of two persons for transfer and assistance of one person for locomotion on and off the unit while in a wheelchair. The Resident Care Plan dated 3/13/2023 identified Resident #25 had a deficit in the performance of self-care related to chronic kidney disease. Intervention included in part, to provide Resident #25 assistance with mobility using a wheelchair. An interview with Resident #25 on 4/25/23 at 11:05 AM indicated the specialized treatment transport person was concerned about his/her wheelchair currently used because each brake locks differently one forward and the other backward and further indicated the s/he informed a staff member who said they do not have another chair. An interview with the Administrator on 4/25/2023 at 3:40 PM indicated he would address this concern immediately. An interview on 4/26/23 at 8:40 AM with the Administrator who reports the wheelchair was replaced and that more wheelchairs have been ordered. An interview and review of maintenance logbooks on 4/26/2023 at 8:50 AM with the Maintenance Director indicated the condition of wheelchairs (W/C) are observed by him and the assistant when they are out on the units or in a resident room and any concerns noted would be corrected. Although he also indicated that a monthly check of wheelchairs are completed with the monthly room check, no log confirming completion was provided. The Maintenance Director further indicated that the assistant recently revised the logbook and now he noticed that there is no section for the room checks and would check with his assistant for other documentation, but none was provided. The Maintenance Director further indicated when he replaced the wheelchair for Resident #25 the new wheelchair was inspected by therapy for appropriateness for the resident and that he threw away the old wheelchair secondary to the opposite braking, one of the wheels had excessive wear and no parts could have been salvaged. An interview on 4/27/2023 at 3:05 PM with OT #1 indicated the therapy department provides wheelchairs to residents and indicated that the wheelchair Resident#25 was using was provided by the therapy department and was inspected by the therapists at the time for safety. OT # 1 further indicated s/he believes that the brakes may have been worked on once or twice since. OT # 1 indicated she was not aware Resident#25's wheelchair brakes operated in opposite directions but indicated the other day the Maintenance Director got rid of the wheelchair. OT #1 further indicated that they have had a limited number of wheelchairs and she indicated that it is time to order more. The facility policy labeled use of Wheelchairs initially dated 9/2016 with no update indicated in part wheelchair function and cleanliness should be monitored quarterly per the facility preventative maintenance program. 3. Resident # 68's diagnosis' included cerebral infarction, diabetes mellitus, and chronic kidney disease. The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified no cognitive impairment and required assistance of one person for bed mobility, extensive assistance of one person for transfer and toilet use. The Resident Care Plan dated 3/22/2023 identified Resident #68 had limited physical mobility related to stroke and an Activity of daily living self-care deficit related to a partial lower extremity amputation and a stroke. The care plan also indicated in part Resident #68 is independent to stand pivot transfer from the wheelchair to the toilet. Interventions included in part to provide assistance of one person with Activities of living (ADL's) and Resident #68 is independent with transfers to and from the wheelchair and toilet. A physician's order dated 3/25/2022 identified Resident #68 is independent in transfers to and from the wheelchair to the toilet. An observation on 4/25/2023 at 12:56 PM identified Resident #68's bathroom safety handrail between the sink and the toilet was loose and moves when putting pressure on it. An interview with the Administrator on 4/25/2023 at 12:56 PM identified s/he was made aware of the finding and indicated he would have handrail repaired immediately. An interview on 4/26/2023 at 8:30 AM with the Administrator indicated the safety handrail in Resident #68's bathroom was repaired and sturdy and has a different design rail with support not only on the wall but also on the floor for extra support has been ordered. The ordered handrail device will be installed once received. An interview with the Maintenance Director 4/26/2023 at 2:50 PM indicated the bathrooms are checked monthly, and the log was reviewed noting all monthly checks were initialed as completed and the most recent review was completed March 20th, 2023. 46117

Based on review of the clinical record, facility documentation, facility policy, and interviews for 1 of 5 residents (Resident #212) reviewed for pressure ulcers, the facility failed to ensure the resident was free from neglect with resulting physical harm when necessary care and services were not provided including skin assessments, RN assessments of wounds, and notification to the physician and dietitian of changes in skin condition. Further, the facility failed to complete treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Subsequent to these failures, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. The Findings include: Resident #212 was readmitted to the facility on [DATE] with diagnoses that included dementia, stroke and hypertension. Review of the clinical record failed to reflect that a full nursing readmission evaluation, including a skin assessment, had been completed on 3/30/22 by a registered nurse when Resident #212 returned from the hospital. A progress note written by APRN #2, dated 3/31/22 at 12:55 AM identified that Resident #212 had bilateral heel pressure injuries. During an interview with APRN #2 on 10/20/22 at 3:05 PM she described the heels as red and boggy but intact. The note lacked a thorough assessment of the heels including a wound description, measurements; length, width, and depth, drainage, pain associated with the wound, odor and condition of surrounding skin. Further, APRN #2 did not make recommendations or write an order for treatment to the heels. The admission MDS assessment dated [DATE] identified Resident #212 had severely impaired cognition, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and required 2-person total assistance with transfers. Additionally, Resident #212 was at risk for skin breakdown or pressure ulcer development but did not have any current pressure ulcers. A nurse's note dated 4/13/22 at 9:50 PM, written by LPN #12, identified that Resident #212 verbalized discomfort in both heels, and upon observation, the heels were discolored. A progress note written by APRN #2 dated 4/14/22 at 12:09 AM identified nursing reported Resident #212 had blackened areas to both heels and the resident was complaining of pain and discomfort to both heels. APRN #2 elevated both feet with pillows and diagnosed the right and left heel's as unstageable pressure ulcers with recommendations to start skin prep 2 times a day to blackened areas on bilateral heels. The note lacked a thorough assessment of the heels including a wound description, measurements; length, width, and depth, drainage, pain associated with the wound, odor and condition of surrounding skin. A review of the clinical record from 4/14/22 - 5/21/22, (5 weeks,) lacked weekly pressure ulcer assessments by a RN of the resident's heels. Although APRN #2 documented on 3/31/22 that Resident #212 had bilateral heel pressure injuries, and on 4/14/22 had blackened areas to both heels and was complaining of pain and discomfort, the Wound Physician, MD #1 did not see the pressure ulcers on the heels until 5/27/22, 8 weeks after the heels were identified as pressure injuries and 6 weeks after the heels were noted to be black. A progress note written by the Wound Physician, MD #1, dated 5/27/22 identified Resident #212 was seen in an initial consultation for evaluation of bilateral heel wounds. The left heel was identified as a stage III pressure ulcer that measured 1.4cm by 0.7cm by 0.2 cm with no slough or eschar. The right heel was identified as an unstageable pressure ulcer that measured 2.5cm by 2.5cm by 0 depth with 76 - 100% eschar and no drainage. Resident #212 reports pain to both heels. Recommendations included pressure relief and offloading of heels, facility pressure ulcer prevention protocol, a group 2 powered pressure reducing mattress, offload pressure by repositioning patient every 2 hours, and optimize nutrition with a registered dietitian consultation. Plan of care discussed with ADNS #2. (There was no documentation in the record to indicate the air mattress had been ordered or implemented or signed off in the TAR until 7/14/22 and the dietitian did not evaluate the residents condition related to the pressure ulcers until 6/11/22 (for a period of 2 months following the identification). In an interview with DNS #2 on 10/20/22 at 9:10 AM DNS #2 identified the physicians order for an air mattress did not go into place until 7/14/22. DNS #2 identified that an air mattress had not been ordered from an outside vendor and the maintenance record did not show an air mattress had been placed until 7/14/22. Interview with MD #1 on 10/20/22 at 10:00 AM identified that the nurse who does wound rounds with her weekly is responsible to write the orders for the recommendations she makes during wound rounds. Although APRN #2 documented on 3/31/22 that Resident #212 had bilateral heel pressure injuries, and on 4/14/22 had blackened areas to both heels, and MD #1 asked for a dietitian consultation to optimize nutrition on 5/27/22, the dietitian did not evaluate the resident's nutritional status related to the wounds until 6/11/22, 8 weeks after the heels were identified as blackened and 2 weeks after MD #1 asked for a dietitian consultation. A dietitian note dated 6/11/22 identified skin; pressure injury right heel unstageable no change, left heel unstageable no change, DTI right and left Achilles new. Further, the resident is being followed by MD #1. Recommendations include add Resources 2.0 - 60 ml's 2 times a day, cottage cheese with fruit 3 times a week, and increase the liquid protein to 30ml's to 3 times a day. A Wound Physician note, written by MD #1, dated 6/10/22 identified the resident's bilateral heel wounds are stable with 100% eschar. Will reclassify left heel to unstageable today. There are new non blanchable discolorations to both Achilles, consistent with Deep Tissue Injury (DTI). Will change treatment to betadine every shift to all areas and ensure patients heels are appropriately off-loaded. A nurse's note dated 6/11/22 by LPN #13 identified Resident #212 had a left hip abrasion (new area). Monitor area every shift and position off hip as tolerated over weekend. Left hip abrasion put in APRN book for follow up on Monday, 6/13/22. The record failed to reflect an RN assessment of the left hip had been done or that the physician/APRN had been immediately notified of the new area. A wound note, written by MD #1 dated 6/24/22 at 8:35 PM identified bilateral lower extremity wounds were stable, and there is a new left hip wound. Nursing reports overall decline. The left hip is unstageable, measures 5.0cm by 3.0cm by 0.1cm with a small amount of serosanguinous drainage, and wound bed with 76 - 100% slough. Resident reports pain to hip. Start Alginate with Silver followed by dry clean dressing daily and as needed if soiled. A physician's order dated 6/27/22 directed to apply Betadine to the left outer ankle every shift for DTI. (New area). A physician's order dated 7/14/22 directed to apply a pressure reducing mattress to the bed, check function every shift. The nurse's note dated 7/20/22 at 10:44 PM by LPN #16 identified that the dressing to the left hip had a foul odor and large amount of purulent drainage. (The note lacked documentation that the physician/APRN had been made aware). A progress note written by APRN #2 dated 7/27/22 at 1:05 AM identified Resident #212 had poor appetite, poor fluid intake, weakness, bilateral heel wounds, a left hip wound and right elbow wound. Responsible party requested Resident #212 be sent to the emergency room . Resident #212 tested positive for Covid-19 and was sent to the emergency room for further evaluation. Interview with DNS #2 on 10/20/22 at 9:10 AM and 1:15 PM indicated that when Resident #212's bilateral heel dressings were found as not being changed for 20 days it should have been reported to the state agency as neglect and she does not know if education was completed or if an investigation was done. DNS #2 found wound education done in July with about 10 nurses from an outside vendor. DNS #2 identified the APRN, or physician and family should be notified the same day with changes in condition and obtain new treatment orders. DNS #2 indicated that the nurses should not leave new wounds for notification in the APRN book and must call the APRN. DNS #2 noted all wounds are to be measured initially and then weekly by the RN with a description of the wound bed and the peri wound area. DNS #2 noted Resident #212 was at risk for skin breakdown on admission and should have had an air mattress from admission but when APRN #2 noted on 3/30/22 bilateral heel injuries, the air mattress should have been placed then or if it had to be ordered within a day or two. DNS #2 noted she could not confirm when the air mattress was initiated because the physicians order for an air mattress did not go into place until 7/14/22. DNS #2 identified that the registered nurses are responsible to do the admission body assessment but noted an LPN did the body assessment for Resident #212 on the resident's first admission, and a body audit or skin assessment was not done when the resident was readmitted from the hospital on 3/30/22. DNS #2 noted the dietitian should have seen Resident #212 no later than a week after the APRN wrote the note on 3/30/22 noting bilateral heel pressure injuries. DNS #2 noted the dietitian did not see Resident #212 for the wounds until 6/11/22, over 2 months later. Interview with the previous DNS, (DNS #1) on 10/20/22 at 9:15 AM (DNS #1 left facility employment on 9/20/22, DNS #2 assumed the role of DNS on 9/20/22) identified that a dressing was on a resident's heels that had not been changed for an extended period of time and she thought it was Resident #212 who resided on Center 2 unit. DNS #1 did not recall if she did an investigation or reported the incident to the state agency. DNS #1 did not recall the dates, who reported it to her, or who found it. DNS #1 indicated she expected the nurses to follow the physician's orders but did not recall if she did a reportable event form or investigation or education at that time the dressing was not changed for 20 days. DNS #1 did not know there was no RN assessment of the resident ' s wounds, she just knew the APRN was aware. Interview with the Wound Physician, MD #1, on 10/20/22 at 10:00 AM identified she was consulted to see Resident #212 on 5/27/22 by ADNS #2 and updated about the resident's heels. MD #1 noted that ADNS #2 informed her Resident #212 had bilateral heel dressings left on for an extended period of time prior to her seeing Resident #212. MD #1 indicated on the first visit the heels were already broken down and she did not know why she was not consulted earlier. MD #1 noted on the initial visit the heels had depth, the left heel was a stage III with a small amount of drainage, and the right heel was unstageable with eschar. MD #1 identified that moisture gets trapped under a dressing and it is never good to leave a dressing on for longer than the physician orders it to be on. MD #1 noted that the heel that had eschar should not have had a dressing on it, it should have been treated with betadine. MD #1 noted the longest time a dressing could stay on would be for a hydrocolloid dressing for 5 days, but she would write for every 3 days to make sure it would get changed. MD #1 noted the wound needs to be cleaned and changes done often so germs and moisture don't build up. Interview LPN #17 on 10/20/22 at 10:32 AM identified that on 5/21/22 a nurse aide notified her that Resident #212 had dressings on both heels that needed to be looked at. Upon further observation, the dressings on both of Resident #212's heels were dated 4/30/22, 20 days prior. The left heel dressing appeared to be saturated in a yellowish-brown color that was dry on the outside, but moist on the inside. LPN #17 noted the wound bed was eschar in the center with a red open area around the eschar and slough. LPN #17 noted the right heel dressing had a moderate amount of dark brown dry drainage on the outside and slight moisture inside. The wound bed was yellow slough with red edging and pink area surrounding the wound bed surrounded by a dry flaky callous. LPN #17 noted she did not measure either the left or right heels because she reported it to the Supervisor, (RN #5), and APRN #2. LPN #17 indicated she took a picture of the heels with the dressings on and off and text them to APRN #2 to notify her that the dressings had been on since 4/30/22. LPN #17 requested an antibiotic because the heels looked infected and disgusting. LPN #17 indicated that at that time, Resident #212 had an order for skin prep to both heels. LPN #17 indicated although she notified RN #5 about the heels that shift that day, he did not come to the unit to assess the resident's heels during her shift. Interview with Dietitian #2 on 10/20/22 at 11:45 AM indicated she was not notified of the resident's wounds until the last week of May 2022. Dietitian #2 noted if she had been made aware when of the pressure ulcers on the resident's heels, she would have done an assessment, including an assessment of the resident's protein levels. Dietitian #2 indicated Resident #212 was on the low side of body weight and she would have added fortified drinks and food. Dietitian #2 noted she would have prioritized protein high foods like cottage cheese and added multivitamins. Dietitian #2 indicated if the resident has pressure areas, the resident should have been evaluated by a dietitian within 72 hours after admission and interventions would be put in place at that time. Dietitian #2 indicated if there was a new pressure ulcer, it should be on the weekly wound report. Dietitian indicated she could not remember if she got the weekly wound reports during this timeframe and indicated for a timeframe, she was not getting them at all. Dietitian #2 identified if she had been made aware of the wound, she would have seen the resident immediately and if she wasn't in the facility, she would see the resident the next time she was in the facility. Dietitian #2 indicated it would be a priority. Interview with APRN #2 on 10/20/22 at 3:05 PM identified she had seen Resident #212 for readmission on 3/31/22 and documented the resident had bilateral heel pressure injuries. APRN #2 indicated although not in the note, the resident's heels were soft, red, and boggy but intact. APRN #2 noted she assumed nursing had already put skin prep in place. APRN #2 noted she did not write an order or interventions to address the heels because she assumed that nursing would have done that on admission. APRN #2 noted she was notified on 4/14/22 that the bilateral heels were a dark brown to black color, so she ordered skin prep twice a day and assumed the wound nurse would see Resident #212. APRN #2 noted she was not informed there was anything wrong with Resident #212's bilateral heels from 4/30/22 - 5/21/22. APRN #2 noted she was made aware on 5/21/22 via text from an LPN that the bilateral heels had a dressing on them dated 4/30/22, 20 days prior. APRN #2 noted 5/21/22 was a Saturday and she did not look at the bilateral heels, she just informed the nurse to have the wound physician look at them because there was not a consistent nurse doing wound rounds with MD #1 or general wound rounds. APRN #2 noted she had put Resident #212 on an antibiotic at that time. APRN #2 indicated she was not notified that Resident #212 had any abrasions, redness, or open areas on the hips or left ankle. Although a dressing dated 4/30/22 was on both of the resident's heels until 5/21/22 20 days, interview with LPN #11 on 10/21/22 at 1:30 PM, who worked on 5/3, 5/9, 5/12 and 5/18/22 caring for Resident #212 identified she signed the TAR and identified the border gauze was changed as per the order. LPN #11 indicated she only remembered there was a skin prep order and does not remember signing off on changing the border gauze. LPN #11 indicated she does not know how she applied the skin prep if there was a border gauze dressing already on the heels. In another interview with DNS #2 on 10/26/22 at 9:05 she identified she had meet with LPN #14 who came in and completed a written a statement on 10/21/22. DNS #2 noted LPN #14 informed her that she had missed doing the skin prep to Resident #212's heels a few times and forgot to go back and circle the treatment as not being done. DNS #2 noted LPN #14 informed her she would lift up the corner of the dressing that was on the heel and put the skin prep under the dressing when she had the supplies. DNS #2 indicated LPN #14 informed her she would sign off on all the treatments in the TAR, make a list, and then later go do the treatments. At times that was how she forgot to go back and circle some of the skin prep treatments as not being done. DNS #2 noted LPN #14 informed her she did not notice the date of dressing on Resident #212's heels as 4/30/22 all the times she had applied skin prep under the dressing. DNS #2 indicated her expectation would be that the nurses would follow the physician's orders for treatments, and that an RN would do an assessment of any new wound or if there was a change in the wound like more drainage. Further, the RN is responsible to do wound measurements weekly and if there was a change in the wound, the RN is responsible to notify the physician or APRN, and document who was notified, when notified and of what. Further, DNS #2 could not provide documentation that a registered nurse ever assessed the resident's wounds, and the only assessments of the resident's wounds were done by MD #1. DNS #2 identified the dietitian should have known on admission that Resident #212 had wounds and should have seen the resident immediately and put intervention in place at that time and continue to follow the resident to make sure the interventions were working, or if resident had developed new areas. DNS #2 indicated she does not know what happened at that time other than no one was paying attention that the treatments were not being done. DNS #2 indicated there was no explanation or justification for the dressings to have stayed on from 4/30/22 - 5/21/22. DNS #2 noted there was no RN assessment done on 3/30/22 when the resident was admitted , and she did not know why. DNS #2 indicated she was not able to determine the type of mattress Resident #212 was on and based on clinical record review, the air mattress went on the bed on 7/14/22 when there was a physician's order for it. Further, DNS #2 indicated that after review of the nursing schedule, there was no nurse listed on the schedules to do treatments, and that from her investigation there was no treatment nurse until July or August 2022. DNS #2 identified there was no treatment nurse between March 2022 - June 2022. Interview with LPN #11 on 10/26/22 at 9:30 AM, who was the 7:00 AM to 3:00 PM nurse on Center 2 unit on 5/3, 5/4, 5/9, 5/10, 5/12, 5/13, 5/16, 5/17, 5/18, 5/19 and 5/20/22 and was the charge nurse for Resident #212 (the timeframe that both heel dressings had not been changed 4/30/22 - 5/21/22). LPN #11 indicated that she did not do treatments on those days because there was a treatment nurse from North 2 to do all her treatments on the day shift. Review of the nursing schedules with LPN #11 failed to reflect a treatment nurse was assigned to do treatments on her unit and LPN #11, in revieing the schedule, could not identify who she though had done the treatments for her on those dates. LPN #11, in review of the schedule, could not identify who did the treatments those days. LPN #11 identified she just signed off on the treatments as being done, but the treatment nurse was supposed to do them. LPN #11 identified the treatment nurse would not sign the TAR, so LPN #11 did. LPN #11 noted most of the nurses were from the agency. LPN #11 noted she saw the nurse on the floor, so she assumed she did the treatments. Although review of the nursing schedules at that time, LPN #11 could not identify what nurse she was referring to. LPN #11 identified she just made sure Resident #212 had waffle boots on. LPN #11 noted during that time the nursing assistants did not report to her that the dressings on the heels were old or to look at the heels. Review of the nursing schedules with LPN #11 dated 5/1/22 - 5/21/22 identified she could not recall who did the treatments on the days she signed the treatments as having been completed. LPN #11 indicated no one told her to sign the treatments as completed on the TAR without doing them but all the nurses did it. LPN #11 indicated that unit had a very heavy medication pass and a lot of treatments. LPN #11 indicated she had told the ADNS and DNS #1 that she needed help, but nothing changed. Interview with LPN #14 on 10/26/22 at 12:45 PM indicated she was full time on 3:00 PM - 11:00 PM on the Center 2 unit and worked 5/2, 5/3, 5/4, 5/5, 5/8, 5/8, 5/9, 5/10, 5/12, 5/13, 5/17, 5/18, 5/19 and 5/21/22 (the timeframe that both heel dressings had not been changed 4/30/22 - 5/21/22). Although she was not able to give a date, LPN #14 notified RN #5 that the residents heels were red with small black dots on each and he said to put boarder gauze treatment in place to be done on day shift. LPN #14 identified the unit was heavy and they started having the North 2 nurses come help with treatments. LPN #14 noted after the medication pass, she would sign off on all the resident's treatments on the TAR ahead of time because she was going to go do it. LPN #14 identified if she did not have the supplies to do the treatments she had signed as completed, she would forget to go back and strike it out as not being done. LPN #14 identified she did not have supplies and she should not have signed that those treatments as having been done before she had the supplies. LPN #14 indicated for the 12 days she signed off that Resident #212's treatments had been done, she did not do the treatments because she did not have supplies and forgot to strike out that she did not do it. LPN #14 recalls there was one day that there was a nurse from another unit that was going to come over and do her treatments, so she signed them off as done, but did not know if the other nurse did the treatments or not. LPN #14 indicated she did not see the heel dressings dated 4/30/22 between 5/1/22 - 5/20/22 because she did not do the skin prep as per the physician's order, and instead just signed off on the treatment as done but did not do them. LPN #14 noted when she did not have the skin prep and she did not have the supplies, she would write it on the supply sheet on the unit and would not bother the supervisor because she would be busy with admissions. LPN #14 noted the nurse aides between 5/1/22- 5/20/22 never informed her to look at Resident #212's heel dressings. Although attempted, an interview with ADNS #2, RN #5, LPN #18 was unable to be obtained. Review of the Avoidable vs. Unavoidable Wounds Policy dated 10/18/21 identified the facility must establish that it provided care that was reasonably necessary to prevent the formation of pressure ulcers and must institute prevention measures promptly for a resident at high risk for developing pressure ulcers. Complete a Braden scale assessment on admission and for 4 weeks that addresses predisposing medical conditions, potential risk factors, pressure intensity and duration, muscle mass, mobility status, (especially in the bed and chair), urinary and fecal incontinence, feeding assistance, pressure ulcer history, recent weight loss, cognition, and a skin exam. Additionally, conduct and document ongoing weekly skin assessments. Implement care planned interventions for routine skin care such as treatments, identify repositioning needs, determine incontinent care, evaluate pain, and evaluate nutrition and hydration status. When a pressure ulcer is identified provide prompt care planning, notification to the physician and the family, and implementation of interventions designed to minimize or resolve the pressure ulcer. Inform the physician and the family by proving ongoing assessments, wound and treatment status information to the physician, resident and family and document notification and response. Treatments by the physician and nursing notes should illustrate a coordinated plan of oversight with treatments and consistent follow up. Review of the Pressure Ulcer Policy identified prevention of pressure ulcers requires early identification of at-risk resident ' s and the implementation of prevention strategies. Identify residents at risk and initiate an early prevention program. A skin assessment along with a Braden scale will be done upon admission and for 4 weeks. Skin assessments are done by a licensed nurse weekly and the Braden Scale will then be done quarterly. A Braden scale score of 14 or less indicates a risk for skin breakdown. So, assess and preparation of identified risk factors, immobilization, sensory loss such as a stroke or spinal cord injury, malnutrition, diabetes, incontinence, age, dehydration, edema, existing or history of pressure ulcers. Assess residents' skin over regions of pressure skin color for redness, purplish, or blue and was tissue boggy or firm. Educate staff and resident on risks for developing pressure ulcers. Review of the Abuse and Neglect policy defines neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The facility prohibits the mistreatment, neglect, and abuse of residents and misappropriation of resident/patient property by anyone including staff, family, friends, etc. The facility has designed and implemented processes, which strive to ensure the prevention and reporting of suspected or alleged resident/patient abuse, neglect, mistreatment, and/or misappropriation of property. All allegations of abuse, mistreatment or misappropriation will be reported to CT DPH within 2 hours per Federal Elder Justice Act. The facility failed to ensure Resident #213 was free from neglect with resulting physical harm. The facility failed to provide care including skin assessments, RN assessments, notification to the physician of changes in skin, notification to the dietitian of changes in skin, and treatments according to the physicians to prevent the development and worsening of pressure ulcers. Further, although the resident had orders for skin prep to the heels twice daily, on 5/21/22, dressings were found on the resident ' s heels dated 4/30/22, 20 days prior. Subsequently, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy.

Based on review of the clinical record, facility documentation, facility policy, and interviews for 3 of 4 residents (Resident #212, 213 and 95) reviewed for pressure ulcers, the facility did not provide necessary care and services including skin assessments, RN assessments of wounds, and notification to the physician and dietitian of changes in skin condition. Further, the facility failed to complete treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Subsequent to these failures, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. The Findings include: 1. Resident #212 was readmitted to the facility on [DATE] with diagnoses that included dementia, stroke, and hypertension. A progress note by APRN #2, dated 3/31/22 at 12:55 AM identified that Resident #212 had bilateral heel pressure injuries. During an interview with APRN #2 on 10/20/22 at 3:05 PM she described the heels as red and boggy but intact. The note lacked a thorough assessment of the heels including a wound description, measurements; length, width, and depth, drainage, pain associated with the wound, odor and condition of surrounding skin. Further, APRN #2 did not make recommendations or write an order for treatment to the heels. The admission MDS dated [DATE] identified Resident #212 had severely impaired cognition, was always incontinent of bowel and bladder, required extensive assistance with bed mobility, dressing, toilet use, and personal hygiene, and required 2-person total assistance with transfers. Additionally, Resident #212 was at risk for skin breakdown or pressure ulcers but did not have any current pressure ulcers. A physician's order dated 4/3/22 directed to apply border foam gauze to both heels every 3 days. The clinical record lacked documentation of an assessment of the heels. A nurses note dated 4/13/22 at 9:50 PM, written by LPN #12, identified that Resident #212 verbalized discomfort in both heels, and upon observation, the heels were discolored. This was placed in APRN book for further follow up. A progress note written by APRN #2 dated 4/14/22 at 12:09 AM identified nursing reported Resident #212 had blackened areas to both heels and the resident was complaining of pain and discomfort to both heels. APRN #2 elevated both feet with pillows and diagnosed the right and left heel's as unstageable pressure ulcers with recommendations to start skin prep two times a day to blackened areas on bilateral heels. A thorough assessment of the heels was not documented including a wound description, measurements; length, width, and depth, drainage, pain associated with the wound, odor and condition of surrounding skin. A physician's order dated 4/14/22 directed to apply skin prep to both heels 2 times a day and to apply bunny boots to both feet. The order failed to address or discontinue the 4/3/22 order which directed to apply border foam gauze to both heels every 3 days. The clinical record dated 4/14/22 - 5/21/22, 5 weeks, lacked weekly wound assessment documentation of the resident's heels and evidence of turning and repositioning. A nurse's note dated 5/21/22 at 11:21 PM written by ADNS #2, indicated there were new orders for Amoxicillin (antibiotic) 875 mg twice a day, ProSource 30 ml (protein supplement) twice a day, and treatment orders for the pressure ulcers to both heels per the APRN. A physician's order dated 5/23/22 directed to apply bunny boots at all times to both blackened heels. Although APRN #2 documented on 3/31/22 that Resident #212 had bilateral heel pressure injuries, and on 4/14/22 had blackened areas to both heels and was complaining of pain and discomfort, the Wound Physician, MD #1 completed her first assessment of the heels on 5/27/22, 8 weeks after the heels were identified as pressure injuries and 6 weeks after the heels were noted to be black. A progress note written by the Wound Physician, MD #1, dated 5/27/22 identified Resident #212 was seen in an initial consultation for evaluation of bilateral heel wounds. The note indicated: The left heel was identified as a stage III pressure ulcer that measured 1.4cm by 0.7cm by 0.2 cm with no slough or eschar. The right heel was identified as an unstageable pressure ulcer that measured 2.5cm by 2.5cm by 0 depth with 76-100% eschar and no drainage. Resident #212 reports pain to both heels. Recommendations included pressure relief and offloading of heels, facility pressure ulcer prevention protocol, a group 2 powered pressure reducing mattress, offload pressure by repositioning patient every 2 hours, and optimize nutrition with a registered dietitian consultation. Plan of care discussed with ADNS #2. (There was no documentation in the record to indicate the air mattress had been ordered or implemented or signed off in the TAR until 7/14/22 and the dietitian did not evaluate the residents condition related to the pressure ulcers until 6/11/22 (for a period of 2 months following the identification). In an interview with DNS #2 on 10/20/22 at 9:10 AM DNS #2 identified the physicians order for an air mattress did not go into place until 7/14/22. DNS #2 identified that an air mattress had not been ordered from an outside vendor and the maintenance record did not show an air mattress had been placed until 7/14/22. Interview with MD #1 on 10/20/22 at 10:00 AM identified that the nurse who does wound rounds with her weekly is responsible to write the orders for the recommendations she makes during wound rounds. A Wound Physician note, written by MD #1 dated 6/10/22 identified the bilateral heel wounds are stable with 100% eschar. Will reclassify left heel to unstageable today. There are new non blanchable discolorations to both Achilles, consistent with Deep Tissue Injury (DTI). Will change treatment to betadine every shift to all areas and ensure patients heels are appropriately off-loaded. (New areas identified by MD #1). Although APRN #2 documented on 3/31/22 that Resident #212 had bilateral heel pressure injuries, and on 4/14/22 had blackened areas to both heels, and MD #1 asked for a dietitian consultation to optimize nutrition on 5/27/22, the dietitian did not evaluate the resident's nutritional status related to the wounds until 6/11/22, 8 weeks after the heels were identified as blackened and 2 weeks after MD #1 asked for a dietitian consultation. A dietitian note dated 6/11/22 identified skin; pressure injury right heel unstageable no change, left heel unstageable no change, DTI right and left Achilles new. Further, the resident is being followed by MD #1. Recommendations include add Resources 2.0 - 60 ml's 2 times a day, cottage cheese with fruit 3 times a week, and increase the liquid protein to 30ml's to 3 times a day. A nurse's note dated 6/11/22 by LPN #13 identified Resident #212 had a left hip abrasion. Monitor area every shift and position off hip as tolerated over weekend. Left hip abrasion put in APRN book for follow up on Monday. The record failed to reflect an RN assessment of the left hip had been done. Interview with DNS #2 on 10/26/22 at 12:25 PM identified her expectation would be that an RN would do an assessment of any new wound or if there was a change in the wound like more drainage. Further, the RN is responsible to do wound measurements weekly and if there was a change in the wound or skin, the RN is responsible to notify the physician or APRN, and document who was notified, when notified and of what. The clinical record indicated that on 6/14/22 Resident #212 was transferred to the emergency department due to stroke like symptoms. The hospital discharge summary, upon the resident's return to the facility, dated 6/14/22 identified Resident #212 was brought to the emergency room and noted with a stage 1 pressure ulcer to the left hip. Skin non blanchable with redness, dressing applied. Bilateral lower extremities with contractures. A nurse's note dated 6/19/22 written by LPN #14 identified that the left hip blister has opened. LPN #14 reported the opening to the supervisor. Border foam in place. The note lacked an RN assessment and physician notification. A progress note written by APRN #2 dated 6/21/22 at 10:25 PM identified the blister to the left hip has opened. Recommendations included to cleanse the left hip with normal saline, apply bacitracin followed by clean dry dressing over open blister once a day and update the wound nurse. The note failed to document a thorough wound assessment. A wound note, written by MD #1 dated 6/24/22 at 8:35 PM identified bilateral lower extremity wounds were stable, and there is a new left hip wound. Nursing reports overall decline. The left hip is unstageable, measures 5.0cm by 3.0cm by 0.1cm with a small amount of serosanguinous drainage, and wound bed with 76 - 100% slough. Resident reports pain to hip. Start Alginate with Silver followed by dry clean dressing daily and as needed if soiled. The nurse's note dated 6/27/22 at 1:46 PM by LPN #15 identified Resident #212's left outer ankle was dark red/purple in color. The wound nurse was updated and obtained new orders for betadine. A physician's order dated 6/27/22 directed to apply betadine to the left outer ankle every shift for DTI. A wound note written by a wound physician, MD #3, dated 7/8/22, covering for MD #1, identified the left hip with lifting slough will need debridement. Although MD #1 made a recommendation on 5/27/22 for pressure relief, including a group 2 powered pressure reducing mattress, the order was not written until 7/14/22. A physician's order dated 7/14/22 directed to apply a pressure reducing mattress to the bed and check function every shift. Interview with MD #1 on 10/20/22 at 10:00 AM identified that she would give recommendations to the nurse who was doing wound rounds with her weekly and that nurse was responsible to write the orders and implement the recommendations. The nurse's note dated 7/20/22 at 10:44 PM by LPN #16 identified that the dressing to the left hip had a foul odor and large amount of purulent drainage. The note lacked an RN assessment and physician notification. The wound physician note, written by MD #1 dated 7/22/22 at 7:28 PM identified no change in the left and right heels. The left hip is a stage III pressure ulcer with undermining noted at 1:00 o'clock and ends at 12:00 o'clock with a maximum distance of 6.5 cm. A large amount of serosanguinous drainage noted and wound bed 76 - 100% slough. The wound is deteriorating. Treatment orders in place. The note lacks assessment of the right hip wound. A progress note written by APRN #2 dated 7/27/22 at 1:05 AM identified Resident #212 had poor appetite, poor fluid intake, weakness, bilateral heel wounds, a left hip wound and right elbow wound. Responsible party requested Resident #212 be sent to the emergency room . Resident #212 tested positive for Covid-19 and was sent to the emergency room for further evaluation. Interview with DNS #2 on 10/20/22 at 9:10 AM and 1:15 PM indicated that in May 2022, Resident #213's dressing was found to have not been changed for 20 days. DNS #2 identified that should have been reported to the state agency as neglect and she does not know if education was done or if an investigation was done. DNS #2 found wound education done in July by an outside vendor that had approximately 10 nurses listed. DNS #2 identified the APRN or physician and family should be notified the same day with changes in condition and new treatment orders. DNS #2 indicated that the nurses should not leave new wounds for notification in the APRN book and must call the APRN. DNS #2 noted all wounds are to be measured initially and then weekly by the RN with a description of the wound bed and the peri wound area. DNS #2 noted Resident #212 was at risk for skin breakdown on admission and should have had an air mattress put in place on admission, but when APRN #2 noted on 3/30/22 the resident had bilateral heel pressure injuries, the air mattress should have been placed then or if it had to be ordered, it should have been placed within a day or two. DNS #2 noted she could not confirm when the air mattress was placed because the physicians order for an air mattress did not go into place until 7/14/22. (Although MD #1 recommended a pressure relieving mattress on 5/27/22, there was no documentation or indication from staff interviews or record review that MD #1's recommendations were written as a physician's order and implemented). DNS #2 identified that the registered nurses are responsible to do the admission body assessment but noted an LPN did the body assessment for Resident #212 on the resident's first admission 3/21/22, and a body audit/skin assessment was not done when the resident was readmitted on [DATE]. DNS #2 noted the dietitian should have seen Resident #212 the next time she was in the facility and no later than a week after the APRN wrote the note on 3/30/22 noting bilateral heel pressure injuries. DNS #2 noted the dietitian did not see Resident #212 for the wounds until 6/11/22, over 2 months later. Interview with the previous DNS, (DNS #1) on 10/20/22 at 9:15 AM (left facility employment on 9/20/22, DNS #2 assumed the role of DNS on 9/20/22). DNS #1 did recall that it was identified that a dressing was on a resident's heels that had not been changed for an extended timeframe. DNS #1 indicated she thought it was Resident #212 who resided on Center 2 unit. DNS #1 did not recall if she did an investigation or reported the incident to the state agency. DNS #1 did not recall the dates, who reported it to her, or who found it. DNS #1 indicated she expected the nurses to follow the physician's orders but did not recall if she did a reportable event form or investigation or education at that time the dressing was not changed for 20 days. DNS #1 did not know there was no RN assessment of the wounds, she just knew the APRN was aware. Interview with the Wound Physician, MD #1, on 10/20/22 at 10:00 AM identified she was consulted to see Resident #212 on 5/27/22 by ADNS #2 and updated about the resident's heels. MD #1 noted that ADNS #2 informed her Resident #212 had bilateral heel dressings that had been left on for an extended period of time prior to her seeing Resident #212. MD #1 indicated on the first visit the heels were already broken down and she did not know why she was not consulted earlier. MD # 1 noted on the initial visit the heels had depth, the left heel was a stage III with a small amount of drainage, and the right heel was unstageable with eschar. MD #1 indicated that based on her experience, germs and moisture get trapped under dressings, and it is never good to leave a dressing on for longer than the physician orders it to be on. MD #1 noted that the heel that had eschar should not have had a dressing on it, it should have been treated with betadine. MD #1 noted the longest time a dressing could stay on would be for a hydrocolloid dressing for 5 days, but she would write for every 3 days to make sure it would get changed. MD #1 noted the wound needs to be cleaned and changes done often so germs and moisture don't build up. Interview LPN #17 on 10/20/22 at 10:32 AM identified that on 5/21/22 a nurse aide notified her that Resident #212 had dressings on both heels that needed to be looked at. Upon further observation, the dressings on both of Resident #212's heels were dated 4/30/22, 20 days prior. The left heel dressing appeared to be saturated in a yellowish-brown color that was dry on the outside, but moist on the inside. LPN # 17 noted the wound bed was eschar in the center with a red open area around the eschar and slough. LPN #17 noted the right heel dressing had a moderate amount of dark brown dry drainage on the outside and slight moisture inside. The wound bed was yellow slough with red edging and pink area surrounding the wound bed surrounded by a dry flaky callous. LPN #17 noted she did not measure either the left or right heels because she reported it to the Supervisor, (RN #5), and APRN #2. LPN #17 indicated she took a picture of the heels with the dressings on and off and text them to APRN #2 to notify her that the dressings had been on since 4/30/22. LPN #17 requested an antibiotic because the heels looked infected and disgusting. LPN #17 indicated that at that time, Resident #212 had an order for skin prep to both heels. LPN #17 indicated although she notified RN #5 about the heels that shift that day, he did not come to the unit to assess the resident's heels during her shift. Interview with Dietitian #2 on 10/20/22 at 11:45 AM indicated she was not notified of the resident's wounds until the last week of May 2022. Dietitian #2 noted if she had been made aware when of the pressure ulcers on the resident's heels, she would have done an assessment, including an assessment of the resident's protein levels. Dietitian #2 indicated Resident #212 was on the low side of body weight and she would have added fortified drinks and food. Dietitian #2 noted she would have prioritized protein high foods like cottage cheese and added multivitamins. Dietitian #2 indicated if the resident has pressure areas, the resident should been evaluated by a dietitian within 72 hours after admission and interventions would be put in place at that time. Dietitian #2 indicated if there was a new pressure ulcer, it should be on the weekly wound report. Dietitian indicated she could not remember if she got the weekly wound reports during this timeframe and indicated for a period of time she was not getting them at all. Dietitian #2 identified if she had been made aware of the wound, she would have seen the resident immediately and if she wasn't in the facility, she would see the resident the next time she was in the facility. Dietitian #2 indicated it would be a priority. Interview with APRN #2 on 10/20/22 at 3:05 PM identified she had seen Resident #212 for readmission on 3/31/22 and documented the resident had bilateral heel pressure injuries. APRN #2 indicated although not in the note, the resident's heels were soft, red, and boggy but intact. APRN #2 noted she assumed nursing had already put skin prep in place. APRN #2 noted she did not write an order or interventions to address the heels because she assumed that nursing would have done that on admission. APRN #2 noted she was notified on 4/14/22 that the bilateral heels were a dark brown to black color, so she ordered skin prep twice a day and assumed the wound nurse would see Resident #212. APRN #2 noted she was not informed there was anything wrong with Resident #212's bilateral heels from 4/30/22 - 5/21/22. APRN #2 noted she was made aware on 5/21/22 via text from an LPN that the bilateral heels had a dressing on them dated 4/30/22, 20 days prior. APRN #2 noted 5/21/22 was a Saturday and she did not look at the bilateral heels, she just informed the nurse to have the wound physician look at them because there was not a consistent nurse doing wound rounds with MD #1 or general wound rounds. APRN #2 noted she had put Resident #212 on an antibiotic at that time. APRN #2 indicated she was not notified that Resident #212 had any abrasions, redness, or open areas on the hips or left ankle. The Pressure Ulcer policy directs a skin assessment along with a Braden Scale (a skin risk assessment) will be done upon admission and for 4 weeks after admission. Skin assessments are done by a licensed nurse weekly and the Braden Scale will then be done quarterly. Interview and review of the Braden scale with DNS #2 on 10/20/22 at 3:00 PM noted the policy was to do a Braden Scale on admission and every week for 4 weeks following the admission, and then on a quarterly basis. DNS #2 noted that 3 out of the 5 required Braden Scale evaluations were not completed. DNS #2 noted the admission Braden Scale was completed on 3/31/22 with a score of 13 (moderate risk for skin breakdown) but the following weeks were not completed, 4/6/22, 4/13/22 and the 4/20/22. The DNS noted that due to the moderate risk for skin breakdown, interventions should have been put into place on admission like an air mattress, turning and repositioning every 2 hours, and heel elevation either with pillows or bunny boots. The Pressure Ulcer policy directs skin assessments are done by a licensed nurse upon admission and weekly. Interview and review of weekly skin assessments with DNS #2 on 10/20/22 at 4:30 PM indicated weekly skin assessments were not completed for 6 weeks, the weeks of 4/3, 4/10, 4/24, 5/29, 6/5 and 6/12/22. DNS #2 noted the weekly skin assessments were to be completed weekly by the charge nurse and she did not know why they had not been completed. Additionally, DNS #2 noted on 6/20/22 the LPN noted skin areas but did not put in the measurements or describe the wound appearance and there was no RN assessment. Interview with LPN #11 on 10/26/22 at 9:30 AM, who was the 7:00 AM to 3:00 PM nurse on Center 2 unit on 5/3, 5/4, 5/9, 5/10, 5/12, 5/13, 5/16, 5/17, 5/18, 5/19 and 5/20/22 and was the charge nurse for Resident #212 (the timeframe that both heel dressings had not been changed 4/30/22 - 5/21/22). LPN #11 indicated that she did not do treatments on those days because there was a treatment nurse from North 2 to do all her treatments on the day shift. Review of the nursing schedules with LPN #11 failed to reflect a treatment nurse was assigned to do treatments on her unit and LPN #11, in revieing the schedule, could not identify who she though had done the treatments for her on those dates. LPN #11, in review of the schedule, could not identify who did the treatments those days. LPN #11 identified she just signed off on the treatments as being done, but the treatment nurse was supposed to do them. LPN #11 identified the treatment nurse would not sign the TAR, so LPN #11 did. LPN #11 noted most of the nurses were from the agency. LPN #11 noted she saw the nurse on the floor, so she assumed she did the treatments. Although review of the nursing schedules at that time, LPN #11 could not identify what nurse she was referring to. LPN #11 identified she just made sure Resident #212 had waffle boots on. LPN #11 noted during that time the nursing assistants did not report to her that the dressings on the heels were old or to look at the heels. Review of the nursing schedules with LPN #11 dated 5/1/22 - 5/21/22 identified she could not recall who did the treatments on the days she signed the treatments as having been completed. LPN #11 indicated no one told her to sign the treatments as completed on the TAR without doing them but all the nurses did it. LPN #11 indicated that unit had a very heavy medication pass and a lot of treatments. LPN #11 indicated she had told the ADNS and DNS #1 that she needed help, but nothing changed. Interview with DNS #2 on 10/26/22 at 9:05 identified she had meet with LPN #14 who came in and completed a written a statement on 10/21/22. DNS #2 noted LPN #14 informed her that she had missed doing the skin prep to Resident #212's heels a few times and forgot to go back and circle the treatment as not being done. DNS #2 noted LPN #14 informed her she would lift up the corner of the dressing on the heel and put the skin prep under the dressing when she had the supplies to do so. DNS #2 indicated LPN #14 informed her she would sign off on all the treatments in the TAR, make a list, and then later go do the treatments. At times that was how she forgot to go back and circle some of the skin prep treatments as not being done. DNS #2 indicated that LPN #14 should have taken the treatment cart and computer and signed off on the treatments as she did them. DNS #2 noted LPN #14 informed her she did not notice the date of dressing on Resident #212's heels as 4/30/22 all the times she had applied skin prep under the dressing. In another interview with DNS #2 on 10/26/22 at 12:25 PM she indicated her expectation would be that the nurses would follow the physicians' orders for treatments, and that an RN should do an assessment of any new wound or if there was a change in the wound like more drainage. Further, DNS #2 identified that the RN was responsible to do wound measurements weekly and if there was a change in the wound, the RN was responsible to notify the physician or APRN, and document who was notified, when notified and of what with a change in skin condition. DNS #2 identified the dietitian should have known on admission that Resident #212 had wounds because she should have reviewed the record and should have seen the resident immediately and put intervention in place at that time and continue to follow the resident to make sure the interventions were working, or if resident had developed new areas. DNS #2 indicated she does not know what happened between the resident's admission 3/30/22 to the time he/she was discharged other than no one was paying attention and the treatments were not being done, and interventions were not put in place. DNS #2 indicated there was no explanation or justification for the dressings to have stayed on from 4/30/22 - 5/21/22. DNS #2 noted there was no RN assessment done on 3/30/22 when the resident was readmitted , and she did not know why. DNS #2 indicated she was not able to determine the type of mattress Resident #212 was on, if it and based on clinical record review, the air mattress went on the bed on 7/14/22 when there was a physician's order for it. Interview with LPN #14 on 10/26/22 at 12:45 PM indicated she was full time on 3:00 PM - 11:00 PM on the Center 2 unit and worked 5/2, 5/3, 5/4, 5/5, 5/8, 5/8, 5/9, 5/10, 5/12, 5/13, 5/17, 5/18, 5/19 and 5/21/22 (the timeframe that both heel dressings had not been changed 4/30/22 - 5/21/22). Although she was not able to give a date, LPN #14 notified RN #5 that the residents heels were red with small black dots on each and he said to put boarder gauze treatment in place to be done on day shift. LPN #14 identified the unit was heavy and they started having the North 2 nurses come help with treatments. LPN #14 noted after the medication pass, she would sign off on all the resident's treatments on the TAR ahead of time because she was going to go do it. LPN #14 identified if she did not have the supplies to do the treatments she had signed as completed, she would forget to go back and strike it out as not being done. LPN #14 identified she did not have supplies and she should not have signed that those treatments as having been done before she had the supplies. LPN #14 indicated for the 12 days she signed off that Resident #212's treatments had been done, she did not do the treatments because she did not have supplies and forgot to strike out that she did not do it. LPN #14 recalls there was one day that there was a nurse from another unit that was going to come over and do her treatments, so she signed them off as done, but did not know if the other nurse did the treatments or not. LPN #14 indicated she did not see the heel dressings dated 4/30/22 between 5/1/22 - 5/20/22 because she did not do the skin prep as per the physician's order, and instead just signed off on the treatment as done but did not do them. LPN #14 noted when she did not have the skin prep and she did not have the supplies, she would write it on the supply sheet on the unit and would not bother the supervisor because she would be busy with admissions. LPN #14 noted the nurse aides between 5/1/22- 5/20/22 never informed her to look at Resident #212's heel dressings. Although attempted, an interview with ADNS #2, RN #5, LPN #18 were not unable to be obtained. Review of the Avoidable vs. Unavoidable Wounds Policy dated 10/18/21 identified the facility must establish that it provided care that was reasonably necessary to prevent the formation of pressure ulcers and must institute prevention measures promptly for a resident at high risk for developing pressure ulcers. Complete a Braden scale assessment on admission and for 4 weeks that addresses predisposing medical conditions, potential risk factors, pressure intensity and duration, muscle mass, mobility status, (especially in the bed and chair), urinary and fecal incontinence, feeding assistance, pressure ulcer history, recent weight loss, cognition, and a skin exam. Additionally, conduct and document ongoing weekly skin assessments. Implement care planned interventions for routine skin care such as treatments, identify repositioning needs, determine incontinent care, evaluate pain, and evaluate nutrition and hydration status. When a pressure ulcer is identified provide prompt care planning, notification to the physician and the family, and implementation of interventions designed to minimize or resolve the pressure ulcer. Inform the physician and the family by proving ongoing assessments, wound and treatment status information to the physician, resident and family and document notification and response. Treatments by the physician and nursing notes should illustrate a coordinated plan of oversight with treatments and consistent follow up. Review of the Pressure Ulcer Policy identified prevention of pressure ulcers requires early identification of at-risk resident ' s and the implementation of prevention strategies. Identify residents at risk and initiate an early prevention program. A skin assessment along with a Braden scale will be done upon admission and for 4 weeks. Skin assessments are done by a licensed nurse weekly and the Braden Scale will then be done quarterly. A Braden scale score of 14 or less indicates a risk for skin breakdown. So, assess and preparation of identified risk factors, immobilization, sensory loss such as a stroke or spinal cord injury, malnutrition, diabetes, incontinence, age, dehydration, edema, existing or history of pressure ulcers. Assess residents' skin over regions of pressure skin color for redness, purplish, or blue and was tissue boggy or firm. Educate staff and resident on risks for developing pressure ulcers. Review of the Monitoring, and Staging Wounds Policy dated 8/2016 identified to promote healing, prevent infection, and prevent new pressure ulcers from developing. A licensed nurse will assess the pressure ulcer weekly and keep the physician informed of progress with prescribed treatments. The wound care coordinator or licensed nurse that was responsible for the wound care will examine wounds weekly to assess and document findings. The Braden scale will be completed on any resident who develops a new wound and was not at risk when the last assessment was completed. The wound nurse will complete a weekly wound description including measurements. Daily documentation will reflect if dressing was intact, drainage noted, pain associated with the wound, and odor and condition of surrounding skin which was visual around dressing. Documentation of wound should include the length, width, and depth. Identify the location and location of any tunneling or undermining using the clock reference. Describe condition of the wound at each dressing change. The dressing must be assessed daily. The wound nurse will document if dressing was intact, skin surrounding, drainage, odor, and pain level. The facility failed to provide care, including skin assessments, RN assessments, notification to the physician of changes in skin, notification to the dietitian of changes in skin, and treatments according to the physician's orders to prevent the development and worsening of pressure ulcers. Further, although the resident had orders for skin prep to the heels twice daily, on 5/21/22, dressings were found on the resident's heels dated 4/30/22, 20 days prior. Subsequently, Resident #212 developed a stage III pressure ulcer, multiple unstageable pressure ulcers and Deep Tissue Injures (DTI) which resulted in a finding Immediate Jeopardy. 2. Resident #213 was admitted to the facility on [DATE] with diagnosis that included diabetes, open right hip wound. (A skin assessment was not done on admission). The hospital discharge summary dated 6/17/22 directed a low air loss bed, turn and r [TRUNCATED]

42117 Based on review of the clinical record, facility documentation, facility policy and interviews for 3 of 4 residents (Resident #213, 212 and 95) reviewed for pressure ulcers, for Resident #213, the facility failed to notify the physician on [DATE] when abnormal bloodwork was reported, which led to a delay in transferring the resident to the hospital for necessary treatment, and for Resident #212 and 95, the facility failed to notify the physician/APRN and resident representative with changes in the residents' condition, including changes to the skin. The findings include: 1. Resident #213 was admitted to the facility on [DATE] with diagnosis that included diabetes, open right hip wound. The hospital discharge summary dated [DATE] directed a low air loss bed, turn and reposition the resident every 2 hours, waffle cushion when in chair, limit sit time to 1 - 2 hours in chair, elevate heels off bed with pillows or boots, optimize nutrition, protective sacral foam dressing, change every 3 days and as needed remove and reapply twice daily for skin assessments. The summary directed dressings as follows to the right upper arm, back and right hip wounds; cleanse with normal saline, apply xeroform, and cover with bordered foam dressing daily. (These recommendations were not implemented). The care plan dated [DATE] identified Resident #213 had the potential for skin impairment. Interventions included to follow facility protocols for treatment of injuries, keep skin clean and dry, monitor and document location and size of skin injury, weekly treatment documentation to include measurement of each area of skin breakdown, width, length, depth, type of tissue, any exudate and other notable changes. An APRN note dated [DATE] identified Resident #213 was seen as a new admission. Complaints of right hip pain limiting ability to weight bear when standing. Has chronic right foot wound. Went to hospital with altered mental status after being found on the ground. Had multiple bruises and abrasions and had a trauma work up due to being found on the ground. Medial buttock stage III pressure injury, right shoulder open area. The admission MDS dated [DATE] identified Resident #213 had moderately impaired cognition, required extensive assistance with bed mobility, dressing, toilet use, personal hygiene, and total assistance with bathing, and was frequently incontinent of bowel and bladder. The resident had a stage III unhealed pressure ulcer, was at risk to develop pressure ulcers, had an open lesion on the foot and skin tear(s). A nurses note dated [DATE] identified a body audit was done, all open areas reported and have protective dressings in place. Treatment orders pending. Physician's orders dated [DATE] directed cleanse coccyx with normal saline, apply Triad to wound bed, cover with hydrocolloid every Monday/Wednesday/Friday. Cleanse mid back wound with normal saline, apply Triad to wound bed, cover with hydrocolloid every Monday/Wednesday/Friday. Cleanse right hip wound with normal saline, apply Triad to wound bed, cover with hydrocolloid every Monday/Wednesday/Friday. A wound doctors note dated [DATE] identified (first evaluation of the resident's wounds) the coccyx is an unstageable pressure ulcer that measures 2.0cm by 0.6cm by 0.1cm with 76 - 100% slough and a small amount of serosanguinous drainage with no odor. The right hip is an unstageable pressure ulcer that measures 2.0cm by 1.5cm by 0.1cm with 76 - 100% slough with a small amount of serosanguinous drainage with no odor. Both have 100% slough to wound beds, recommend Santyl. Recommendations include to implement facility pressure ulcer prevention protocol, powered pressure reducing air mattress, reposition every 2 hours, and ROHO in wheelchair. An APRN note dated [DATE] identified Resident #213 was seen for diaphoretic, not feeling good, nausea and vomited once, elevated blood sugars and elevated heart rate. Resident states he/she feels uncomfortable and is visibly sweating. Recommendations to continue to monitor and report change to APRN/MD. An APRN note dated [DATE] identified Resident #213 was seen for elevated blood sugars with blood sugars 125 - 410. Recommendations to continue to monitor and report change to APRN/MD. A wound doctors note dated [DATE] identified the coccyx is an unstageable pressure ulcer with a moderate amount of serosanguinous drainage with no odor. The right hip is an unstageable pressure ulcer with a moderate amount of serosanguinous drainage with no odor. An APRN note dated [DATE] identified Resident #213 was seen for complaints of right hip wound infection. The right hip has an open wound with drainage and the resident is yelling out in pain. Recommendation to start Keflex and Tramadol. Physician's order dated [DATE] directed to administer Keflex (antibiotic) 500mg four times daily for excessive right hip drainage. An APRN note dated [DATE] identified Resident #213 had elevated blood sugars. No acute complaints of pain, chest pain, nausea, no fever, no edema. Recommendations to continue to monitor and report change to APRN/MD. An APRN note dated [DATE] identified Resident #213 had increased right hip pain and drainage, increased blood sugars and altered mental status. Nursing reports that the resident sticks his/her fingers into the wound and the drainage is foul smelling. There is a medial buttock stage III pressure ulcer. No edema or varicosities. Recommendations included to obtain bloodwork, urine culture, right hip wound culture, and start Tramadol 100mg (pain medication) every 8 hours around the clock. A laboratory requisition dated [DATE] identified the bloodwork was collected at 8:30 AM and the results were faxed and put into the facility computer system on [DATE] at 2:14 PM. A wound doctors note dated [DATE] identified the right hip wound had increased depth and drainage. Will increase frequency of dressing changes. Coccyx wound is unstageable with a moderate amount of sero sanguineous drainage with no odor. The right hip wound is unstageable with a moderate amount of sero sanguineous drainage with no odor and is deteriorating. Recommendations to change hip dressing twice daily. Physician's orders dated [DATE] directed to cleanse the coccyx with normal saline, apply calcium alginate and cover with dry clean dressing daily and cleanse the right hip with normal saline, apply calcium alginate and cover with dry clean dressing twice daily. A nurses note dated [DATE] identified Resident #213 had increased confusion and pain with increased green yellow drainage from right hip. Subsequent to APRN notification, the resident was sent to the hospital. Interview with DNS #2 on [DATE] at 8:50 AM identified Resident #213 had moderate cognitive impairment and required total assistance for washing, dressing and all personal care. DNS #2 identified with every change of condition the physician/APRN should have been notified of any skin changes, change in conditions, and new wounds, treatment changes, falls, and medication changes. Interview with the Wound Physician, MD #1, on [DATE] at 3:00 PM indicated that there was a pattern of inconsistences with the wound care at the facility. MD #1 indicated that the majority of the time, she observed dressings with no dates, so she did not know when they were last changed, and based on the amount of drainage, the dressings were most likely more than a day or 2 old. MD #1 indicated the right hip was getting worse and deteriorating because the nurses were not putting the Alginate in the wound to absorb the drainage, so the drainage was just sitting in the wound bed in the tissue. MD #1 indicated on [DATE] when she saw Resident #213's wounds, they did not look infected and she was aware that the bloodwork had been done that morning, but she did not order the bloodwork. MD #1 indicated if the facility had notified her on [DATE] that the resident ' s white blood count was 14.9K/uL (normal range 4.8 K/uL - 10.8 K/uL) and that there was a left shift, she would have ordered a chest x-ray to rule out pneumonia and a urine culture to rule of urinary infection before determining that it was a wound infection, and she would have started a broad spectrum antibiotics in case it was MRSA. MD #1 noted if the facility could not do that immediately, she would have sent the resident to the emergency room for evaluation and would not have waited until [DATE]. MD #1 indicated Resident #213 should have gone to the emergency room sooner, and not have waited 2 days until [DATE]. Interview with Lab Person #3 on [DATE] at 9:45 AM indicated the bloodwork ordered on [DATE] was drawn on [DATE] at 8:30 AM and the facility was notified of the results when the lab uploaded online in the computer at 2:14 PM on [DATE]. The bloodwork was also faxed to the facility on [DATE] at 2:14 PM. Lab Person #3 indicated the facility was notified of critical low values on [DATE] at 6:12 PM, Prealbumin of 6.5 mg/dL (normal range 16 mg/dL - 40 mg/dL), and Cardio CRP of 227 mg/L (normal range 0mg/L - 1 mg/L. Lab Person #3 noted the usual practice is that lab faxes and uploads the results to the facility and only calls the facility if a lab value is critical for specific tests. These results would not have been called in, they were faxed and uploaded. Interview with APRN #2 on [DATE] at 10:45 AM indicated she ordered bloodwork on [DATE], which would have been drawn the next morning. APRN #2 indicated the facility staff did not update her on the resident bloodwork until 2 days later, [DATE] when LPN #8 called her on a Sunday. APRN #2 noted if she had been notified on [DATE] of the resident ' s elevated white blood count and the other bloodwork she would have immediately sent the resident to the emergency room . APRN #2 indicated RN #5, RN #6 and RN #7, and others that are no longer employed by the facility would put in telephone orders from her that she was not aware of and had not given. APRN #2 indicated she notified ADNS #1, DNS #1 and the Administrator that orders were being put in the records that she was not aware of and had not given. Further, DNS #1 would call or text the name of a new admission and proceed to put in all the new admission orders without her knowledge or discussion. Interview with DNS #2 on [DATE] at 11:25 AM indicated the bloodwork results came to the facility on [DATE] and APRN #2 was not notified for 2 days, until [DATE]. DNS #2 indicated the bloodwork fell through the cracks. DNS #2 indicated whoever received the bloodwork when it was faxed to the facility on [DATE] at 2:14 PM should have notified the APRN or MD immediately and no more than 2 - 3 hours after the facility received the results. DNS #2 noted the bloodwork needed to be reported right away on [DATE], however, were not reported until [DATE] when the resident deteriorated and was sent to the emergency room . DNS #2 identified that the charge nurses are responsible to check the fax machines during their shift for bloodwork results, and the RN Supervisors are responsible to check the fax machines when making rounds. Hospital records dated [DATE] identified Resident #213 was sent in for evaluation of a right hip wound associated with fevers and purulent drainage. Bloodwork notable for leukocytosis of 15,000 (Leukocytosis is a condition in which the white cell is above the normal range in the blood and is frequently a sign of an inflammatory response, most commonly the result of infection). CT scan was obtained and reviewed and showed multiple complex collections with foci of air involving multiple compartments of the right thigh as well as the right gluteus extending along fascial planes and musculature concerning for necrotizing soft tissue infection. On examination, Resident #213 was noted to have a quarter size skin defect over the right ischial tuberosity with purulent/dishwater drainage. There is significant surrounding edema with induration extending up to the right hemipelvis and extending down to the knee with crepitus and cellulitis. The resident was admitted for necrotizing fasciitis of right posterior pelvis and lateral thigh, started on IV antibiotics status post I&D. The resident's care was thoroughly discussed with the COP regarding the gravity of the resident's condition along with the high likelihood of morbidity and mortality. Consent was obtained for debridement of the right buttock, thigh, and lower back. The COP understands that resident may require an amputation and possible colostomy down the line based on the severity of the infection. The resident received broad-spectrum antibiotics and Clindamycin and will be taken to the operating room emergently. A second opinion was obtained in the operating room to assess the resident's wounds to facilitate goals of care and conversations with the COP. The resident's COP indicated it would be against the resident's and COPs wishes to proceed with an aggressive treatment plan and the resident's status was changed to comfort measures. Resident #213 expired on [DATE]. 2. Resident #212 was readmitted to the facility on [DATE] with diagnoses that included dementia, stroke, and hypertension. A nurse's note dated [DATE] at 1:06 AM identified Resident #212 was found lying on the floor mat beside the bed with no injuries. Resident #212 was transferred back to bed and the bed was placed in the lowest position. The nurse's note did not reflect the physician/APRN or resident representative had been made aware of the fall. The admission MDS dated [DATE] identified Resident #212 had severely impaired cognition, was always incontinent of bowel and bladder and required extensive assistance with bed mobility, dressing, toilet use, personal hygiene and was totally dependent for transfers. Additionally, Resident #212 was at risk for skin breakdown or pressure ulcers but did not have any pressure ulcers. A physician's order dated [DATE] directed to apply border foam gauze to both heels and change every 3 days. The clinical record failed to reflect the resident representative had been notified. A physician's order dated [DATE] directed to apply skin prep to both heels twice a day and apply bunny boots to both heels while in bed. The clinical record failed to reflect the resident representative had been notified. A physician's order dated [DATE] directed to administer Olanzapine (antipsychotic medication) 2.5 mg every morning for agitation. The clinical record failed to reflect the resident representative had been notified. A nursing note dated [DATE] at 3:14 PM by LPN # 11 indicated Resident #212 had refused medications. The clinical record failed to reflect the physician or resident representative had been notified. A nursing note dated [DATE] at 3:14 PM by LPN #14 indicated Resident #212 had refused medications. The clinical record failed to reflect the physician or resident representative had been notified. A nursing note dated [DATE] at 2:55 PM by LPN #11 indicated Resident #212 had refused medications. The clinical record failed to reflect the physician or resident representative had been notified. The wound physician progress note dated [DATE] at 5:59 PM identified Resident #212 was seen as an initial consultation for evaluation of bilateral heel wounds. MD #1 noted a left heel stage III pressure ulcer and an unstageable right heel. New order for the left heel to apply Alginate with silver secured with rolled gauze and change daily, and the right heel apply betadine every shift. Additional recommendations included pressure relief and offloading of heels, facility pressure ulcer prevention protocol, a group 2 powered pressure reducing mattress, and offload pressure and reposition patient every 2 hours, and optimize nutrition with a registered dietitian consultation. The clinical record failed to reflect the resident representative had been notified of the new pressure ulcers or treatments. A physician ' s order dated [DATE] directed to give a multivitamin once a day and zinc sulfate 220 mg once a day from [DATE] - [DATE]. The clinical record failed to reflect the resident representative had been notified. MD #1 wound note dated [DATE] identified 2 new pressure areas to the left and right Achilles with new treatment orders for betadine to both Achilles every shift. The clinical record failed to reflect the resident representative had been notified of the new pressure ulcers or treatments. The nurse's note dated [DATE] at 1:55 PM identified a new left hip abrasion had been observed. The clinical record failed to reflect the physician or resident representative had been notified. The nursing note dated [DATE] identified the left hip blister opened. The clinical record failed to reflect the physician or resident representative had been notified. A physician's order dated [DATE] directed to cleanse left hip with normal saline followed by Alginate Ag, cover with a dry clean dressing every day. The clinical record failed to reflect the resident representative had been notified of the new open area or treatment. The nursing note dated [DATE] at 1:46 PM identified left outer ankle observed dark red/purple. Wound nurse updated. The clinical record failed to reflect the physician or resident representative had been notified. A physician's order dated [DATE] directed to cleanse right heel with normal saline apply silver alginate and cover dry clean dressing daily. The clinical record failed to reflect the resident representative had been notified. The nursing note dated [DATE] identified Resident #212 had refused all medications and observed a change in skin condition to the right elbow and right rib lateral side. The clinical record failed to reflect the physician or resident representative had been notified. Interview and review of the clinical record review with the DNS #2 on [DATE] at 1:15 PM identified the APRN/physician and resident representative should be notified the same day of any changes in condition, new treatment orders, or medication changes. DNS #2 noted after review of the clinical record and the changes in resident condition, the APRN or physician and the resident representative were not updated on many occasions. DNS #2 noted leaving a note in the APRN is not notification to the physician/APRN. DNS #2 noted the nurses must call the APRN. 3. Resident #95 was admitted to the facility on [DATE] with diagnoses that included protein-calorie malnutrition, anorexia, and dysphagia. Review of the admission/readmission evaluation form dated [DATE] identified the admission assessment was completed by LPN #21. Resident #95's skin integrity had blanchable redness to bilateral buttocks and discoloration to left inner knee. Skin intact otherwise no open areas noted. A nurse's note dated [DATE] at 12:49 AM identified Resident #95 was admitted to the facility at approximately 11:45 PM. LPN #21 performed the admission assessment and identified that Resident #95 had blanchable redness noted to bilateral buttocks. The nurse's note failed to reflect documentation that RN #9 was notified of the blanchable redness noted to bilateral buttocks. A nurse's note dated [DATE] at 6:00 AM identified RN #9 concurs with LPN #21 documentation of Resident #95 admission notes. With addendum added that on-call APRN was updated on admission, medications reviewed and approved. Admission bloodwork ordered for [DATE]. LPN #21 directed to update the responsible party at the end of shift that Resident #95 had arrived at the facility and that the responsible party needed to come to the facility and sign paperwork. The nurse's note failed to reflect documentation that RN #9 assessed Resident #95 blanchable redness to bilateral buttocks. A nurse's note dated [DATE] at 6:39 AM identified a voice message was left for Resident #95 responsible party. The admission MDS dated [DATE] identified Resident #95 had moderately impaired cognition and required extensive assistance with toilet use, and supervision with bed mobility. Additionally, the MDS identified Resident #95 was at risk of developing pressure ulcer/injuries. Review of nurse's note dated [DATE] - [DATE] failed to reflect documentation that a facility staff had spoken to the responsible party. A physician's order dated [DATE] directed to administer ProMod Liquid 30 ml by mouth two times a day for increased needs secondary to altered labs. A nurse's note dated [DATE] at 3:14 PM identified a peripheral IV was placed with orders for IV fluids. The nurse's note failed to reflect the resident representative had been made aware. Review of the APRN progress note dated [DATE] at 3:48 PM identified Resident #95 had poor appetite and poor fluid intake. Per nursing, Resident #95 has not been voiding much lately. New orders to obtain STAT bloodwork, a peripheral line, start Normal Saline 0.9% via peripheral line at 60 ml/hr times 2 liters. Review of a weekly skin monitoring form dated [DATE] identified LPN #5 performed a skin assessment with documentation of a pressure ulcer to coccyx stage I, and pressure ulcer to left outer ankle stage I. Review of the nurse's note dated [DATE] - [DATE] failed to reflect documentation that the physician/APRN and the resident representative had been notified of the pressure ulcer to coccyx stage I, and pressure ulcer to left outer ankle stage I. A nurse's note dated [DATE] at 3:36 PM identified Resident #95 complained of coccyx pain, and pain medication was offered. LPN #22 identified reddened area on coccyx. Cream applied and cushion border pad applied for protection. The clinical record failed to reflect the physician/APRN or resident representative had been notified. The wound physician note dated [DATE] at 8:55 PM identified Resident #95 has a stage II pressure ulcer to the coccyx measuring 0.3 centimeters (cm) (length) by 0.2 cm (width) by 0.1 cm (depth). There was small amount of sero-sanguineous drainage with no odor. Wound bed has no granulation, no slough, no eschar, and no epithelialization present. Resident #95 reported a wound pain of level 1 out 10. New orders cleanse wound with Normal Saline followed by apply Alginate, followed by cover wound with Bordered Foam, change daily, and change as needed for soiling, saturation, or accidental removal. Pressure reducing air mattress per facility protocol. Wheelchair ROHO cushion. Offload pressure/reposition every 2 hours. Registered Dietician consultation. Review of the nurse's note dated [DATE] - [DATE] failed to reflect the resident representative had been notified. A nurse's note dated [DATE] at 12:40 AM identified late note [DATE] at 3:20 PM Resident #95 was seen by the wound physician with new orders obtained for treatment, air mattress applied to bed and care card updated for side-to-side positioning. Left voice message for the dietitian to evaluate. The nurse's note failed to reflect the resident representative had been notified of the stage II coccyx pressure wound, and the new orders. A dietitian note dated [DATE] at 1:14 PM identified Resident #95 had a significant weight change, and a new stage II pressure ulcer to coccyx per wound note on [DATE]. Recommendations made. A dietitian note dated [DATE] at 5:19 PM identified a meeting took place with the dietitian, APRN, Resident #95, and the responsible party regarding 22.2% significant weight loss, decreased and poor intake, and refusal of weights. Resident #95 appears with severe muscle/fat wasting, showing evident signs of cachexia. APRN reiterated that Resident #95 is a full code at this time given advanced of age, clinical status, and decline in weight. Resident #95 requested to remain full code. The note failed to reflect that the resident representative was notified of the stage II coccyx pressure wound. Review of the weekly skin monitoring form dated [DATE] at 2:16 PM identified an assessment performed by LPN #13 noted Resident #95 with a small open area to the left gluteal fold, no drainage, scant amount of blood, measuring 0.2 cm x 0.5cm. APRN notified with new order for cleanse with Normal Saline, pat dry, apply Silver AG, followed by Border Foam once a day until seen by the wound physician. The note failed to reflect that the resident representative was notified. Interview and review of the clinical record with RN #4 on [DATE] at 11:00 AM indicated she was unable to provide documentation to reflect that the physician/APRN and the resident representative were notified of the blanchable redness to bilateral buttocks, or of the STAT bloodwork, the peripheral line, IV fluids, repeat bloodwork on [DATE], pressure ulcer to coccyx stage I, pressure ulcer to left outer ankle stage I, complaints of coccyx pain, reddened area on coccyx, pain medication offered or the stage II pressure ulcer to the coccyx. RN #4 indicated that the nurses should have informed the resident representative every time the resident received a new order, the changes in the skin condition, and the stage II pressure ulcer to coccyx. Interview and review of the clinical record with DNS #2 on [DATE] at 3:00 PM identified she was unable to provide documentation to reflect that the physician/APRN and the resident representative was notified of the blanchable redness to bilateral buttocks, of the STAT bloodwork, the peripheral line, IV fluids, repeat bloodwork on [DATE], pressure ulcers, or Resident #95's complained of coccyx pain. DNS #2 indicated the expectation is the nurses is to inform the resident representative every time the resident receives a new order or change in condition. Interview with MD #1 (wound physician) on [DATE] at 3:20 PM indicated she has been with the facility for over a year. MD #1 indicated she was not informed of the coccyx redness or stage I pressure ulcer to the coccyx on [DATE] and [DATE]. MD #1 indicated the first evaluation of Resident #95 was [DATE] for a stage II pressure ulcer to the coccyx. Interview with LPN #15 on [DATE] at 10:04 AM identified she does not remember that far back in February 2022. LPN #15 indicated she thought the supervisor had called Resident #95's responsible party with the new orders and that is why she did not call. Interview with LPN #5 on [DATE] at 10:13 AM identified he has been with the facility for approximately 2 years. LPN #5 indicated he works on the 7:00 AM - 3:00 PM shift. LPN #5 indicated he did notify the RN regarding Resident #95's stage I pressure area to the coccyx. LPN #5 indicated the RN never came to the unit to do the RN assessment. LPN #5 indicated he thought the RN was going to pass the assessment to the next shift. LPN #5 indicated the RN is supposed to call the physician/APRN and the responsible party with any issues or change in condition. Interview with LPN #22 on [DATE] at 11:28 AM identified she had work for the facility through an agency and she has not returned to the facility for approximately 6 months. LPN #22 indicated she did notify the RN supervisor on [DATE] regarding Resident #95 redden coccyx. LPN #22 indicated the RN never came to assess the resident. LPN #22 indicated she documented in the APRN and wound physician book at the nurse station for an evaluation of Resident #95 coccyx. LPN #22 indicated the RN supervisor is to notify the MD/APRN and the responsible party of any changes regarding the residents. LPN #22 indicated she does not remember who the RN supervisor was on duty. Interview with LPN #21 on [DATE] at 12:39 PM identified she works per-diem at the facility and has not been to the facility in a long time. LPN #21 indicated she did the admission and the admission assessment for Resident #95. LPN #21 indicated RN #9 was not in the room with her when she performed Resident #95 admission assessments. LPN #21 indicated she notified RN #9 of Resident #95 redden buttocks and discoloration to the knee. LPN #21 indicated she does not recall the RN #9 coming to do an assessment. LPN #21 indicated the RN supervisor is supposed to call the physician/APRN and the resident family of any changes. Although attempted, an interview with DNS #1, LPN #13 and Dietitian #2 was not able to be obtained. Review of the change in condition/resident notification policy dated ,d+[DATE] identified the clinical nurse will recognize and appropriately intervene in the event of a change in resident condition. The physician/family/responsible party will be notified as soon as possible. Include but not limited to significant change, accident/incident, change in treatment, transfer/discharge. Review of the facility avoidable vs unavoidable wounds policy dated [DATE] identified inform the physician and family - provide ongoing assessment, wound and treatment status information to the physician, resident and family and document notification and response. Document education provided to the resident and/or family regarding potential or actual risks, reduction interventions, non-compliance outcomes, prognosis, etc.

Based on clinical record reviews, facility documentation, facility policy and interviews for one of three sampled residents (Resident #14) who was reviewed for sexual abuse, was not able to make decisions for himself/herself and had a Conservator of Person, the facility failed to ensure the resident was free from inappropriate sexual conduct by another resident and failed to communicate and follow through to ensure new interventions were implemented to prevent future incidences with Resident #14 and other residents on the dementia unit after the resident had an incident of physical contact with Resident #14. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #14's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #14 was not able to make decisions regarding tasks of daily living, exhibited no behavioral symptoms, was independent with walking in the room, and required one (1) person supervision with walking in the corridor. The Resident Care Plan dated 1/20/22 identified Resident #14 had impaired cognitive function and impaired thought process related to the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Interventions directed to ask yes/no questions to determine Resident #14 ' s needs, communicate with Resident #14 and his/her family regarding the resident's capabilities and needs, present just one thought, idea, question, or command at a time. Upon further review, the Resident Care Plan identified Resident #14 had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #14 did exit seeking looking for his/her children and at times was difficult to redirect. Interventions directed wanderguard in place, re-approach at later time, when the resident refuses care another staff member to re-approach, and psychiatric consult routinely and as needed. The psychiatric evaluation and consultation dated 3/2/22 identified Resident #14 was oriented to time and loosely oriented to situation ant circumstantial thought process and per the nursing staff Resident #14 was at his/her baseline with occasional anxiety but redirectable. The assessment identified Resident #14 was alert but confused with no meaningful contribution to history of present illness or the review of symptoms and no agitation or aggression was noted. The evaluation identified Resident #14 ' s targeted behavior of wandering appeared to be adequately managed at this time and the plan was to continue to provide consistency of care and redirection. Resident #98's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] The quarterly Minimum Data Set assessment dated [DATE] identified Resident #98 had some short- and long-term memory recall deficits, was cognitively impaired and required limited one (1) person assistance with walking in the room and corridor. The undated Resident Care Plan associated to the MDS assessment dated [DATE] identified Resident #98 was a registered sex offender and was at risk for exhibiting inappropriate behavior. Interventions directed to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation, and take to alternate location as needed, follow facility, state, and federal protocols related to sex offenders, maintain contact with police department, psychiatrist to follow, provide medications as ordered by physician, the resident may not attend any recreation activities that have minors present. The psychiatric evaluation and consultation dated 2/24/22 identified Resident #98 was oriented to time, partially to the situation and his/her thought process was relevant and was cooperative and engaging in today's evaluation. The evaluation identified Resident #98 denied hastened anxiety or symptoms of depression, no agitation or aggression was noted and there were no concerns of sleep or appetite per nursing. The evaluation indicated Resident #98 was offered emotional support and positive feedback for engaging in today's evaluation and the plan was to continue the current medications and psychiatric follow up with the resident. Review of Resident #14 and #98's nurse's note dated 3/21/22 at 2:26 AM identified the 11PM-7AM charge nurse found Resident #14 standing in the dining room kissing Resident #98, both residents were fully clothed, and the Supervisor was made aware. Upon further review, the clinical records failed to reflect documentation the residents were assessed to determine if they had the capacity to consent to sexual activity and the Conservators of both Residents #14 and #98 were notified. The 24-Hour Supervisor Report dated 3/20/22 11PM-7AM shift, identified Resident #98 was observed kissing Resident #14 in the dining room. Resident #14 was standing, and Resident #98 was sitting, both residents were fully clothed, the residents were separated and redirected with no further kissing. Although the 24-Hour Supervisor Report identified Resident #98 and Resident #14 had engaged in an inappropriate physical conduct, review of the clinical records and facility documentation failed to reflect an investigation was initiated and followed through to ensure interventions were put into place to protect Resident #14 and other residents on the dementia unit. Resident #98's Resident Care Plan that identified Resident #98 a registered sex offender and was at risk for exhibiting inappropriate behavior was revised on 3/21/22 which now included the incident when Resident #98 was found sitting in the dining room kissing another resident on 3/21/22. Upon further review of the care plan, the interventions directed to intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation, and take to alternate location as needed, follow facility, state, and federal protocols related to sex offenders, maintain contact with police department, psychiatrist to follow, provide medications as ordered by physician, the resident may not attend any recreation activities that have minors present. The resident care plan failed to reflect documentation that new interventions were implemented to prevent further incidences of inappropriate sexual contact. The 11PM-7AM shift nurse's note dated 9/11/22 identified at 11:05 PM Resident #98 was observed sitting adjacent to Resident #14 in the lounge, Resident #98's hand was in between the thighs of Resident #14, Resident #98 was rubbing the genital area over the nightgown, the residents were fully clothed, and the Supervisor was notified. The Facility Reported Incident form dated 9/11/22 at 11:15 PM identified Resident #14 was observed sitting in a chair in the lounge, Resident #98 was sitting next to Resident #14 and Resident #98 was observed to have his/her fingertips inside of the Resident #14's genitals with the nightgown between Resident #98's fingers and Resident #14's genitals. The report indicated Resident #14's brief was on the floor next to him/her, the residents were immediately separated, and both residents were sent to the hospital for evaluation. The Inter-Agency Patient Referral Report dated 9/12/22 at 2:03 AM identified Resident #14 presented to the hospital after the nursing staff found Resident #98 had digitally penetrated Resident #14. The report identified the hospital staff examined Resident #14 and saw no injury. The report identified Resident #14 was non-verbal, unable to explain the incident, and a vaginal exam was completed at the bedside and no signs of trauma or bleeding were noted. The psychiatric evaluation and consultation note dated 9/13/22 identified Resident #98 was sent to the hospital on 9/12/22 after Resident #98 was observed to be making inappropriate advances toward Resident #14. The note identified Resident #98 disclosed that he/she became too friendly with Resident #14 prior to being sent to the hospital on 9/11/22, Resident #98 reported he/she perceived Resident #14 was in love with him/her and Resident #98 wanted to put his/her hands on Resident #14's shoulder. The note identified Resident #98 could not recall any other physical contact except for touching Resident #14's shoulder, psychiatry and Resident #98 discussed appropriate boundaries and Resident #98 acknowledged that he/she intended to maintain appropriate boundaries. The note indicated Resident #98 reported he/she will not seek out any residents inappropriately, there will be no sexual proclivity (tendency to do something you should not). The evaluation identified Resident #98 contracted for safety towards self and others, Resident #98 verbalized a desire to maintain appropriate boundaries with other residents, stated I need to remember to keep my hands to myself, and Resident #98 was provided with positive feedback for verbalizing his/her desire to maintain appropriate boundaries with other residents. Interview with Resident #14 on 9/21/22 at 9:40 AM identified there was no eye contact or acknowledgement of the surveyor or a translator. Resident #14 did not answer any questions asked by the translator. Resident #14 was observed sitting at a table in the lounge/dining room and was moving his/her hand in a circular motion like he/she was cleaning the table he/she was sitting at. Interview with Resident #98 on 9/21/22 at 9:45 AM identified Resident #98 was alert and oriented to person, place, and time at the time of the interview. Resident #98 identified the incident happened in the recreation room and he/she denied everything to protect Resident #14. Resident #98 indicated he/she should not have done it and it was hard to explain why he/she did it. Resident #98 identified he/she also had a psychiatric evaluation done and denied everything. Resident #98 indicated he/she was Resident #14's partner. Interview with the 11PM-7AM charge nurse, Licensed Practical Nurse (LPN) #3, on 9/21/22 at 12:10 PM identified on 3/21/22 she observed Resident #98 and Resident #14 sitting in chairs next to each other in the lounge/dining room. LPN #3 explained Resident #98 was hugging and feeling Resident #14's body and kissed Resident #14 on the cheek. LPN #3 indicated Resident #98 was touchy and feely, Resident #98 was touching Resident #14 down the side of his/her body, feeling his/her curves. LPN #3 identified Resident #98 was going for Resident #14's lips, when she separated them, both residents were redirected back to their rooms and went to sleep. LPN #3 indicated she reported the incident to the supervisor on duty. LPN #3 indicated the Supervisor notified the Director of Nursing. Interview with Resident #14's Conservator, Person #1, on 9/21/22 at 4:15 PM identified Resident #14 had dementia, could not consent to a relationship, and did not really know what was going on. Person #1 indicated he/she was never contacted by the facility staff and asked if he/she would consent to Resident #14 and Resident #98's relationship. Person #1 identified she was unaware of the incident on 3/21/22 and had he/she known, Resident #98 would not be on the same unit as Resident #14. Person #1 indicated he/she visited Resident #14 after the incident 9/11/22 and Resident #14 was fine, and timid but Resident #14 was okay. Interview with 11PM-7AM Nursing Supervisor, Registered Nurse (RN) #3, on 9/22/22 at 11:17 AM identified she was unable to recall the incident between Resident #98 and Resident #14 on 3/21/22 and was unable to recall if she notified the Director of Nursing about the incident. Interview with the Director of Nursing (DON) #1 on 9/23/22 at 11:10 AM identified she did not remember hearing about the incident between Resident #98 and Resident #14 on 3/21/22 because there was a lot of reportable events in March of 2022. DON #1 indicated had she known about the incident she would have reported the incident to the state agency, she would have investigated the incident and put measures in place to protect Resident #14. DON #1 identified monitoring of Resident #98's behaviors, any type of interactions with other residents, should have been implemented after the incident on 3/21/22. Review of the Abuse Prevention policy directed to maintain the rights of all residents to be free from abuse. In the event there was evidence of suspected or reported abuse by another resident the facility will intervene and follow these guidelines. During the investigation, the facility will protect the resident as appropriate, including but not limited to the following: separation and/or redirection of residents, institute visual checks/monitors as appropriate, notify physician of resident behavior and discuss appropriate measures. Appropriate actions will be taken to manage and monitor the behavior of a resident against whom there was a substantiated charge of abuse. Actions may include but not limited to discharging the resident.

Based on clinical record review, review of facility documentation, facility policy and interviews for one sampled resident (Resident #1) who received the anti-seizure medication, Dilantin, the facility failed to document, communicate, and follow through from shift to shift that a Dilantin level was drawn, reported to the practitioner, and a new order for Dilantin was obtained. The failures resulted in a finding of Immediate Jeopardy. The findings include: Resident #1's diagnoses included seizure disorder, cerebrovascular disease, and end stage renal disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life, required total assistance with eating and had a feeding tube (nasogastric or abdominal). The laboratory report dated 6/27/22 identified a Dilantin level of 3.1 microgram/milliliter (ug/ml) (normal range 10.0 to 20.0). A physician's order dated 6/27/22 directed to increase the Dilantin (medication used to prevent and control seizures) suspension 125 milligrams (mg)/5 milliliters (ml) from 4 ml to 8 ml via the gastrostomy tube every eight (8) hours for a low Dilantin level, start 6/28/22 until 6/30/22 and then repeat the Dilantin level on 7/1/22. The laboratory report dated 7/1/22 identified the repeat Dilantin level was 7.7 ug/ml. Review of the laboratory report dated 7/1/22 identified the Dilantin level of 7.7 ug/ml was reviewed by the Advanced Practice Registered Nurse (APRN) #1 on 7/1/22 at 5:31 PM. Review of the 24-hour Supervisor Report from June 30 through July 2, 2022 failed to reflect documentation regarding a Dilantin level drawn was on 7/1/22, reported to the APRN or physician and the need for a new order for Dilantin. Review of the clinical record and the Electronic Medication Administration Record (EMAR) for July 2022 (7/1/22 through 7/30/222), failed to reflect a renewal order for the Dilantin was obtained on 7/1/22 resulting in Resident #1 missing eighty-eight (88) doses of Dilantin. Review of the APRN and nursing communication forms from June 26 through July 31, 2022 failed to identify Resident #1's Dilantin level result remained below the normal range and a new order for the Dilantin was documented for APRN #1 to follow up on. The nurse's note dated 7/30/22 at 6:23 AM identified at 6:15 AM staff reported Resident #1 was bleeding from his/her mouth, fresh [NAME] red blood at the mouth was noted and the bleeding was of unknown etiology. The note indicated there was no labored breathing, Resident #1 was very lethargic, 911 was called and Resident #1 was transferred to the hospital for further evaluation. The hospital clinical record identified Resident #1 presented to the hospital on 7/30/22 with profuse bleeding from the mouth and left sided facial twitching. The profuse bleeding from the mouth, likely from either teeth or tongue injury when the resident started having focal seizures, required suctioning and consultation from an Ear, Nose, And Throat (ENT) physician. The ENT physician was able to cauterize a lesion on the resident's tooth that was presumed to be the source of bleeding with little improvement. Resident #1 required additional suctioning and topical tranexamic acid (the medication is used to treat heavy bleeding) to control the bleeding with little effect, pressure was applied to the tooth with improvement in the bleeding. The hospital laboratory report on admission indicated the Dilantin level was almost undetectable. The hospital record identified Resident #1 had received Keppra and Dilantin load (medications to treat seizures) and, the decision was made to intubate Resident #1 for further management of the seizures and transfer Resident #1 to the Intensive Care Unit (ICU). During the course of treatment Resident #1 was placed on long-term electroencephalographic monitoring and received a combination of Vimpat (a medication to treat partial on-set seizures), Keppra, Dilantin, a Versed (sedative) drip, and Valproic Acid (a medication to treat seizures) in an attempt to control the seizures, however the seizures failed to resolve and remain uncontrolled. The record identified Resident #1 was still seizing despite three (3) attempts with the Automated External Defibrillations (AED) which works by changing the levels of chemicals in the brain. On 8/2/22 Resident #1 was transferred to another hospital. Interview and review of the clinical record with Advanced Practice Registered Nurse (APRN) #1 on 8/18/22 at 3:26 PM identified on 6/27/22 she increased the Dilantin from 4 ml to 8 ml every eight (8) hours due to the Dilantin level of 3.1 ug/ml and had the Dilantin level rechecked on 7/1/22. APRN #1 indicated on 7/1/22 she reviewed the Dilantin level results while she was at home, the Dilantin level came up to 7.7 ug/ml, she called the facility and gave an order to the Nursing Supervisor to keep Resident #1 on the same dose of Dilantin 8 ml every eight (8) hours and to repeat the Dilantin level in one (1) week. APRN #1 indicated she could not recall who the Supervisor was that day or evening because it has been over a month ago since she gave the order, and she did not write a progress note in the clinical record regarding the 7/1/22 Dilantin results and verbal orders given to the Supervisor when she returned to the facility. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 8/18/22 at 4:12 PM identified if on 7/1/22 she had received an order from the APRN she must have forgotten to write the order for the Dilantin and repeat bloodwork. Interview with the Director of Nursing (DON) on 8/18/22 at 12:25 PM identified on Tuesday 8/16/22 she reviewed Resident #1's hospital record to follow up with the reason for the admission to the hospital and after she completed the review, she learned that Resident #1 did not receive the Dilantin for thirty (30) days. In a follow up interview with the DON on 8/19/22 at 10:45 AM identified the Supervisor or any nurse, if they were aware of the Dilantin level drawn, were responsible to monitor for the results. The DON indicated the 24-hour shift to shift Supervisor report was where the Dilantin level draw should have been documented especially if it required a follow up for orders. The facility confirmed there was no current policy and procedure for documentation on the 24-hour report.

Based on clinical record reviews, review of facility documentation, facility policy and interviews for two sampled residents (Resident #1 and #2) who received the anti-seizure medication, Dilantin, the facility failed to follow through after a Dilantin level was drawn to ensure the Dilantin was re-ordered to prevent a significant medication error that resulted in an Immediate Jeopardy. The finding include: 1.Resident #1's diagnoses included seizure disorder, cerebrovascular disease, and end stage renal disease. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #1 rarely or never made decision regarding tasks of daily life, required total assistance with eating and had a feeding tube (nasogastric or abdominal). The laboratory report dated 6/27/22 identified a Dilantin level of 3.1 microgram/milliliter (ug/ml) (normal range 10.0 to 20.0). A physician's order dated 6/27/22 directed to increase the Dilantin (medication used to prevent and control seizures) suspension 125 milligrams (mg)/5 milliliters (ml) from 4 ml to 8 ml via the gastrostomy tube every eight (8) hours for a low Dilantin level, start 6/28/22 until 6/30/22 and then repeat the Dilantin level on 7/1/22. The laboratory report dated 7/1/22 identified the repeat Dilantin level was 7.7 ug/ml. Review of the laboratory report dated 7/1/22 identified the Dilantin level of 7.7 ug/ml was reviewed by the Advanced Practice Registered Nurse (APRN) #1 on 7/1/22 at 5:31 PM. Review of the 24-hour Supervisor Report from June 30 through July 2, 2022 failed to reflect documentation regarding a Dilantin level drawn was on 7/1/22, reported to the APRN or physician and the need for a new order for Dilantin. Review of the clinical record and the Electronic Medication Administration Record (EMAR) for July 2022 (7/1/22 through 7/30/222), failed to reflect a renewal order for the Dilantin was obtained on 7/1/22 resulting in Resident #1 missing eighty-eight (88) doses of Dilantin. Review of the APRN and nursing communication forms from June 26 through July 31, 2022 failed to identify Resident #1's Dilantin level result remained below the normal range and a new order for the Dilantin was documented for APRN #1 to follow up on. The nurse's note dated 7/30/22 at 6:23 AM identified at 6:15 AM staff reported Resident #1 was bleeding from his/her mouth, fresh [NAME] red blood at the mouth was noted and the bleeding was of unknown etiology. The note indicated there was no labored breathing, Resident #1 was very lethargic, 911 was called and Resident #1 was transferred to the hospital for further evaluation. The hospital clinical record identified Resident #1 presented to the hospital on 7/30/22 with profuse bleeding from the mouth and left sided facial twitching. The profuse bleeding from the mouth, likely from either teeth or tongue injury when the resident started having focal seizures, required suctioning and consultation from an Ear, Nose, And Throat (ENT) physician. The ENT physician was able to cauterize a lesion on the resident's tooth that was presumed to be the source of bleeding with little improvement. Resident #1 required additional suctioning and topical tranexamic acid (the medication is used to treat heavy bleeding) to control the bleeding with little effect, pressure was applied to the tooth with improvement in the bleeding. The hospital laboratory report on admission indicated the Dilantin level was almost undetectable. The hospital record identified Resident #1 had received Keppra and Dilantin load (medications to treat seizures) and, the decision was made to intubate Resident #1 for further management of the seizures and transfer Resident #1 to the Intensive Care Unit (ICU). During the course of treatment Resident #1 was placed on long-term electroencephalographic monitoring and received a combination of Vimpat (a medication to treat partial on-set seizures), Keppra, Dilantin, a Versed (sedative) drip, and Valproic Acid (a medication to treat seizures) in an attempt to control the seizures, however the seizures failed to resolve and remain uncontrolled. The record identified Resident #1 was still seizing despite three (3) attempts with the Automated External Defibrillations (AED) which works by changing the levels of chemicals in the brain. On 8/2/22 Resident #1 was transferred to another hospital. The Facility Reported Incident Form dated 8/16/22 at 3:00 PM identified a review of Resident #1's hospitalization record by the Director of Nursing indicated Resident #1's Dilantin medication was not re-ordered resulting in Resident #1 not receiving the medication for thirty (30) days (eighty-one (81) doses). Resident #1 was hospitalized with what appeared to be a seizure with oral bleeding and lethargy. The report identified the Dilantin was to be re-ordered on 7/1/22. Review of the APRN and nursing communication forms from June 26 through July 31, 2022 failed to identify Resident #1's Dilantin level result remained below the normal range and a new order for the Dilantin was documented for APRN #1 to follow up on. Interview and review of the clinical record with Advanced Practice Registered Nurse (APRN) #1 on 8/18/22 at 3:26 PM identified on 6/27/22 she increased the Dilantin from 4 ml to 8 ml every eight (8) hours due to the Dilantin level of 3.1 ug/ml and had the Dilantin level rechecked on 7/1/22. APRN #1 indicated on 7/1/22 she reviewed the Dilantin level results while she was at home, the Dilantin level came up to 7.7 ug/ml, she called the facility and gave an order to the Nursing Supervisor to keep Resident #1 on the same dose of Dilantin 8 ml every eight (8) hours and to repeat the Dilantin level in one (1) week. APRN #1 indicated she could not recall who the Supervisor was that day or evening because it has been over a month ago since she gave the order, and she did not write a progress note in the clinical record regarding the 7/1/22 Dilantin results and verbal orders given to the Supervisor when she returned to the facility. Interview with the 3-11PM Nursing Supervisor, Registered Nurse (RN) #1, on 8/18/22 at 4:12 PM identified if on 7/1/22 she had received an order from the APRN she must have forgotten to write the order for Dilantin and repeat bloodwork. Interview with the Director of Nursing (DON) on 8/18/22 at 12:25 PM identified on Tuesday 8/16/22 she reviewed Resident #1's hospital record to follow up with the reason for the admission to the hospital and after she completed the review, she learned that Resident #1 did not receive the Dilantin for thirty (30) days. In a follow up interview with the DON on 8/19/22 at 10:45 AM identified the Supervisor or any nurse, if they were aware of the Dilantin level drawn, were responsible to monitor for the results. The DON indicated the 24-hour shift to shift Supervisor report was where the Dilantin level draw should have been documented especially if it required a follow up for orders. 2. Resident #2's diagnoses included seizure disorder, anoxic brain damage, dysphagia, quadriplegia, and hepatic failure. The Resident Care Plan dated 1/26/22 identified Resident #2 had a seizure disorder. Interventions directed to obtain and monitor laboratory/diagnostic work as ordered, follow up as indicated, monitor bloodwork and report any sub-therapeutic or toxic results to the physician. The quarterly Minimum Data Set assessment dated [DATE] identified Resident #2 had some short- and long-term care deficits, required total assistance with activities of daily living and had a feeding tube (nasogastric or abdominal) for nutritional support. The laboratory report dated 4/15/22 identified a Dilantin level of 38.1 microgram/milliliter (ug/ml) (normal range 10.0 to 20.0). A physician's order dated 4/15/22 directed to decrease the Dilantin (medication used to prevent and control seizures) suspension 125 milligrams (mg)/5 milliliters (ml) give 10 ml via the gastrostomy tube from two (2) times a day to one (1) time a day for an elevated Dilantin level, related to seizures, start 4/15/22 until 4/18/22 and then repeat the Dilantin level on 4/18/22. Upon further review, the physician's orders directed Keppra Solution 100mg/ml give 7.5ml via the gastrostomy tube two (2) times a day. Review of the clinical record failed to reflect documentation the Dilantin level had been obtained on 4/18/22. Review of the clinical record and the Electronic Medication Administration Record (EMAR) for April 2022 (4/1/22 through 4/30/222) and May 2022 (5/1/22 through 5/31/22), failed to reflect documentation that a renewal order for the Dilantin was obtained on 4/18/22. The record identified an order was not obtained until 5/16/22, resulting in Resident #2 missing twenty-eight (28) doses of Dilantin. Review of the nurse's notes from 4/1/22 through 5/31/22 identified Resident #2 experienced no adverse effects due to Dilantin omissions from 4/18/22 through 5/16/22. A physician's order dated 5/16/22 directed to obtain a Dilantin level today. The laboratory report dated 5/16/22 identified the Dilantin level was less than 0.6. A physician's order directed Dilantin suspension 125 milligrams (mg)/5 milliliters (ml) give 10 ml via the gastrostomy tube two (2) times a day. Interview and review of the clinical record with the Advanced Practice Registered Nurse (APRN) #1 on 8/30/22 at 1:00 PM identified she was unaware of the Dilantin omissions, or the Dilantin level not being obtained as per physician's order. APRN #1 indicated she evaluated Resident #2 on 4/18/22 due to elevated temperature and vomiting and added a Complete Blood Count (CBC), Complete Metabolic Panel (CMP), folate level to be drawn on 4/20/22 and to obtain a chest x-ray. APRN #1 identified the laboratory blood work scheduled for 4/20/22 was obtained as ordered. APRN #1 identified the omission was four (4) months ago, however, normally if the blood work was missed on one (1) day, then it would be drawn on the next laboratory day, however that clearly did not happen. Interview and review of the clinical record with the Director of Nursing (DON) on 8/30/22 at 1:15 PM identified the Dilantin level was not obtained on 4/18/22. The DON indicated the order for the Dilantin level was entered into the computer system, however the laboratory slip had rebook on it. The DON identified the 11PM-7AM shift books the laboratory blood work through the laboratory website and then prints all the laboratory slips for the day. The DON indicated she was not sure if Resident #2 refused the blood work to be drawn on 4/18/22, however the nurse's note failed to reflect documentation if Resident #2 refused the blood work on 4/18/22.

Based on clinical record review, review of facility documentation, and interviews, review of policy for one of three residents reviewed for neglect for (Resident # 87), the facility failed to notify the physician of the resident's elevated blood pressure and elevated blood sugar levels prior to a discharge and failed to develop a comprehensive and safe discharge plan. These omissions resulted in a failure of the facility to provide the necessary care and services to support a safe discharge resulting in neglect and in a finding of Immediate Jeopardy. The findings include: Resident #87 was admitted to the facility on [DATE] with a readmitted d of 5/8/21. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment, was independent with bed mobility and transfers, however, needed set up support with transfers between surfaces, including to or from bed, chair, wheelchair, and the standing position. Additionally, the assessment identified the resident was independent with eating after set-up help was provided. The assessment further identified the resident was continent of bowel and bladder function, is at risk of developing pressure ulcers, has been on a scheduled pain medication regime and the level of pain experienced, has limited the resident's day to day activities. Further review of care planning documents identified a care plan dated 7/26/21 and 8/17//21 for risk of malnutrition related to diabetes and malnutrition. Interventions included diet education, reinforcing importance of dietary compliance, and monitoring laboratory work. Social services notes dated 8/6/21 indicated the resident's family was informed if they purchase cigarettes for the resident, they should be given to the nurses. Further, the note indicated the resident was provided his/her last warning regarding non-compliance with the smoking policy. Additional review of the social service notes from 8/6/21-8/16/21 indicated discharge planning was occurring with discharge to a motel, however, the room was not ready and/or the resident wanted a motel closer to his/her existing home. A subsequent progress note date 8/17/21 identified the resident stated, I don't want to go anywhere. The Smoking Policy for August 2021 indicated on admission, all residents will have a smoking assessment to identify whether he/she is safe to smoke. All residents will be offered a smoking cessation program. The policy for smoking rules notes residents are not permitted to carry any smoking materials, such as: cigarettes, cigars, pipes, and lighting devices (matches, lighters) etc. Anyone noted to be in violation of this rule will be re-assessed and re-educated on the Smoking Policy by Social Services. If non-compliance continues, the resident could receive a 30-day Involuntary Discharge Notice. All personal smoking items will be kept in designated locked smoking cart and noted no e-cigarettes or vaping devices are permitted. Review of progress notes from 6/1/21 through 8/19/21 identified 3 incidents, 6/17/21, 7/24/21 and 8/6/21 in which the resident was found smoking, specifically, unsupervised smoking outside (6/17) and smoking materials were found in the resident's room (7/24 and 8/6/21). On 8/6/21 a progress note identified the resident was placed on 1:1 supervision. The Activities of Daily Living Flow Record August 1-19, 2021 identified the resident was independent with eating with set up or one person assist on 25/57 occasions, independent with transfers and independent with toileting with set up help on 13/57 occasions and independent with personal hygiene with set up or one person assist on 12/57 occasions. Further review of the clinical record identified a Notice of Emergency discharge date d 8/18/21 for Resident # 87. The reason stated: distribution of smoking materials on 8/6/21. Although the Notice of Emergency Discharge form was provided to the resident, it was signed by the Administrator only and did not include the resident's signature. Resident # 87 remained in the facility until formally discharged on [DATE] at 3:32 P.M. Review of Licensed Practical Nurse (LPN #3) progress note dated 8/19/21 at 3:32 P.M. identified Resident #87 was discharged home with medications and the RN supervisor was made aware. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] A review of Resident #87's discharge summary/plan failed to: 1. Accurately reflect the resident's ability to perform ADL's. Although the August 2021 ADL Flow records indicated the resident needed set up support or one person assist on multiple occasions with eating, toileting and personal hygiene, the discharge summary indicated the resident was independent with ADL's. 2. Ensure the motel room was handicapped accessible to ensure the resident could navigate throughout the room in a wheelchair, the resident's primary source of locomotion. 3. Accurately list Resident #87's medications to include, the date/time the medications were last taken and when the medications were next due to be taken. 4. Identify the quantity of pills and the amount of insulin the resident was provided. 5. Provide prescriptions for current medication regime and/or provide information to the resident regarding obtaining additional medication and or prescriptions. 6. Identify any follow up with a primary physician. 7. Identify that education was provided regarding the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Although the discharge summary identified follow up with a Nephrologist as soon as possible and the cardiologist in two weeks, the summary failed to include the information reflected in the 8/6/21 progress note which identified a cardiology appointment on 9/8/21; and 9. Identify the RN who signed off on the resident's discharge paperwork. Interview with the Director of Nursing Services (DNS) on 8/25/21 at 12:45 P.M. identified she could not provide evidence of what the resident's blood pressure was after the 189/100 reading on 8/19/21 at 11:30 A.M., she could not identify if the resident was re-assessed before discharge regarding the elevated blood pressure 189/100 and elevated blood sugar. DNS also could not identify which RN was responsible for assessing the resident prior to discharge. Interview with LPN #3 on 8/25/21 at 1:30 P.M. to 1:45 P.M. identified she was instructed to do an emergency discharge for Resident # 87. LPN #3 indicated s/he could not recall if she was made aware of Resident #87's blood pressure of 189/100 at 11:30 A.M. on 8/19/21 even though the clinical record indicated LPN #3 recorded the data. LPN #3 also indicated that although s/he did document the resident's vital signs were stable, s/he could not recall what the vital signs were on 8/19/21. LPN #3 indicated s/he provided teaching on the insulin pen but could not recall how much remained in the insulin pen at the time of discharge. LPN #3 identified at the time of discharge s/he grabbed a fist full of lancets for blood sugar testing, provided 10 syringes for short acting administration (3 days administration), 8 insulin cap pen needles (4 days coverage), alcohol wipes, and could not recall how many insulin tests strips s/he sent with the resident. LPN #3 also indicated Resident #87 was not given any prescriptions at the time of discharge for medication or diabetic supply refills. However, the clinical record indicated the patient was discharged with a few days of controlled pain medication [MEDICATION(S)] 8 tablets (1 tablet 3 times daily), and [MEDICATION(S)] 9 tablets (1 tablet every 6 hours as needed for severe pain), all other medications did not include the quantity of pills given. LPN #3 also stated that an RN supervisor whose name s/he could not remember assisted in the discharge process. Interview with Resident #87 on 8/25/21 at 2:05 P.M. identified s/he felt like the facility just wanted to discharge him /her by singling him/her out for smoking and did not punish others who violated the policy. Resident #87 also indicated s/he did not have his long-acting insulin pen and did not have enough pain medication after s/he was discharged from the facility. The Resident also indicated it was hard for him/her to obtain food while being at the motel because he/she could not go out and get food. Interview with the Administrator on 8/25/21 and 8/26/21 at 7:50 P.M. and 8:10 P.M. identified s/he believed Resident #87 had at the time of discharge, enough money on his/her credit card to buy food. After the resident called the facility on 8/23/21 asking about pain medication, the Administrator stated s/he went to see the resident on 8/23/21 to bring his/her pain medication ([MEDICATION(S)] 50 mg) and noted the resident was in a non-handicapped room. The Administrator asked the motel staff why a handicapped room was not provided to Resident # 87 per facility request at the time of payment and the motel staff told him/her it was because Resident # 87 was not discharged on [DATE], therefore s/he lost the room. The Administrator then requested that the motel move Resident # 87 to a handicap room and subsequently assisted the resident to move all personal belongings to the handicapped accessible room.

Based on clinical record reviews, review of facility documentation, and interviews, review of policy for three of six residents reviewed for discharge for (Resident # 87), the facility failed notify the physician of the resident's elevated blood pressure and elevated blood sugar levels prior to a discharge and failed to develop a comprehensive and safe discharge plan. The resident was discharged to a motel absent clear discharge instructions which failed to include: the date and time the resident's medications were last administered in the facility, facility contact telephone number for staff for any questions, which physician to contact for elevated blood sugar levels and elevated blood pressure and management of multiple co-morbidities, including a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Further the facility failed to provide at discharge, adequate supplies to monitor blood glucose levels four times a day as directed by the physician, and an adequate supply of medications to manage diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . These omissions resulted in a failure of the facility to provide the necessary care and services to support a safe discharge resulting in a finding of Immediate Jeopardy and for (Residents # 1 and # 326), the facility failed to ensure the resident had the appropriate discharge information regarding medication administration date and time and medical equipment at the time of discharge. The findings included: 1.Resident #87 was admitted to the facility on [DATE] with a readmitted d of 5/8/21. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment, was independent with bed mobility and transfers, however, needed set up support with transfers between surfaces, including to or from bed, chair, wheelchair, and the standing position. Additionally, the assessment identified the resident was independent with eating after set-up help was provided. The assessment further identified the resident was continent of bowel and bladder function, is at risk of developing pressure ulcers, has been on a scheduled pain medication regime and the level of pain experienced, has limited day to day activities. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication orders included: [MEDICATION(S)] 25 (Anti-hypertensive) Milligrams (mg) twice a day, [MEDICATION(S)] (Anti-hypertensive) 5 mg one capsule at bedtime, [MEDICATION(S)] (Anti-hypertensive) 20 mg take 4 tablets by mouth once day at 9:00 P.M., [MEDICATION(S)] 25 mg every 8 hours for nerve pain, [MEDICATION(S)] (pain medication), 50 mg every 6 hours as needed for severe pain and [MEDICATION(S)] 50 mg (Anti-hypertensive) two tablets every 8 hours. Additionally, the orders directed Serriglee Solution (Basal Insulin 100 units per ml inject 15 units in the morning and 40 units at hour of sleep, and [MEDICATION(S)] insulin 17 unit Subcutaneously (SQ) before meals. Further, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11:00 A.M. and 4:30 P.M. for blood glucose results as follows: 200-250: 2 units 251-300: 4 units 301-350: 6 units 351-400: 8 units 401+: 10 units and call the physician. A care plan dated 8/11/21 indicated the resident was at risk for injury to self or others secondary to unsafe smoking practices. It further identified the resident was sharing smoking supplies with other residents. Interventions included, provide health teaching regarding safe smoking to the client and family, resident to cooperate with staff for room search as needed, staff to review smoking policy with resident and have resident sign the smoking contract. Further review of care planning documents identified a care plan for risk of malnutrition related to diabetes and malnutrition. Interventions included diet education, reinforcing importance of dietary compliance, and monitoring lab work. The Activities of Daily Living Flow Record August 1-19, 2021 identified the resident was independent with eating with set up or one person assist on 25/57 occasions, independent with transfers and independent with toileting with set up help on 13/57 occasions and independent with personal hygiene with set up or one person assist on 12/57 occasions. Review of progress notes from 6/1/21 through 8/19/21 identified 3 incidents, 6/17/21, 7/24/21 and 8/6/21 in which the resident was found smoking, specifically, unsupervised smoking outside (6/17) and smoking materials were found in the resident's room (7/24 and 8/6/21). Further review identified a progress note dated 8/5/21 indicating the resident returned from a cardiology consult with a follow up scheduled for 9/8/21 at 2:00PM. On 8/6/21 a progress note identified the resident was placed on 1:1 supervision. A review of the clinical record identified a Resident Smoking Rules/Contract with Resident # 87's signature, but with no date. Although the smoking contract indicated if non-compliance continues, the resident could receive a 30-day Involuntary Discharge Notice, the facility issued a notice of emergency discharge on 8/18/21. During an interview with multiple facility staff on multiple occasions including 8/25/21, it was noted the facility does not have a policy for an emergency discharge. Social services notes dated 8/6/21 indicated the resident was provided his last warning regarding non-compliance with the smoking policy. Additional review of the social service notes from 8/6/21-8/16/21 indicated discharge planning was occurring with discharge to a motel, however, the room was not ready and/or the resident wanted a motel closer to his existing home. A subsequent progress note date 8/17/21 identified the resident stated, I don't want to go anywhere. A review of Resident 87's Weights and Vital Sign Summary sheet dated 8/19/21 identified the resident's blood pressure was 189/100 (Normal Range 120/80) at 11:30 A.M (Approximately 4 hours prior to discharge). Review of the Weight and Vital Summary for Resident #87's blood sugars identified the following: 8/18/21 at 11:28 A.M., 453 mg/dl (Normal Blood Sugar Level less than 140 mg/dl) 8/18/21 at 6:26 P.M., 497 mg/dl 8/18/21 at 9:51 P.M., 470 mg/dl 8/19/21 at 8:26 A.M., 402 mg/dl 8/19/21 at 12:24 PM 303 mg/dl (3 hours prior to discharge) Although the physician was notified of the discharge, review of the clinical record failed to identify that the physician and/or Advanced Practice Registered Nurse (APRN) had been notified of Resident# 87's elevated blood pressure prior to discharge and elevated blood glucose levels preceding discharge. Further review of the clinical record identified a Notice of Emergency discharge date d 8/18/21 for Resident # 87. The reason stated: distribution of smoking materials on 8/6/21. Although the Notice of Emergency Discharge form was provided to the resident, it was signed by the Administrator only and did not include the resident's signature. Resident # 87 remained in the facility until formally discharged on [DATE] at 3:32 P.M. Although the nursing note dated 8/19/21 at 3:32 P.M. identified the resident was discharged home, the resident was discharged to a motel. A review of Resident #87's discharge summary/plan failed to: 1. Accurately reflect the resident's ability to perform ADL's. Although the August 2021 ADL Flow records indicated the resident needed set up support or one person assist on multiple occasions with eating, toileting and personal hygiene, the discharge summary indicated the resident was independent with ADL's. 2. Ensure the motel room was handicapped accessible to ensure the resident could navigate throughout the room in a wheelchair, the resident's primary source of locomotion. 3. Accurately list Resident #87's medications to include, the date/time the medications were last taken and when the medications were next due to be taken. 4. Identify the quantity of pills and the amount of insulin the resident was provided. 5. Provide prescriptions for current medication regime and/or provide information to the resident regarding obtaining additional medication and or prescriptions. 6. Identify any follow up with a primary physician. 7. Identify that education was provided regarding the resident's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . 8. Although the discharge summary identified follow up with a nephrologist as soon as possible and the cardiologist in two weeks, the summary failed to include the information reflected in the 8/6/21 progress note which identified a cardiology appointment on 9/8/21; and 9. Identify the RN who signed off on the resident's discharge paperwork. Interview with the Director of Nursing Services (DNS) on 8/25/21 at 12:45 P.M. identified she could not provide evidence of what the resident's blood pressure was after the 189/100 reading on 8/19/21 at 11:45 A.M., she could not identify if the resident was re-assessed before discharge regarding the elevated blood pressure 189/100 and elevated blood sugars and which RN was responsible for assessing the resident prior to discharge. Interview with the Medical Director, who was the resident's primary physician on 8/27/21 at 10:35 A.M. identified s/he was not aware of Resident # 87's blood pressure of 189/100 prior to discharge and indicated if s/he had been made aware, s/he would have instructed the facility staff not to discharge the resident until they could re-evaluate the blood pressure to see if it was trending up or down. The Medical Director also indicated staff had made him/her aware of the blood sugars over 401 in the past but could not recall if he or his colleagues had been notified of the elevated blood pressure and elevated blood sugars on 8/18/21 and 8/19/21. Interview with the Social Worker (SW) #1 in the presence of the Director of Social Service on 8/25/21 at 3:45 P.M. identified she/he was directed by the Administrator on 8/19/21 that Resident #87 needed to be an emergency discharge and indicated the Administrator was assisting her/him with some of the discharge process secondary to the Director of Social Service scheduled absence. SW #1 also indicated this was her first position as a social worker in long-term care and her first emergency discharge. SW #1 also indicated she thought the nursing department was responsible for obtaining the resident's follow up appointments, medication, supplies and assisting with home care service but she was later told after discharge and surveyor inquiry s/he was responsible for all the above. SW #1 also indicated she took her direction from the Administrator for the Emergency Discharge in the absence of the Director of Social Service. SW #1 indicated after the incident s/he now knows that s/he is responsible for scheduling all follow up appointments and making sure home care is set up. SW #1 also indicated on 8/19/21 she did attempt to call two home care agencies for Resident #87, but both denied acceptance of the case. SW #1 could not provide evidence that on the date of discharge 8/19/21, s/he had a home care agency who had agreed to take the resident as a client. Interview with LPN #3 on 8/25/21 at 1:30 P.M. to 1:45 P.M. identified s/he was instructed to do an emergency discharge for Resident # 87. LPN #3 indicated s/he could not recall if she was made aware of Resident #87's blood pressure of 189/100 at 11:45 A.M. on 8/19/21 even though the clinical record indicated LPN #3 recorded the data. LPN #3 also indicated that although s/he did document the resident's vital signs were stable, s/he could not recall what the vital signs were on 8/19/21. LPN #3 indicated s/he provided teaching on the insulin pen but could not recall how much remained in the insulin pen at the time of discharge. LPN #3 identified at the time of discharge s/he grabbed a fist full of lancets for blood sugar testing, provided 10 syringes for short acting administration (3 days administration), 8 insulin cap pen needles (4 days coverage), alcohol wipes, and could not recall how many insulin tests strips s/he sent with the resident. LPN #3 also indicated Resident #87 was not given any prescriptions at the time of discharge for medication or diabetic supply refills. However, the clinical record indicated the patient was discharged with a few days of controlled pain medication [MEDICATION(S)] 8 tablets (1 tablet 3 times daily), and [MEDICATION(S)] 9 tablets (1 tablet every 6 hours as needed for severe pain), all other medications did not include the quantity of pills given. LPN #3 also stated that an RN supervisor whose name s/he could not remember assisted in the discharge process. Interview with Advanced Practice Registered Nurse (APRN #3) on 8/25/21 at 4:00 P.M. identified on 8/17/21 when s/he came into the facility to participate in discharge planning and to write the discharge order for Resident # 87, s/he was told by licensed staff nurse the resident was all set with medication therefore s/he did not provide any prescriptions. APRN #3 also indicated it was not until after the resident discharge s/he received a telephone call from the facility to say that the resident needed pain medication at which time s/he sent a prescription for [MEDICATION(S)] (28 tablets) to the pharmacy. When questioned why not an order for [MEDICAL RECORD OR PHYSICIAN ORDER] #3 indicated s/he did not review the clinical record and took the word of the RN. APRN #3 also indicated s/he had not examined Resident #87 or seen the resident since 8/17/21 and thought the resident had been discharged on [DATE] until s/he received the call for pain medication. Interview with the Long-Term Care Ombudsman (LTCO) on 8/26/21 identified s/he went to visit Resident #87 at the motel on 8/20/21 and 8/23/21. On 8/20/21, the appeals paperwork for the Involuntary Discharge was delivered and signed by the resident. The resident shared that s/he propelled the wheelchair across the street (four lanes) to obtain food. The LTCO was concerned the resident did not have food and/or funds to buy food, therefore, provided the resident with food and water. S/he further identified that there was a bucket of urine on the floor and Resident #87's bed was soaked in urine and feces. The resident was observed having difficulty moving around the room in the wheelchair. On 8/23/21 during the subsequent visit, the resident indicated he/she could not find the blood glucose meter strips for blood sugar testing. The glucometer was noted on the bed. The resident's blood sugar level was 593 at the time of the visit, and the resident appeared to not know how to test his/her blood sugar. The resident was observed self-administering [MEDICATION(S)] short-acting insulin in the amount of 27 units, the physician was notified of the blood sugar of 593, and recommended the resident be evaluated in the emergency department, however, s/he refused. Also, during the visit, the LTCO assisted Resident #87 to look for his/her medication at which time it was discovered the resident's long-acting insulin pen was not provided by the facility. The resident was in a non-handicapped room, rendering an inability to utilize the bathroom absent a grab bar needed to self-transfer. Interview with Resident #87 on 8/25/21 at 2:05 P.M. identified s/he felt like the facility just wanted to discharge him /her by singling him/her out for smoking and did not punish others who violated the policy. Resident #87 also indicated s/he did not have his long-acting insulin pen and did not have enough pain medication after s/he was discharged from the facility. The Resident also indicated it was hard for him/her to obtain food while being at the motel because he/she could not go out and get food. Interview with the Administrator on 8/25/21 and 8/26/21 at 7:50 P.M. and 8:10 P.M. identified s/he believed Resident #87 had at the time of discharge, enough money on his/her credit card to buy food. After the resident called the facility on 8/23/21 asking about pain medication, the Administrator stated s/he went to see the resident on 8/23/21 to bring his/her pain medication ([MEDICATION(S)] 50 mg) and noted the resident was in a non-handicapped room. The Administrator asked the motel staff why a handicapped room was not provided to Resident # 87 per facility request at the time of payment and the motel staff told him/her it was because Resident # 87 was not discharged on [DATE], therefore s/he lost the room. The Administrator then requested that the motel move Resident # 87 to a handicap room and subsequently assisted the resident to move all personal belongings to the handicapped accessible room. The Administrator further indicated that s/he has a responsibility to keep all residents safe in the building and believed Resident #87's smoking non-compliance placed other residents at risk. The Administrator further indicated that after the incident s/he now believes things could have been handled a little different. The facility provided the Department with an immediate action plan on 8/26/21 that included education to all licensed staff and Social Service staff on appropriate documentation of discharges in the record, nursing staff would also be educated to complete the medication document sheet, document an adequate supply of medication and supplies on the discharge form until the resident is seen by a medical professional in the community. Social Services would be educated on the responsibility for executing the discharge planning process to ensure a safe discharge, to make referrals to home care services as needed and follow-up with medical professionals in the community, the interdisciplinary team will meet and discuss upcoming discharges in morning report to determine status of resident discharge, and the MD/APRN perform assessment prior to approving discharge. 2.Resident # 1's was admitted to the facility on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The RCP for [CONDITION(S)]/[CONDITION(S)] related to smoking dated 8/24/21. Interventions directed to administer aerosol or bronchodilators as ordered, to monitor and document any side effects and effectiveness, to keep head of bed elevated in high -Fowler's or out of bed in upright position in the chair and administer medications for anxiety when needed. The admission MDS assessment dated [DATE] identified the resident had no cognitive impairment, no mood and behavior symptoms, required extensive assistance with personal hygiene, no respiratory treatment. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M. off P.M. daily. The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the MAR for September 2021 directed [CONDITION(S)] 14/8 with 4 lpm of oxygen to maintain SPO2 greater than 92 % every night at bedtime to start on 9/3/21 at 10:00 P.M. However, the September [DATE] noted the resident received the treatment 9/3, 4, 5, 6, 7, 8 and 9, 2021. Additionally, the MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . The social service note dated 8/24/21 for the resident's admission identified the resident was alert and oriented, cooperative, seen by mental health in the community, receiving PT and OT, and indicated the resident was admitted for short term rehabilitation and plan was to be discharged back home. The social service note dated 9/3/21 identified Resident # 1 informed the social worker that s/he wanted to be discharged by next Tuesday 9/7/21. Resident #1 indicated s/he had oxygen supplies at home and was scheduled to see PCP on 9/10/21 in the community. The nurse's notes dated 9/8/21 at 11:30 A.M. identified Resident # 1 informed the licensed staff that s/he would be leaving AMA. Resident # 1 also indicated s/he wanted to leave because s/he did not want to lose benefits and indicated s/he had a medical doctor in the community. A review of the clinical record on 9/10/21 failed to reflect that the resident had been scheduled for a sleep study for [CONDITION(S)] machine during his/her stay at facility, the staff had attempted to educate the resident regarding his/her medications regarding last time and date of when medications were administration in the facility, ensure that the resident had all necessary medications in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with RN # 9 on 9/10/21 at 3:10 P.M. identified Resident # 1 told her s/he was leaving and would not wait. Resident #1 indicated s/he could not be convinced to stay. Interview with the Social Worker # 1 on 9/10/21 at 3:05 P.M. identified Resident # 1 told her on the day of discharge s/he (Resident #1) had oxygen at home. Social Worker # 1 further indicated she informed nursing that the resident would need a [CONDITION(S)] machine at time of discharge. Social Worker #1 also indicated the resident left without a [CONDITION(S)] machine on the day of discharge. Interview with RN # 3 on 9/10/21 at 3: 48 P.M. identified he was told by the staff the resident was waiting for a sleep study. The resident had an appointment with the PCP on 9/13/21 or 9/14/21 to discuss the appointment for the sleep study. RN # 3 further indicated when he was reviewing the resident's medications, he noticed the [MEDICATION(S)] and [MEDICATION(S)] and was not available in the medication cart at time of discharge and could not explain why the medication were not available. RN # 3 indicated on 9/10/21 the resident's [MEDICATION(S)] was discontinued at the time of discharge. 3. Resident #326's was admitted on [DATE]. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Intra-Agency Discharge Summary dated 8/13/21 and the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Intra-Agency Discharge Summary dated 8/13/21 directed for the [CONDITION(S)] settings 16/6-PS10 with 3L of oxygen inline. The nurse's note written by RN #5 on 8/13/21 identified Resident #326 arrived at the facility on 8/13/21 at 10:55 P.M. The resident was alert and oriented and a full code. The nurse's note further indicated Resident # 326 diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident utilized 6 liters of Oxygen, required assistance with transfers, ADL and utilized [CONDITION(S)] at hour of sleep 5 L Nasal Canula. The nurse's notes dated 8/15/21 at 12:15 P.M. identified RN # 8 was notified by Resident # 326 s/he would be leaving against medical advice (AMA) and his/her family would be coming in to pick her/him up. The supervisor on 8/15/21 tried to convince Resident # 326 to stay but the resident continued to leave. Interview with LPN # 8 on 8/20/21 at 1:40 P.M. identified she could not recall if Resident # 326 had a [CONDITION(S)] machine in the room at the time of admission. A review of Resident # 326's clinical record on 8/25/21 failed to reflect in the resident's discharge plan that the resident received a list of dates and time medications were last administered if the resident went home on oxygen, if the Primary Care Physician (PCP) had been notified the resident left AMA and had the necessary education for [CONDITION(S)] treatment in accordance with physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Interview with Resident #326 on 8/30/21 at 9:27 A.M. indicated his/her medications were administered late at the facility and indicated s/he did not receive his/her [MEDICATION(S)] as needed. After multiple attempts to receive medications in a timely manner on 8/14/21 Saturday and no [CONDITION(S)] s/he notified his/her spouse on 8/15/21 Sunday to come pick him/her up. Resident # 326 further indicated that although s/he had a [CONDITION(S)] machine at the facility the machine was never used. The resident also indicated that at the time of discharge he/she was not educated by the facility on how to use the [CONDITION(S)] machine. Resident # 326's also indicated the facility did not give him/her a list of his/her medications at the time of discharge. Interview with RN # 5 on 8/20/21 at 1:30 P.M. and again on 9/2/21 at 2:27 P.M. identified she did not look for a [CONDITION(S)] machine at the time of admission.

Based on observations, clinical record reviews, review of facility documentation, facility policy and interviews for six of six residents (Residents #474, #120, #475, #477, #478, #480) reviewed for infection control, the facility failed to ensure that an approved multi-use resident glucometer was cleaned and disinfected by staff in accordance with facility policy and manufactures guidelines to prevent the spread of bloodborne pathogens. This resulted in a finding of Immediate Jeopardy, Additionally, for one sampled resident reviewed for transmission -base precautions, the facility failed to ensure staff applied PPE in accordance with facility guidelines. The findings included: 1. a. Resident #474 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] .M. b. Resident #120 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . c. Resident #475 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00 A.M. d. Resident #477 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00. A.M. f. Resident #478 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. g. Resident #480 was admitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] The physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] .M. and 11:00. A.M. An observation on 8/12/21 at 10:24 A.M. and interview on 8/12/21 at 10:24 A.M. and another interview on 8/16/21 at 10:34 A.M. with Licensed Practical Nurse (LPN #1) identified she completed 6 blood glucose checks during her shift without the benefit of cleaning and disinfecting the glucometer device between each resident in accordance to manufactures guidelines. LPN #1 further indicated she only disinfected the glucometer after her last resident (Resident #474) on 8/12/21 at 10:24 A.M. LPN #1 further indicated she worked as an agency nurse for the facility 2-3 times a week for the preceding 4 weeks and had not previously cleaned or disinfected the glucometer device between residents. LPN #1 further indicated she was unaware of the facility policy and manufactures guidelines for cleaning and disinfecting glucometer devices. An interview and policy review on 8/12/21 at 12:30 P.M. with the Director of Nursing Services (DNS) identified nursing staff are expected to clean the glucometer device between each resident with an approved disinfection wipe. The facility policy for Cleaning and Disinfection of Shared Blood Glucose Meters directed that the cleaning and disinfection of the glucometer device should be completed between resident use. Manufactures guidelines direct the glucometer test device was approved for multiple residents and cleaning and disinfection should take place between each resident with the approved Environmental Protection Agency (EPA) wipe. An Immediate Action Plan was put in place on 8/17/21 which included the following: The facility will provide education to LPN #1 prior to return to resident care. The supervisor will provide education to all licensed staff at the beginning of the shift on proper glucometer cleaning techniques between each patient until all staff have been educated. The licensed staff will be given a protocol sheet with instructions on glucometer disinfecting and cleaning to sign and keep as a reference. The licensed staff will be required to conduct a return demonstration of the training. All licensed staff prior to their first medication pass will be given a competency test to ensure compliance. The supervisor and the DNS will conduct weekly audits of all patients receiving blood glucose testing until substantial compliance. The Plan of Correction will be taken to QAPI Committee immediately for review. The Immediate Jeopardy was verified as corrected on 8/17/21. 2. Resident #327 was admitted to the facility on [DATE] at 3:30 P.M. with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Observations on 8/26/27 at 5:15 P.M. identified an isolation cart out the resident's room (fully stocked with supplies) and a sign for visitors and staff to alert them that the resident was precautions. Further observation identified NA #1 in Resident # 327's room obtaining vital signs without the benefit of PPE in accordance with facility practice. Interview with NA #1 on 8/26//21 at 5:15 P.M. the time of the incident identified s/he was aware that Resident # 327 was a new admission from the hospital and was on COVID 19 precautions. However, s/he overheard the EMT state the resident was negative for COVID -19. Interview with RN #5 on 8/26/21 at 5:30 P.M. identified she/he would expect staff to use the appropriate PPE. Facilities guidelines posted for COVID-19 precaution directs ensure patients who are unvaccinated and are admitted from the hospital are on precautions for 14 days to reduce the possible of spread of COVID-19 in skilled nursing facilities. It is imperative that workers providing care adhere to the guidelines to minimize the spread of COVID-19.

Based on clinical record reviews, review of facility policy and facility documentation and interviews for one of two sampled residents (Resident #36) who had behavioral symptoms and received an antipsychotic medication, the facility failed to administer a medication per the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] Residents #36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 rarely or never made decisions regarding tasks of daily life, at the time of the assessment had exhibited no behavioral symptoms, and received antipsychotic, antianxiety and antidepressant medications daily. The Resident Care Plan dated 6/28/21 identified Resident #36 received [CONDITION(S)] medications that included [MEDICATION(S)]. Interventions included to administer [CONDITION(S)] medications as ordered by the physician, to monitor for side effects and effectiveness and to monitor and record occurrence of the targeted behavioral symptoms and document per facility protocol. The psychiatric Advanced Practice Registered Nurse (APRN) evaluation and consultation dated 7/1/21 identified Resident #36 was seen to evaluate for stabbing a staff member with a fork, hitting and scratching a staff member and Resident #36 was currently on one (1) to one (1) observation. The note indicated Resident #36 admitted to slapping and grabbing a staff member's arm however Resident #36 denied the stabbing. The note identified staff reported Resident #36 continued to go in and out of resident rooms taking food and clothing. The note indicated at the time of the evaluation Resident #36 was not agitated or aggressive and denied any complaints. The plan was to keep the [MEDICATION(S)] 15 milligrams (mg) twice a day, to increase the [MEDICATION(S)] to 100 mg twice a day and to continue to monitor Resident #36's behaviors. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' notes from 7/1/21 through 7/27/2121 identified Resident #36 continued to wander in and out of resident rooms taking their belongings, food and drinks, redirection was ineffective, remained on visual checks every fifteen (15) minutes, was taking spoons and pudding off the mediation cart. The Nurse Practitioner's note dated 7/27/21 at 5:00 PM identified Resident #36 was evaluated for medical clearance for pending discharge to another facility for psychiatric management. The nurse's note dated 7/27/21 at 10:22 PM identified Resident #36 continued to wander into resident rooms taking their food and clothing from other residents causing those residents to be agitated. Review of the nurse's notes from 7/27/21 through 8/30/21 identified Resident #36 exhibited new behaviors of eating out of the trash cans, trying to or urinating into the trash can in the resident lounge, pulling his/her pants down trying to expose self in the resident lounge and inappropriately touching other residents in the lounge. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon further review, the nurse's notes along with the August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the bloodwork section in the clinical record identified bloodwork was obtained on 7/30/21, 8/6/21, 8/11/21, 8/16/21, 8/18/21 and 8/23/21. The August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the psychiatric Advanced Practice registered Nurse (APRN) #7 on 9/2/21 at 3:49 PM identified she was concerned with the [MEDICATION(S)] availability for Resident #36 as she had checked with the charge nurse on the unit and the medication was unavailable on more than one (1) occasion and she reported her concerns to the Director of Nursing, Administrator, and the pharmacy. APRN #7 indicated although she brought her concerns to the facility about the availability of the [MEDICATION(S)] for Resident #36, the [MEDICATION(S)] was still not available on many occasions. APRN #7 identified the facility informed her they would look into the issue which also included concerns with the lab technician. APRN #7 identified after three (3) days of not receiving the [MEDICATION(S)], Resident #36's [CONDITION(S)] and [CONDITION(S)] symptoms could greatly increase. Interview with the Director of Nursing (DON) on 9/2/21 at 5:15 PM identified she was aware there had been issues with Resident #36 receiving the [MEDICATION(S)] and she had disciplined approximately four (4) licensed nurses for signing off that the [MEDICATION(S)] was administered when the medication was not available and not following up on requesting the medication from the pharmacy when needed. The DON identified she had instructed staff to alert her when the medication was not available. Interview and review of the pharmacy's record of communication to the facility with Pharmacist #1 on 9/2/21 at 6:00 PM identified on 7/30/21 the bloodwork results were sent to the pharmacy and a seven (7) day supply of [MEDICATION(S)] was delivered at 11:16 PM; on 8/9/21 a nurse called to request a refill and the nurse was informed the pharmacy needed updated bloodwork and to make sure the bloodwork was drawn every Monday and sent to the pharmacy every Tuesday, the nurse indicated he would have emergency bloodwork drawn and a two (2) day supply of [MEDICATION(S)] was delivered at 11:42 PM. Upon further review of the pharmacy communication and interview, Pharmacist #1 identified on 8/11/21 the pharmacy received a refill request for [MEDICATION(S)], the bloodwork was obtained and a seven day (7) day supply was delivered at 7:08 PM; on 8/23/20 the bloodwork was faxed but were dated 8/16/21 therefore a one (1) day supply of [MEDICATION(S)] was delivered at 6:54 PM and on 8/28/21 a nurse called to request the [MEDICATION(S)], she was advised that the bloodwork was needed within seven (7) days, she stated she would resend them and the updated bloodwork dated 8/25/21 was received one (1) hour later at which point a seven (7) day supply was delivered at 7:00 PM. Review of facility policy entitled Medication Administration directed in part for medications to be administered in accordance with written orders of the prescriber.

Based on clinical record review, review of facility policy and facility documentation and interviews for one sampled resident (Resident #36) who had behavioral symptoms and received an antipsychotic, the facility failed to notify a physician or the Advanced Practice Registered Nurse when a medication was unavailable and for one of three sampled residents ( Resident # 87) reviewed for change of condition, the facility failed to notify the physician when the resident exhibited an elevated blood pressure and blood sugar levels. The findings included: 1.Residents #36's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] identified Resident #36 rarely or never made decisions regarding tasks of daily life, at the time of the assessment had exhibited no behavioral symptoms, and received antipsychotic, antianxiety and antidepressant medications daily. The Resident Care Plan dated 6/28/21 identified Resident #36 received [CONDITION(S)] medications that included [MEDICATION(S)]. Interventions included to administer [CONDITION(S)] medications as ordered by the physician, to monitor for side effects and effectiveness and to monitor and record occurrence of the targeted behavioral symptoms and document per facility protocol. The psychiatric Advanced Practice Registered Nurse (APRN) evaluation and consultation dated 7/1/21 identified Resident #36 was seen to evaluate for stabbing a staff member with a fork, hitting and scratching a staff member and Resident #36 was currently on one (1) to one (1) observation. The note indicated Resident #36 admitted to slapping and grabbing a staff member's arm however Resident #36 denied the stabbing. The note identified staff reported Resident #36 continued to go in and out of resident rooms taking food and clothing. The note indicated at the time of the evaluation Resident #36 was not agitated or aggressive and denied any complaints. The plan was to keep the [MEDICATION(S)] 15 milligrams (mg) twice a day, to increase the [MEDICATION(S)] to 100 mg twice a day and to continue to monitor Resident #36's behaviors. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurses' notes from 7/1/21 through 7/27/2121 identified Resident #36 continued to wander in and out of resident rooms taking their belongings, food and drinks, redirection was ineffective, remained on visual checks every fifteen (15) minutes, was taking spoons and pudding off the mediation cart. The Nurse Practitioner's note dated 7/27/21 at 5:00 PM identified Resident #36 was evaluated for medical clearance for pending discharge to another facility for psychiatric management. The nurse's note dated 7/27/21 at 10:22 PM identified Resident #36 continued to wander into resident rooms taking their food and clothing from other residents causing those residents to be agitated. Review of the nurse's notes from 7/27/21 through 8/30/21 identified Resident #36 exhibited new behaviors of eating out of the trash cans, urinating into the trash can in the resident lounge, pulling his/her pants down trying to expose self in the resident lounge and inappropriately touching other residents when in the lounge. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the nurse's notes and the August 2021 Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] . Upon further review, the clinical record failed to reflect documentation a physician or Advanced Practice Nurse Practitioner (APRN) had been notified when the [MEDICATION(S)] was not available to be administered due to the bloodwork results. Review of the bloodwork section in the clinical record identified bloodwork was obtained on 7/30/21, 8/6/21, 8/11/21, 8/16/21, 8/18/21 and 8/23/21. Interview with the psychiatric Advanced Practice registered Nurse (APRN) #7, on 9/2/21 at 3:49 PM identified she was concerned with the [MEDICATION(S)] availability for Resident # 36 as she had checked with the charge nurse on the unit and the medication was unavailable on more than one (1) occasion and she reported her concerns to the Director of Nursing, Administrator, and the pharmacy. APRN #7 indicated although she brought her concerns to the facility about the availability of the [MEDICATION(S)] for Resident #36, the [MEDICATION(S)] was still not available on many occasions. APRN #7 identified the facility informed her they would look into the issue which also included concerns with the lab technician. APRN #7 identified after three (3) days of not receiving the [MEDICATION(S)], Resident #36's [CONDITION(S)] and [CONDITION(S)] symptoms could greatly increase, and she identified had she been notified of the unavailability of the [MEDICATION(S)] she would have titrated the orders to reintroduce dosing to help reduce a risk of harm. Interview with the medical APRN #6, on 9/2/21 at 4:15 PM identified she was not notified that Resident #36 had not received the [MEDICATION(S)] on several occasions and no notes were placed in her communication book by staff. APRN #6 identified had she been notified of the unavailability of the [MEDICATION(S)] she would have titrated the orders to reintroduce dosing of medications to help reduce risk of harm and typically missing one dose of the medication can start causing symptoms of [CONDITION(S)] in someone. Interview with the psychiatrist, MD #2, on 9/2/21 at 4:55 PM identified he was not notified that Resident #36 had missed doses of the [MEDICATION(S)]. MD #2 indicated had he been informed he would have recommended titrating the dose to obtain the prescribed recommended dose after missing a few days of the [MEDICATION(S)] to prevent side effects and help prevent psychotic behavior like symptoms. Interview with the Director of Nursing (DON) on 9/2/21 at 5:15 PM identified she was aware there had been issues with Resident #36 receiving the [MEDICATION(S)] and updating the physician about the missed doses and she would be auditing Resident #36's medication administration daily. The DON identified she had disciplined approximately four (4) licensed nurses for signing off the [MEDICATION(S)] was administered when the medication was not available. Review of the August 2021communication log for the APRN identified there were no notes or communication regarding Resident #36. Review of facility policy entitled physician notification of change in condition directed in part to ensure resident care problems are communicated to the medical staff in a timely manner and if no physician call back received to call the medical director after 4 hours for further instructions. 2.Resident #87 was admitted to the facility on [DATE] with a readmitted d of 5/8/21. The resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified the resident had no cognitive impairment, was independent with bed mobility and transfers, however, needed set up support with transfers between surfaces, including to or from bed, chair, wheelchair, and the standing position. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Medication orders included: [MEDICATION(S)] 25 (Anti-hypertensive) Milligrams (mg) twice a day, [MEDICATION(S)] (Anti-hypertensive) 5 mg one capsule at bedtime, [MEDICATION(S)] (Anti-hypertensive) 20 mg take 4 tablets by mouth once day at 9:00 P.M., [MEDICATION(S)] 25 mg every 8 hours for nerve pain, [MEDICATION(S)] (pain medication), 50 mg every 6 hours as needed for severe pain and [MEDICATION(S)] 50 mg (Anti-hypertensive) two tablets every 8 hours. Additionally, the orders directed Serriglee Solution (Basal Insulin 100 units per ml inject 15 units in the morning and 40 units at hour of sleep, and [MEDICATION(S)] insulin 17 unit Subcutaneously (SQ) before meals. Further, the physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] .M., 11:00 A.M. and 4:30 P.M. for blood glucose results as follows: 200-250: 2 units 251-300: 4 units 301-350: 6 units 351-400: 8 units 401+: 10 units and call the physician. A review of Resident 87's Weights and Vital Sign Summary sheet dated 8/19/21 identified the resident's blood pressure was 189/100 (Normal Range 120/80) at 11:30 A.M (Approximately 4 hours prior to discharge). Review of the Weight and Vital Summary for Resident #87's blood sugars identified the following: 8/18/21 at 11:28 A.M., 453 mg/dl (Normal Blood Sugar Level less than 140 mg/dl) 8/18/21 at 6:26 P.M., 497 mg/dl 8/18/21 at 9:51 P.M., 470 mg/dl 8/19/21 at 8:26 A.M., 402 mg/dl 8/19/21 at 12:24 PM 303 mg/dl (3 hours prior to discharge) Although the physician was notified of the discharge, review of the clinical record failed to identify that the physician and/or Advanced Practice Registered Nurse (APRN) had been notified of Resident# 87's elevated blood pressure prior to discharge and elevated blood glucose levels preceding discharge. Interview with the Director of Nursing Services (DNS) on 8/25/21 at 12:45 P.M. identified she could not provide evidence of what the resident's blood pressure was after the 189/100 reading on 8/19/21 at 11:30 A.M., she could not identify if the resident was re-assessed before discharge regarding the elevated blood pressure 189/100 and elevated blood sugar. Interview with LPN #3 on 8/25/21 at 1:30 P.M. to 1:45 P.M. identified s/he was instructed to do an emergency discharge for Resident # 87. LPN #3 indicated s/he could not recall if she was made aware of Resident #87's blood pressure of 189/100 at 11:45 A.M. on 8/19/21 even though the clinical record indicated LPN #3 recorded the data. LPN #3 also indicated that although s/he did document the resident's vital signs were stable, s/he could not recall what the vital signs were on 8/19/21. Interview with the Medical Director, who was the resident's primary care physician, on 8/27/21 at 10:35 A.M. identified he was not aware of Resident # 87's blood pressure of 189/100 prior to discharge and indicated if he had been made aware, he would have instructed the facility staff not to discharge the resident until they could re-evaluate the blood pressure to see if it was trending up or down. The Medical Director also indicated staff had made him aware of the blood sugars over 401 in the past. The Medical Director also indicated he could not recall if he or his colleagues had been notified of the elevated blood pressure and elevated blood sugars on 8/18/21 and 8/19/21.

Based on clinical record review, interviews and review of facility documentation for one of four sampled residents (Resident #40) reviewed for accidents, the facility failed to provide adequate supervision for a resident with a history of falls to prevent an accident resulting in an injury.The findings include: Resident # 40 [DIAGNOSES REDACTED]. The physician orders [REDACTED]. The Quarterly Minimum Data Set assessment dated [DATE] identified moderately impaired cognition requiring extensive assistance of one for ADL ' s including transfers and ambulation. The care plan dated 7/23/14 identified a self-care deficit and a potential for falls related to a decrease in strength and endurance and non-compliant with calling and/ or waiting for assistance. Interventions included to keep the call bell within reach, transfer and ambulate with assist on one, and allow resident to self-propel in the wheelchair. The nurses notes dated 8/5/14 identified Resident #40 was found on the floor at 10:20 AM and stated he/she was attempting to get something out of the closet and slipped from the wheelchair. The care plan was revised following the incident to include the use of gripper socks at all times. A physician progress notes [REDACTED].#40 was evaluated for insomnia and directed the administration of Ambien(sedative-hypnotic) 5 mg at bedtime, as needed for sleep. Review of the medication administration record for the month of August 2014 identified that although Resident #40 received Ambien 5 mg on 8/8/14, 8/10/14, 8/11/14 and 8/13/14, the clinical record lacked documentation of the resident ' s response to the new medication and /or adverse effects .The nurses notes dated 8/13/14 identified at 12:45 AM Resident #40 was found on the floor in the unit lounge complaining of back and neck pain. The physician was notified and directed to transfer the resident to the ED for an evaluation. Resident #40 was admitted to the acute care hospital with [DIAGNOSES REDACTED]. A CT Spine Cervical (without contrast) report dated 8/13/14 identified a minimally displaced odontoid fracture of the C2 vertebral body and a compression fracture of the T2 vertebral body. Interview, review of the clinical record and facility documentation on 10/22/14 at 10:00 AM with LPN#1 identified he/she administered Ambien 5 mg at 12:00 AM for insomnia to Resident #40. LPN#1 proceeded to provide care to another resident and the two NA ' s on duty were in another resident ' s room providing care. Resident #40 continued to refuse to go to bed and self-propelled in the wheelchair after receiving Ambien. At 12:45 AM while the staff were providing care to other residents, NA# 1 came out of a resident ' s room and responded to the resident calling out for help. Resident #40 was found on the floor in the lounge. Interview on 10/22/14 at 1:00 PM with the consulting Pharmacist identified the effects of Ambien are different for each person; therefore the staff should monitor and document the resident ' s response when a new medication is initiated. The effect of the medication should be documented after each dose to determine if the medication is appropriate for that person. According to the manufacturers recommendations; do not take Ambien unless you are able to stay in bed for a full night (7-8 hours) before you are active again and take Ambien right before you get in bed, not sooner.

Resident #149's [DIAGNOSES REDACTED]. The hospital Inter-Agency Patient Referral Report dated 5/19/12 identified that the resident had a stage II coccyx ulcer. The Nursing Admission assessment dated [DATE] identified the resident with a stage II area to the coccyx measuring 3 centimeters (cm) by 2 cm by 0.1 cm. A Braden scale pressure ulcer risk assessment dated [DATE] identified the resident with a risk score of 12 (12 or less represents high risk). The admission Minimum (MDS) data set [DATE] identified that Resident #149 required total assist with activities of daily living and had an indwelling catheter and stage II pressure ulcer. Review of the resident's care plan dated 5/19/12 identified the potential for urinary tract infection related to indwelling catheter. Interventions directed foley catheter to straight drainage, foley care every shift ,and check for proper positioning of catheter and drainage. Review of a nurse's note dated 6/23/12 at 4:50 AM identified small amount of penile bleeding times two while NA was repositioning resident. Resident's foley catheter was repositioned and at 5:56 PM with foley catheter in place, bleeding from penis continues, cleansed with normal saline and patted dry, [MEDICATION NAME] applied to urinary meatus. Further review of the nurse's notes identified that on 6/25/12 at 3:34 AM small amount of frank bleeding continues from urinary meatus. The hospital Inter-Agency Patient Referral Report dated 6/26/12 identified that the resident had penile erosion from foley catheter and directed staff to change bandages twice a day to outside of penis and to follow up with urology to evaluate. Review of nurse's notes dated 6/26/12 at 6:12 PM noted hematuria related to penile erosion from foley catheter, resident continues with a scan amount from foley catheter. physician's orders [REDACTED]. Review of APRN assessment dated [DATE] noted penile bleeding secondary penile erosion secondary to foley catheter, not new this occurred in June. physician's orders [REDACTED]. Review of Wound/Ostomy APRN consultation note dated 10/2/12 identified penile erosion secondary to foley, urinary meatus with erosion secondary to foley, no drainage noted today, and erosion is through the glens and into the penile shaft. Recommendations included good foley care every shift and to make sure foley is not with tension and/or pressure to penis. Interview and review of the clinical record and facility documentation with the Director of Nurses on 11/29/12 at 11: AM failed to provide reflect that assessments of the penile erosion were conducted when the area was open. Observation on 11/30/12 at 10:30 AM identified the resident was without benefit of the foley catheter being secured. Further observation with Licensed Practical Nurse #1 identified that the resident had a healed urinary meatus with deep erosion; foley catheter was stretched out and was pulling. Interview with LPN #1 at that time identified that resident was to have foley catheter strip fastener applied to hold the catheter in place and/or to prevent from being pulled on. LPN #1 was unable to identify why the foley catheter was not secured. Subsequent to surveyor inquiry the physician was updated and directed to secure foley to prevent tension and pressure to penis every shift.

Based on clinical record review, interviews with staff, and review of facility documentation for 2 of 3 residents (R#1 and R#2) who were reviewed for abuse, the facility failed to provide the resident with an environment free of abuse resulting in a finding of immediate jeopardy. The findings include: a. Resident #1 was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] identified R#1 was cognitively intact with no deficits in long or short term memory. The MDS indicated R#1 required minimal assistance with transfers and extensive assistance with hygiene. A state agency Reportable Event Form dated [DATE] identified R#1 was alleging that he/she was being abused by the facility's Business Office Manager, the facility Scheduler, and the "Assistant Administrator" (who was not a licensed Administrator and was not an employee of the facility). Nurse's notes dated [DATE] at 2:41 PM indicated R#1 was transferred out of his/her bedroom and moved to a room on the Alzheimer's/dementia unit due to facility construction. The nurse's note indicated that during the packing of R#1's personal belongings, R#1 was yelling, refused to change rooms, and R#1 called the police. Staff proceded with the room change, moved some belongings to the new room, and all other belongings were placed in storage. A subsequent nurse's note at 11:42 PM identified R#1 was not satisfied with the room change and voiced complaints the nurse. Interview with R#1 on [DATE] at 11:45 AM identified that he/she had been asked to change rooms due to construction and when R#1 asked the Business Office Manager if he/she could later return to his/her old room, the Business Office Manager told R#1 "never." R#1 identified that he/she had objected to the move to the Alzheimer's Unit because there were other beds available in the facility. In a written statement dated [DATE], the interim Director of Nursing (DNS) identified that he/she discussed appropriate roommates for R#1 with the "Assistant Administrator" and Business Office Manager in order to avoid a conflict between residents. Instead, a resident who screamed frequently was selected as a roommate for R#1. In a written statement dated [DATE], LPN #9 identified R#1 was not appropriate for the Alzheimer's Unit because he/she was alert, oriented and able to go out of the building independently. When R#1 was moved to the Alzheimer's Unit, there were other beds in the facility that would be more appropriate for R#1. However, the "Assistant Administrator" and Business Office Manager indicated R#1 was to be moved to the Alzheimer's Unit because R#1 would not like it and would ultimately leave the facility. When R#1's roommate died ([DATE]), the "Assistant Administrator" and Business Office Manager inquired who could be moved to R#1's room that would drive R #1 out of the facility. In the documentation, LPN #9 indicated the "Assistant Administrator" told her that R#1 no longer had any rights. During an interview with the Business Office Manager on [DATE] at 3:45 PM, she identified that when R#1 was moved to the Alzheimer's Unit there were no female beds available in the facility. However, a review of the facility daily census reports dated [DATE] and [DATE] identified that female beds were available, as well as single occupancy vacant rooms. b. A statement provided by LPN #9 to the State Agency on [DATE], identified that on [DATE], R#1 left the building to make arrangements to have his/her belongings placed in an off-site storage facility. While R#1 was gone the "Assistant Administrator" and Business Office Manager emptied R#1's room of belongings, without R #1's permission, and placed them with other belongings that R#1 had designated for offsite storage. The "Assistant Administrator" and Business Office Manager indicated that R#1 no longer had any rights as all of R#1's rights were terminated. LPN#9 indicated that on [DATE], after R#1 became aware of the removal of his/her belongings, R#1 cried and slept in his/her wheelchair all night. A nurse's note dated [DATE] at 8:36 PM identified that when R#1 returned from leaving the facility at 8:00 PM, he/she was very upset that her room had been cleaned and belongings were missing. Staff were unable to calm or redirect R#1. In a written statement dated [DATE], the interim Director of Nursing (DNS) indicated that the "Assistant Administrator" and/or Business Office Manager had canceled the movers because if R#1's belongings were not move to storage, the belongings would be sent to Goodwill without the resident's permission. Interview with the "Assistant Administrator" on on [DATE] at 3:45 PM indicated that R#1 did not identified which items that he/she did not want removed from his/her room. On [DATE], R#1 had left the building without signing out and no one was aware of where R#1 went. The "Assistant Administrator" indicated that R#1 had transportation problems and had not returned to the facility by the agreed upon time to move the items (1:00 PM). The "Assistant Administrator" indicated that R#1's room was a disaster and it needed to be done (removal of belongings). However, interview with LPN#5 on [DATE] at 12:10 PM indicated that he/she was aware that R#1 had left early for an appointment and prior to leaving, R#1 had indicated that personal paperwork in a box on the dresser was not to be removed from the facility. LPN #5 indicated that she had told the "Assistant Administrator" who indicated that he/she did not care. In a written statement dated [DATE], LPN#1 indicated that R#1 had identified specific papers such as bus passes that he/she wanted to be kept separated and not packed. After R#1 left the facility, these items were packed and placed on the facility's loading dock. A review of the medical record identified a Release of Responsibility for Leave of Absence form which identified R#1 had signed out of the building on [DATE] at 8:20 AM. c. In a written statement given by LPN #9 on [DATE] at 9:34 AM, LPN #9 identified that approximately 2 weeks prior, she heard the "Assistant Administrator" yelling at R#1 in the recreation room while R#1 was packing his/her belongings. The "Assistant Administrator" told R#1 that if he/she was not out of the recreation room by a certain time, R#1 would "see what would happen." Additional written statements were obtained from the interim DNS on [DATE] at 8:45 PM, Office Staff Member #1 on [DATE] at 1:35 PM, LPN#1 on [DATE] at 2:10 PM, LPN#2 on [DATE] at 2:40 PM and interviews with LPN#4 on [DATE] at 10:50 AM and Office Staff Member #2 on [DATE] at 1:00 PM. Each staff member identified that they had heard the "Assistant Administrator" yell and/or be rude to R#1, and displayed behaviors such as ignoring R#1's presence when spoken to, and slaming the door in R#1's face. Interviews with the "Assistant Administrator" on [DATE] at 3:25 PM and the Business Office Manager on [DATE] at 3:45 PM identified that they each denied that the "Assistant Administrator" ever yelled at R#1. d. Interview with R#1 on [DATE] indicated that he/she did not feel safe in the facility. R#1 identified that the "Assistant Administrator" would get so mad, R#1 could "feel his/her spit on my face" and did not know what the "Assistant Administrator" might do. R#1 identified that he/she did not know if staff would protect him/her from the "Assistant Administrator" because the staff were also afraid of the Assistant Administrator. Interview with Nursing Assistant (NA) #1 and the interim ADNS on [DATE] at 2:00 PM, identified that there was an an incident where the "Assistant Administrator" took a dirty/soiled brief out of the garbage, placed it on the floor, and demanded that he/she pick it up or risk being fired. The interim ADNS indicated that following the incident, NA#1 experienced an anxiety attack and needed to be transferred to the hospital by ambulance for evaluation. Interviews with the interim DNS and LPN#9 on [DATE] identified that since this investigation began, they feared for R#1's well being. e. Interview with the Administrator on [DATE] at 8:34 AM identified that he/she had heard that the Buisiness Office Manager (who was currently suspended from duty) was interested in obtaining video and other documents related to R#1. The Administrator identified that the video in question showed the "Assistant Administrator" and Business Office Manager allegedly spying on R#1 while R#1 was in his/her bedroom on the telephone complaining to the "State" about being abused. On [DATE] at 9:50 AM, the facility's video surveillance in question was reviewed with the Administrator and an information technology staff member. The surviellence video time stamped [DATE] from 2:38 PM to 2:48 PM depicted the "Assistant Administrator" and Business Office Manager standing outside R#1's bed room for approximately 10 minutes allegedly "ease dropping" on R#1. At approximately 2:46 PM, the "Assistant Administrator" sat in another residents' wheelchair, pretended to be a resident, and was pushed passed R#1's bedroom door by the Business Office Manager. Once passed R#1's bedroom door, the "Assistant Administrator" stood up from the wheelchair and left the area. f. Resident #2 had [DIAGNOSES REDACTED]. A minimum data set ((MDS) dated [DATE] identified the resident was able to understand and be understood, was cognitively impaired, and was independent with eating. However, nursing notes dated [DATE] identified the resident as alert, oriented, and hard of hearing. On [DATE], Resident #1 reported that over the passed weekend, LPN #10 pinched his/her nose and held his/her mouth closed in order to force the resident to swallow scheduled medications which the resident did not want to take. A body audit was obtained and no injuries were noted. According to the facility investigation, Resident #2 was consistent in reporting the details of the allegation to multiple employees, and also reported this allegation to a friend who then reported it to facility staff. LPN #10 was suspended pending the outcome of an investigation. The facility's investigation was conducted according to facility's abuse policy. Based on the facility investigation, LPN #10 was terminated for abusing Resident #2 while administering medications. Interview with Resident #2 on [DATE] at 1:15 PM identified that LPN #10 did pinch his/her nose and held his/her mouth closed. Interview with LPN #10 on [DATE] at 11:40 AM identified that he/she denied pinching the nose and holding Resident #2's mouth closed while administering medications. g. The Department requested an immediate action plan from the facility on [DATE] and again on [DATE] to address immediate inservicing of staff on the abuse policy and suspension of staff to ensure that residents were safe. Interview with LPN #9 (staff development) on [DATE] at 11:50 AM identified that he/she was aware of the plan to provide, in part, inservicing on abuse to all staff members. However, LPN #9 stated that inservicing had not yet begun because he/she was gathering information for the inservice. Interviews with CNA's #23, #24, #25, and #26 on [DATE] between 7:00 AM and 7:05 AM identified that they had not received and inservicing on the facility's abuse policy, as identified in the immediate action plan. Interview with LPN #9 on [DATE] at 11:15 AM identified that he/she had not yet provided inservicing to the staff members who worked on the 7:00 AM to 3:00 PM shift. The deficiencies cited above were found to constitute immediate jeopardy on [DATE].

Based on clinical record review, interviews and review of facility documentation for 1 of 3 residents (R#1) who were reviewed for abuse, the facility failed to provide oversight related to reporting allegations of abuse to appropriate agencies such as the state agency and local law enforcement, investigate the allegations and protect the resident during the investigation resulting in a finding of immediate jeopardy. The findings include: a. Resident #1 was admitted with [DIAGNOSES REDACTED]. A Minimum Data Set ((MDS) dated [DATE] identified R#1 was cognitively intact with no deficits in long or short term memory. The MDS indicated R#1 required minimal assistance with transfers and extensive assistance with hygiene. A state agency Reportable Event Form dated [DATE] identified R#1 was alleging that he/she was being abused by the facility's Business Office Manager, the facility Scheduler, and the "Assistant Administrator" (who was not a licensed Administrator and was not an employee of the facility). Nurse's notes dated [DATE] at 2:41 PM indicated R#1 was transferred out of his/her bedroom and moved to a room on the Alzheimer's/dementia unit due to facility construction. The nurse's note indicated that during the packing of R#1's personal belongings, R#1 was yelling, refused to change rooms, and R#1 called the police. Staff proceeded with the room change, moved some belongings to the new room, and all other belongings were placed in storage. A subsequent nurse's note at 11:42 PM identified R#1 was not satisfied with the room change and voiced complaints the nurse. Interview with R#1 on [DATE] at 11:45 AM identified that he/she had been asked to change rooms due to construction and when R#1 asked the Business Office Manager if he/she could later return to his/her old room, the Business Office Manager told R#1 "never." R#1 identified that he/she had objected to the move to the Alzheimer's Unit because there were other beds available in the facility. In a written statement dated [DATE], the interim Director of Nursing (DNS) identified that he/she discussed appropriate roommates for R#1 with the "Assistant Administrator" and Business Office Manager in order to avoid a conflict between residents. Instead, a resident who screamed frequently was selected as a roommate for R#1. In a written statement dated [DATE], LPN #9 identified R#1 was not appropriate for the Alzheimer's Unit because he/she was alert, oriented and able to go out of the building independently. When R#1 was moved to the Alzheimer's Unit, there were other beds in the facility that would be more appropriate for R#1. However, the "Assistant Administrator" and Business Office Manager indicated R#1 was to be moved to the Alzheimer's Unit because R#1 would not like it and would ultimately leave the facility. When R#1's roommate died ([DATE]), the "Assistant Administrator" and Business Office Manager inquired who could be moved to R#1's room that would drive R #1 out of the facility. In the documentation, LPN #9 indicated the "Assistant Administrator" told her that R#1 no longer had any rights. During an interview with the Business Office Manager on [DATE] at 3:45 PM, she identified that when R#1 was moved to the Alzheimer's Unit there were no female beds available in the facility. However, a review of the facility daily census reports dated [DATE] and [DATE] identified that female beds were available, as well as single occupancy vacant rooms. b. A statement provided by LPN #9 to the State Agency on [DATE], identified that on [DATE], R#1 left the building to make arrangements to have his/her belongings placed in an off-site storage facility. While R#1 was gone the "Assistant Administrator" and Business Office Manager emptied R#1's room of belongings, without R #1's permission, and placed them with other belongings that R#1 had designated for offsite storage. The "Assistant Administrator" and Business Office Manager indicated that R#1 no longer had any rights as all of R#1's rights were terminated. LPN#9 indicated that on [DATE], after R#1 became aware of the removal of his/her belongings, R#1 cried and slept in his/her wheelchair all night. A nurse's note dated [DATE] at 8:36 PM identified that when R#1 returned from leaving the facility at 8:00 PM, he/she was very upset that her room had been cleaned and belongings were missing. Staff were unable to calm or redirect R#1. In a written statement dated [DATE], the interim Director of Nursing (DNS) indicated that the "Assistant Administrator" and/or Business Office Manager had canceled the movers because if R#1's belongings were not move to storage, the belongings would be sent to Goodwill without the resident's permission. Interview with the "Assistant Administrator" on on [DATE] at 3:45 PM indicated that R#1 did not identified which items that he/she did not want removed from his/her room. On [DATE], R#1 had left the building without signing out and no one was aware of where R#1 went. The "Assistant Administrator" indicated that R#1 had transportation problems and had not returned to the facility by the agreed upon time to move the items (1:00 PM). The "Assistant Administrator" indicated that R#1's room was a disaster and it needed to be done (removal of belongings). However, interview with LPN#5 on [DATE] at 12:10 PM indicated that he/she was aware that R#1 had left early for an appointment and prior to leaving, R#1 had indicated that personal paperwork in a box on the dresser was not to be removed from the facility. LPN #5 indicated that she had told the "Assistant Administrator" who indicated that he/she did not care. In a written statement dated [DATE], LPN#1 indicated that R#1 had identified specific papers such as bus passes that he/she wanted to be kept separated and not packed. After R#1 left the facility, these items were packed and placed on the facility's loading dock. A review of the medical record identified a Release of Responsibility for Leave of Absence form which identified R#1 had signed out of the building on [DATE] at 8:20 AM. c. In a written statement given by LPN #9 on [DATE] at 9:34 AM, LPN #9 identified that approximately 2 weeks prior, she heard the "Assistant Administrator" yelling at R#1 in the recreation room while R#1 was packing his/her belongings. The "Assistant Administrator" told R#1 that if he/she was not out of the recreation room by a certain time, R#1 would "see what would happen." Additional written statements were obtained from the interim DNS on [DATE] at 8:45 PM, Office Staff Member #1 on [DATE] at 1:35 PM, LPN#1 on [DATE] at 2:10 PM, LPN#2 on [DATE] at 2:40 PM and interviews with LPN#4 on [DATE] at 10:50 AM and Office Staff Member #2 on [DATE] at 1:00 PM. Each staff member identified that they had heard the "Assistant Administrator" yell and/or be rude to R#1, and displayed behaviors such as ignoring R#1's presence when spoken to, and slamming the door in R#1's face. Interviews with the "Assistant Administrator" on [DATE] at 3:25 PM and the Business Office Manager on [DATE] at 3:45 PM identified that they each denied that the "Assistant Administrator" ever yelled at R#1. d. Interview with R#1 on [DATE] indicated that he/she did not feel safe in the facility. R#1 identified that the "Assistant Administrator" would get so mad, R#1 could "feel his/her spit on my face" and did not know what the "Assistant Administrator" might do. R#1 identified that he/she did not know if staff would protect him/her from the "Assistant Administrator" because the staff were also afraid of the Assistant Administrator. Interview with Nursing Assistant (NA) #1 and the interim ADNS on [DATE] at 2:00 PM, identified that there was an an incident where the "Assistant Administrator" took a dirty/soiled brief out of the garbage, placed it on the floor, and demanded that he/she pick it up or risk being fired. The interim ADNS indicated that following the incident, NA#1 experienced an anxiety attack and needed to be transferred to the hospital by ambulance for evaluation. Interviews with the interim DNS and LPN#9 on [DATE] identified that since this investigation began, they feared for R#1's well being. e. Interview with the Administrator on [DATE] at 8:34 AM identified that he/she had heard that the Business Office Manager (who was currently suspended from duty) was interested in obtaining video and other documents related to R#1. The Administrator identified that the video in question showed the "Assistant Administrator" and Business Office Manager allegedly spying on R#1 while R#1 was in his/her bedroom on the telephone complaining to the "State" about being abused. On [DATE] at 9:50 AM, the facility's video surveillance in question was reviewed with the Administrator and an information technology staff member. The surveillance video time stamped [DATE] from 2:38 PM to 2:48 PM depicted the "Assistant Administrator" and Business Office Manager standing outside R#1's bed room for approximately 10 minutes allegedly "ease dropping" on R#1. At approximately 2:46 PM, the "Assistant Administrator" sat in another residents' wheelchair, pretended to be a resident, and was pushed passed R#1's bedroom door by the Business Office Manager. Once passed R#1's bedroom door, the "Assistant Administrator" stood up from the wheelchair and left the area. A review of facility documentation failed to identify reporting of alleged abuse and failed to demonstrate that investigations were conducted based on the allegations related to the aforementioned incidents. Interviews with LPN#1 on [DATE] and LPN#4 on [DATE], identified that they had reported the incidents to DNS #1 (previous DNS). In an interview with LPN#9 on [DATE] at 9:00 AM, LPN#9 indicated that he/she had reported the incident to DNS #1 (previous DNS) and DNS #1 indicated he/she was "not going there" and "needed her job." In an interview with the interim DNS on [DATE] at 8:45 AM, the interim DNS identified that the Administrator was aware of the behaviors exhibited by the "Assistant Administrator" and Business Office Manager. The interim DNS identified that several incidents occurred in the doorway to the Administrators office, and the Administrator in the office at that time. In an interview with the interim DNS dated [DATE] at 3:25 PM, the interim DNS indicated that he/she had been in the DNS position since [DATE] and had not received reports of abuse allegations related to R#1 until [DATE]. On [DATE] he/she called the state agency to report the incident and written documentation was completed. However, the documentation lacked evidence of an investigation, suspension of staff during the investigation, and notification of the local law enforcement agency according to the facility abuse policy. The DNS had indicated he/she was not familiar with the processes involved in identifying and reporting abuse. The interim DNS indicated when he/she received the allegation of abuse pertaining to R#1 on [DATE], he/she spoke with the Administrator, "Assistant Administrator", Business Office Manager and Scheduler and was told to hold off reporting the incident. The interim DNS identified she was not comfortable with this and called the state agency on [DATE] at 3:30 PM for further clarification. The state agency Reportable Event Form was signed by the Administrator. The facility abuse policy indicated when an allegation of abuse has been made, the DNS, ADNS, and the Administrator would be notified immediately. The policy identified written statements would be taken of the staff member implicated and as well as from witnesses. The implicated staff member would be removed from duty, sent home immediately, and local law enforcement, the ombudsman and state agency would be notified. The Department requested an immediate action plan from the facility on [DATE] and again on [DATE] to address immediate inservicing of staff on the abuse policy and suspension of staff to ensure that residents were safe. Interview with LPN #9 (staff development) on [DATE] at 11:50 AM identified that he/she was aware of the plan to provide, in part, inservicing on abuse to all staff members. However, LPN #9 stated that inservicing had not yet begun because he/she was gathering information for the inservice. Interviews with CNA's #23, #24, #25, and #26 on [DATE] between 7:00 AM and 7:05 AM identified that they had not received and inservicing on the facility's abuse policy, as identified in the immediate action plan. Interview with LPN #9 on [DATE] at 11:15 AM identified that he/she had not yet provided inservicing to the staff members who worked on the 7:00 AM to 3:00 PM shift. In addition, the facility failed to contact the police after R #1's allegation of abuse in accordance with their policy even after the State Agency's inquiry on [DATE], [DATE], and [DATE]. The deficiencies cited above were found to constitute immediate jeopardy on [DATE].

Based on observations, clinical record reviews, interviews, review of facility policies, and review of facility documentation for 1 (R#1) of 3 residents reviewed for abuse, the Administrator failed to provide oversight related to identifying allegations of abuse, reporting allegations of abuse to appropriate agencies such as the state agency and local law enforcement, investigation of allegations and/or failed to protect the resident during the investigation and/or the facility failed to be administered in a manner that promoted resident rights and freedom from abuse and/or the Administrator failed to be aware of significant issues in the facility related to the "Assistant Administrator" (who was not a licensed Administrator and was not an employee of the facility) and/or failed to ensure the overall management of the facility resulting in a finding of immediate jeopardy. The findings include: a. During the survey from 6/18/12 through 6/21/12, it was identified that the Administrator had failed to: 1. Ensure residents were not fearful of staff or the "Assistant Administrator." 2. Ensure resident privacy while on the telephone. 3. Ensure staff treated residents appropriately and without fear of retaliation. 4. Ensure that staff respected residents' personal property. 5. Ensure that a resident had choices regarding room changes and/or roommates. 6. To have Governing Body ByLaws and a functioning Governing Body. 7. To have Medical Staff ByLaws and regular Medical Staff Meetings. 8. To appoint a Director of Nurses qualified to act in the position based on management experience, training, and knowledge of processes required to perform in the role of Director of Nursing. 9. To designate a registered nurse as the infection control nurse to be responsible for the day to day operation of a surveillance program. 10. Ensure that the Medical Director acquired a drug enforcement agency (DEA) certificate to allow delivery and stocking of narcotic medications for residents. 11. Ensure that facility policies and procedures were reviewed and/or revised on a regular basis. The Department requested an immediate action plan from the facility on 6/18/12 and again on 6/19/12 to address immediate inservicing of staff on the abuse policy and suspension of staff to ensure that residents were safe. Interview with LPN #9 (staff development) on 6/20/12 at 11:50 AM identified that he/she was aware of the plan to provide, in part, inservicing on abuse to all staff members. However, LPN #9 stated that inservicing had not yet begun because he/she was gathering information for the inservice. Interviews with CNA's #23, #24, #25, and #26 on 6/21/12 between 7:00 AM and 7:05 AM identified that they had not received and inservicing on the facility's abuse policy, as identified in the immediate action plan. Interview with LPN #9 on 6/21/12 at 11:15 AM identified that he/she had not yet provided inservicing to the staff members who worked on the 7:00 AM to 3:00 PM shift. In addition, the facility failed to contact the police after R #1's allegation of abuse in accordance with their policy even after the State Agency's inquiry on 6/19/12, 6/20/12, and 6/21/12. The deficiencies cited under F490 were identified on 6/19/12 to constitute immediate jeopardy. The related deficiencies under F223 and F225 also resulted in findings of immediate jeopardy. c. The facility policy and procedure manual indicated policies and procedures annual review as last completed on 6/15/09. d. Monthly Administrator/DNS meeting minutes were identified for April, May and June 2012. The facility lacked documentation of monthly Administrator/DNS meeting minutes prior to April 2012.