Every finding on record at Greystone Health Care Center

Based on facility policy review, medical record reviews, and interviews, the facility failed to ensure appropriate and timely Notice of Medicare Non-Coverage (NOMNC) Form CMS-10123 and Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form CMS-10055 were provided to 4 residents (Resident #20, Resident #42, Resident #60 and Resident #103) of 6 residents reviewed for beneficiary notices.The findings include: Review of the facility policy titled, Advance Beneficiary Notices, revised 10/30/2023, revealed .It is the policy of this facility to provide timely notices regarding Medicare eligibility and coverage .For Part A items and services, the facility shall use the Skilled Nursing Facility Advance Beneficiary Notice .Form CMS-10055 .A Notice of Medicare Non-Coverage .Form CMS-10123, shall be issued to the resident/representative when Medicare covered service(s) are ending, no matter if resident is leaving the facility or remaining in the facility .the notice shall be provided within two days of the last anticipated covered day . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Acute and Chronic Respiratory Failure, and Congestive Heart Failure. Review of a discharge Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 discharged from the facility on 6/8/2026. Review of the medical record for Resident #20 revealed no documentation a NOMNC or SNFABN was provided to the resident or resident reprasentative. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Heart Disease, and Hypothyroidism. Review of an End of a Part A stay MDS assessment dated [DATE], revealed Resident #42's Medicare Part A Stay ended on 7/15/2026 and the resident remained at the facility. Review of the medical record for Resident #42 revealed no documentation a NOMNC or SNFABN was provided to the resident or resident representative. Review of the medical record revealed Resident #60 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, and Spinal Stenosis. Review of a Modification of End of a Part A Stay MDS assessment dated [DATE], revealed Resident #60's Medicare Part A Stay ended on 5/15/2026. Review of the NOMNC form revealed Resident #60 signed the form on 5/15/2026 and services ended on 5/15/2026. The notice was not provided within two days of the last anticipated covered day. Review of the medical record revealed Resident #103 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Muscle Weakness, and Chronic Pain Syndrome. Review of an End of PPS Part A Stay MDS assessment dated [DATE], revealed Resident #103's Medicare Part A Stay ended on 5/29/2026. Review of the medical record for Resident #103 revealed no documentation a NOMNC or SNFABN was provided to the resident or resident representative. During an interview on 7/22/2026 at 9:25 AM, the Social Service Director stated she was responsible for the completion of the CMS Forms and confirmed SNFABN Form CMS-10055 was not completed for Resident #20, Resident #42, Resident #60, and Resident #103 and NOMNC Form CMS-10123 was not provided within two days of the last anticipated covered day for Resident #103. During an interview on 7/22/2026 at 9:35 AM, the Administrator stated his expectation was for the appropriate forms to be completed within the correct time frame.

Based on Centers for Medicare and (&) Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 review, medical record reviews, observations, and interviews, the facility failed to accurately code a Minimum Data Set (MDS) assessment for Pre-admission Screening and Resident Review (PASRR) for 4 residents (Resident #14, #42 #108 and #12) of 36 residents reviewed for MDS assessment accuracy. The findings include: Review of Centers for Medicare and Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.20.1, dated 10/2025, revealed .primary purpose as an assessment instrument is to identify resident care problems .the assessment [MDS] accurately reflects the resident's status .A1500 .Preadmission Screening and Resident Review [PASRR] .Code .yes .if PASRR Level II screening determined that the resident has a serious mental illness . Review of the medical record revealed Resident #14 was admitted to the facility on [DATE] with diagnoses including Schizophrenia, Depression, and Hypertension. Review of a Notice of PASRR Level II Outcome for Resident #14 dated 9/17/2025, revealed .You had a Level II PASRR evaluation .you need special services for your mental health .your PASRR Level II evaluation remains good during your stay . Review of an annual MDS assessment dated [DATE] revealed Resident #14 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state Level II PASRR process to have a serious mental illness .No . During an observation and interview on 7/22/2026 at 9:50 AM, the Licensed Practice Nurse/MDS Coordinator reviewed the Level II PASRR outcome and the annual MDS assessment for Resident #14 and confirmed the MDS assessment had not been coded correctly to reflect the Level II PASRR. Review of the medical record revealed Resident #42 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Vascular Dementia, Bipolar Disorder, and Chronic Obstructive Pulmonary Disease. Review of a Notice of PASRR Level II Outcome for Resident #42 dated 2/20/2025 (prior to admission), revealed .You had a Level II PASRR evaluation .you need special services for your mental health your PASRR Level II evaluation remains good during your stay . Review of an annual MDS assessment dated [DATE], revealed Resident #42 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have a serious mental illness .or a related condition .No . During an observation and interview on 7/22/2026 at 2:57 PM, the Registered Nurse (RN) MDS Coordinator reviewed the Level II PASRR outcome and the annual MDS assessment for Resident #108 and confirmed the MDS assessment had not been coded correctly to reflect the Level II PASRR. During an interview on 7/22/2026 at 3:58 PM, the Director of Nursing confirmed it was her expectation for the MDS assessment to be coded to accurately reflect the resident's Level II PASRR status. Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Major Depressive Disorder, Impulse Disorder, Unspecified Psychosis, and Mild Intellectual Disabilities. Review of a Notice of PASRR Level II Outcome for Resident #108 dated 12/18/2019, revealed .You had a Level II PASRR evaluation .you need special services for your mental health, intellectual disabilities or related condition .your PASRR Level II evaluation remains good during your stay . Review of a significant change in status MDS assessment dated [DATE], revealed Resident #108 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed .Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition .No . During an observation and interview on 7/22/2026 at 2:57 PM, the RN MDS Coordinator reviewed the Level II PASRR outcome and the significant change MDS assessment for Resident #108 and confirmed the MDS assessment had not been coded correctly to reflect the Level II PASRR. During an interview on 7/22/2026 at 3:58 PM, the Director of Nursing confirmed it was her expectation for the MDS assessment to be coded to accurately reflect the resident's Level II PASRR status. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] with diagnoses including Delusional Disorder, Anxiety Disorder, and Psychosis. Review of a Notice of PASRR Level II Outcome for Resident #12 dated 8/15/2023, revealed .You had a Level II PASRR evaluation .you need special services for your mental health .your PASRR Level II evaluation remains good during your stay . Review of an annual MDS assessment dated [DATE], revealed Resident #12 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed .Is the resident currently considered by the state Level II PASRR process to have a serious mental illness .No . Further review revealed Resident #12 had diagnoses of Anxiety Disorder, Depression, and Psychotic Disorder coded on the MDS assessment. During an observation and interview on 7/22/2026 at 2:50 PM, the RN MDS Coordinator reviewed the Level II PASRR and annual MDS assessment for Resident #12 and confirmed the annual MDS assessment had not been coded correctly to reflect the Level II PASRR. During an interview on 7/22/2026 at 3:58 PM, the Director of Nursing confirmed that it was her expectation that MDS assessments should be coded accurately and Level II PASRRs should have been coded on the MDS assessments for Residents #14, #42, #108 and #12.

Based on facility policy review, medical record review, and interviews, the facility failed to develop a care plan for 1 resident (Resident #40) of 36 residents reviewed for care planning. The findings include: Review of the facility's policy titled, Comprehensive Care Plans, revised 6/30/2022 revealed .It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Diabetes Mellitus, and Severe Protein-Calorie Malnutrition. Review of a comprehensive care plan for Resident #40 revised 7/9/2026, revealed the resident's Stage IV (4) pressure ulcer was not addressed on the comprehensive care plan. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed the resident had a Stage IV pressure ulcer. During an interview on 7/22/2026 at 3:07 PM, the Registered Nurse (RN) MDS Coordinator confirmed Resident #40 did not have a comprehensive care plan developed for the Stage IV pressure ulcer.

Based on facility policy review, medical record review, and interview, the facility failed to revise a care plan for 1 resident (Resident #95) for respiratory interventions of 16 care plans reviewed.The findings include: Review of the facility policy titled, Comprehensive Care Plans, revised 6/30/2022, revealed .policy of this facility .implement .comprehensive person-centered care plan .to meet a resident's medical .needs that are identified in .resident's .Minimum Data Set . Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Tracheostomy (a surgically created opening in the front of the neck leading to the windpipe/trachea for breathing) Status, and Chronic Obstructive Pulmonary Disease (COPD). Review of the Physician's Order for Resident #95 dated 7/18/2024, revealed .Trach [Tracheostomy] Change. Trach [Tracheostomy] .one time a day .for Routine Trach Care related to TRACHEOSTOMY STATUS .and as needed for Trach Change .Suction tracheostomy as needed .Use sterile saline lavage .Trach tie change with baths and as needed .Trach care every shift and as needed .change inner cannula every shift and as needed . Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #95 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment. Further review indicated Resident #95 had a tracheostomy. Review of a comprehensive care plan for Resident #95 dated 7/18/2026, revealed .Resident has an impaired .respiratory status related to dx [diagnosis] of COPD, trach [trachesotomy] status and respiratory failure .Oxygen as ordered .Ensure trach ties are secured . During an interview on 7/22/2026 at 2:15 PM, the Registered Nurse (RN) MDS Coordinator confirmed the care plan for Resident #95 had not been revised to reflect tracheostomy care. During an interview on 7/22/2026 at 3:50 PM, the Director of Nursing confirmed she would expect care plans to be revised with tracheostomy care and confirmed Resident #95's care plan had not been revised to reflect the tracheostomy care.

Based on facility policy review, medical record reviews, observations, and interviews, the facility failed to ensure the environment was free of accidental hazards for 1 resident (Resident #5) when an unsecured scalpel (a small extremely sharp instrument used in surgery, anatomical dissection, and podiatry) was observed on the bedside table and failed to secure medications for 3 residents (Resident #12, #54, and Resident #111) of 36 residents reviewed for accident hazards. The findings include: Review of the facility's policy titled, Sharps Disposal, revised 10/30/2023, revealed .Contaminated sharps will discard them immediately or as soon as feasible into designated containers . Review of the facility's policy titled, Medication Storage, revised 1/30/2024, revealed .medication must be under the direct observation of the person administering medications or locked in the medication storage area/cart . Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Lack of Coordination, Muscle Weakness, and Acute Respiratory Failure. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #5 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated resident was cognitively intact. Review of a physician's progress note for Resident #5 dated 7/16/2026, revealed .15 blade [sharp] was used to surgically excise [remove] devitalized [dead] tissue . During an observation and interview in Resident #5's room on 7/20/2026 at 12:42 PM, revealed a scalpel on the nightstand beside the resident's bed. Resident #5 stated the scalpel looked like the one used by the wound care during a wound care treatment to his toe (unsure of exact date) and must have left the scalpel on his bedside table but was unsure if the particular scalpel observed had been used. Resident #5 stated he recently broke his leg, stayed in bed at all times, and there were no residents who wandered into his room. During an observation and interview in Resident #5's room on 7/20/2026 at 1:39 PM, Certified Nursing Assistant (CNA) E stated the object on the bedside table was a scalpel and there were no residents with wandering behaviors on the hall. During an observation and interview in Resident #5's room on 7/20/2026 at 1:42 PM, Licensed Practical Nurse (LPN) H confirmed a scalpel was on the residents bedside table, removed the scalpel, and disposed of the scalpel in the sharp's disposal box located in the resident's room. During an interview on 7/20/2026 at 3:45 PM, the Director of Nursing stated it was her expectation sharps be disposed of immediately in the appropriate containers once used. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Delusional Disorder, Anxiety Disorder, and Psychosis. Review of an annual MDS assessment dated [DATE], revealed Resident #12 scored a 15 on the BIMS assessment which indicated resident was cognitively intact. Review of the medical record for Resident #12 revealed no documentation Resident #12 had been assessed to self-administer topical medications. During an observation in Resident #12's room on 7/22/2026 at 9:00 AM, revealed a tube of Nystatin Cream on the resident's bedside table. During an observation and interview in Resident #12's room on 7/22/2026 at 3:35 PM, with Registered Nurse (RN) A revealed a tube of Nystatin Cream on the resident' bedside table. RN A confirmed the Nystatin Cream at the resident's bedside and should not be on the bedside table. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] with diagnoses including Diabetes, Chronic Obstructive Pulmonary Disease, and Heart Failure. Review of a quarterly MDS assessment dated [DATE], revealed Resident #54 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of a comprehensive care plan for Resident #54 dated 7/15/2026, revealed Resident #54 was not care planned to self-administer medications. During an observation in Resident #54's room on 7/20/2026 at 11:40 AM, revealed a plastic container of antacid tablets and a container of VapoRub on the resident's bedside table. During an observation and interview in Resident #54's room on 7/20/2026 at 4:10 PM, with LPN H revealed a plastic container of antacid tablets and a container of VapoRub on the resident's bedside table and LPN H removed the medication. LPN H confirmed Resident #54 had not been assessed to self- administer medications. Review of the medical record revealed Resident #111 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Congestive Heart Failure, and Depression. Review of the Physician's Orders for Resident #111 dated 3/11/2026, revealed .Insulin Glargine [medication used to treat high blood sugar] Pen-Injector 100 UNIT/ML [milliliter] .Inject 22 unit .two times a day for DM [Diabetes Mellitus] . Review of an annual MDS assessment dated [DATE], revealed Resident #111 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed the resident had a diagnosis of Diabetes and had received insulin injections during the assessment period. Review of a Medication Administration Record (MAR) for Resident #111 dated 7/1/2026-7/31/2026, revealed the resident received Insulin Glargine twice a day as ordered. During an observation and interview in Resident #111's room on 7/21/2026 at 8:05 AM, a Glargine insulin pen was observed to be lying on the dresser next to the resident's bed. Resident #111 stated the nurse had administered the medication (insulin) this morning.

Based on facility policy review, observations, and interview the facility failed to serve a meal tray timely for 1 resident (Resident #9) of 3 residents reviewed for meal tray distribution. The findings include: Review of the facility's policy titled, Meal Distribution, revised 2/2023, revealed .Meals are .delivered in a timely .manner .nursing staff will be responsible for the .timely delivery of meals to residents . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Chronic Respiratory Failure, and Atrial Fibrillation. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #9 scored a 12 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderative cognitive impairment. Further review revealed Resident #12 required set-up or clean-up assistance with eating. Review of a comprehensive care plan for Resident #9 revised 7/6/2026, revealed .Resident has an ADL [Activities of Daily Living] self-care performance deficit related to .COPD .needs will be met .EATING: Independent - offer assistance with meal setup as needed . During an interview and observation on 7/21/2026 at 7:50 AM, Resident #9 stated .I am ready to get my breakfast tray and especially some coffee . Observation revealed the breakfast meal trays were on meal carts on the hallway and was being delivered to the residents. During an observation on 7/21/2026 at 8:15 AM (25 minutes later), Resident #9 did not have a breakfast tray. Continued observation the other residents on the hallway had been served. During an interview on 7/21/2026 at 8:17 AM, Certified Nursing Assistant (CNA) E stated that he had not served Resident #9's breakfast tray nor did he know who had. During an interview on 7/21/2026 at 8:20 AM, CNA M stated that someone had taken Resident #9's breakfast and the resident had refused (later discovered the resident had not refused). During an interview on 7/21/2026 at 8:25 AM, the Wound Care nurse stated she had not delivered Resident #9's breakfast tray. During an interview on 7/21/2026 at 8:35 AM (approximately 45 minutes after meal delivery service began), CNA E and CNA N confirmed Resident #9's breakfast tray was still on the food cart. CNA E confirmed Resident #9's breakfast tray had not been served timely. During an interview on 7/21/2026 at 8:36 AM, Resident #9 stated he had not received a breakfast tray. During an observation on 7/21/2026 at 8:37 AM, CNA E served Resident #9's breakfast tray. CNA E heated the resident's breakfast try and provided coffee. During an interview on 7/21/2026 at 8:49 AM, LPN L confirmed Resident #9 had not been served breakfast timely. During an interview on 7/22/2026 at 4:51 PM, the Director of Nursing confirmed Resident #9 had not been served breakfast timely on 7/21/2026.

Based on facility policy reviews, medical record reviews, observations, and interviews the facility failed to ensure oxygen was administered according to Physician's Orders for 2 residents (Residents #20 and #19) of 10 residents reviewed for oxygen (O2) therapy, the facility failed to maintain infection control practices during tracheostomy (trach) (a surgically created opening in the front of the neck leading to the windpipe/trachea for breathing) care and failed to perform tracheostomy care appropriately for 1 resident (Resident #95) of 4 residents reviewed for tracheostomies.The findings include: Review of the facility policy titled, Oxygen Administration, revised 10/26/2023, revealed .Oxygen is administered to residents who need it .Oxygen therapy .administered under orders of a physician . Review of the facility policy titled, Tracheostomy Care, revised 10/26/2023, revealed .facility will ensure that residents who need respiratory care .tracheostomy care and tracheal suctioning .provided .with professional standards of practice .remove old dressing .discard .appropriate receptacle .perform hand hygiene .clean the stoma with normal saline moistened gauze .dry the area with additional gauze . Review of the facility policy titled, Sterile Suction, revised 6/23/2025, revealed .tracheal suctioning with a catheter inserted .artificial airway .effective strategy .important for resident comfort . Review of the facility policy titled, Hand Hygiene, revised 5/11/2026, revealed .staff will perform proper hand hygiene .to prevent the spread of infection to .residents .the use of gloves does not replace hand hygiene .if your task requires gloves, perform hand hygiene prior to donning gloves, and immediately after removing gloves . Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease (COPD), Acute and Chronic Respiratory Failure, and Congestive Heart Failure. Review of the Physician's Order for Resident #20 dated 3/31/2026, revealed .oxygen .run @ [at] 2L [Liters]/Min [Minute] via [by way of] N/C [nasal cannula] continuous .related to COPD . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #20 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed Resident #20 had received oxygen. Review of a comprehensive care plan for Resident #20 dated 7/3/2026, revealed .Resident has an impaired pulmonary/respiratory status related to COPD .Oxygen as ordered . During an observation on 7/21/2026 at 4:11 PM, in Resident #20's room revealed the resident lying in bed with 02 tubing in place and had a portable 02 tank secured on the back of the resident's wheelchair at the bedside. Further observation revealed the 02 tank was empty, and the resident had no signs of respiratory distress. During an interview on 7/21/2026 at 4:13 PM, Registered Nurse (RN) B confirmed Resident #20's 02 tank was empty. RN B obtained Resident #20's 02 saturation level, and it was 95% (Normal O2 saturation for a resident with COPD ranges from 88%-92%). Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Chronic Obstructive Pulmonary Disease, and Atrial Fibrillation. Review of the Physician's Order for Resident #19 dated 11/15/2025, revealed .Oxygen .run @ 1 L/Min via trach[tracheostomy] .continuous .related to COPD . Review of a comprehensive care plan for Resident #19 dated 6/14/2026, revealed .Resident has an impaired respiratory status related to .COPD .Oxygen as ordered . Review of a quarterly MDS assessment dated [DATE], revealed Resident #19 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Further review revealed Resident #19 received 02. During an observation on 7/22/2026 at 7:31 AM, in Resident #19's room revealed the resident sitting up in a wheelchair with 02 tubing in place and a portable 02 tank secured on the back of the resident's wheelchair. Further observation revealed the 02 tank was empty, and the resident had no signs of respiratory distress. During an interview and observation on 7/22/2026 at 7:32 AM, RN J confirmed Resident #19 had physician orders for continuous 02 and confirmed the 02 tank was empty. RN J obtained Resident #19's 02 saturation level, and it was 98%. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE] with diagnoses including Cerebral Palsy, Tracheostomy Status, and COPD. Review of the Physician's Order for Resident #95 dated 7/18/2024, revealed .Trach Change .one time a day .for Routine Trach Care related to TRACHEOSTOMY STATUS .and as needed for Trach Change .Suction tracheostomy as needed .Use sterile saline lavage .Trach tie change with baths and as needed .Trach care every shift and as needed .Change inner cannula every shift and as needed . Review of an annual MDS assessment dated [DATE], revealed Resident #95 scored a 10 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review indicated Resident #95 had a tracheostomy. Review of a comprehensive care plan for Resident #95 dated 7/18/2026, revealed .Resident has an impaired .respiratory status related to dx [diagnosis] of COPD, trach [tracheostomy] status and respiratory failure .Oxygen as ordered .Ensure trach ties are secured . During an observation in Resident #95's room on 7/22/2026 at 7:43 AM, revealed Respiratory Therapist (RT) I performed trach care. RT donned appropriate Personal Protective Equipment (PPE), removed single use inner cannula, performed in-line suctioning with single use sterile water already attached to tubing, removed gloves, donned gloves, replaced new single use inner cannula, removed old dressing around trach (tracheostomy) site, and replaced clean dressing around trach stoma. Observation revealed RT I did not clean the hands between the glove changes. During an interview on 7/22/2026 at 7:47 AM, RT I confirmed that she had not cleaned around Resident #95's trach stoma and had not utilized new single use sterile saline for suctioning the resident. During an interview on 7/22/2026 at 8:09 AM, RT I confirmed she did not wash her hands when she changed gloves during tracheostomy care for Resident #95. RT I asked, .should I have sanitized my hands between glove change . During an interview on 7/22/2026 at 4:51 PM, the Director of Nursing confirmed she would expect hands to be sanitized between glove changes, new single use sterile saline utilized when suctioning resident's tracheostomy, and trach stoma should be cleaned when changing out the gauze.

Based on facility policy review, medical record review, observations, and interviews, the facility failed to check refrigerator temperatures for 3 resident's (Resident #25, Resident #73, and Resident #104) and failed to ensure expired food items were discarded for 1 resident (Resident #104) of 7 personal refrigerators observed. The findings include: Review of the facility's policy titled, Resident Refrigerators, revised 7/1/2025 revealed .Housekeeping staff shall record refrigerator temperatures daily on a temperature log attached to the refrigerator .Housekeeping staff shall clean the refrigerator daily and discard any foods that are out of compliance . Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease and Depression. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #25 scored a 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Review of a personal refrigerator temperature log for Resident #25 revealed temperatures were not documented on the following days: April 1st, 2nd, 6th, 7th, 10th, 11th, 12th, 15th, 16th, 17th, 18th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th 2026. Further review revealed temperatures were not documented on the following days: May 1st, 2nd, 3rd, 4th, 8th, 9th, 10th, 26th, and 28th 2026. Review of the medical record revealed Resident #73 was admitted to the facility on [DATE] with diagnoses including Cirrhosis of Liver, Schizophrenia, Anxiety Disorder, and Depression. Review of a quarterly MDS assessment dated [DATE], revealed Resident #73 scored a 14 on the BIMS assessment which indicated the resident was cognitively intact. Review of a personal refrigerator temperature log for Resident #73 revealed temperatures were not documented on the following days: April 1st, 2nd, 6th, 7th, 10th, 11th, 14th, 15th, 16th, 17th, 18th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, and 30th 2026. Further review revealed temperatures were not documented on the following days: May 1st, 2nd, 3rd, 4th, 8th, 9th, 10th, 26th, and 28th 2026. Review of the medical record revealed Resident #104 was admitted to the facility on [DATE] with diagnoses including Spinal Stenosis, Generalized Muscle Weakness, and Chronic Pain Syndrome. Review of a quarterly MDS assessment dated [DATE], revealed Resident #104 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. During an observation and interview on 7/20/2026 at 3:37 PM in Resident #104's room revealed a personal refrigerator with expired items. Further review revealed 1 carton of milk expired on 6/22/2026, and 1 carton of milk had expired on 7/13/2026. Resident #104 stated she did not know who was responsible for checking the refrigerator temperatures, cleaning out her refrigerator, or ensuring expired foods were disposed of properly. Further observation revealed no temperature log on the refrigerator. During an interview and observation in Resident 104's room on 7/20/2026 at 4:09 PM, Licensed Practical Nurse (LPN) D stated all staff were responsible for keeping the residents' personal refrigerators clean and disposing of expired items. LPN D also stated the temperature logs for the residents' personal refrigerators were supposed to be checked daily, with the temperature logs kept at the nurse's station. LPN D confirmed the 2 cartons of milk were expired, and available for resident use. LPN D removed the expired milk. Review of a personal refrigerator temperature log for Resident #104 revealed temperatures were not documented on the following days: April 1st, 2nd, 6th, 10th, 11th, 12th, 15th, 16th, 17th, 18th, 20th, 21st, 22nd, 23rd, 24th, 25th, 26th, 27th, 28th, 29th, 30th 2026. Further review revealed temperatures were not documented on the following days: May 1st, 2nd, 3rd, 4th, 8th, 9th, 10th, 26th, and 28th 2026. During an interview on 7/22/2026 at 4:00 PM, the Director of Nursing confirmed the residents' personal refrigerators were to be cleaned, expired food items to be checked and disposed when expired, and temperatures to be checked and documented daily.

Based on facility policy review, facility contract review, medical record review, and interviews, the facility failed to ensure communication between the facility and hospice services for 1 resident (Resident #16) of 3 residents reviewed for hospice services. The findings include: Review of a Nursing Facility Services Agreement dated 4/15/2010, revealed .Hospice and Facility will jointly develop and agree upon a coordinated Plan of Care .Coordination of Care .Facility shall participate in .meetings .for the coordination, supervision, and evaluation by Hospice of the provision of Facility Services. Hospice and Facility shall communicate with one another regularly .for each particular Hospice Patient . Review of the facility's policy titled, Hospice, revised 10/26/2023, revealed .When a resident chooses to receive hospice care .the facility will coordinate .in cooperation with hospice staff in order to promote the resident's highest practicable physical, mental, and psychosocial well-being .The facility will communicate with hospice and identify, communicate, follow and document all interventions put into place by hospice and the facility .The facility will maintain communication with hospice as it relates to the resident's plan of care and services to ensure each entity is aware of their responsibilities . Review of the medical record revealed Resident #16 was admitted to the facility on [DATE] with diagnoses including Encounter for Palliative Care, Dementia, and Cerebrovascular Disease. Review of the Physician's Orders for Resident #16 dated 2/18/2026, revealed .Admit to Hospice . Review of a comprehensive care plan for Resident #16 dated 2/19/2026, revealed .has a terminal prognosis with Amedysis Hospice Care related to end of life diagnosis senile deterioration of brain . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #16 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and the resident received hospice care. During an interview on 7/22/2026 at 7:58 AM, the Social Service Director (SSD) stated Amedisys staff contacted the facility when they wanted to have a care plan meeting to discuss coordination of care for residents who received hospice services. The SSD also stated there was no documentation of a coordinated care plan meeting between the facility and the hospice provider for Resident #16. During an interview on 7/22/2026 at 4:10 PM, the SSD stated there was a care plan meeting scheduled for Resident #16 on 7/23/2026 with Amedisys hospice and .moving forward we [facility] will have monthly care plan meetings . with Amedisys hospice to discuss coordination of care for all residents who received hospice services. During an interview on 7/22/2026 at 4:13 PM, the Director of Nursing confirmed the facility failed to ensure coordination of care between the facility and hospice for Resident #16.

Based on facility policy review, disinfectant label review, medical record review, observation, and interview, the facility failed to ensure a glucometer (blood glucose machine) (a handheld device used to measure blood glucose levels, to assist with the management of Diabetes) was sanitized after each use for 2 residents (Resident #54 and #5), failed to follow infection control practices during 1 of 2 medication administration observations for 2 Residents (Resident #54 and #5) and failed to follow infection control practices during wound care for 1 resident (Resident #40) of 2 residents observed for wound care. The findings include: Review of the facility policy titled, Medication Administration, dated 1/17/2023, revealed .Medications are administered by licensed nurses .as ordered by the physician.in a manner to prevent contamination or infection .Remove medication .taking care not to touch medication with bare hand .Administer medication .Observe resident consumption of medication .Wash hands . Review of the facility policy titled, Blood Glucose Machine Disinfection, dated 4/2/2026, revealed .The purpose of this procedure is to provide guidelines for the disinfection of blood sampling devices to prevent transmission of blood borne diseases to residents and employees .The facility will ensure blood glucose machines [glucometers] will be disinfected after each use .The blood glucose machine should be disinfected with a wipe pre-saturated with . healthcare disinfectant that is effective against HIV [Human Immunodeficiency Virus], Hepatitis C and Hepatitis B virus . Review of the facility policy's titled, Hand Hygiene, dated 5/11/2026, revealed .All staff will perform proper hand hygiene procedures to prevent the spread of infection to other .residents .Staff will perform hand hygiene when indicated .After handling contaminated objects . Review of a Super Sani-Cloth Germicidal Disposable Wipe (Environmental Protection Agency (EPA) registered healthcare disinfectant wipe used to clean glucometers) label revealed .Effective against .Bloodborne Pathogens .Hepatitis B virus .Hepatitis C virus .HIV .virus . 1. Review of the medical record revealed Resident #54 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Congestive Heart Failure, and Autistic Disorder. 1 a. Review of the Physician's Orders for Resident #54 dated 7/9/2026, revealed .Furosemide [Lasix] [medication used to treat Heart Failure] .20 MG [milligram] .by mouth one time a day related to HEART FAILURE .Insulin Lispro .[medication used to treat Diabetes]100 unit/ml [per milliliter] .Inject 5 unit [s] .before meals related to Diabetes . 2. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Hypertension, and Atrial Fibrillation. 2 a. Review of the Physician's Orders for Resident #5 dated 7/1/2026, revealed .Insulin Lispro .100 unit/ml . Inject per sliding scale .151-200 .2 [administer 2 units] .Potassium Chloride ER [extended release] [supplement used to prevent or treat low blood levels of potassium] Oral Tablet .20 MEQ [milliequivalent] .Give 1 tablet by mouth two times a day for supplement . During an observation and interview of medication administration on 7/21/2026 at 7:50 AM, revealed Registered Nurse (RN) K prepared oral medications for Resident #54 and then stated she needed to check the residents blood glucose level before she administered the medications. RN K placed a small plastic cup of medications labeled with Resident #54's name in the medication cart, locked the cart, donned gloves, and entered the resident's room. RN K checked the resident's blood glucose level using a glucometer. Resident #54 informed RN K he did not want his Lasix administered today because he was going out to eat. RN K removed her gloves and exited the room without washing or sanitizing her hands. Further observation revealed RN K placed the glucometer on top of the medication cart, retrieved Resident #54's medication, removed the Lasix 20 mg tablet from the small plastic cup with her bare hands, and prepared the resident's insulin medication. RN K re-entered Resident #54's room, administered the remaining oral medications, donned gloves, administered the Lispro insulin 5 units, removed her gloves, and exited the room without washing or sanitizing her hands. Continued observation at 8:20 AM, revealed RN K prepared medications for Resident #5, the RN removed Potassium 20 MEQ from the small plastic cup and broke the pill in half with her bare hands and placed the medication back in the cup. The RN entered Resident #5's room, administered oral medications to the resident and exited the room without washing or sanitizing her hands. RN K retrieved the non-sanitized glucometer (used previously for Resident #54) off the medication cart, re-entered Resident #5's room, donned gloves, checked the resident's blood glucose level using the non-sanitized glucometer, removed the gloves, and exited the room without washing or sanitizing her hands. RN K placed the glucometer on top of the medication cart and failed to sanitize the blood glucose machine. RN K stated the facility protocol for sanitizing glucometers was to use Sani-wipes with the purple lid to disinfect the glucometers and were to be disinfected after each resident use. RN K confirmed she failed to follow proper infection control practices when she failed to wash or sanitize her hands when she administered medications to Resident #54 and #5, when she touched Resident #54 and #5's medication with her bare hands, and when she failed to sanitize the glucometer after each resident use. During an interview on 7/21/2026 at 8:45 AM, the Assistant Director of Nursing (ADON) confirmed glucometers were to be sanitized after each use. During an interview on 7/22/2026 at 4:07 PM, the Director of Nursing (DON) confirmed RN K failed to follow proper infection control practices during the medication administration of Residents #54 and #5 and failed to disinfect the glucometer after each resident use. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including Quadriplegia, Diabetes Mellitus, and Severe Protein-Calorie Malnutrition. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #40 scored a 00 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. During an observation and interview on 7/21/2026 at 10:53 AM, revealed the Wound Care Nurse prepared wound care supplies for Resident #40. Further observation revealed the Wound Care Nurse sanitized her hands, applied gloves, and removed the resident's soiled dressings using scissors from the resident's bilateral legs. The Wound Care Nurse failed to use the disinfectant to clean the scissors and placed the soiled scissors in her pocket. The Wound Care Nurse confirmed she placed soiled scissors in her pocket without using the disinfectant. Continued observation revealed no signs or symptoms of infection of Resident #40's bilateral extremities. During an interview on 7/22/2026 at 4:00 PM, the DON confirmed the Wound Care Nurse did not follow appropriate infection control practices during wound care for Resident #40.

Based on facility policy review, medical record review, observations, and interviews the facility failed to ensure the call light was in reach for 2 residents (Resident #13 and Resident #108) of 35 residents reviewed.The findings include: Review of the facility policy titled, Call Lights: Accessibility and Timely Response, revised 12/28/2023, revealed .The purpose of this policy is to assure the facility is adequately equipped with a call light at each residents' bedside .to allow resident to call for assistance .Staff are educated in the proper use of the resident call system .ensuring resident access to .call light . Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses including Post-Polio Syndrome, Footdrop Left, Mild Cognitive Impairment, Osteoarthritis and Age-Related Osteoporosis. Review of a comprehensive care plan for Resident #13 dated 5/24/2026, revealed resident had .ADL [Activities of Daily Living] self-care performance deficit related to .weakness, impaired mobility .OA [Osteoarthritis] .left foot drop, pain .Encourage resident to use call light when assistance is needed .Place call light within reach . Review of a significant change Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #13 scored a 10 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had moderate cognitive impairment and required substantial/maximal assistance on staff for ADL's and mobility. During an observation on 7/21/2026 at 8:15 AM, in Resident #13's room revealed the resident yelling out for assistance, lying in bed with the head of bed elevated, with her breakfast tray in front of her on the overbed table. Further observation revealed Resident #13's call light was on the floor out of reach of the resident. During an observation and interview in Resident #13's room on 7/21/2026 at 8:25 AM, revealed the resident requested assistance opening the milk carton. The call light was on the floor out of reach of the resident. The surveyor exited the room to get staff assistance.During an observation and interview in Resident #13's room on 7/21/2026 at 8:30 AM, with Registered Nurse (RN) B revealed the call light remained out of reach of the resident, the resident's milk had not been opened, and RN B opened the milk and placed the call light within the resident's reach. RN B confirmed Resident #13's call light was out of reach.Review of the medical record revealed Resident #108 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Need for Assistance with Personal Care, Other Abnormalities of Gait and Mobility, Impulse Disorder, and Mild Intellectual Disabilities.Review of a comprehensive care plan for Resident #108 revised 4/29/2026, revealed .at risk for falls/injury .Place call light within reach .Review of a quarterly MDS assessment dated [DATE], revealed Resident #108 scored a 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. During an observation in Resident #108's room on 7/20/2026 at 11:34 AM, revealed Resident #108 lying in bed. Further observation revealed Resident #108's call light was out of reach. During an observation in Resident #108's room on 7/20/2026 at 3:47 PM, revealed Resident #108 lying in bed. Further observation revealed Resident #108's call light was out of reach. During an observation and interview on 7/20/2026 at 3:49 PM, RN C confirmed Resident #108's call light was out of reach.During an interview on 7/22/2026 at 3:59 PM, the Director of Nursing confirmed it was her expectation for call lights to be placed within the residents' reach.

Based on medical record review, observation, and interview the facility failed to ensure resident's right to retain personal possessions for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Dependence on Ventilator, Gastrostomy Status, Need for Assistance with Personal Care. Review of a Minimum Data Set (MDS) assessment for Resident #1 revealed a Discharge return anticipated MDS assessment was completed on 1/29/2025 and an entry MDS assessment was completed on 3/18/2025. Review of nurse's progress notes for Resident #1 revealed the resident was transferred to the hospital on 1/29/2025 and returned to the facility on [DATE]. Review of an admission MDS assessment dated [DATE] revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During a telephone interview on 5/13/2025 at 4:47 PM, Resident #1's family member stated the resident had been hospitalized for 1 month related to trouble breathing. When Resident #1 returned to the facility, the resident's personal belongings, including a statue of [NAME] and a small tree the family decorated for the holidays, were missing from the room. The resident's family member stated a facility staff member was notified of the missing personal items, but did not know the staff member's name. Further interview revealed a staff member had told Resident #1's granddaughter the resident's personal belongings had been packed in a box and reported later the resident's items could not be found. During an observation of Resident #1's room on 5/14/2025 at 8:30 AM, revealed a tree and statue of [NAME] were not in the resident's room. During an interview on 5/14/2025 at 9:01 AM, Social Worker A stated housekeeping boxed resident items and stored them on 3rd floor when a resident left the facility. During an interview on 5/14/2025 at 1:35 PM, the Housekeeping Manager stated Resident #1 asked a housekeeper where her personal belongings were when she returned from the hospital. The Housekeeping Supervisor recalled Resident #1 was missing a .Christmas tree and trinkets .I remember she had a tree .she [Resident #1] asked about the tree .When I went up there [3rd floor], I found a journal, notepad, brush, crossword puzzle book, and a daily devotional book. I brought those down to her . The Housekeeping Manager stated resident's belongings who left the facility were placed in a box or bag and labeled with the resident's name and date and was placed in storage. Any boxes/bags dated 30 days or older were to be discarded.We started the 30 day thing because the room [where resident items were stored] was packed . The Housekeeping Manager stated a previous administrator had instructed them [housekeeping staff] to discard resident's personal items which had been stored for 30 days. She stated .when I went to Social Services, I was told the resident [Resident #1] had been gone over 30 days . so the items would have been discarded. During an interview on 5/14/2025 at 1:45 PM, the Social Services Director (SSD) stated she did not recall if she reached out to Resident #1's family to see if they wanted the resident's belongings or to notify them the resident's belongings were going to be discarded after the 30 days. The SSD stated she spoke with Social Worker A, who told her she did not contact Resident #1's family regarding discarding the resident's personal belongings. During an interview on 5/14/2025 at 2:00 PM, the Regional Clinical Director stated she was not aware the former Administrator had advised the housekeeping staff to discard discharged or hospitlized residents' personal items after 30 days and the facility did not have a policy regarding disposal of resident's personal items. During an interview on 5/14/2025 at 3:25 PM, the Director of Nursing (DON) stated staff were expected to notify Administration when resident personal items could not be found.

Based on medical record review, observation, and interview the facility failed to ensure resident's right to retain personal possessions for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Dependence on Ventilator, Gastrostomy Status, Need for Assistance with Personal Care. Review of a Minimum Data Set (MDS) assessment for Resident #1 revealed a Discharge return anticipated MDS assessment was completed on 1/29/2025 and an entry MDS assessment was completed on 3/18/2025. Review of nurse's progress notes for Resident #1 revealed the resident was transferred to the hospital on 1/29/2025 and returned to the facility on [DATE]. Review of an admission MDS assessment dated [DATE] revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During a telephone interview on 5/13/2025 at 4:47 PM, Resident #1's family member stated the resident had been hospitalized for 1 month related to trouble breathing. When Resident #1 returned to the facility, the resident's personal belongings, including a statue of [NAME] and a small tree the family decorated for the holidays, were missing from the room. The resident's family member stated a facility staff member was notified of the missing personal items, but did not know the staff member's name. Further interview revealed a staff member had told Resident #1's granddaughter the resident's personal belongings had been packed in a box and reported later the resident's items could not be found. During an observation of Resident #1's room on 5/14/2025 at 8:30 AM, revealed a tree and statue of [NAME] were not in the resident's room. During an interview on 5/14/2025 at 9:01 AM, Social Worker A stated housekeeping boxed resident items and stored them on 3rd floor when a resident left the facility. During an interview on 5/14/2025 at 1:35 PM, the Housekeeping Manager stated Resident #1 asked a housekeeper where her personal belongings were when she returned from the hospital. The Housekeeping Supervisor recalled Resident #1 was missing a .Christmas tree and trinkets .I remember she had a tree .she [Resident #1] asked about the tree .When I went up there [3rd floor], I found a journal, notepad, brush, crossword puzzle book, and a daily devotional book. I brought those down to her . The Housekeeping Manager stated resident's belongings who left the facility were placed in a box or bag and labeled with the resident's name and date and was placed in storage. Any boxes/bags dated 30 days or older were to be discarded.We started the 30 day thing because the room [where resident items were stored] was packed . The Housekeeping Manager stated a previous administrator had instructed them [housekeeping staff] to discard resident's personal items which had been stored for 30 days. She stated .when I went to Social Services, I was told the resident [Resident #1] had been gone over 30 days . so the items would have been discarded. During an interview on 5/14/2025 at 1:45 PM, the Social Services Director (SSD) stated she did not recall if she reached out to Resident #1's family to see if they wanted the resident's belongings or to notify them the resident's belongings were going to be discarded after the 30 days. The SSD stated she spoke with Social Worker A, who told her she did not contact Resident #1's family regarding discarding the resident's personal belongings. During an interview on 5/14/2025 at 2:00 PM, the Regional Clinical Director stated she was not aware the former Administrator had advised the housekeeping staff to discard discharged or hospitlized residents' personal items after 30 days and the facility did not have a policy regarding disposal of resident's personal items. During an interview on 5/14/2025 at 3:25 PM, the Director of Nursing (DON) stated staff were expected to notify Administration when resident personal items could not be found. Refer to Event ID: 52HY11

Based on medical record review, observation, and interview the facility failed to ensure resident's right to retain personal possessions for 1 resident (Resident #1) of 3 residents reviewed. The findings include: Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Acute and Chronic Respiratory Failure with Hypoxia, Chronic Obstructive Pulmonary Disease, Tracheostomy, Dependence on Ventilator, Gastrostomy Status, Need for Assistance with Personal Care. Review of a Minimum Data Set (MDS) assessment for Resident #1 revealed a Discharge return anticipated MDS assessment was completed on 1/29/2025 and an entry MDS assessment was completed on 3/18/2025. Review of nurse's progress notes for Resident #1 revealed the resident was transferred to the hospital on 1/29/2025 and returned to the facility on 3/18/2025. Review of an admission MDS assessment dated [DATE] revealed Resident #1 scored a 13 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. During a telephone interview on 5/13/2025 at 4:47 PM, Resident #1's family member stated the resident had been hospitalized for 1 month related to trouble breathing. When Resident #1 returned to the facility, the resident's personal belongings, including a statue of [NAME] and a small tree the family decorated for the holidays, were missing from the room. The resident's family member stated a facility staff member was notified of the missing personal items, but did not know the staff member's name. Further interview revealed a staff member had told Resident #1's granddaughter the resident's personal belongings had been packed in a box and reported later the resident's items could not be found. During an observation of Resident #1's room on 5/14/2025 at 8:30 AM, revealed a tree and statue of [NAME] were not in the resident's room. During an interview on 5/14/2025 at 9:01 AM, Social Worker A stated housekeeping boxed resident items and stored them on 3rd floor when a resident left the facility. During an interview on 5/14/2025 at 1:35 PM, the Housekeeping Manager stated Resident #1 asked a housekeeper where her personal belongings were when she returned from the hospital. The Housekeeping Supervisor recalled Resident #1 was missing a .Christmas tree and trinkets .I remember she had a tree .she [Resident #1] asked about the tree .When I went up there [3rd floor], I found a journal, notepad, brush, crossword puzzle book, and a daily devotional book. I brought those down to her . The Housekeeping Manager stated resident's belongings who left the facility were placed in a box or bag and labeled with the resident's name and date and was placed in storage. Any boxes/bags dated 30 days or older were to be discarded. .We started the 30 day thing because the room [where resident items were stored] was packed . The Housekeeping Manager stated a previous administrator had instructed them [housekeeping staff] to discard resident's personal items which had been stored for 30 days. She stated .when I went to Social Services, I was told the resident [Resident #1] had been gone over 30 days . so the items would have been discarded. During an interview on 5/14/2025 at 1:45 PM, the Social Services Director (SSD) stated she did not recall if she reached out to Resident #1's family to see if they wanted the resident's belongings or to notify them the resident's belongings were going to be discarded after the 30 days. The SSD stated she spoke with Social Worker A, who told her she did not contact Resident #1's family regarding discarding the resident's personal belongings. During an interview on 5/14/2025 at 2:00 PM, the Regional Clinical Director stated she was not aware the former Administrator had advised the housekeeping staff to discard discharged or hospitlized residents' personal items after 30 days and the facility did not have a policy regarding disposal of resident's personal items. During an interview on 5/14/2025 at 3:25 PM, the Director of Nursing (DON) stated staff were expected to notify Administration when resident personal items could not be found. Refer to Event ID: 52HY11

Based on facility documentation review, observation, and interview the facility failed to use a disinfectant according to the manufacturer's instructions on 1 of 3 hallways observed for disinfectant use to prevent the spread of candida auris and other infectios organisms. The findings include: Review of facility undated document titled, Healthcare SEVICES GROUP, revealed .PURPOSE: To teach environmental Services employees the proper cleaning method to sanitize .any area in a healthcare facility .when using cleaning products always refer to the manufacturer's recommended dwell time. Dwell time .is how long a chemical needs to be in contact with the surface in order to effectively sanitize or disinfect . Review of facility undated document titled .VIRASEPT . revealed .is a .Detergent-Disinfectant .Effective in 4 minutes .Apply Virasept with a coarse trigger sprayer, cloth .or by soaking to thoroughly wet surface .Allow surface to remain wet for at least 4 minutes . During an observation on 4/2/2025 at 2:30 PM, on the 100 hall, Housekeeper M was observed disinfecting the entrance doorknob to room [ROOM NUMBER] the housekeeper sprayed Virasept cleaning solution on a washcloth, wiped the doorknob with the washcloth, then sprayed the doorknob with the Virasept cleaning solution the doorknob was dry within 3 minutes the housekeeper did not respray the doorknob with the solution at any time in order to keep the doorknob wet for at least 4 minutes per the manufacturer's instructions. During an interview on 4/2/2025 at 2:00 PM, The Housekeeping Manger stated .we have the Vircept that we use we spray the surface, and we got to let it set for 4 minutes it has to be wet for 4 minutes and then we wipe it . During an interview on 4/2/2025 at 2:25 PM, Housekeeper M stated .it's [the doorknob surface] supposed to be wet for 4 minutes .I did see it wasn't wet .it was dry before 4 minutes . and the doorknob was not properly disinfected according to the manufacturer's instructions.

Based on facility policy review, observations, and interviews, the facility failed to ensure daily staff posting information included the resident census, the facility name, and actual number of hours worked by Registered Nurses (RN), Licensed Practical Nurses (LPN), and Certified Nursing Assistants (CNA) on 3 of 3 days reviewed for staff postings. The findings include: Review of the facility policy titled, Facility Required Postings, revised on 1/1/2022, revealed .The facility will post required postings .staffing information . Review of the Daily Staffing Sheets dated 10/28/2024-10/30/2024 revealed the following: The resident census and facility name was not listed for 3 days on the Daily Posted Staffing Sheets from 10/28/2024-10/30/2024. The RN hours, LPN hours, and CNA hours were not documented on the Daily Posted Staffing Sheets for 3 days from 10/28/2024-10/30/2024. During an interview on 10/30/2024 at 8:45 AM, the Staffing/Central Supply Coordinator confirmed the Daily Posted Staffing Sheets on 10/28/2024-10/30/2024 did not include the resident census, the facility name, or the actual hours worked by RNs, LPNs, and CNAs. During an interview on 10/30/2024 at 9:26 AM, the Director of Nursing (DON) reviewed the Daily Posted Staffing Sheets for 10/28/2024, 10/29/2024, and 10/30/2024. The DON confirmed the resident census, the facility name, and actual hours worked by RNs, LPNs, and CNAs were not included on the staffing sheets.

Based on facility policy review, observations, and interviews, the facility failed to maintain kitchen equipment in a sanitary condition, ensure spices were properly sealed, and failed to discard expired food which had the potential to affect 92 of 95 residents. The findings include: Review of the facility's policy titled, Environment, revised ,d+[DATE], revealed .Dining Services Director will ensure kitchen is maintained in a clean sanitary manner, including floors, walls . Review of the facility's policy titled, Food Storage: Dry Goods, revised ,d+[DATE], revealed .packaged .foods items will be kept .properly sealed . During an observation of the food preparation area on [DATE] at 10:15 AM, with the Certified Dietary Manager (CDM), revealed the following: 1. 12-ounce bottle of salt and pepper seasoning salt was not sealed and available for use. 2. An unopened container of mild wing sauce, with an expiration date of [DATE], available for use. 3. The area behind the deep fryer contained a greasy film with food particles. 4. The pipe under the dirty sink area actively dripping significant amounts of water into a full bucket of cloudy water, and moist food particles on the wall. During an observation and interview on [DATE] at 10:15 AM, the Certified Dietary Manager (CDM) stated equipment and floors were cleaned daily and confirmed the area behind the deep fryer contained a greasy film with food particles and was not maintained in a clean sanitary condition. During an observation and interview on [DATE] at 10:30 AM, the CDM stated the pipe under the dirty sink area had been leaking for a few days and confirmed a bucket of cloudy water and food particles on the wall. The CDM confirmed the kitchen areas had not been maintained in a clean sanitary manner. During an observation and interview on [DATE] 10:40 AM, the CDM confirmed the dry storage area contained an unopened container of mild wing sauce, expiration date [DATE], had not been discarded, and was availabe for use. During an observation and interview on [DATE] at 8:20 AM, the CDM confirmed a 12-ounce container of Salt and Pepper Seasoning Salt, ,d+[DATE] full, was left open to air and not properly sealed to prevent contamination.

Based on facility document review, medical record review, and interviews, the facility failed to ensure Durable Power of Attorney (POA) documents were entered into the medical record for 2 residents (Residents #23 and #86) and failed to provide education regarding Advance Directives on admission for 6 residents (Residents #7, #8, #18, #37, #342 and #343). The findings include: Medical record review revealed Resident #23 was initially admitted to the facility on [DATE], and was most recently readmitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Seizures, Dementia, Depression, Bipolar Disorder, Anxiety, and Psychosis. Review of Resident #23's admission document dated 10/18/2018, titled, Advanced Directives and Other Legal Documents, revealed the resident had previously formulated a Durable Power of Attorney (POA) prior to admission to the facility and also revealed the POA signed legal documents on the behalf of the resident. Review of the resident's undated document titled ADMISSION RECORD revealed [POA name] .Contact Type .POA .Medical (Not activated) . Review of Resident #23's medical record revealed the durable POA documents had not been entered into the resident's medical record. Review of an annual MDS assessment dated [DATE], revealed Resident #23 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment, indicating severe cognitive impairment. Medical review revealed Resident #86 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Stroke, Paralysis, Depression, Post Traumatic Stress Disorder, and Tracheostomy Care. Review of an annual Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #86 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of Resident #86's admission document dated 9/18/2024, titled, Advanced Directives and Other Legal Documents, revealed the resident's family chose to execute advance directives. Review of Resident #86's medical record revealed advance directive documents had not been entered into the resident's medical record. Medical record review revealed Resident #7 was admitted to the facility with diagnoses including Dementia, Bipolar Disorder, and Psychosis. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #7 scored a 9 on the BIMS assessment which indicated moderate cognitive impairment. Review of Resident #7's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #8 was admitted to the facility on [DATE] with diagnoses including Dementia, Type 2 Diabetes, and Unspecified Psychosis. Review of a quarterly MDS assessment dated [DATE], revealed Resident #8 scored a 9 on the BIMS assessment, which indicated moderate cognitive impairment. Review of Resident #8's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #18 was admitted to the facility on [DATE] with diagnosis including Hemiplegia, Generalized Anxiety Disorder, and Mood Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #18 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #18's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including Dementia, Muscle Weakness, and Generalized Anxiety. Review of an annual MDS assessment dated [DATE], revealed Resident #37 scored a 4 on the BIMS assessment, indicating severe cognitive impairment. Review of Resident #37's medical record revealed no written information to the resident and/or resident representative concerning the right to formulate an advance directive. Medical record review revealed Resident #342 was admitted to the facility on [DATE], with diagnoses including Respiratory Failure, Mood Disorder, Critical Illness, Anxiety, and Myasthenia Gravis. Review of an admission MDS assessment dated [DATE], revealed Resident #342 scored a 15 on the BIMS assessment which indicated the resident was cognitively intact. Review of Resident #342's undated admission document titled, Advanced Directives and Other Legal Documents, revealed the resident had not received education to formulate an advance directive at admission. Medical record review revealed Resident #343 was admitted to the facility on [DATE], with diagnoses including Stroke, Tracheostomy Status, Depression, Difficulty Speaking, and Anxiety. Review of an admission MDS assessment dated [DATE], revealed Resident #343 scored a 00 on the BIMS assessment, indicating severe cognitive impairment. Review of Resident #343's undated admission document titled, Advanced Directives and Other Legal Documents, revealed the resident and/or the resident's representative did not receive education to formulate an advance directive at admission. During a record review and interview on 10/30/2024 at 12:40 PM, the Social Services Director (SSD) reviewed the medical records for Resident #23 and Resident #86 and stated Resident #23 had not signed her own documents and stated Resident #86's family had requested to execute an advance directive on admission. The SSD stated she was not knowledgeable of when Resident #23's POA advance directive was activated, confirmed the durable POA document was not entered in the medical record for Resident #23, and confirmed the facility did not obtain or execute advance directives for Resident #86. During a record review and interview on 10/30/2024 at 2:55 PM, the Admissions Director reviewed admission documents for Resident's #7, #8, #18, #37, #342, and #343, and confirmed education to formulate an advance directive was not provided to these residents or their representatives at admission. 50480

Based on facility policy review, observations, and interviews, the facility failed to ensure garbage and refuse were properly contained in 3 of 3 dumpsters. The findings include: Review of the facility's policy titled, Environment, revised 9/2017, revealed .trash will be properly disposed of in external receptacles (dumpsters) and the surrounding area will be free of debris . During an observation and interview on 10/28/2024 at 12:00 PM, the CDM confirmed the outside dumpster area contained three dumpsters for waste disposal and was observed with scattered refuse including used gloves, plastic medicine cups, plastic drinking cups, used wipes, drinking straws, plastic spoons, clear plastic bag filled with trash and was not maintained in a clean sanitary condition.

Based on facility document review, observations, and interviews, the facility failed to offer 8 residents (Residents #33, #8, #34, #1, #63, #70, #292, and #24) with hand hygiene assistance before a lunch and breakfast meal on 2 of 3 hallways observed for meal service. The findings include: Review of the facility's document titled, Validation Checklist Hand Hygiene, undated, revealed .Purpose .to validate staff and residents are following hand hygiene protocols .Residents are offered hand hygiene prior to meals . During an observation on 10/28/2024 at 12:40 PM, on the 300 Hallway, Certified Nursing Assistant (CNA) F delivered the lunch meal tray to Resident #33 and did not offer hand hygiene assistance to the resident, prior to setting up the meal tray. During an interview on 10/28/2024 at 12:44 PM, CNA F confirmed hand hygiene assistance was not offered to Resident #33, prior to setting up the lunch meal tray. During an observation on 10/28/2024 at 12:52 PM, on the 200 Hallway, CNA G delivered the lunch meal tray to Resident #8 and did not offer hand hygiene assistance, prior to setting up the meal tray. During an interview on 10/28/2024 at 12:55 PM, CNA G confirmed hand hygiene assistance was not offered to Resident #8, prior to setting up the lunch meal tray. During an observation on 10/28/2024 at 12:56 PM, on the 200 Hallway, CNA H delivered the lunch meal tray to Resident #34 and did not offer hand hygiene assistance, prior to setting up the meal tray. During an interview on 10/28/2024 at 12:58 PM, CNA H confirmed hand hygiene assistance was not offered to Resident #34, prior to setting up the lunch meal tray. During an observation on 10/28/2024 at 12:59 PM, on the 200 Hallway, Licensed Practical Nurse (LPN) D delivered the lunch meal tray to Resident #1 and did not offer hand hygiene assistance, prior to setting up the meal tray. During an interview on 10/28/2024 at 1:03 PM, LPN D confirmed hand hygiene assistance was not offered to Resident #1, prior to setting up the lunch meal tray. During an observation on 10/28/2024 at 1:34 PM, on the 200 Hallway, CNA H delivered the lunch meal tray to Resident #63 and did not offer hand hygiene assistance, prior to setting up the meal tray. During an observation on 10/28/2024 at 1:38 PM, on the 200 Hallway, CNA H delivered the lunch meal tray to Resident #70 and did not offer hand hygiene assistance, prior to setting up the meal tray. During an interview on 10/28/2024 at 1:48 PM, CNA H confirmed hand hygiene assistance was not offered to Resident #63 and Resident #70 prior to setting up their lunch meal tray. During an observation on 10/29/2024 at 8:15 AM, on the 200 Hallway, CNA H delivered the breakfast meal tray to Resident #292 and did not offer hand hygiene assistance to the resident prior to setting up the breakfast meal tray. During an observation on 10/29/2024 at 8:18 AM, on the 200 Hallway, CNA H delivered the breakfast meal tray to Resident #24 and did not offer hand hygiene assistance to the resident, prior to setting up the breakfast meal tray. During an interview on 10/29/2024 at 8:27 AM, CNA H confirmed she did not offer hand hygiene assistance to Residents #292 and #24 prior to setting up their breakfast meal tray. During an interview on 10/30/2024 at 9:26 AM, the Director of Nursing confirmed it was the facility's expectation residents were offered hand hygiene assistance prior to meals.

Based on facility policy review, medical record review, police report review, facility investigation review, and interview the facility failed to protect the residents' right to be free from sexual abuse and physical abuse by another resident for 4 of 14 (Resident #11, #17, #18, and #5) sampled residents reviewed for abuse. On 6/25/2024, Resident #9 was observed with his hand on Resident #11's pelvic region and Resident #11 was observed shaking his head no. On 11/26/2023, Resident #18 grabbed Resident #17's arm resulting in a scratch to her finger and Resident #17 scratched Resident #18 on the face when Resident #18 entered Resident #17's room. On 3/15/2024, Resident #6 hit Resident #5 with a soda can in her chest area. The facility's failure to protect the residents' right to be free from abuse resulted in actual harm for Resident #11, #17, and #18. The findings include: Review of the facility policy titled, Abuse, Neglect and Exploitation, revised 1/10/2024, revealed .it is the policy of this facility to provide protections for the health, welfare, and rights of each resident by .implementing written policies and procedures that prohibit and prevent abuse . 'Abuse' means the willful infliction .which can include .resident to resident altercations . 'Sexual Abuse' is non-consensual sexual contact of any type with a resident. 'Physical Abuse' includes, but is not limited to hitting . 1. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Chronic Respiratory Failure, Hemiplegia following a Cerebral Infarction, and Epilepsy. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #11 scored 00 on the Brief Interview for Mental Status (BIMS) which indicated the resident had severe cognitive impairment. Resident #11 was nonverbal and dependent on staff for all activities of daily living. Review of the comprehensive care plan revised on 2/19/2024, revealed Resident #11 required staff assistance with all activities of daily living. Resident #11 also had impaired ability to communicate due to inability to speak with an intervention to .Pay attention to resident's body language and facial expressions . Review of a Psychiatric Periodic Evaluation for Resident #11 dated 6/26/2024, revealed .patient was the victim of another resident's inappropriate behavior .There has been no indication of increased anxiety, agitation, mood swings. No .psychosocial harm noted . Review of the medical record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus, Chronic Kidney Disease, Major Depressive Disorder, and Anxiety Disorder. Review of a Psychiatric Periodic Evaluation for Resident #9 dated 4/4/2024, revealed the resident's medications were changed from Sertraline to Paroxetine (antidepressants) . to get better impulse control coverage . Review of a Psychiatric Periodic Evaluation for Resident #9 dated 5/16/2024, revealed .He [Resident #9] reports his [Sertraline] is effective at this time . Review of an annual MDS assessment dated [DATE], revealed Resident #9 scored 15 on the BIMS which indicated the resident was cognitively intact. Resident #9 was dependent on staff for transfers into and out of a wheelchair and was able to move around in the wheelchair without assistance. Review of the Nurse's Notes dated 6/25/2024 at 6:30 PM, revealed Resident #9 was observed with his hand on Resident #11's pelvic region. Review of a Psychiatric Periodic Evaluation for Resident #9 dated 6/26/2024, revealed .thought to be touching another patient inappropriately. He vehemently denies this, states he was only 'straightening his blankets' Patient is currently on 1:1 [1 on 1] supervision with no further reports . Review of the comprehensive care plan for Resident #9 revised 7/19/2024, revealed verbal aggression and sexually inappropriate behaviors towards residents. Review of a local police report dated 6/25/2024, revealed the .Deputy .spoke with the nurse [Registered Nurse (RN) C]. RN C advised she needed a report completed for two residents involved in a sexual assault .[Respiratory Therapist (RT) A] saw [Resident #9] grope [Resident #11] .RT A stated she saw [Resident #9] pulling the blanket over himself and [Resident #11] and grope [Resident #11's] genital area. [Resident #11] was shaking his head no during the assault . Review of the undated witness statement from Hospitality Aide (HA) B revealed .on 6/25/2024 at 4:30 PM [HA B] saw [Resident #9] pulling down his [Resident #11] cover prior to the incident where Resident #9 was touching [Resident #11's] arm. [Resident #9] had his hand under [Resident #11's] arm and forearm .6 PM 6/25/2024 .[HA B] pointed out to [RT A] .[Resident #9] been .moving/adjusting [Resident #11's] cover. [Resident #9] was sliding his hand under his blanket .[RT A] responded and [Resident #9] stopped immediately . Review of a undated witness statement from HA A revealed .on 6/25/2024 [RT A] was standing at the nurse's station .[HA B] tapped me on the shoulder .told me to look and pointed towards [Resident #11]. [Resident #11] was in his wheelchair facing the nurse's station and [Resident #9] was facing the main entrance with their chairs touching. [Resident #9] had [Resident #11's] blanket pulled down and [Resident #11] was shaking his head no, while [Resident #9] was touching his pubic area. RT A started saying .hey hey stop .but before [RT A] could reach them [Resident #9] had already stopped and pulled the blanket up and patted [Resident #11] on the shoulder . During an interview on 7/29/2024 at 9:50 AM, Resident #9 stated he had been in an altercation with Resident #11. Resident #9 stated Resident #11 looked scared, Resident #9 reached over to hold Resident #11's hand and noticed Resident #11 was unable to use his hand. Resident #9 then reached across Resident #11's lap to hold Resident #11's other hand. Resident #9 stated someone witnessed him holding Resident #11's hand and thought he was trying to touch Resident #11's crotch area. Resident #9 stated after the incident the facility had a staff person follow him around for a few weeks. Resident #9 stated he understood touching Resident #11 was wrong. During an interview on 7/30/2024 at 12:45 PM, HA B stated on 6/25/2024 at approximately 5:50 PM, Resident #11 was sitting across from the nurse's desk, Resident #9 rolled up to Resident #11, and Resident #9 had his hand under the blanket covering Resident #11. HA B stated she tapped RT A to get her attention and pointed out the two residents. HA B stated Resident #11 had his hands and arms on the armrests of his wheelchair and Resident #9 had his hand on Resident #11's pubic area then the RT intervened and separated the two residents immediately. During an interview on 7/30/2024 at 1:11 PM, Registered Nurse (RN) C stated on 6/25/2024 at 5:50 PM, she was alerted by RT A Resident #9 had touched Resident #11's pubic area. The RN stated Resident #9 and Resident #11 were separated immediately. RN C stated the Administrator and Director of Nursing (DON) were notified of the incident. RN C stated when she interviewed Resident #9 the resident informed her he touched Resident #11's right arm, realized the resident could not move his right arm, and he reached for Resident #11's other arm. Resident #9 stated, he was trying to cover Resident #11 with the blanket. RN C stated she was unaware of any past incidents of sexually inappropriate behavior by Resident #9. During a telephone interview on 7/30/2024 at 1:18 PM, RT A stated HA B got her attention and pointed at Residents' #9 and #11. RT A was standing on the right side of the nurse's desk and noticed Resident #9 .caressing [Resident #11's] groin area . RT A stated she informed Resident #9 to stop (Resident #9 stopped), called for the nursing supervisor to come to the desk, and reported the incident between Resident #9 and #11. RT A stated she could clearly see Resident #11 had his arms on the armrests of his wheelchair, and Resident #9 was touching Resident #11's groin area. RT A stated Resident #9 was immediately placed on 1 to 1 supervision. During an interview on 7/30/2024 at 2:35 PM, the Administrator stated, the DON notified him of the incident which occurred between Resident #9 and Resident #11 which occurred on 6/25/2024. The Administrator stated RT A informed him she saw Resident #9 with his hand on Resident #11's pelvic area under the blanket. The Administrator stated Resident #9 was placed on 1 to 1 supervision immediately to protect the other residents. Review of facility documentation and interviews revealed Resident #11 was cognitively impaired and unable to speak. Resident #9 was cognitively intact, touched Resident #11's pubic area, and Resident #11 shook his head no wanting Resident #9 to stop. A reasonable person would not expect they would be harmed in a health care facility and would experience a negative psychosocial outcome to include fear, anxiety, anger, and/or humiliation. 49568 2. Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Epilepsy, Chronic Kidney Disease, Hypertension, Chronic Pain Syndrome, and Generalized Anxiety Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #17 scored a 15 on the BIMS which indicated the resident was cognitively intact. Review of the Skin Assessment for Resident #17 dated 11/24/2023, revealed the resident had no abnormal skin areas. Review of an Event Note for Resident #17 dated 11/26/2023, revealed .at [4:00 PM] resident [Resident #17] was noted with skin tear to right fourth finger. When asked what happened she stated, .[Resident #18] came into my room [Resident #17's] and grabbed my hand and I wasn't putting up with it . Continued review revealed Resident #18 stated, .I don't know [when asked about the incident] .[Resident #18] placed on 1:1 observation with CNA [Certified Nursing Assistant] .The facility notified state[State Survey Agency] .residents families .MD [Medical Doctor] .and Psych NP [Psychiatric Nurse Practitioner] . Review of the Skin Assessment for Resident #17 dated 11/26/2023, revealed a skin tear on the right-hand 4th finger. Review of a NP's Progress Note for Resident #17 dated 11/28/2023, revealed .skin tear to right fourth finger .Steri-Strips [wound closure tape] .No signs of infection noted .calm .No pain . Review of a Psychiatric Evaluation for Resident #17 dated 11/28/2023, revealed .evaluation of mood and behaviors .resident recently involved in resident to resident altercation .another resident approached [Resident #17] .other resident [Resident #18] grabbed [Resident #17's] arm .[Resident #17] hit [Resident #18] and scratched her face .[Resident #17] stated the other resident [Resident #18] came into her room .[Resident #17] wanted her [Resident #18] to leave .[Resident #18] grabbed her [Resident #17] arm . Review of a Psychiatric Evaluation for Resident #17 dated 12/5/2023, revealed .no other behaviors reported .no other altercations reported . Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Chronic Kidney Disease, Hypertension, Dementia, and Generalized Anxiety Disorder. Review of a comprehensive care plan dated 10/3/2023, revealed Resident #18 had .behaviors related to psychotic disorder .anxiety .delusions .thinking that she works here [at the facility] . Review of a quarterly MDS assessment dated [DATE], revealed Resident #18 scored 00 on the BIMS which indicated the resident had severe cognitive impairment. Review of a Skin Assessment for Resident #18 dated 11/20/2023, revealed the resident had no abnormal skin areas. Review of a Skin Assessment for Resident #18 dated 11/26/2023, revealed .left side of face scratch . Review of a NP Progress Note for Resident #18 dated 11/26/2023, revealed .[Resident#18] has an abrasion to the left side of her face .caused from an altercation with another resident [Resident #17] .does not appear to have any pain .confused .Apply [topical ointment] daily until healed . Review of a Psychiatric Evaluation for Resident #18 dated 11/28/2023, revealed .[Resident #18] was .involved in a resident-to-resident altercation .[Resident #18] grabbed another resident [Resident #17's] arm .[Resident #17] hit her [Resident #18] and scratched her [Resident #18] face .[Resident #18] has no recollection of this occurring .[Resident #18] was placed one-on-one sitter . Review of CNA I's Witness Statement dated 11/26/2023, revealed .found [Resident #18] standing in front of [Resident #17's] room .noticed large scratch on [Resident #18's] face .notified nurse . Review of Licensed Practical Nurse (LPN) J's Witness Statement dated 11/26/2023, revealed .CNA I brought [Resident #18] and [Resident #17] to desk .[Resident #18] had a scratch on right cheek .[Resident #17] had an open area on right fourth finger .[Resident #17] stated [Resident #18] came into her [Resident #17] room .when she [Resident #17] told her [Resident #18] to get out [Resident #18] grabbed her hand [Resident #17] and twisted it .[Resident #18] wouldn't let go .so she [Resident #17] scratched her [Resident #18] on left cheek .[Resident #18] was placed behind desk with staff .[Resident #17] was on the other side of desk . Review of the DON's Written Statement dated 11/27/2023, revealed .interviewed [Resident #17] at [8:20 AM] .what happened to your finger .[Resident #17] stated [Resident #18] came into my room .grabbed my [Resident #17] hand and twisted it .I wasn't putting up with it .so I [Resident #17] scratched her [Resident #18] face .asked if she [Resident #17] was afraid and [Resident #17] stated no .asked if she [Resident #17] felt safe .[Resident #17] stated yes . During an interview and observation on 7/29/2024 at 10:35 AM, Resident #17 stated she had been in an altercation with Resident #18. Resident #18 wandered into Resident #17's room and grabbed her arm. Resident #17 told Resident #18 to get out of her room, scratched Resident #18 across the cheek, and Resident #18 left the room. Resident #17 stated Resident #18 cut her right finger. Resident #17 stated the nurse applied treatment to her finger. Resident #17 stated staff offered to relocate her to the 1st floor, but the resident refused because she wanted to stay in her room. Resident #17 stated that she felt safe in the facility, was not afraid, and the facility placed a stop sign across her doorway to keep Resident #18 out of her room. During an interview on 7/30/2024 at 8:35 AM, LPN J stated she worked on 11/26/2023 when the incident between Resident #17 and #18 occurred. CNA I brought the residents to the nurses desk, Resident #17 had small skin tear on her right finger, and Resident #18 had a scratch to her right cheek. LPN J stated Resident #17 informed the LPN Resident #18 walked into her room and grabbed her [Resident #17] arm resulting in a skin tear to her finger and Resident #17 scratched Resident #18's face after Resident #18 grabbed her finger. LPN J stated the residents were immediately separated and a head-to-toe assessment was completed on both residents. Resident #18 was placed on 1:1 supervision, Resident #17 was offered to move to another location in the facility, the resident declined and wanted to stay in her room. During an interview on 7/30/2024 at 2:00 PM, the DON stated Resident #17 and Resident #18 had an altercation on 11/26/2023. Resident #18 entered Resident #17's room, Resident #17 told Resident #18 to leave, and Resident #18 grabbed Resident #17's arm causing a skin tear to the resident's right finger. Resident #17 stated when Resident #18 grabbed her arm the resident scratched Resident 18's face. The facility offered to move Resident #17 to another area of the facility but Resident #17 declined. The facility placed a STOP sign on Resident #17's door to prevent other residents from entering her room. The DON stated Residents #17 and #18 did not have any behavioral changes after the altercation. The DON confirmed that the facility substantiated the resident-to-resident altercation between Resident #17 and Resident #18 and both residents were harmed. 37078 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnoses including Anxiety Disorder, Depressive Disorder, and Intellectual Disabilities. Review of a quarterly MDS assessment dated [DATE], revealed Resident #5 scored a 13 on the BIMS which indicated the resident was cognitively intact. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE] with diagnoses including Need for Assistance with Personal Care, Anxiety Disorder, and Depressive Disorder. Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 scored a 15 on the BIMS which indicated the resident was cognitively intact. Review of the facility's investigation revealed on 3/15/2024 at 1:15 PM, the Activities Director witnessed Resident #6 hit Resident #5 with a soda can in Resident #5's upper chest. Resident #6 was upset because Resident #5 touched her drink. Assessment and interview with Resident #5 revealed the resident was not injured and was not upset by the incident. During an interview on 7/29/2024 at 10:00 AM, Resident #6 stated, .I told her [Resident #5] not to put her hands on my food. I hit her cause [because] I told her not to do it she put her hands on my drink .I just reached up and hit her . During an interview on 7/30/2024 at 8:00 AM, Resident #5 stated, .I picked up a soda can and [Resident #6] don't like her stuff touched .she [Resident #6] hit me [Resident #5] on the chest with it [soda can] it was empty it didn't hurt me or nothing .no [it didn't leave a mark or nothing] .oh yes [feels safe at the facility] . During an interview on 7/30/2024 at 1:45 PM, the Administrator confirmed Resident #6 hit Resident #5 on the chest with a soda can.

Based on facility policy review, medical record review, facility investigation review, and interview, the facility failed to prevent abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse. Resident #1 was sitting in the doorway of her room when Resident #2 wandered to the doorway, placed his right hand on the left side of Resident #1's neck, and grabbed the front of her shirt causing Resident #1 psychosocial distress and harm. The findings included: Review of the facility's abuse policy titled, Abuse, Neglect and Exploitation last reviewed 10/24/2022 showed .It is the policy of this facility to provide protections .that prohibit and prevent abuse .'Abuse' means the willful infliction of injury .with resulting .mental anguish, which can include .resident to resident altercations .'willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm . Review of the medical record showed Resident #1 was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, Heart Failure, and Chronic Obstructive Pulmonary Disease. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] showed Resident #1's Brief Interview of Mental Status (BIMS) score was 9 indicating the resident had moderate cognitive impairment. The resident required assistance of one person with activities of daily living (ADLs). Review of the facility's investigation showed on 12/30/2022 at 6:10 PM, Resident #2 was witnessed inside the doorway of Resident #1's room by Certified Nurse Assistant (CNA) #1 with his right hand on the left side of Resident #1's neck, and grabbing the front of Resident #1's shirt. Review of Progress notes for Resident #1 showed .12/30/2022 .At 18:30 [6:30 PM] this nurse started sitting and talking with Resident [Resident #1] upon noticing that she was crying and very anxious .attempted to redirect her with conversation .after several unsuccessful attempts to calm Resident and redirect her after an hour of one on one engagement .Resident physician was notified and new orders was [were] received for Ativan [antianxiety medication] 1 mg [milligram] .Q [every] 12 HRS [hours] PRN [as needed] x [times] 14 days .License Practical Nurse [LPN #2] . Review of a PSYCHIATRIC EVALUATION dated 1/3/2022 for Resident #1 showed .Resident recently involved in resident to resident [altercation] with other resident being aggressive toward this patient on 12/30/2022 this provider was notified due to resident's increased anxiety, tearfulness, crying Ativan 1 mg po [by mouth] every 12 hours as needed x 14 days was ordered . Review of the medical record showed Resident #2 was admitted to the facility on [DATE] with diagnoses including Dementia, Anxiety Disorder, and Unspecified Psychosis. Review of the quarterly MDS assessment dated [DATE] showed Resident #2's BIMS score was 0 indicating the resident had severe cognitive impairment. The resident had behavior of wandering and physical behavioral symptoms directed towards others 1 to 3 days per week. The resident required assistance of one or more persons with ADLs. Review of a current care plan for Resident #2 showed .the resident is at risk for wander [wandering] r/t [related to] Resident wanders aimlessly. Date Initiated 06/06/2022 .Revision on 11/20/2022 .Distract resident from wandering by offering pleasant diversions. Structured activities, food .Identify pattern of wandering .intervene as appropriate .The resident has potential to be physically aggressive or agitated r/t [related to] Dementia Date Initiated 12/30/2022 . Review of facility behavior monitoring documentation from 11/2022 through 12/29/2022 for Resident #2 showed no prior incidences of physical aggression and multiple behaviors of wandering. Review of facility Progress notes for Resident #2 showed .Event Date: 12/30/2022 .Behavior Displayed: Resident was trying to enter another resident's room and became aggressive and put his hand around the female resident's neck when she tried to stop him . Review of a PSYCHIATRIC EVALUATION note dated 1/3/2022 for Resident #2 showed .reports of physical aggression. Patient had recent episode of increased anxiety, aggression toward another resident .Depakote [seizure/bipolar medication] increased on 12/31/2022 to 250 mg 3 times a day for mood stabilization . Review of facility's 1 on 1 documentation for Resident #2 showed documentation resident had one on one supervision from 12/30/2022 at 6:00 PM to 1/4/2023 at 6:00 PM. Review of facility's Monitoring Worksheet for Resident #2 showed from 1/4/2023 through 1/11/2023 the resident was on 10-15 minute checks. During an interview with Resident #1 on 1/17/2023 at 9:10 AM, in the resident's room, the resident stated . he [Resident #2] grabbed me by my shirt collar and pulled on my neck .it scared me . During observation and attempted interview with Resident #2 on 1/17/2023 at 9:25 AM, on the 200-hall, Resident #2 was unable to answer questions appropriately when asked. Observation showed Resident #2 was calm and walked up and down the hallway. During a telephone interview on 1/17/2023 at 10:10 AM, CNA #1 stated .we [staff] was passing dinner trays and I heard one of the residents screaming. She [Resident #1] was saying 'get out, get out' .I was standing in the hallway and I went down the hall and I went to the doorway. [Resident #1] was sitting in the door way [Resident #1's doorway] in a wheelchair. She was just inside the doorway. [Resident #2] wasn't actually in her room. He was trying to go in .he had a hold of her neck and I ran over there real quick and got it off and after that he reached and grabbed at her shirt and pulled. It was the front of her shirt at the top near her chest .he had ahold of her neck pretty tight .when it happened she just kind of hollered. When he had a hold of her she screamed .she acted scared. Just the expression on her face. She had a shocked look on her face .she was pretty shaken up . During an interview on 1/17/2023 at 10:25 AM, the Nurse Practitioner (NP) stated .they [staff] called me after it happened and I ordered a Ativan because she [Resident #1] was anxious and tearful. This was right after the incident .she [LPN #2] called and said that [Resident #1] was upset .I would think that at the time the incident would have caused her to be upset . During a telephone interview on 1/18/2022 at 10:25 AM, LPN #2 stated .I worked that night [12/30/2022] .it happened just before I got there. I got there about 6:00 [6:00 PM] .I seen [Resident #1] sitting outside of her door in her wheelchair .I went down there where she was at and she was at that time crying .she said .'is he [Resident #2] gonna get away with that?' .she put her hands on the front of her shirt and she said 'he [Resident #2] grabbed me, he grabbed my shirt' .she had been doing fine and we had not had to use her prn order for Ativan and it had dropped off past the 14 days .the call was made to the doctor because she made two references to [Resident #2] .she still was crying .I called to get an order to give her the dose of 1 milligram Ativan. I explained that we were just trying to get her settled down . During an interview on 1/18/2023 at 1:45 PM the Director of Nursing (DON) stated .I got a call that evening [12/30/2022] and they [staff] told me what had happened .apparently when she [Resident #1] was yelling 'get, get, get' he [Resident #2] had grabbed her collar and the CNA [CNA #1] said his hand was around her neck .

Based on medical record review and interview, the facility failed to implement a care plan for pain management for 1 resident (#282) of 4 residents reviewed for pain of 42 residents sampled. The facility's failure to implement the care plan for pain management resulted in an increase in pain and Harm to Resident #282. The findings include: Medical record review revealed Resident #282 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 6 (on a 0-10 pain scale with zero being no pain and ten as the worst pain possible). Medical record review of the Care Plan dated 7/27/18 revealed .Resident is at risk for side effects related to Opioid medication (narcotic pain medication that can cause symptoms of withdrawal if abruptly stopped) use .Administer Opioid medication(s) as ordered by physician .Notify physician if pain management interventions are unsuccessful . Further review of the Care Plan dated 7/29/18 revealed .The resident has/is at risk for (acute and chronic) pain related to Depression, Disease process .Administer pain medications as ordered .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Notify physician if interventions are unsuccessful .provide the resident and family with information about pain and options available for pain management . Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (pain medication) .Tablet 15mg (milligram), give 1 tablet by mouth every 6 hours as needed for pain . Medical record review of the Controlled Drug Record dated 7/30/18 revealed Resident #282 had received the pain medication 3 to 4 times per day from 8/18/18 through 9/4/18. Further review revealed the resident had received the last dose available on 9/4/18 at 4:21 PM. Review of the Medication Administration Record [REDACTED]. Continued review revealed from 9/1/18 through 9/5/18, the pain level ranged from 0-9. Interview with Resident #282 on 9/5/18 at 3:40 PM, in the resident's room, revealed the resident stated .I'm not too good .my pain medication run out and I'm laying here hurting until my pain medication gets here . Further interview revealed the resident's pain level was at 10 with a tolerable pain level of 7. Continued interview revealed the resident's pain level had been at 10 since 12:00 AM on 9/5/18. The resident further stated .I didn't sleep well .it (the pain medicine) helps me sleep, I usually sleep better . I wake up but I go back to sleep .I went to sleep last night about 4 (4:00AM) and woke up at 7 (7:00 AM) and I haven't been back to sleep . Telephone interview with Licensed Practical Nurse (LPN) #1 on 9/5/18 at 4:15 PM, confirmed Resident #282 had .asked for a pain pill I guess around 3:00 AM (on 9/5/18) and I went to get it but she didn't have any. I offered her a Tylenol but she said she couldn't take it because of her liver .I offered her an [MEDICATION NAME] but she said she was allergic to it . Further interview confirmed LPN #1 stated .I called the pharmacy and they said they needed a new prescription signed .the pharmacy said they had faxed a script (prescription) to be signed .I checked the box and it was not in the box for the doctor to sign so I figured the doctor had already gotten it and would fax it back . Continued interview confirmed LPN #1 did not contact the physician. Interview with LPN #2 on 9/6/18 at 9:10 AM, in the 200 East Wing hallway, confirmed Resident #282's pain medication arrived on 9/5/18 at 6:25 PM with the resident's pain level at 10 when the pain medication was administered at 6:27 PM. Further interview revealed LPN #2 had been aware of the medication being unavailable on 9/5/18. Continued interview revealed LPN #2 had kept the resident updated on the expected arrival time of the medication but the arrival time .kept being longer than I thought . Further interview confirmed LPN #2 had not contacted the physician at any time on 9/5/18 to request an order to obtain a pain medication from the facility's emergency medication box. (Locked box which contains small amounts of drugs for emergency use) Interview with Resident #282 on 9/6/18 at 9:28 AM, in the resident's room, confirmed the resident received the pain medication on 9/5/18 .yeah I got it about 6:25 (PM) . Continued interview with Resident #282 revealed the pain level was 10 prior to the medication administration. Interview with LPN #1 on 09/6/18 at 9:33 AM, at the 2nd floor nurse's station, confirmed the LPN had not notified the physician on 9/5/18 of Resident #282's pain medication not being available or to request an order to use a pain medication from the emergency medication box. Further interview with LPN #1 revealed .no I didn't I should have went ahead and called . Telephone interview with the Pharmacist on 9/6/18 at 10:02 AM, confirmed the refill request had been received by the pharmacy on 9/4/18 at 4:04 PM and the pain medication was sent out for delivery to the facility on [DATE] at 3:32 PM. Continued interview confirmed the pharmacy required a 2 to 3 day advance notification for a refill request of a Schedule II (drug or other substance that has a high potential for abuse) medication. Telephone interview with the Physician on 9/6/18 at 3:14 PM, confirmed the physician's expectation was for the resident to receive the pain medication per his order, and Resident #282 should have received a pain medication from the emergency box while the resident's pain medication was not available. Continued interview confirmed the nurses from the facility had not contacted him to get an order to administer a medication from the emergency box. Interview with the Director of Nursing (DON) on 9/6/18 at 4:10 PM, in the conference room, confirmed Resident #282 had been without the physician prescribed pain medication for over 24 hours from 9/4/18 through 9/5/18 with Resident #282's pain reported as a 10 while the pain medication was not available. Further interview confirmed the facility failed to implement the care plan to provide pain medications as ordered by the Physician for Resident #282 resulting in an increase in the resident's pain level and Harm.

Based on facility policy review, medical record review, and interview, the facility failed to ensure Physician ordered pain medication was available for 1 resident (#282) of 4 residents reviewed for pain of 42 residents sampled. The facility's failure to ensure the pain medication was available resulted in an increase in pain and Harm to Resident #282. The findings include: Review of the facility's policy Controlled Substance Medication Orders dated 5/2016 revealed .The pharmacy can dispense a Schedule II controlled substance (drug or other substance that has a high potential for abuse and can cause withdrawal) medication only after the receipt of a practitioner signed valid Schedule II prescription (original and/or FAX) OR in the case of an emergency, the practitioner may speak directly to the pharmacist providing an emergency authorization for the pharmacy to supply a small quantity of the Schedule II medication until the practitioner can provide a valid signed prescription . Medical record review revealed Resident #282 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the Admission Minimum Data Set ((MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident was cognitively intact. Further review revealed the resident had frequent pain rated at 6 (on a 0-10 pain scale with 0 being no pain and 10 as the worst pain possible). Medical record review of the Care Plan dated 7/27/18 revealed .Resident is at risk for side effects related to Opioid (pain medication) medication use .Administer Opioid medication(s) as ordered by physician .Notify physician if pain management interventions are unsuccessful . Further review of the Care Plan dated 7/29/18 revealed .The resident has/is at risk for (acute and chronic) pain related to Depression, Disease process .Administer pain medications as ordered .Anticipate the resident's need for pain relief and respond immediately to any complaint of pain .Notify physician if interventions are unsuccessful .provide the resident and family with information about pain and options available for pain management . Medical record review of a physician's orders [REDACTED].[MEDICATION NAME] (pain medication) .Tablet 15mg (milligrams), give 1 tablet by mouth every 6 hours as needed for pain . Medical record review of the Controlled Drug Record dated 7/30/18 revealed Resident #282 had received the pain medication 3 to 4 times per day from 8/18/18 through 9/4/18. Further review revealed the resident had received the last dose available on 9/4/18 at 4:21 PM. Medical record review of the Medication Administration Record [REDACTED].Ask the resident if their pain program is effective. If not notify MD . Further review revealed the resident had a documented pain level of 9 on 9/5/18 for the day and evening shifts with previous pain levels documented as 0-7 when Resident #282 was receiving her pain medication. Interview with Resident #282 on 9/5/18 at 3:40 PM, in the resident's room, revealed the resident stated .I'm not too good .my pain medication run out and I'm laying here hurting until my pain medication gets here . Further interview revealed the resident reported her pain level was at 10 with a tolerable pain level of 7. Continued interview revealed the resident's pain level had been at 10 since 12:00 AM on 9/5/18. Resident #282 further stated .I didn't sleep well .it (the pain medicine) helps me sleep, I usually sleep better . I wake up but I go back to sleep .I went to sleep last night about 4 (4:00AM) and woke up at 7 (7:00 AM) and I haven't been back to sleep . Telephone interview with Licensed Practical Nurse (LPN) #1 on 9/5/18 at 4:15 PM, confirmed Resident #282 had .asked for a pain pill I guess around 3:00 AM (on 9/5/18) and I went to get it but she didn't have any. I offered her a Tylenol but she said she couldn't take it because of her liver .I offered her an [MEDICATION NAME] but she said she was allergic to it . Further interview confirmed LPN #1 stated .I called the pharmacy and they said they needed a new prescription signed .the pharmacy said they had faxed a script (prescription) to be signed .I checked the box and it was not in the box for the doctor to sign so I figured the doctor had already gotten it and would fax it back . Continued interview confirmed LPN #1 did not contact the physician to request an order to use a pain medication from the emergency medication box. Interview with LPN #2 on 9/6/18 at 9:10 AM, in the 200 East Wing hallway, confirmed Resident #282's pain medication arrived on 9/5/18 at 6:25 PM with the resident's pain level at 10 when the pain medication was administered at 6:27 PM. Further interview revealed LPN #2 had been aware of the medication being unavailable on 9/5/18. Continued interview revealed LPN #2 had kept the resident updated on the expected arrival time of the medication but the arrival time .kept being longer than I thought . Further interview confirmed LPN #2 had not contacted the physician at any time on 9/5/18 to request an order to use a pain medication from the emergency medication box. Interview with Resident #282 on 9/6/18 at 9:28 AM, in the resident's room, confirmed the resident received the pain medication on 9/5/18 .yeah I got it about 6:25 (PM) . Continued interview with Resident #282 revealed the pain level was at 10 prior to the medication administration. Interview with LPN #1 on 09/6/18 at 9:33 AM, at the 2nd floor nurse's station, confirmed the LPN had not notified the physician on 9/5/18 of the resident's pain medication not being available or to request an order to use a pain medication from the emergency medication box. Further interview with LPN #1 revealed .no I didn't I should have went ahead and called . Telephone interview with the Pharmacist on 9/6/18 at 10:02 AM, confirmed the refill request had been received by the pharmacy on 9/4/18 at 4:04 PM and the pain medication was sent out for delivery to the facility on [DATE] at 3:32 PM. Continued interview confirmed the pharmacy required a 2 to 3 day advance notification for a refill request of a schedule II medication. Phone interview with the Physician on 9/6/18 at 3:14 PM, confirmed the physician's expectation was for the resident to receive the pain medication per his order, and Resident #282 should have received a pain medication from the emergency box while the resident's pain medication was not available. Continued interview confirmed the nurses from the facility had not contacted him to get an order to administer a medication from the emergency box. Interview with the Director of Nursing (DON) on 9/6/18 at 4:10 PM, in the conference room, confirmed Resident #282 had been without the Physician prescribed pain medication for over 24 hours from 9/4/18 through 9/5/18. Continued interview confirmed the facility's failure to ensure the Physician prescribed pain medication was available resulted in an increase in pain and resulting in Harm for Resident #282.

Based on medical record review and interview, the facility failed to maintain dignity by providing incontinence care for 2 residents (#12, #126), of 13 residents interviewed, of 75 residents dependent on staff for toileting needs. The facility's failure to provide incontinence care resulted in psychosocial harm for residents #12 and #126. The findings included: Medical record review revealed Resident #12 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of a significant change Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored an 11 on the Brief Interview for Mental Status (BIMS), indicating the resident had moderate cognitive impairment. Further review revealed the resident required extensive assistance with bed mobility, was totally incontinent of bowel and bladder, and was dependent on staff for incontinence care. Interview with Resident #12 on 8/9/17 at 11:05 AM, in her room, revealed the resident had to wait until after meals for incontinence care. Continued interview revealed several staff informed her incontinence care was unable to be completed during meal times. Further interview confirmed she had to wait for up to 2 hours to get incontinence care during meal times, which resulted in having to lay in soiled briefs. Interview continued and the resident stated, .it upsets me when they don't get to me in time, staying in that mess embarrasses me and belittles me . Medical record review revealed Resident #126 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Medical record review of the MDS revealed the resident scored a 15 on the BIMS, indicating the resident was cognitively intact, was continent of bowel and bladder, and was dependent on staff for toileting needs. Interview with Resident #126 on 8/7/17 at 3:00 PM, in the resident's room, revealed the resident had a prolapsed bladder and was unable to hold her urine for a long period of time. Continued interview revealed there had been several occasions staff had failed to respond to her call light timely and she had urinated and had bowel movements on herself. Continued interview revealed breakfast time was when the staff failed to respond to her needs. Continued interview confirmed that it had happened three times so far and she had only been at the facility for approximately 3 weeks. Continued interview confirmed 2 or 3 staff members told her staff were not allowed to help her to the bathroom or with the bed pan during mealtime tray pass or when they were feeding residents. Continued interview revealed she felt degraded and less than a human when she urinated or had bowel movements on herself. Interview with Licensed Practical Nurse (LPN) #5 on 8/8/17 at 4:19 PM, at the unit 2 nurses station, confirmed if a Certified Nurse Assistant (CNA) was feeding a resident and another resident needed assistance with toileting, the resident needing to go to the bathroom would have to wait for assistance until feeding was completed. Interview with CNA #5 on 8/8/17 at 4:25 PM, in the unit 2 hallway, confirmed residents were instructed staff could not take them to the bathroom during meals .until after feeding is done and trays are picked up . Further interview confirmed residents had complained about having to wait for assistance. Interview with LPN #6 on 8/8/17 at 4:30 PM, in the unit 2 hallway, confirmed Activities of Daily Living (ADL) care was not to be provided until meal time was complete. Interview with CNA #6 on 8/9/17 at 7:35 AM, in the unit 2 hallway, confirmed if a resident needed to go to bathroom they had to wait until the meal was finished. Interview with CNA #7 on 8/9/17 at 7:40 AM, at the unit 2 nurses station, confirmed residents had become upset and had experienced incontinent episodes due to staff not responding to calls for assistance until after meal time was complete. Interview with the Director of Nursing on 8/9/17 at 9:30 AM, in the conference room, confirmed she was aware of a complaint concerning resident #12 being upset about incontinence care during meal times. Further interview confirmed if staff were actively feeding residents they were not to stop to toilet residents.

Based on the facility policy review, medical record review, review of the facility's investigation, and interview, the facility failed to report and complete an investigation after a fall for 1 resident (Resident #153), who suffered a wrist fracture (Harm), of 4 residents reviewed for falls. The findings included: Review of the facility's policy for Accidents and Incidents - Investigating and Reporting dated 2/8/11, revealed: Accidents or incidents involving residents .will be investigated and reported to the Administrator. 1. Reporting of Accidents/Incidents: a. Regardless of how minor an accident or incident may be, including injuries of an unknown source, it will be reported to the department supervisor as soon as such accident/incident is discovered or when information of such accident/incident is learned. b. A Report of Incident/Accident will be completed for accidents or incidents. c. An employee witnessing an accident or incident involving a resident .should report such occurrence to his or her immediate supervisor as soon as practical. d. The Nurse Supervisor/Charge Nurse should be immediately informed of accidents or incidents so that medical attention can be provided . 4. Investigative Action: a. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor will conduct an investigation of the accident or incident. b. The following data, as it may apply, must be included on the Report of Incident/Accident: the date and time the accident or incident took place, the nature of the injury/illness, the circumstances surrounding the accident or incident, where the accident or incident took place the name(s) of witnesses and their accounts of the accident or incident, the injured person's account of the accident or incident, the time the injured person's attending physician was notified, the condition of the injured person, the disposition of the injured, any corrective action taken, follow-up information, other pertinent data as necessary or required and the signature and title of the person completing the report. c. A completed Report of Incident/Accident will be submitted to the Director of Nursing Services. Medical record review revealed Resident #153 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Medical record review of the quarterly Minimum Data Set ((MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 4 out of 15 indicating severe cognitive impairment. The resident did not display behaviors and required supervision with all activities of daily living except for bathing which required total assistance. The resident utilized a walker and had not had any falls since the last assessment. Medical record review of the care plan dated 4/22/15 revealed the interventions: May use walker/wheelchair at times for mobility throughout the facility; assist with transfers as needed; and maintain safe environment. Medical record review of the Falls Risk assessment dated [DATE] revealed the resident scored 12 with a score of 10 or higher indicating the resident was at risk for falls. Medical record review of the Nurses Notes dated 6/10/15 through 6/13/15, revealed no documentation the resident had fallen during that timeframe. Medical record review of a Nurses Note dated 6/14/15, at 6:45 AM, revealed Resident #153 complained of right wrist pain, right wrist looked swollen, Tylenol 650 milligrams was given for pain, and the wrist was elevated on a pillow. The MD (Medical Doctor) and family were notified. Medical record review of a Nurses Note dated 6/14/15 at 6:50 AM, revealed the doctor was called with new orders for right hand and right wrist x-rays for pain/swelling. Continued review revealed at 7:00 AM, the daughter was notified of swelling and pain and informed of x-rays that were ordered. Continued review revealed at 12:00 PM, x-ray results came back and were called to the doctor with new orders given for splint/immobilizer to the right wrist/arm with stocking net at end of splint, seen by ortho (orthopedic), and daughter notified. Medical record review of the 6/14/15 x-ray of the right wrist revealed an impacted fracture involving the distal radial metaphysis with associated soft tissue swelling. Review of the facility's investigation of the injury revealed there were two witnesses to the resident sliding out of her wheelchair on 6/13/15. Review of a licensed nurse's statement (dated 6/15/15 with no time) revealed the resident was constantly trying to push herself up out of the geriatric chair that she was seated in during the weekend. The resident also did slide out of her geriatric chair on Saturday night, the 13th and we put her back in the chair. Review of another witness statement by a direct care staff (dated 6/15/16 with no time) revealed the resident slid out of her geriatric chair and onto the floor on 6/13/15, and the nurse and I put her back into the chair. Review of the facility investigation results revealed the following: Witness statement revealed the resident had slid out of her geri-chair the evening of 6/13/15. The impacted wrist fracture is thought to be caused by the resident's attempt to get herself (up) and reposition after a fall on 6/13/15, or from the fall itself. The origin of the injury is known. Resident also has [DIAGNOSES REDACTED]. With the [DIAGNOSES REDACTED]. Medical record review of the Care Plan dated 6/21/15 revealed the facility added Dycem (a non-skid material) to the resident's chair to prevent sliding. Interview with Licensed Nurse #10 on 7/28/16 at 2:49 PM, in her office, revealed after a fall the staff should document in the nurses' notes and complete the Event Recommendation form; then that form is turned into the unit manager and she keeps them. This nurse was unable to find any documentation about the fall the facility stated caused the fracture. Interview with Administrative Staff #3 on 7/28/16 at 5:28 PM, in the surveyor's workroom, confirmed the facility did not have any investigation/documentation regarding the fall which they believed caused the wrist fracture. The nurse who was working at the time of the fall did not complete the Event Recommendation form, follow facility policy for reporting the fall to administration, and the facility did not begin a falls investigation for the causes of the fall and interventions. The facility was unaware of the fall until the resident complained of pain, swelling was noted, and an investigation was begun for an injury of unknown origin on 6/14/15, one day after the fall.

Based on medical record review, review of hospital records, review of a thirty-day letter of involuntary discharge and interview, the facility failed to ensure documentation by the physician in the clinical record to justify the involuntary discharge of one resident (#26) of thirty-three residents reviewed. The facility's failure resulted in harm for resident #26 causing emotional and mental distress. The findings included: Resident #26 was admitted to the facility on [DATE] (six years in facility) with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had short-term memory impairment and modified independence with daily decision-making (difficulty in new situations only); usually understood (missed some part/intent of the message but comprehended most conversation); reported trouble falling or staying asleep, or sleeping too much); was not short-tempered or easily annoyed; had no physical or verbal behavior symptoms toward others; had no rejection of care and no wandering behavior; reported choosing own bedtime and going outside to get fresh air was "very important"; and received no antipsychotic, anti-anxiety, antidepressant or hypnotic medications. Medical record review of nurses' notes, social services notes, activity notes, physician's orders [REDACTED]. Medical record review of a social services note dated March 5, 2013 revealed, "...complains of restlessness @ (at) night...Continues to perform activity of choice as...wishes...Receives volunteer visits at least weekly from Ombudsman..." Medical record review of the care plan updated May 2013 revealed, "...Impaired thought processes related to advanced Dementia...Resident establishes own goals...Encourage to make own decisions at own level of ability...Monitor for changes in cognition, mood, behavior...(signs of) Depression...Activity: walking outside, sitting on porch, chewing tobacco...Monitor for Anxiety/[MEDICAL CONDITION] and report..." Continued review revealed "[MEDICAL CONDITION] pattern disturbance RT (related to) [MEDICAL CONDITION] consistent care routine at night..." Continued review revealed, "...Sensory-perceptual alteration: Hearing RT hearing loss...Speak in a well-modulated tone. Use appropriate gestures..." Medical record review of a social services progress note dated May 20, 2013 revealed "...suffers impaired memory d/t (due to) Dementia..."; had trouble staying asleep and "...walks as...pleases, knows...where wants to go..." Continued review revealed the resident was emotionally stable; exhibited good coping skills; and had accepted placement in the facility. Continued review revealed "...generally pleasant...Does become agitated at times, i.e. with unwanted food/meds...Expected to stay long term..." Medical record review of the physician's monthly recapitulation orders dated June 1-30, 2013 revealed the resident received no scheduled medications except for an antibiotic ([MEDICATION NAME]) which was ordered June 19, 2013 to treat a possible spider bite on the right lower leg. Medical record review of a nurse's note dated June 15, 2013 at 8:40 p.m. revealed, "Resident in room yelling @ (at) roommate/trying to hit roommate. Nurse stood between two residents. (Physician) called for order to send to (hospital) ER (emergency room ) for psych (psychiatric) eval (evaluation)...Roommate immediately moved out of room to another area...Resident layed (laid) in bed & (and) covered up..." Medical record review revealed the resident was transported to the hospital on June 15, 2013 at 9:20 p.m. Medical record review of a nurse's note dated June 16, 2013 at 12:05 a.m. revealed a Registered Nurse from the hospital called and notified the facility the resident "...is (no) harm to anyone..." Medical record review of the hospital emergency room report dated June 16, 2013 at 1:30 a.m. revealed "...(Psychiatric staff) came and evaluated the patient and felt that...was not a risk to self or others and would be appropriate to go back to the nursing home...Disposition decision is discharge..." Medical record review of a nurse's note dated June 16, 2013 at 2:00 a.m. revealed the resident returned to the facility. Medical record review of nurses' notes dated June 16, 2013 through June 26, 2013 revealed the resident had no further aggressive behaviors toward other residents. Medical record review of a social services note dated June 18, 2013 revealed "...Notified that resident was to receive a 30 day discharge notice...(No) further incidents of aggression..." Medical record review of a mental health progress note dated June 19, 2013 revealed the resident's prognosis was "good" with "...Person centered therapy...Relaxation techniques...Confrontation of inappropriate behavior...group activities...Stress/Anger management..." Medical record review of a physician's orders [REDACTED].) 5 mg po q hs x (times) 1 wk (week) then (increase) to BID (twice daily)[MEDICATION NAME] (used for Anxiety and [MEDICAL CONDITION]) 0.5 mg po TID (three times daily) prn (as needed)..." Medical record review of a social services note dated June 20, 2013 revealed, "(No) further behavioral incidents..." Medical record review of social services note dated June 21, 2013 revealed, "...Resident had continued to enjoy own activity. Monitored for behavioral issues...None to note..." Medical record review of a social services note dated June 26, 2013 revealed the resident was transferred to another facility on June 26, 2013. Review of an "Involuntary Discharge" notice dated June 18, 2013 revealed "...Please accept this notice that due to the reasons listed below, (resident) will be discharged from (facility) on or about Thursday, July 18, 2013...due to the following facts: "The safety of the individuals in the facility is endangered...The health of individuals in the facility would otherwise be endangered..." Interview on August 15, 2013 at 12:10 p.m. in the family room with the Director of Nursing (DON-employed in July 2013) confirmed the DON had reviewed the resident's clinical record and confirmed no documentation by the physician related to the health and safety of other residents and the need to discharge the resident involuntarily from the facility. Telephone interview on August 20, 2013 at 9:30 a.m. with the Ombudsman revealed the resident was "not doing well and keeps asking to go home (back to the facility from which he was discharged )." Telephone interview on September 5, 2013 at 10:05 a.m. with the volunteer Ombudsman who continued to visit the resident at the current facility revealed the resident "keeps asking to go back to the facility to see his sister (who still resides in the facility)." Continued interview revealed the volunteer Ombudsman told the resident his sister would not know him if he did go visit her. Continued interview revealed the resident stated, "I just want to go see her." Continued interview revealed the Ombudsman had discussed with the family the possibility of moving the sister to the same facility with the resident. The family refused because the distance was too far for the family to visit (53 miles round trip between facilities). Telephone interview on September 5, 2013 at 1:30 p.m. with the volunteer Ombudsman revealed the Ombudsman had visited the resident at least once during the weeks since the discharge and had also visited the resident on Sundays (August 4, 11, and 18, 2013) in addition to the weekly visits. The Ombudsman reported the last time he saw the resident was Tuesday, September 3, 2013. The Ombudsman stated, "Every time I go he's asking to go back to Greystone." The Ombudsman stated, "I tried to make him feel a little better" about the current facility. The resident responded by stating, "Yeah, but I can't see (sister named)." C/O #

Based on medical record review, review of hospital records, review of a thirty-day letter of involuntary discharge and interview, the facility failed to ensure one resident (#26) was provided a thirty-day involuntary discharge notice of thirty-three residents reviewed. The facility's failure resulted in harm for resident #26 causing emotional and mental distress. Resident #26 was admitted to the facility on [DATE] (six years in facility) with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had short-term memory impairment and modified independence with daily decision-making (difficulty in new situations only) and usually understood (missed some part/intent of the message but comprehended most conversation). Medical record review of nurses' notes, social services notes, activity notes, physician's orders [REDACTED]. Medical record review of the care plan updated May 2013 revealed, "...Impaired thought processes related to advanced Dementia...Resident establishes own goals...Encourage to make own decisions at own level of ability...Monitor for changes in cognition, mood, behavior..." Medical record review of a social services progress note dated May 20, 2013 revealed "...suffers impaired memory d/t (due to) Dementia..." Medical record review of a nurse's note dated June 15, 2013 at 8:40 p.m. revealed, "Resident in room yelling @ (at) roommate/trying to hit roommate. Nurse stood between two residents. (Physician) called for order to send to (hospital) ER (emergency room ) for psych (psychiatric) eval (evaluation)...Roommate immediately moved out of room to another area...Resident layed (laid) in bed & (and) covered up..." Medical record review revealed the resident was transported to the hospital on June 15, 2013 at 9:20 p.m. Medical record review of a nurse's note dated June 16, 2013 at 12:05 a.m. revealed a Registered Nurse from the hospital called and notified the facility the resident "...is (no) harm to anyone..." Medical record review of the hospital emergency room report dated June 16, 2013 at 1:30 a.m. revealed "...(Psychiatric staff) came and evaluated the patient and felt that...was not a risk to self or others and would be appropriate to go back to the nursing home...Disposition decision is discharge..." Medical record review of a nurse's note dated June 16, 2013 at 2:00 a.m. revealed the resident returned to the facility. Medical record review of nurses' notes dated June 16, 2013 through June 26, 2013 revealed the resident had no further aggressive behaviors toward other residents. Medical record review of a social services note dated June 18, 2013 revealed "...Notified that resident was to receive a 30 day discharge notice. Notice was hand delivered..." Medical record review of a mental health progress note dated June 19, 2013 revealed the resident's prognosis was "good" with "...Person centered therapy...Relaxation techniques...Confrontation of inappropriate behavior...group activities...Stress/Anger management..." Medical record review of a physician's orders [REDACTED].) 5 mg po q hs x (times) 1 wk (week) then (increase) to BID (twice daily)[MEDICATION NAME] (used for Anxiety and [MEDICAL CONDITION]) 0.5 mg po TID (three times daily) prn (as needed)..." Medical record review of a social services note dated June 20, 2013 revealed, "(No) further behavioral incidents..." Medical record review of social services note dated June 21, 2013 revealed, "Spoke (with resident's) emergency contact re: 30 day discharge (and) acceptance of resident by (two named facilities)...Resident had continued to enjoy own activity. Monitored for behavioral issues...None to note..." Medical record review of a social services note dated June 26, 2013 revealed the resident was transferred to another facility. Review of an "Involuntary Discharge" notice addressed to the resident and dated June 18, 2013 revealed "...Please accept this notice that due to the reasons listed below, (resident) will be discharged from (facility) on or about Thursday, July 18, 2013...due to the following facts: "The safety of the individuals in the facility is endangered...The health of individuals in the facility would otherwise be endangered..." Interview on August 6, 2013 at 10:40 a.m. in the family room with the volunteer Ombudsman revealed the volunteer Ombudsman visited the resident on a weekly basis. Continued interview revealed the facility "handed" a 30-day notice of involuntary discharge to the resident. Continued interview revealed the resident could not read and gave the letter to the volunteer Ombudsman (date not identified). Continued interview revealed the facility discharged the resident "within a week" of giving the discharge notice to the resident. Interview on August 6, 2013 at 1:10 p.m. in the family room with the Social Worker revealed the facility's "...legal department decided (resident) needed to go..." Continued interview revealed the Social Worker delivered the 30-day discharge to the resident; had no knowledge of whether the resident was able to read; and did not read the discharge notice to the resident. Continued interview revealed the Social Worker reported no recall of discussing the appeal rights with the resident. Continued interview confirmed the resident was not given thirty days to file an appeal and confirmed the facility was "actively" seeking placement in another facility immediately after the discharge notice was issued. Interview on August 15, 2013 at 11:50 a.m. in the family room with the Administrator revealed a discharge notice was sent Certified mail to "a family member" (unspecified) which was returned to the facility and the discharge notice was sent to the Ombudsman's. Continued interview revealed the facility had "safety" concerns with the resident (non included in the 30-day involuntary discharge notice) and confirmed, "afraid he might get hurt..." Continued interview confirmed the resident was not given thirty days to file an appeal. Telephone interview on August 19, 2013 at 3:30 p.m. with the Social Worker confirmed the Social Worker had talked with a family member (named nephew) on June 21, 2013 (5 days prior to the resident's discharge), and the family had no understanding of why and was "upset" the resident was being discharged to another facility. Continued interview confirmed the Social Worker did not discuss the resident's appeal rights with the family. Continued interview confirmed the Social Worker "learned after the discharge" that the resident could not read. Continued interview confirmed, at the time of discharge, the resident had no clear understanding he was being permanently discharged from the facility to another nursing home. Telephone interview on August 19, 2013 at 3:50 p.m. with the nephew (identified by the Social Worker as noted above) revealed, "They picked him up and hauled him off like a bag of garbage." Continued interview revealed the facility refused to give the family any information related to the reason for discharge. Continued interview revealed no family member had received the 30-day notice of involuntary discharge. Continued interview confirmed the resident "never went to school a day in his life...could not read..." Telephone interview on August 20, 2013 at 9:30 a.m. with the Long-Term Care Ombudsman confirmed the Ombudsman received the 30-day notice of discharge from the volunteer Ombudsman who visited the resident. Continued interview confirmed a meeting was held with the family, the facility's administrative staff and the Ombudsman, after the resident was discharged , to determine why the resident was discharged and was not given his appeal rights. Continued interview confirmed, during the meeting, the only reason given by the administrative staff for the discharge was the "safety of others." Telephone interview on August 20, 2013 at 9:30 a.m. with the Ombudsman revealed the resident was "not doing well and keeps asking to go home (back to the facility from which he was discharged )." Telephone interview on September 5, 2013 at 10:05 a.m. with the volunteer Ombudsman who continued to visit the resident at the current facility revealed the resident "keeps asking to go back to the facility to see his sister (who still resides in the facility)." Continued interview revealed the volunteer Ombudsman told the resident his sister would not know him if he did go visit her. Continued interview revealed the resident stated, "I just want to go see her." Continued interview revealed the Ombudsman had discussed with the family the possibility of moving the sister to the same facility with the resident. The family refused because the distance was too far for the family to visit (53 miles round trip between facilities). Telephone interview on September 5, 2013 at 1:30 p.m. with the volunteer Ombudsman revealed the Ombudsman had visited the resident at least once during the weeks since the discharge and had also visited the resident on Sundays (August 4, 11, and 18, 2013) in addition to the weekly visits. The Ombudsman reported the last time he saw the resident was Tuesday, September 3, 2013. The Ombudsman stated, "Every time I go he's asking to go back to Greystone." The Ombudsman stated, "I tried to make him feel a little better" about the current facility. The resident responded by stating, "Yeah, but I can't see (sister named)." Refer to F-202 C/O #

Based on medical record review, review of hospital records, review of a thirty-day letter of involuntary discharge and interview, the facility failed to provide sufficient preparation and orientation for an involuntary discharge of one resident (#26) of thirty-three residents reviewed. The facility's failure resulted in harm for resident #26 causing emotional and mental distress. Resident #26 was admitted to the facility on [DATE] (six years in facility) with [DIAGNOSES REDACTED]. Medical record review of the annual Minimum Data Set (MDS) dated [DATE] revealed the resident had short-term memory impairment and modified independence with daily decision-making (difficulty in new situations only); usually understood (missed some part/intent of the message but comprehended most conversation); reported trouble falling or staying asleep, or sleeping too much); was not short-tempered or easily annoyed; had no physical or verbal behavior symptoms toward others; had no rejection of care and no wandering behavior; reported choosing own bedtime and going outside to get fresh air was "very important"; was independent with bed mobility, transfer, ambulation and toileting; required supervision (oversight, encouragement or cueing) with dressing, eating, hygiene and bathing; had no limitation in range of motion; required no devices (cane, walker or wheelchair) for mobility; was continent of bowel and bladder; had no pain or history of fall; and received no antipsychotic, anti-anxiety, antidepressant or hypnotic medications. Medical record review of nurses' notes, social services notes, activity notes, physician's orders [REDACTED]. Medical record review of the care plan updated May 2013 revealed, "...Impaired thought processes related to advanced Dementia...Resident establishes own goals...Encourage to make own decisions at own level of ability...Activity: walking outside, sitting on porch, chewing tobacco...Monitor for Anxiety/[MEDICAL CONDITION] and report..." Continued review revealed "[MEDICAL CONDITION] pattern disturbance RT (related to) [MEDICAL CONDITION] consistent care routine at night..." Continued review revealed, "...Sensory-perceptual alteration: Hearing RT hearing loss...Speak in a well-modulated tone. Use appropriate gestures..." Medical record review of a social services progress note dated May 20, 2013 revealed "...suffers impaired memory d/t (due to) Dementia...walks as...pleases, knows...where wants to go..." Continued review revealed the resident was emotionally stable; exhibited good coping skills; and had accepted placement in the facility. Continued review revealed "...Does often speak of going to Jonesboro or Iowa...generally pleasant...Does become agitated at times, i.e. with unwanted food/meds...Expected to stay long term..." Medical record review of the physician's monthly recapitulation orders dated June 1-30, 2013 revealed the resident received no scheduled medications except for an antibiotic ([MEDICATION NAME]) which was ordered June 19, 2013 for ten days to treat a possible spider bite on the right lower leg. Medical record review of a document entitled "Wander/Elopement Risk Evaluation" dated June 13, 2013 revealed the resident was not at risk for elopement and "Pt (Patient) walks around outside-however...stays on grounds. Verbalized (no) desire to leave facility..." Medical record review of a nurse's note dated June 15, 2013 at 8:40 p.m. revealed, "Resident in room yelling @ (at) roommate/trying to hit roommate. Nurse stood between two residents. (Physician) called for order to send to (hospital) ER (emergency room ) for psych (psychiatric) eval (evaluation)...Roommate immediately moved out of room to another area...Resident layed (laid) in bed & (and) covered up..." Medical record review revealed the resident was transported to the hospital on June 15, 2013 at 9:20 p.m. Medical record review of a nurse's note dated June 16, 2013 at 12:05 a.m. revealed a Registered Nurse from the hospital called and notified the facility the resident "...is (no) harm to anyone..." Medical record review of the hospital emergency room report dated June 16, 2013 at 1:30 a.m. revealed "Mental Status...within normal limits...states that roommate leaves the TV on and (resident) went to cut it off and got into an altercation with roommate...(Psychiatric staff) came and evaluated the patient and felt that...was not a risk to self or others and would be appropriate to go back to the nursing home..." Medical record review of a nurse's note dated June 16, 2013 at 2:00 a.m. revealed the resident returned to the facility. Medical record review of nurses' noted dated June 16, 2013 through June 26, 2013 revealed the resident had no further aggressive behaviors towards staff or other residents. Medical record review of a social services note dated June 17, 2013 revealed "...Contacted resident's niece and explained that we wanted to keep all residents safe and asked permission to move resident to the 3rd floor...stated...would talk it over (with) family and let me know..." Medical record review of a social services note dated June 18, 2013 revealed "...Notified that resident was to receive a 30-day discharge notice. Notice was hand delivered. Resident stated that he would like to go to another place...(No) further incidents of aggression..." Medical record review of a mental health progress note dated June 19, 2013 revealed the resident's prognosis was "good" with "...Person centered therapy...Relaxation techniques...Confrontation of inappropriate behavior...group activities...Stress/Anger management..." Medical record review of a physician's orders [REDACTED].) 5 mg po q hs x (times) 1 wk (week) then (increase) to BID (twice daily)[MEDICATION NAME] (used for Anxiety and [MEDICAL CONDITION]) 0.5 mg po TID (three times daily) prn (as needed)..." Medical record review of a social services note dated June 20, 2013 revealed, "(No) further behavioral incidents..." Medical record review of social services note dated June 21, 2013 revealed, "Spoke (with resident's) emergency contact re: 30 day discharge (and) acceptance of resident by (two named facilities)...Resident has continued to enjoy own activity. Monitored for behavioral issues...None to note..." Medical record review of a social services note dated June 26, 2013 revealed the resident was transferred to another facility. Review of an "Involuntary Discharge" notice addressed to the resident and dated June 18, 2013 revealed "...Please accept this notice that due to the reasons listed below, (resident) will be discharged from (facility) on or about Thursday, July 18, 2013...due to the following facts: "The safety of the individuals in the facility is endangered...The health of individuals in the facility would otherwise be endangered...On the effective date of July 18, 2013, (resident) will be transferred to your custody by ambulance, at your expense, to an appropriate facility. The locations and contact information of the facility will be given prior to discharge. You will be responsible for meeting (resident's) care needs as of the effective date. Our Social Work...and nursing staff members will help you arrange for home health services, and physician follow-up. You have the right to appeal this discharge to the State of Tennessee Department of Health..." Continued review revealed a copy was given to the Interim Director of Nursing (in place at the time of the involuntary discharge), the physician and the Ombudsman. Continued review revealed the involuntary discharge notice was signed by the Administrator. Interview on August 6, 2013 at 10:40 a.m. in the family room with the volunteer Ombudsman revealed the volunteer Ombudsman visited the resident on a weekly basis. Continued interview revealed the resident "took care of himself...was ambulatory...talked to people for hours...was an old farmer...did everything for himself...didn't even take an Aspirin..." Continued interview revealed the resident "would sit and talk to...sister (also a resident in the facility)...about their childhood...only habit was chewing Red Man...could go outside spit...could go out front or out back to edge of woods...would stay out all day watching the planes or helicopters fly in (facility near airport)...had deer and squirrels that came around...been doing this for at least four and one-half years." Continued interview revealed the resident was confined to an enclosed courtyard at the new facility and since the transfer; the resident's mental status had declined. Continued interview revealed the day the resident was transferred to the new facility, the resident refused to get out of the transport van. The Social Worker for the facility was contacted by the new facility and asked to "come get him out of the van." Telephone interview on August 19, 2013 at 3:30 p.m. with the Social Worker revealed the Social Worker was reticent to discuss the resident's understanding of the discharge; however continued interview confirmed the Social Worker documented in the social services note dated June 18, 2013 that the resident stated he would like to go to another place. Continued interview revealed the Social Worker stated, "I don't know" when asked if the resident meant he wanted to go to a different nursing home or another town. Continued interview confirmed the resident had spoken of going to "Jonesboro" (TN), Iowa or to a facility that had better food. Continued interview confirmed the resident "thought he was going to Limestone (TN) or to an apartment" at the time of discharge, and had "no clear understanding" he was being permanently discharged from the facility to another nursing home. Continued interview confirmed the day the resident was discharged to the new facility, the Social Worker was notified the resident refused to get out of the van and confirmed the Social Worker was "called to assist with getting him out of the van" and into the facility. Continued interview revealed when the Social Worker arrived at the facility the resident was outside the van but refused to enter the facility. The Social Worker stated, "We kept talking to him to try and get him to go inside...Asked him if he wanted to look at the pond. He said he did. He had done some kind of work in that area. That's how we got him to go inside the building." Continued interview revealed the Social Worker had talked with a family member (named nephew) prior to the discharge, and the family had no understanding of why and was "upset" the resident was being discharged to another facility. Telephone interview on August 19, 2013 at 3:50 p.m. with the nephew (identified by the Social Worker as noted above) revealed, "They picked him up and hauled him off like a bag of garbage....didn't even take his clothes. If they had taken his clothes, he would have known what was happening and he wouldn't have gotten in the van to begin with." Continued interview confirmed the facility did not involve the family or the resident in the planning of or the preparation for the discharge. Telephone interview on August 20, 2013 at 9:30 a.m. with the Ombudsman revealed the resident was "not doing well and keeps asking to go home (back to the facility from which he was discharged )." Telephone interview on September 5, 2013 at 10:05 a.m. with the volunteer Ombudsman who continued to visit the resident at the current facility revealed the resident "keeps asking to go back to the facility to see his sister (who still resides in the facility)." Continued interview revealed the volunteer Ombudsman told the resident his sister would not know him if he did go visit her. Continued interview revealed the resident stated, "I just want to go see her." Continued interview revealed the Ombudsman had discussed with the family the possibility of moving the sister to the same facility with the resident. The family refused because the distance was too far for the family to visit (53 miles round trip between facilities). Telephone interview on September 5, 2013 at 1:30 p.m. with the volunteer Ombudsman revealed the Ombudsman had visited the resident at least once during the weeks since the discharge and had also visited the resident on Sundays (August 4, 11, and 18, 2013) in addition to the weekly visits. The Ombudsman reported the last time he saw the resident was Tuesday, September 3, 2013. The Ombudsman stated, "Every time I go he's asking to go back to Greystone." The Ombudsman stated, "I tried to make him feel a little better" about the current facility. The resident responded by stating, "Yeah, but I can't see (sister named)." Refer to F-202 Refer to F-203 C/O #