Every finding on record at Heritage at Longview Healthcare Center

Based on interview and record review, it was determined the facility failed to coordinate the PASRR assessment for specialized services for 1 of 1 resident (Resident #1) reviewed for resident assessment, in that:The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #1's customized manual wheelchair (CMWC) by a specific deadline of 9/12/2025. This failure could place residents with intellectual and developmental disabilities at risk for a decline in physical, mental, psychosocial well-being and quality of life.Findings included:Record review of Resident #1's undated face sheet reflected Resident #1 was a [AGE] year old male resident who was originally admitted to the facility on [DATE] and most recently re-admitted on [DATE] with diagnoses that included: Cerebral Infarction (Tissue death caused by a severe reduction in brain blood flow due to arterial blockage, typically triggering the ischemic cascade), Convulsions (sudden, involuntary, and rapid shaking or stiffening of muscles, often representing the violent physical manifestation of a seizure), Cognitive Communication Deficit (a communication impairment caused by underlying disruptions in cognitive processes-such as memory, attention, organization, and reasoning-rather than a primary language deficit).Record review of Resident #1's quarterly MDS assessment, dated 01/07/26, reflected Resident #1 had severe cognitive impairment with a BIMS score of 00. Further review revealed the resident required use of a manual wheelchair.Record review of Resident #1's care plan, problem initiation date on 06/06/20234, reflected Resident #1 had a positive PASRR status. I have IDD and I am PASRR positive.I will have the specialized services recommended by local authority per PASRR Specialized Services program. The LA will be invited Annually to the care plan meeting for review of SpecializedServices. Record review of Resident #1's initial PCSP form, dated 08/18/2025, reflected Resident #1 required a new CMWC.Review of the PASRR Compliance Call Report for August 2025's spreadsheet for Resident #1's DD services PASRR Unit indicated the following: *IDT meeting was held on 08/18/2025,*PCSP was created on 08/18/2025,*IDT date plus 30 days was 09/30/2025,*NF contacted 11/07/2025,*Due date for NF to submit NFSS form in LTC portal for therapies was 09/12/2025.*Resident #1 needed a CMWC. Record review of the undated Simple LTC PASRR NFSS Activity Portal History, for Resident #1, reflected services requested for CMWC indicated NFSS form request for CMWC was not submitted within 20 business days of the IDT meeting.During an observation on 4/27/26 at 10:48 a.m., Resident #1 was observed sitting on a couch next to him was his CMWC. Resident #1 is a non-verbal individual and an interview was therefore not conducted.During an interview on 04/27/2026 at 11:05 a.m. with the Director of Therapy, she said that Resident #1 received his custom wheelchair that he was eligible for from his PASRR IDT meeting on 12/17/2025. She said that his initial IDT meeting indicated he qualified for a custom wheelchair was conducted on 08/18/2025. She said the facility then had 20 business days to submit into the Simple Online Portal his NFSS request that would start the process of Resident #1 to receive his custom wheelchair. She said that this NFSS request was sent in on 11/07/2025 which was past the 20-business day requirement. She said that it was an oversight that the 20-business day requirement was missed.During an interview on 04/28/2026 at 9:30 a.m. with the Director of Nurses,. she said that responsibility to ensure that the deadline was met to place the NFSS request was the Director of Therapy. She stated that the Director of Therapy missed this deadline after she reviewed the details of this investigation. She said that residents could be placed at risk of not receiving specialized services they are eligible for if deadlines were not met.During an interview on 04/28/2026 at 10:00 a.m. with the Administrator, he said that responsibility to ensure residents received their specialized custom wheelchair was the Director of Therapy. He said that residents could be placed at risk of not receiving the services they were eligible for if staff did not follow up timely on their reports.Record review of the facility's policy revised 03/06/2016, titled, PASRR Level 1 Screen Policy and Procedure, reflected in part: Policy: It is the policy of facilities to obtain a PL 1 screening form from the RE (referring entity) prior to admission to the NF. The PL 1 will be submitted via Simple LTC timely per PASRR Regulatory timeframes. PASRR is a federally mandated program requiring all states to prescreen all individuals seeking admission to a Medicaid-certified nursing facility, regardless of payer source or age. The PASRR Program is important because it provides options for individuals to choose where they live, who they live with and the training and therapy they need to live as independently as possible. PASRR Program has 3 Goals: To identify individuals with mental illness, Intellectual disability, or developmental disability (this includes adults and children.) To ensure appropriate placement, whether in a community or in a Nursing Facility. To ensure individuals receive the required services for their mental illness, Intellectual disability, or developmental disability. After the IDT meeting, the NF must submit the information from the IDT meeting on the LTC online Portal. When the IDT agrees that a hospice recipient needs NF specialized services, the NF must submit prior authorization requests for all required assessments and NF specialized services via the Authorization Request for PASRR Nursing Facility Specialized Services (NFSS) form on the LTC Online Portal.

Based on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure food stored in the kitchen was labeled and dated on 06/30/25 and 07/01/25. 2. The facility failed to ensure cookware stored near the dishwasher area were free of carbon build up on 06/30/25. 3. The facility failed to ensure the apple juice, cranberry juice, and thickened water, connected to the drink dispenser were dated on 06/30/25. 4. The facility failed to ensure a large bin with small, beige grain, stored underneath a preparation table was labeled on 06/30/25. 5. The facility failed to ensure a floor drain near the walk-in refrigerator was free of rust and drainage. 6. The facility failed to ensure the kitchen's ceiling vents were free of black particles on 07/01/25. 7. The facility failed to ensure food was covered in the walk-in cooler on 07/01/25. These deficient practices could place residents at risk for foodborne illness.Findings included: During an observation on 06/30/25 starting at 7:10 a.m., in the main kitchen area the following was observed:*Twenty-two individually wrapped, triangular shaped pieces of bread were on a metal cart. The pieces of bread were not labeled or dated. *Five metal pans had carbon buildup around the edges of the cookware. *The apple juice, cranberry juice, and thickened water connected to the juice dispenser were not dated. *One large, clear bin underneath a prep table with small, beige grain was not labeled. During an observation on 07/01/25 starting at 10:30 a.m., in the main kitchen area the following was observed:* Two bowels of circular, beige food item, stored on the cereal cart, was not labeled or dated. *Four, white air conditioning vents on the ceiling had small to moderate amount of black matter. Two of the vents were over prep tables. *A floor drain near the walk-in cooler had a creamy, white, and brown drainage and rust. During an observation on 07/01/25 at 10:45 a.m., in the walk-in cooler the following was observed:*Twenty bowels of square, orange food item were not covered, labeled, or dated. During an interview on 07/01/25 at 10:49 a.m., the Maintenance Worker said he recently started at the facility. He said the maintenance worker was responsible for cleaning or changing the floor drains in the kitchen. He said maintenance was responsible for the vents in the kitchen. He said black matter was dirt not mildew. During an interview on 07/02/25 at 8:30 a.m., the DS F said she had been employed at the facility since September 2024. She said the Cooks were responsible for the labeling and dating of the food storage bins. She said everyone was responsible for labeling and dating food items in fridge and freezer. She said whoever used it or whoever made the food item should label and date it. She said the kitchen normally wrapped food items if they were not going to be served in the dining room. She said the cantaloupe not wrapped in the walk-in cooler was for the dining room resident's lunch meal. She said the food items needed to be labeled and dated to know if it was old or new. She said it was also important to know when it was out and what it was. She said the residents could get sick if they ate something old. She said she noticed the a/c vents were dirty and asked the ADM about them. She said the ADM said someone had to come out and clean them. She said she had not been in-serviced recently on labeling and dating or general cleanliness, but the DM reminded them all the time to do it. During an interview on 07/02/25 at 8:39 a.m., [NAME] E said she had worked at the facility for 10 years. She said everyone was responsible for labeling and dating food items. She said whoever put the rice in the bin should have labeled it. She said the cantaloupe should have been wrapped in the walk-in cooler. She said they normally did not wrap the food going to the dining room. She said the food should be wrapped when placed in the fridge, so it did not take on the smell of other things, in the fridge. She said whoever prepared the food item should have wrapped it. She said the cookware should not have carbon buildup. She said it was important to not have carbon buildup because you did not want it to get into the food. She said it was also a fire hazard. She said it was the Cooks responsibility to ensure cookware did not have carbon build up. She said the a/c vent was dirty for about a month. She said it was important not to have dirty a/c vents to make sure the dirt did not fall into the food. She said the dirt could contaminate the food and make the residents sick. She said maintenance was responsible for the floor drains. She said she noticed the rust on the floor drain, near the walk-in cooler. She said the floor drain should not have a buildup of rust or drainage for the general cleanliness of the kitchen. During an interview on 07/02/25 at 8:57 a.m., the DM said she worked at the facility for 11 years. She said everyone was responsible for labeling and dating. She said whoever put the food item in the fridge, freezer, or bin should label and date it. She said the Cooks were responsible for the cookware not having carbon buildup. She said Maintenance was responsible for the floor drain and a/c vents. She said labeling and dating was important to know when new things needed to come out. She said if a resident consumed an expired food item, it depended on what it was, on how it would affect them. She said she did not know the risk of cookware having carbon buildup. She said the dirt from the a/c vent could get in the food. She said she did not know how it would affect the resident if they consumed it. She said the a/c vents and the floor drain needed to be clean for cleanliness of the kitchen. She said she gave an in-service to the dietary staff on 02/2025. She said it was on dietary service and policy and procedures. She said the ADM oversaw her and the kitchen. She said the ADM did not do walk throughs but asked weekly if anything was needed. During an interview on 07/02/25 starting at 3:25 p.m., the ADM answered questions on other citations. The ADM appeared agitated and became abrupt during the interview process. The ADM asked, how many more do you have? The State Surveyor decided to end the interview without questioning about labeling and dating, storage, and general kitchen cleanliness. Interview on 07/02/25 at 5:00 p.m., policies were requested from the DM related to labeling and dating food items, cookware, and general kitchen sanitation. The DM stated they could not find a policy related to carbon build up on cookware and general kitchen sanitation. Record review of the facility's Dietary Service, Personnel, Policy and Procedure in-service, dated 02/04/25, by the DM, indicated seven employees attended and signed the roster. [NAME] E and DS F signed the roster. Record review of the facility's, undated, Food Storage and Supplies policy indicated, .dry bulk foods are stored.containers are labeled.open packages of food are stored in closed containers with covers or in sealed bags and dated as to when opened.

Based on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 3 of 15 residents reviewed for care plans (Resident #49, Resident #55, and Resident #119). 1. The facility failed to ensure Resident #49's fall mat was added as an intervention to her fall care plan. The facility failed to ensure Resident #49's fall mat was in place when she was in the bed on 07/01/25. The facility failed to ensure Resident #49's call light was within reach per her care plan intervention on 06/30/25 and 07/01/25. The facility failed to ensure Resident #49 was care planned for developing a Stage 1 pressure injury (is the mildest form of a pressure injury, characterized by non-blanchable redness of intact skin) to the sacrum (located at the base of the spinal column) on 06/17/25. The facility failed to ensure Resident #49 was care planned for her diagnosis of hypothyroidism. The facility failed to ensure Resident #49 was care planned for her use of an antiplatelet (drugs that prevent blood cells called platelets from clumping together and forming blood clots). The facility failed to ensure Resident #49 meals were documented in June 2025 per the care plan. 2. The facility failed to ensure Resident #55's dressing changes were documented per the care plan on 06/03/25, 06/07/25, and 06/12/25. 3. The facility failed to ensure Resident #119's unclear speech and impaired vision, triggered on the 05/26/25 MDS assessment, was care planned. The facility failed to ensure Resident #119's behavior related resisting ADL care/assistance, urinating in his room and in public areas, and ignoring staff when redirection attempted. These failures could place residents at risk of not having their individualized needs met, and a decline in their quality of care and life. Findings included: Record review of Resident #49's face sheet dated 06/30/25 indicated Resident #49 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #49 had diagnoses including displaced posterior arch fracture of first cervical vertebra (a break in the bony ring of the first cervical vertebra, also known as the atlas), type 1 diabetes (is a chronic autoimmune disease where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas, leading to insufficient or no insulin production), hypothyroidism (is when your thyroid gland doesn't make and release enough hormone into your bloodstream), atherosclerotic heart disease (is a hardening of your arteries from plaque building up gradually inside them), and history of falling. Record review of Resident #49's admission MDS assessment dated [DATE] indicated Resident #49 was usually understood and usually had the ability to understand others. Resident #49 had a BIMS score of 7 which indicated severe cognitive impairment. Resident #49 had a thyroid disorder and history of falling diagnoses. Resident #49 had a fall in the last month prior to admission/entry, in the last 2-6 months prior to admission/entry, and fracture related to fall in the 6 months prior to admission/entry. Resident #49 had a fall with no injury since admission/entry. Resident #49 was at risk for developing pressure ulcers /injuries. Resident #49 received an antiplatelet during the last 7 days or since admission/entry. Record review of Resident #49's care plan dated 04/08/25 indicated Resident #49 was at risk for falls related to history of falls and had an actual fall with no injuries on 04/03/25. Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed and keep bed in lowest position. Resident #49's care plan did not reflect a fall mat as a fall prevention intervention. Resident #49's care plan did not reflect stage 1 pressure injury, hypothyroidism diagnosis, or antiplatelet use. Record review of Resident #49's care plan dated 04/11/25 indicated Resident #49 had a nutritional problem or potential nutritional problem related to unspecified protein calorie malnutrition. Intervention included monitor intake and record every meal. Record review of Resident #49's consolidated physician order dated 06/30/25 indicated:*Stage 1 pressure injury to sacrum area-apply zinc oxide (topical cream) to area after each incontinence episode, one time a day for wound. Order date 06/17/25. *Aspirin (antiplatelet medication) Oral Capsule 81mg, give 1 capsule by mouth one time a day related to atherosclerotic heart disease. Order date 04/03/25. *Levothyroxine (used to treat hypothyroidism) Sodium Oral Tablet 75 mcg, give 1 tablet by mouth at bedtime related to hypothyroidism. Order date 04/05/25. Record review of Resident #49's medication administration record dated 06/01/25-06/30/25 indicated:* Aspirin Oral Capsule 81mg, give 1 capsule by mouth one time a day related to atherosclerotic heart disease. Resident #49 received 30 out of 30 doses. *Levothyroxine Sodium Oral Tablet 75 mcg, give 1 tablet by mouth at bedtime related to hypothyroidism. Resident #49 received 29 out of 29 doses. Record review of Resident #49's wound administration record dated 06/01/25-06/30/25 indicated:* Stage 1 pressure injury to sacrum area-apply zinc oxide to area after each incontinence episode, one time a day for wound. Resident #49 had 13 out of 14 treatments documented. Record review of Resident #49's ADL task sheet dated June 2025 indicated amount eaten:*0900: 06/02/25, 06/03/25, 06/07/25, 06/08/25, 06/11/25, 06/12/25, 06/13/25, 06/18/25, 06/19/25, 06/22/25, 06/27/25. Resident #49's ADL task sheet did not reflect amount eaten for 0900 on 06/01/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/14/25, 06/15/25, 06/16/25, 06/17/25, 06/20/25, 06/21/25, 06/23/25, 06/24/25, 06/25/25, 06/26/25, 06/28/25, 06/29/25.*1300(1pm): 06/02/25, 06/07/25, 06/08/25, 06/11/25, 06/12/25, 06/13/25, 06/18/25, 06/19/25, 06/27/25.Resident #49's ADL task sheet did not reflect amount eaten for 1300(1pm) on 06/01/25, 06/03/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/10/25, 06/14/25, 06/15/25, 06/16/25, 06/17/25, 06/20/25, 06/21/25, 06/22/25, 06/23/25, 06/24/25, 06/25/25, 06/26/26, 06/28/25, 06/29/25. *1800(6pm): 06/01/25, 06/02/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25, 06/16/25, 06/21/25. Resident #49's ADL task sheet did not reflect amount eaten for 1800(6pm) on 06/03/25, 06/07/25, 06/08/25, 06/10/25, 06/11/25, 06/12/25, 06/13/25, 06/14/25, 06/15/25, 06/17/25, 06/18/25, 06/19/25, 06/20/25, 06/22/25, 06/23/25, 06/24/25, 06/25/25, 06/26/25, 06/27/25, 06/28/25, 06/29/25. During an observation on 06/30/25 at 8:39 a.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49's hair was in disarray and oily. Resident #49's fall mat was down but folded in half so the bedside table could fit underneath the bed. Resident #49's call light was draped over the nightstand, not within reach. During an observation on 06/30/25 at 9:41 a.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49's hair was in disarray and oily. Resident #49's fall mat was down but folded in half so the bedside table could fit underneath the bed. Resident #49's call light was draped over the nightstand, not within reach. During an observation on 07/01/25 at 12:05 p.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49's hair was in disarray and oily. Resident #49 had a fall mat down near the bed. Resident #49's call light was clipped at the head of the bed, not within reach. During an observation and interview on 07/01/25 at 1:26 p.m., Resident #49 was lying in her bed hollering out for a family member. Resident #49's fall mat was not bedside the bed. Resident #49's call light was clipped at the head of the bed, not within reach. Resident #49 was asked by this surveyor if she knew where the call light was. Resident #49 said, Can you help me? During an observation on 07/01/25 at 2:08 p.m., Resident #49 was sitting up in bed with a neck brace on. Resident #49's fall mat was not bedside the bed. Resident #49's call light was clipped at the head of the bed, not within reach. During an observation on 07/01/25 at 3:04 p.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49's fall mat was not bedside the bed. Resident #49's call light was clipped at the head of the bed, not within reach. 2. Record review of Resident #55's face sheet dated 06/30/25 indicated Resident #55 was a [AGE] year-old male admitted to the facility on [DATE]. Resident #55 had diagnoses including venous insufficiency (is a condition where the veins in the legs have trouble sending blood back to the heart), lymphedema (is a condition characterized by swelling, usually in the arms or legs, due to a buildup of lymph fluid), chronic kidney disease (is a condition where the kidneys are damaged and can't filter blood as well as they should), heart failure (is a condition where the heart can't pump enough blood to meet the body's needs), and type 2 diabetes (is a chronic condition characterized by elevated blood sugar levels due to either the body's inability to produce enough insulin or the cells becoming resistant to insulin's effects). Record review of Resident #55's quarterly MDS assessment dated [DATE] indicated Resident #55 was usually understood and usually had the ability to understand others. Resident #55 had a BIMS score of 14 which indicated intact cognition. Resident #55 was at risk for developing pressure ulcers/injuries. Resident #55 had nutrition or hydration intervention to manage skin problems and applications of ointments/medications other than to feet. Record review of Resident #55's care plan dated 01/06/25, revised on 03/13/25 indicated Resident #55 had actual impairment to skin integrity related to edema. Resident #55 had lymphedema wound to right lower extremity. Intervention included provide treatment as ordered. Record review of Resident #55's consolidated physician order dated 06/30/25 indicated:*Cleanse open area to right medial lower leg with soap and water, pat dry, apply moisturizer, apply calcium alginate with silver, apply Unna boot (is a compression bandage that treats the slow healing of lower leg wounds and ulcers), wrap with kerlix secure with ace bandage, one time a day for wound healing. Order date 06/25/26. Start date 06/26/25.*Left anterior lymphademic wound, cleanse with soap/water, pat dry, apply calcium alginate, apply dry dressing, wrap with kerlix, secure with ace bandage as needed soiled dislodgement, one time a day. Ordered 06/18/25. Start date 06/19/25. Record review of Resident #55's Wound Administration Record dated 06/01/25-06/30/25 indicated:*Right lateral lymphademic wound, cleanse area with normal saline, pat dry, apply moisturizing lotion to leg (except open areas), apply Unna boot with kerlix then apply ace wrap bandages three times a week and as needed soiled and dislodgment, one time a day every Tuesday, Thursday, and Saturday (AM). Discontinued 06/15/25. Resident #55 had documented for 3 out of 6 treatment days. *Left anterior lymphademic wound, cleanse area with warm water/soap, pat dry, apply moisturizing lotion, apply Unna boot with kerlix then apply ace wrap bandage three times a week as needed soiled dislodgement, one time a day every Tuesday, Thursday, Saturday (AM). Shower prior to wound care. Discontinued 06/18/25. Resident #55 had documented for 4 out of 7 treatment days. *Cleanse area right lower lateral leg with soap/water, apply calcium alginate with silver, apply dry dressing, wrap with kerlix, secure with ace bandage, one time a day for wound healing (PM). Discontinued 06/24/25. Resident #55 had documented 8 out of 13 treatment days. *Cleanse open area to right medial lower leg with soap/water, pat dry, apply moisturizer, apply calcium alginate with silver, apply Unna boot, wrap with kerlix, secure with ace bandage, one time a day for wound healing (AM). Discontinued 06/30/25. Resident #55 had documented 3 out of 4 treatment days. *Left anterior lymphademic wound, cleanse with soap/water, pat dry, apply calcium alginate, apply dry dressing, wrap with kerlix, secure with ace bandage as needed soiled dislodgement, one time a day (AM). Resident #55 had documented 5 out of 11 treatment days. Record review of Resident #55's VOHRA wound evaluation and management summary dated 07/01/25 indicated:*Lymphademic wound of right, medial leg full thickness, wound progress at goal. Poor healing potential, objective to prevent deterioration, no signs of infection.*Lymphademic wound of left, anterior leg, resolved on 07/01/25.*Lymphademic wound of the right, proximal leg, resolved 07/01/25. During an observation and interview on 06/30/25 at 9:13 a.m., Resident #55 was sitting in a chair, in his room. Resident #55 had ace bandage on both legs and yellow non-skid socks on. Underneath Resident #55 feet was a white towel with yellow stained areas. The white towel appeared wet. Resident #55 said he had wounds on his legs that drained fluid. He said he put towels on the floor to catch the leakage. He said he was fluid restricted to try to help with the extra fluid. He said the facility tried to do his dressing changes every day, but he had them change it to every other day. He said even when it was scheduled every day, it was not getting done. He said the dressing changes got done less on the weekends. 3. Record review of Resident #119 face sheet dated 06/30/25 indicated Resident #119 was a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #119 had diagnoses including Huntington's disease (is a progressive, inherited disorder that causes the breakdown of nerve cells in the brain), violent behavior, dementia (is a general term for a decline in mental ability severe enough to interfere with daily life), and anxiety disorder (a group of mental health conditions characterized by excessive, persistent fear and worry that can significantly interfere with daily life). Record review of Resident #119's quarterly MDS assessment dated [DATE] indicated Resident #119 was sometimes understood and usually had the ability to understand others. Resident #119 had unclear speech and impaired vision with corrective lenses. Resident #119 had a BIMS score of 12 which indicated moderate cognitive impairment. No behavioral symptoms or rejection of care were indicated on Resident #119's MDS assessment. Resident #119 required partial/moderate assistance for ADL assistance except for eating which was setup only. Resident #119 had less than 7 episodes of urine incontinence and one episode of bowel incontinence. Record review of Resident #119's care plan, last reviewed on 05/13/25, dated 06/30/25 indicated:*Resident #119 was resistive to care related to refusing ADL care, refusing showers, refusing to use urinal or bathroom with privacy instead urinating in the floor. At times will urinate in the floor in the dining room and then refuse to leave or move to allow care and urine to be cleaned up. Removes briefs, pull ups, and undergarments leading to urine leaking on floor. Intervention included educate resident/family/caregivers of the possible outcome(s) of not complying with treatment or care. *Resident #119 has manipulative behaviors and ignores staff when redirection is attempted. Intervention included intervene as necessary to protect the rights and safety of others. Approach/speak in calm manner. Divert attention. Remove from situation and take to alternate location as needed. Resident #119's unclear speech and impaired vision was not reflected on his care plan. Record review of Resident #119's progress notes dated 01/29/25-06/30/25 indicated:*04/29/25 at 6:02 a.m. by LVN N, .this nurse [LVN N] notice Resident [#119] was soaked, asked Resident [#119] to go to the shower room to be changed.Resident [#119] refused to be changed.attempted 3xs and Resident [#119] continued to head towards the dining room.*05/26/25 at 8:10 p.m. by LVN O, .CNA offered incontinent care, Resident [#119] refused will offer again at another time.*06/03/25 at 3:03 a.m. by RN P, .CNA offered incontinent care, Resident [#119] refused.aide stated Resident [#119] raised his hand up at her.both nurses went to assist and Resident [#119] continued to refuse.will offer again at another time.*06/17/25 at 12:23 p.m. by the DON, .Resident [#119] in dining room and soiled himself.several staff asked resident to remove himself from the dining room and he became agitated.Resident [#119] would not let staff take him from the dining room.Resident [#119] rolled himself from the dining room approx. 30 minutes later.asked resident to let me [DON] shower him and change his clothes.Resident [#119] complied at this time.Resident [#119] encourage to wear pull-ups when coming to dining room instead of cloth underwear.*06/18/25 at 1:24 p.m. by LVN L, .Staff have attempted to clean Resident [#119] up several times this shift due to Resident [#119] being soiled.Resident [#119] continues to allow staff to help him stating 'I need to rest'.staff encouraged Resident [#119] to allow them to get him clean so that he could rest.Resident [#119] continues to refuse care. *06/22/25 at 5:55 p.m. by LVN L, .Staff have attempted to clean Resident [#119] up several times this shift due to Resident [#119] being soiled.Resident [#119] continues to refused.[sic] During an observation and interview on 06/30/25 starting at 9:00 a.m., Resident #119 was self-propelling himself in a wheelchair down the hallway. Resident #119 had a helmet on with a white stained shirt and stained pants. A strong urine odor emitted from Resident #119 when this surveyor passed him. The DON spoke to Resident #119 but, this surveyor was unable to hear the conversation. Approximately 10 minutes later, Resident #119 was headed towards his room with the same clothes on and a urine odor. A few puddles of yellow tinged liquid, with a urine odor was noted down the hall toward Resident #119 's room. When LVN D was asked about Resident #119, she said he refused to let them change him. LVN D said she would get housekeeping to immediately clean the hallway. During an observation and interview on 07/01/25 at 9:35 a.m., Resident #119 was sitting in his manual wheelchair looking through his dresser. A puddle of yellow tinged liquid was noted on Resident #119's floor. Resident #119 was clean and well groomed. When interviewing Resident #119, he made unintelligible noise with jerky head movement but also spoke clearly after long pauses or repeated questioning. During an interview on 07/02/25 at 9:22 a.m., the MDS Coordinator said she had been at the facility since January 2024. She said the care plans were done with MDS assessments and acutely. She said the IDT was responsible for the care plans. She said she was part of the care plan team. She said she was responsible for the MDS care assessment areas and tried to personalize the resident's care plans. She said the nurses primarily did the acute care plans and the day-to-day changes. She said Resident #119's speech and vision care areas should be on his care plan. She said the social worker primarily did those sections. She said Resident #119's behaviors should have been placed on his care plan by the IDT when it was a continual behavior. She said Resident #49 was a fall risk because she was admitted with a fracture. She said the fall mat should have been added to her care plan on admission. She said Resident #49's hypothyroidism and aspirin or antiplatelet use should have triggered on the baseline care plan. She said once it was on the baseline care plan then those things flowed over to the comprehensive care plan. She said the IDT should have ensured Resident #49's hypothyroidism and antiplatelet use was on the comprehensive care plan. She said the comprehensive care plan was important because it was a guide and so the staff knew how to take care of the resident properly. She said when the comprehensive care plan was not accurate, something could be missed when providing care. She said the IDT was responsible for each other and looking at the resident's care plans. She said the facility had scheduled quarterly care plan meetings with the residents or resident representatives on Thursdays. During an interview on 07/02/25 at 10:49 a.m., the ADON said, the IDT was responsible for the comprehensive care plans. She said the comprehensive care plans were done with MDS assessments and acute changes which were triggered from the admission nurse's note. She said the fall and wound care plans were done by the nurses. She said Resident #49's stage 1 pressure ulcer should have been care planned. She said she expected the care plan interventions to be followed. She said she expected the CNAs to document the resident's meal intake every shift. She said the documentation was important to monitoring for weight loss or other underlining conditions. She said she expected the charge nurses to document dressing changes as ordered. She said the documentation was important to indicate it was completed and the doctor's orders were followed. She said the IDT and the nursing administration were responsible to ensure the care plans were developed and interventions were followed by the nursing staff. On 07/02/25 at 12:48 p.m., attempted to contact LVN D by phone. Contact was unsuccessful and unable to leave a message. During an interview on 07/02/25 at 12:52 p.m., RN C said the MDS Coordinator and the nurses were responsible for comprehensive care plans. She said the nurses documented the dressing changes on the wound administration report. She said it was important to document on the wound administration report to prove it was done and described the care of the wound. She said the CNAs were responsible for documenting the resident's meal intake. She said documenting the meal intake let the nurses know how much the residents ate. She said if the residents started not eating enough, there was documentation to report to the medial doctor and family. She said everyone was responsible for fall mats and call light placement. She said the call light was important so the resident could get assistance and prevent falls. She said the fall mat was important to decrease the injury to the resident if a fall happened. During an interview on 07/02/25 at 2:07 p.m., CNA J said everyone should ensure call lights were within reach. She said the resident's call light should be within reach in case of an emergency. She said the resident could fall and hurt themselves if the call light was not within reach. She said the CNAs were responsible for documenting the resident's meal intake. She said the CNAs documented in the facility's charting system. She said every meal was supposed to be documented. She said the resident's meal was supposed to be documented to know if they had a lesser appetite or refused to eat. She said when the CNAs did not document the resident's meal intake, the next shift could not know what was going on. During an interview on 07/02/25 at 2:28 p.m., the DON said the social worker was primarily responsible for vision and speech care areas in the MDS assessment. She said she did not feel like Resident #119 had unclear speech and impaired vision. She said Resident #119 had been rejecting staff assistance when he was wet or soiled for a while. She said he responded to some staff better than others. She said Resident #119's behavior was probably added to the care plan because the State witnessed it on 06/30/25. She said the CNAs were responsible for documenting the resident's meal intakes. She said she expected the CNAs to document every meal before the end of their shift. She said the CNAs documented in the facility's charting system. She said it was important so the nurses knew if the resident was not eating. She said if the resident's meal intake was not documented, they could be experiencing weight loss. She said the dressing changes were documented on the resident's wound administration record. She said the wound care nurse or charge nurses were responsible for documenting dressing changes. She said she expected the dressing changes to be done and documented as scheduled and as needed. She said dressing changes should be done as scheduled to promote healing and decrease infection. She said the IDT was responsible for the comprehensive care plan. She said the comprehensive care plan was important because it was a continuum of care. She said the DON and ADON were responsible for ensuring comprehensive care plans were developed and implemented. During an interview on 07/02/25 at 3:25 p.m., the ADM said the MDS Coordinator was responsible for comprehensive care plans. He said he expected care areas triggered on the MDS to be care planned. He said he expected the nursing staff to implement the care plan interventions. He said the CNAs were responsible for documenting the resident's meal intakes. He said each meal should be documented in the facility's charting system. He said the information was important to make nutrition decisions. He said when the resident's meal intakes were not document they could experience weight loss and deterioration. He said the nursing staff should document the dressing changes as appropriate. He said the nursing staff documented the dressing changes, in the nurse's notes. He said the nurse's documentation was important to make sure physician orders were followed and implementing wound care timely. He said nursing management was responsible for ensuring the nursing staff developed and implemented comprehensive care plans. Record review of an undated facility's Comprehensive Care Planning indicated, .The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services.If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident.

Based on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 1 of 1 facilities reviewed for the environment. The facility failed to maintain an effective pest control program to ensure the facility was free of flies. This failure could place residents at risk for an unsanitary environment.Findings include:During an observation and interview on 6/30/25 at 7:56 a.m. revealed a live fly landed on Resident #24's breakfast. She said the flies were constantly bothering her and in her room. She said it bothered her she had to deal with the flies daily and while she was eating, they were a nuisance. During an observation on 6/30/25 at 12:35 p.m. it revealed during the lunch services 8 live flies were in the dining room and landed on 4 residents' food that were actively being eaten. During an observation on 6/30/25 at 1:00 p.m. revealed live flies in the conference room. Flies were in the conference room while the state surveyors worked throughout the day. During an anonymous interview, 5 anonymous residents stated there were issues with flies in the building and it had only gotten worse. They said there were flies in every room of the building and they were a nuisance when trying to eat. They said it bothered them there were so many flies in the building and felt it was unhygienic to have to swat flies every time they ate. During an interview on 7/2/25 at 9:02 a.m., the Maintenance Director said he was new to the building and did not know where the pest control log was. He said he had only worked for the facility for one week. He said he was still learning where everything was. He said that he was unaware of what was done in the past with pest control services.During an interview on 7/2/25 at 1:32 p.m., the Administrator said they contracted out pest control services for pests such as flies. He said they had a bad case of flies only recently. He said there was a potential risk towards residents who came into contact with pests such as flies. He said he would be the one responsible to ensure the facility was free of pests.Record review of the facility's pest control invoices revealed pest control services had come out to service the facility once monthly for the past 6 months. Pest control services noted flies were an issue and attempted to treat the issue. Record review of the facility's pest control log revealed the facility had a pest control log, but it was on notating when contracted pest control services came to provide service. The pest control log did not have any additional information such as instances of pests in the facility. Record review of the facility's Insect and Rodent Control policy, dated 2012, indicated The facility will maintain an effective pest control program in order to provide an insect and vermin free food service department.Arrangements are made with a reputable company for regular spraying for insects which includes rodent control when required.Facility will maintain appropriate screens, close fitting doors, properly sealed water/sewer pipes, structurally maintained walls, baseboards, etc. to prevent entrance access of insects and rodents.

Based on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 residents (Resident #13, Resident #23 and Resident #118) reviewed for medication storage. 1. The facility failed to securely store over the counter medications (hydrogen peroxide) for Resident #13.2. The facility failed to ensure the Treatment Nurse securely locked the treatment cart while providing care to Resident #23 on 7/1/2025 from 10:04 AM-10:48 AM. 3. The facility failed to ensure Vitamin D3 125 mcg (5000 IU) were stored and locked in accordance with currently accepted professional standards for Resident # 118 on 7/1/2025 at 7:45 AM and 7/1/2025 at 3:22 PM.These failures could place residents at risk for adverse reactions. Findings include:1. Record review of Resident #13's face sheet, dated 11/14/23, indicated a [AGE] year-old female and was admitted to the facility on [DATE]. Resident #13 had diagnoses which included Polyneuropathy (a condition where multiple peripheral nerves throughout the body are affected, causing weakness, numbness, and pain, often starting in the hands and feet), Scoliosis (a sideways curvature of the spine), and Muscle Weakness (a reduced ability of one or more muscles to generate force). Record review of Resident #13's Quarterly MDS, dated [DATE], indicated Resident #13 was understood and understood others. Resident #13 had a BIMS score of 15, which indicated Resident #13 was cognitively intact. During an observation and interview on 6/30/25 at 7:53 a.m., Resident #13 had a bottle of hydrogen peroxide in her room on her bedside nightstand. She said she used it to clean herself. She said she didn't remember where she got it from but had it for a long time. During an observation on 7/1/25 at 10:45 a.m., Resident #13 still had the bottle of hydrogen peroxide in her room. During an interview on 7/1/25 at 1:57 p.m., CNA M said hydrogen peroxide could not be kept in a resident's room. They said it should be stored in a safe location. They said residents could be placed at risk if they used the hydrogen peroxide in an inappropriate manner. During an interview on 7/2/25 at 1:18 p.m., the DON said residents should not keep hydrogen peroxide in their rooms. She said it should be stored with all other medications. She said she was unsure what the potential risk could be if a resident misused hydrogen peroxide. During an interview on 7/2/25 at 1:32 p.m., the Administrator said hydrogen peroxide was not an item residents could keep in their room. He said hydrogen peroxide should be kept with all other medications and stored properly. He said there was a potential for risk of harm if a resident misused hydrogen peroxide. 2. Record review of Resident #23's face sheet, dated 7/2/2025, indicated a [AGE] year-old female who was readmitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (most severe form of spastic cerebral palsy affecting all 4 limbs. It causes widespread muscle stiffness and poor motor control), dysphagia (difficulty swallowing), cognitive communication deficit (deficits refer to difficulties in communication that stem from disruptions in cognitive processes such as attention, memory and executive function), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), pressure ulcer of sacral region, stage 4, and pressure ulcer of right lower back, stage 4 (full-thickness tissue loss, exposing underlying structures such as muscle, tendon or bone). Record review of Resident #23's quarterly MDS, dated [DATE], revealed Resident #23 was sometimes understood and sometimes understood others. Resident #23 had a BIMS of 6, which indicated severe cognitive impairment. Resident #23 was dependent for all ADLs. Resident #23 had 3 total pressure ulcers with 2 Stage 3 pressure ulcers that were present upon admission or reentry. During an observation on 7/1/2025 at 10:04 AM-10:48 AM, revealed the treatment cart was left unlocked while the treatment nurse provided care to Resident # 23 for 44 minutes. During an observation and interview on 7/1/2025 at 10:48 AM, the Treatment Nurse said her cart should be locked. She said she did not lock her treatment cart because she was coming in and out of the room. Observation in drawer revealed #1 Q-Tip's, wound care supplies such as skin prep, band aids, drawer #2 wound care treatments such as Santyl, creams, ointments, and powders. Drawer #3 had wound cleansers such as vashe, wound cleanser, tape. The Treatment Nurse said she was distracted and left it unlocked. She said a visitor could get supplies out of the treatment cart and take something that could be contraindicated, skin issues or irritation. She said they would have to call poison control if a resident drank a cleanser. During an interview on 7/2/2025 at 10:31 AM, RN B said treatments and medication carts should be locked when a nurse stepped away from the cart. He said someone could take something out of the cart and could be injured depending on what they took out. He said there were medications on the treatment care that could cause skin irritation or get in their eyes. During an interview on 7/2/2025 at 12:17 PM, LVN L said whoever was assigned to the medication cart was responsible for ensuring it was locked. She said the treatment cart and medications should be locked unless in use. She said another resident or visitor could take medication or something from the cart that could cause an allergic reaction or death. During an interview on 7/2/2025 at 3:00 PM, the ADON said she expected the medication and treatment cart to be locked while unattended. She said a visitor, resident or any individual could get supplies or chemicals that could cause an allergic reaction. The ADON said the nurse/medication aide/treatment nurse were responsible for keeping the carts locked. During an interview on 7/2/2025 at 3:30 PM, the DON said she expected the nurses/medication aides and treatment nurse to keep carts locked while not in use. The DON said a resident would get something out they should not have and have a reaction. The DON said medication and treatment carts should be locked when not in eye site. During an interview on 7/2/2025 at 4:23 PM, the ADM said he expected the treatment cart was locked if not within eye site. He said there was a potential someone could grab something they should not have. He said there was a potential for misuse. He said there was a potential for everything. 3Record review of Resident #118's face sheet, dated 7/2/2025, revealed an [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #118 had diagnoses which included Type II Diabetes without complications (a group of diseases that affect how the body uses blood sugar), hypertension (occurs when the force of blood against your artery walls are consistently too high), and dissection of descending thoracis aorta (a serious condition in which a tear occurs in the inner layer of the body's main artery). Record review of Resident #118's admission MDS, dated [DATE], indicated he was able to make self-understood and usually understood others. Resident #118 had a BIMS of 4, which indicated severe cognitively impairment. Record review of Resident #118's care plan, revised on 6/16/2025, revealed the resident had impaired cognitive function or impaired thought processes with interventions to administer medications as ordered, communicate with the resident and family regarding the resident's capabilities and needs, and review medications and record possible causes of cognitive deficits such as new medication or dosage increased, anticholinergics, opioids, benzodiazepines and drug interactions. During observation and interview on 7/1/2025 at 7:45 AM, revealed Resident # 118 had Vitamin D3 on the bedside table. The resident said during medication pass, the supplement was his. Resident #118 did not say if staff were aware. During an observation and interview on 7/1/2025 at 3:22 PM, revealed vitamin D 3, 125 mcg (5000 IU) on Resident #118's bedside table. The resident said the staff were aware of the supplement in his room and he took the supplement with each meal. During an interview on 7/2/2025 at 10:31 AM, RN B said residents were not allowed to have medications or supplements in their room. He said if he observed medications on a bedside table, he would remove the medications or supplements. He said a resident could overdose or have a reaction if taken or someone else could took them. During an interview on 7/2/2025 at 12:17 PM, LVN L said no medications or supplements should be stored at a resident's bedside. She said the medications and supplements should be stored on the medication cart. LVN L said a resident or visitor could take medications or supplements that could cause an allergic reaction or overdose depending on what the medication or supplement was. During an interview on 7/2/2025 at 3:00 PM, the ADON said medications and supplements should be stored in the medication cart or in the storage room. The ADON said Resident #118 should not have Vitamin D3 stored on his bedside table. She said another resident could wander in his room and take them. She said a resident could choke or overdose. The ADON said the nurses were responsible for ensuring the medications were reconciled. During an interview on 7/2/2025 at 3:30 PM, the DON said she expected the nurses to reconcile medications brought into the facility. She said Resident #118 should not have Vitamin D3 on his bedside table. The DON said another resident or visitor could overdose on Vitamin D3. The DON said vitamin supplements should be sent home because the facility provided the supplements for Resident #118. During an interview on 7/2/2025 at 4:25 PM, the ADM said Resident #118 should not have medications or supplements at the bedside. He said the floor nurse was responsible for ensuring the medication or supplements were stored properly. He said a resident could have up to 12 IU for a while and did not elaborate on what it could cause. Record review of the facility's policy Medication Storage in the facility, dated 3-2025, stated: .Medications and biologicals are stored safely, securely, and properly following manufacturer's recommendations or those of the supplier. The medication supply only to license nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. Procedure 1. The Provider pharmacy dispenses medications in containers that meet legal requirements.2. Only licensed nurses, the Consultant Pharmacist, and those lawfully authorized to administer medications (e.g., medication aides) are allowed unsupervised access to medications.3. Orally administered medications are kept separate from externally used medication.7. Medications labeled for individual residents are stored separately.8. Potentially harmful substances (e.g., urine test reagent tablets, household poisons, cleaning supplies and disinfectants) are clearly identified and stored in locked area separate from medications. 15. The medication storage area should have accurate Poison control information posted with number to call in the event needed.

Based on interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 15 residents (Resident #49) reviewed for infection control. The facility failed to ensure Resident #49 was placed on contact isolation (implemented to prevent the spread of germs that are transmitted through direct or indirect contact with a person or objects they have touched) after her urinalysis with culture and sensitivity (UA examines urine for physical and chemical characteristics, while C&S identifies any bacterial infection and determines its sensitivity to antibiotics), dated 6/12/25, resulted on 06/16/25 with ESBL E. Coli. This failure could place residents at risk of exposure to cross-contamination and infections. Findings included: Record review of Resident #49's face sheet, dated 06/30/25, indicated an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #49 had diagnoses which included displaced posterior arch fracture of first cervical vertebra (a break in the bony ring of the first cervical vertebra, also known as the atlas), type 1 diabetes (is a chronic autoimmune disease where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas, leading to insufficient or no insulin production), and hypothyroidism (is when your thyroid gland doesn't make and release enough hormone into your bloodstream). Record review of Resident #49's admission MDS assessment, dated 04/07/25, indicated Resident #49 was usually understood and usually had the ability to understand others. Resident #49 had a BIMS score of 7, which indicated severe cognitive impairment. Resident #49 required partial/moderate assistance for toileting hygiene. Resident #49 had no episodes of continent voiding. Record review of Resident #49's care plan, dated 04/08/25, indicated Resident #49 had bladder incontinence. Interventions included monitor/document for signs and symptoms for urinary tract infection and incontinent care at least every 2 hours. Record review of Resident #49's consolidated physician order, dated 06/30/25, indicated:*UA with C&S per in and out catheter due to aggressive behavior. Order date 06/11/25.No active order for contact isolation or antibiotics reflected. Record review of Resident #49's Medication Administration Record, dated 06/01/25-06/30/25, indicated:*Nitrofurantoin Microcrystal Capsule 100mg, give 1 capsule by mouth every 6 hours for urinary tract infection for 7 days. First dose received 06/19/25 (6pm). Received 28 out of 28 doses. No order for contact isolation reflected. Record review of Resident #49's Urine culture and sensitivity results, received 06/12/25 and reported 06/16/25, indicated urine source, final report, Escherichia coli confirmed positive extended-spectrum beta- lactamase (ESBL). These organisms are uniformly resistant to all penicillin (antibiotic), cephalosporins (antibiotic) and aztreonam (antibiotic). E. Coli ESBL (are enzymes that break down certain antibiotics, rendering them ineffective against the bacteria producing the enzyme)-producing Escherichia coli (is a group of bacteria that can cause infections in your gut [GI tract], urinary tract and other parts of your body)). Record review of Resident #49's progress note, dated 06/02/25-07/03/25, indicated:*06/19/25 at 2:03 p.m., .Received UA results with C&S showing Ecoli and ESBL in urine. [NP K] notified.New order received for Nitrofurantoin.RP notified.LVN D.Resident #49's progress notes did not reflect contact isolation was initiated. Record review of Resident #49's Urinary Tract Infection Note 12hr, dated 06/21/25, indicated, .intervention.antibiotic and encourage fluids.precautions.is the resident on any transmission-based precautions.no.LVN L. Record review of Resident #49's Urinary Tract Infection Note 12hr, dated 06/28/25, indicated, .intervention.encourage fluids.precautions.is the resident on any transmission-based precautions.no.LVN D. During an attempted interview on 07/01/25 at 1:26 p.m., Resident #49 had disorganized thinking and was fixated on talking to a family member not in the room. Resident #49 was not interviewable. During an interview on 07/02/25 at 12:52 p.m., RN C said contact isolation precaution was initiated when a resident had ESBL in their urine. She said a physician order was received for contact isolation. She said the nurse did a SBAR (is a structured communication framework used to improve communication, particularly in healthcare settings) initially then charted every shift if a resident was on transmission-based precaution. She said the contact isolation precaution was needed for ESBL because the infection was resistant and contagious. She said when contact isolation was done and used then it could spread to other residents. During an interview on 07/02/25 at 2:28 p.m., the DON said contact isolation precaution was initiated when a resident had ESBL in their urine. She said the resident remained on contact isolation until the completion of their antibiotics. She said the nurses documented every shift, on an attachment connected to the nurse's note, if a resident was on isolation. She said the contact isolation was important, so the infection did not spread. She said she did not know about Resident #49's ESBL UTI. During an interview on 07/02/25 at 3:25 p.m., the ADM said a resident was placed on contact isolation for ESBL in the urine, unless it was self-contained. He said the floor nurses should ensure the residents with ESBL in the urine were placed on contact isolation. He said contact isolation was important, so the ESBL did not spread to the facility. Record review of the facility's Infection Control Plan: Overview, updated 03/2024, indicated, .the facility will establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection.decides what procedures, such as isolation, should be applied to an individual resident.determines that a resident needs isolation to prevent the spread of infection, the facility will isolate the resident.

Based on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care and failed to provide a copy of the summary of the baseline care plan for 1 (Resident #117) of 5 residents reviewed for baseline care plans. The facility failed to ensure Resident #117's baseline care plan include dialysis dependence (is a life-sustaining medical treatment that cleans the blood when the kidneys are unable to do so due to kidney failure). The facility failed to ensure Resident #117's baseline care plan include her diabetes mellitus (is a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels) diagnosis. The facility failed to provide Resident #117, a copy of the summary of the baseline care plan. These failures could place residents at risk of not receiving care and services to meet their needs.Findings included: Record review of Resident #117's face sheet dated 06/30/25 indicated Resident #117 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #117 had diagnoses including type 2 diabetes mellitus (is a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), congestive heart failure (the heart can't pump enough blood), end stage renal disease (is the final stage of chronic kidney disease where the kidneys are no longer able to adequately filter waste and excess fluid from the blood), and dependence on renal dialysis (is a treatment for people whose kidneys are failing). Resident #117 was her own responsible party. Record review of the MDS indicated Resident #117 was admitted to the facility less than 21 days ago. No MDS for Resident #117 was completed prior to exit. Record review of Resident #117's baseline care plan dated 06/19/25 did not reflect renal dialysis dependence or type 2 diabetes mellitus. Record review of Resident #117's Baseline Care Plan Acknowledgement form effective date 06/19/25 did not reflect a copy was provided to the resident or the resident representative nor a date and time provided. During an interview on 07/02/25 at 10:20 a.m., Resident #117 said she did not get a copy of her baseline care plan. She said she would have liked a copy of it. She said she checked her blood sugars at home. She said after admission, the facility did not check her blood sugars. She said she had to ask the facility to call the doctor to get an order to check her blood sugars. During an interview on 07/02/25 at 10:49 a.m., the ADON said, the admission nurse was responsible for the baseline care plans. She said she probably was Resident #117's admission nurse. She said the residents should receive a copy of the summary of the baseline care on admission. She said the admission nurse's note normally populated the care plan problems through the facility's charting system. She said Resident #117's dialysis dependence and diabetes diagnosis should have been on her baseline care plan. She said the baseline care plan was important because it was a structured, focused plan of care. She said the nursing staff used it as a guideline of care for the residents. She said it was the nursing administration responsibility to ensure the nursing staff included pertinent information on the baseline care plan and for the residents to receive a copy of it. During an interview on 07/02/25 at 12:52 p.m., RN C said, the admission nurse was responsible for adding important information to the resident's baseline care plan. She said Resident #117's diabetes diagnosis and dialysis dependence should have been on her baseline care plan. She said it was the admission nurse's responsibility to give the resident or responsible party a copy of the baseline care plan. She said the copy of the summary, of the baseline care plan should be given to the resident before the end of the shift. She said the baseline care plan was important to know where to start at. She said when the baseline care plan was not given to the resident, they could feel out of the loop in their care. She said important information could also be missed. During an interview on 07/02/25 at 2:28 p.m., the DON said, the charge nurses were responsible for baseline care plans. She said she expected Resident #117's diabetes diagnosis and dialysis dependence to be on her baseline care plan. She said it was a team effort to get a copy of the summary of the baseline care plan to the resident or responsible party. She said Resident #117 should have received a copy within 48 hours of admission. She said it was important for the resident or responsible party to receive a copy to know what to expect from the facility. She said the diabetes diagnosis and dialysis being on the baseline care plan was important because it was continuation of care. She said it was the nursing administration's responsibility to ensure the nursing staff included important diagnoses and treatments on the baseline care plan, and for the resident to receive a copy of it. During an interview on 07/02/25 at 3:25 p.m., the ADM said, the nurses were responsible for completing the baseline care plans. He said he expected a resident's baseline care plan to include a diabetes diagnosis and dialysis treatment. He said it was important to include those things on the baseline care plan for an accurate picture of the full healthcare plan. He said the nursing staff was responsible for giving the resident a copy of the baseline care plan to the responsible party within 48 hours. He said the nurse managers were responsible to ensure it was happening. Record review of an undated Base Line Care Plans policy indicated, .Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after admission; and to ensure the resident and representative, if applicable, are informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. This facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will reflect the resident's stated goals and objectives, and include interventions that address his or her current needs.It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident and resident representative, if applicable. This facility will provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to. The medical record will contain evidence that the summary was given to the resident and resident.

Based on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including injuries of unknown source were reported by staff immediately or not later than 24 hours for 2 of 2 residents reviewed for abuse and neglect. The facility failed to report verbal altercation between Resident #45 and Resident #53 during week of 6/23/2025. This failure could place residents at risk for abuse and neglect. Findings included:1. Record review of a face sheet dated 6/30/2025 revealed Resident #45 was [AGE] year-old female who was admitted on [DATE] with diagnoses which included nontraumatic intracerebral hemorrhage (a type of stroke that causes bleeding in the brain), protein-calorie malnutrition (a form of undernutrition is characterized by insufficient intake of protein and calories leading to various health issues), Type II Diabetes (occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin), cerebral infarction (a type of stroke that results from the interruption of blood supply to the brain), and hypertension (a common condition where the force of blood against the artery walls is consistently too high). Record review of a quarterly MDS dated [DATE] indicated Resident #45 was usually able to make self-understood and usually understood others. The MDS indicated a BIMS 10 indicating moderate cognitive impairment. The MDS indicated Resident #45 did not exhibit any physical or verbal behavioral symptoms during the look back period. Further review of MDS revealed Resident #45 was taking an antidepressant for depression. Record review of a care plan last revised on 1/29/2025 indicated Resident #45 required an antidepressant with goal to be free from discomfort or adverse reactions related to antidepressant therapy through the review date. Interventions included to administer antidepressant medication as ordered, monitor and document side effects and effectiveness. Additional interventions included monitoring, documenting and reporting to Physician as needed any ongoing signs and symptoms of depression, unaltered by antidepressant medications such as sadness, irritable, anger, never satisfied, crying, shame, worthlessness, guilt, suicidal ideations, negative mood/comments, slowed movement, agitation, disrupted sleep, fatigue, lethargy, does not enjoy usual activities, changes in cognition, changes in weight/appetite, fear of being alone or with others, unrealistic fears, attention seeking, concern with body functions, anxiety and constant reassurance. During an interview on 6/30/2025 at 11:19 AM, Resident #45 said a white staff member called her a N word and a B word. Resident stated the incident happened sometime last week. Resident said there were witnesses but could not provide names or description. Resident #45 said she was in the TV room with the incident occurred. Resident #45 had difficultly conveying details and information. During an interview on 6/30/2025 at 1:30 PM, discussed with survey team of Resident #45's report of a white staff member who she reported called her the N word and a B word and the story being difficult to follow. This surveyor notified the DON of Resident #45's report. The ADM was out of the building at the time of report and returned at approximately 1:35 PM. He said Resident #45's story was difficult to follow but would make a self-report and begin investigation. During an interview on 6/30/2025 at 2:44 PM, Resident #45's RP said she had been talking with Resident #45. RP said her Resident #45 had not reported any staff being disrespectful to her. RP said the staff call her with any changes with her mother and did not indicate any verbal altercation with staff or residents.2.Record review of Resident #53's face sheet dated 7/2/2025 revealed Resident #53 was a [AGE] year-old female who was admitted on [DATE] with diagnoses which included heart failure (occurs when the heart muscle does not pump blood as well), chronic venous hypertension with ulcer of bilateral lower extremities (when blood refluxes and starts to accumulate in the lower leg), lymphedema (tissue swelling caused by fluid buildup in the lymphatic system), Type II diabetes (occurs when the body becomes resistant to insulin or when the pancreas fails to produce enough insulin), hypertension (a common condition where the force of blood against the artery walls is consistently too high), chronic atrial fibrillation (am irregular and often rapid heart rhythm that can lead to stroke), and chronic obstructive pulmonary disease (a lung condition caused by damage to the airways that limit airway). Record review of a quarterly MDS dated [DATE] indicated Resident #53 was understood and usually understood others. The MDS indicated a BIMS 12 indicating moderate cognitive impairment. The MDS indicated Resident #53 did not exhibit any physical or verbal behavioral symptoms during the look back period. Further review of MDS revealed Resident #53 was taking antianxiety medication. Record review of a care plan last revised on 3/10/2025 indicated Resident #53 used antianxiety medication with goal to decrease episodes of signs and symptoms of anxiety. Interventions included to administer antianxiety medications as ordered by physician, monitor, document side effects and effectiveness, monitor and record occurrence for target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards others and document per facility protocol. During an interview on 7/2/2025 at 9:50 AM, MA G said she had not observed or overheard any staff members being ugly to Resident #45. She said she had overheard other residents being ugly to each other. MA G said she did hear the aftermath of a confrontation between Resident #45 and Resident #53. She said Resident #45 had been upset last Thursday or Friday. MA G said she was not sure what the staff did but she said she had provided Resident #45 with reassurance. MA G said she had asked Resident #45 what was wrong, and Resident #45 told her she had words with a friend. MA G said she did not report this to anyone. MA G said Resident #45 told her Resident #53 called her a B word. MA G said she did not hear or observe the occurrence and did not report it to staff. MA G said the two residents were loud with each other and other staff could hear what was going on. MA G could not recall the date or time of the incident. During an interview on 7/2/2025 at 10:31 AM, RN B said he heard the arguing between Resident #45 and Resident #53. He said Resident #53 said she did not use the N word. He said they were yelling back and forth. RN B said Resident #45 and Resident #53 were good friends. He said the residents separated themselves. RN B said he reported the incident to the DON and said he was not sure what she did. He said he thought something was written up about it yesterday. RN B said there had not been any changes in Resident #45 and Resident #53's mood. RN B said he reported the incident to the DON, family and NP but did not document in the computer about his report. RN B said resident to resident interactions could affect the residents depending on what was said. He said staff monitor behaviors every shift. He said the staff put the information in a 24-hour report and the staff usually send a request for psychiatric referral. RN B said if a resident's feelings were hurt, it could cause depression. During an interview on 7/2/2025 at 12:17 PM, LVN L said she heard it get loud in the dining/TV room next to the nurse's station. She said Resident #45 and Resident #53 were arguing with each other. LVN L said she did not recall all what was said. LVN L said Resident #53 was upset and down after the incident. LVN L said she thought RN B reported the incident to the DON and ADM. LVN L said she was in-serviced on Abuse, Neglect and Exploitation. During an interview on 7/2/2025 at 1:52 PM, Resident #53 said Resident #45 had a bad attitude toward her one-day last week. She said they were both calling each other the B word. She said Resident #45 had told someone that Resident #53 had called her the N word. Resident #53 said she would never do that, and her family would be upset with her if she did something like that. Resident #53 said the staff separated them. Resident #53 said she had been friends with Resident #45 for a long time. Resident #53 said it bothered her that her friend was upset with her. Resident #53 said she was not experiencing any adverse depression symptoms from the incident and she and Resident #45 were friends again. During an interview on 7/2/2025 at 3:00 PM, ADON said she was not aware of the incident between Resident #45 and Resident #53. She said she expected staff to report any resident-to-resident abuse allegations. She said not reporting could result in the resident becoming depressed or perpetrator could continue to abuse the other person. The ADON said the staff had been in-serviced on abuse, neglect, and exploitation. The ADON said the staff jump in and separate residents to keep them safe. She said the facility would complete a trauma informed care assessment at 24 hours, 48 hours, and 72 hours to identify if a resident needed additional services. She said the facility would report to the NP/family and it would be documented on an incident report.During an interview on 7/2/2025 at 3:30 PM, the DON said she did not know what had happened with Resident #45 and Resident #53. She said she was out of town last week and was not made aware of verbal altercation. DON said she expected the staff to report resident to resident altercations and should have been reported to the ADM. She said it was investigated after reported by this surveyor. The DON said the residents should have been separated and staff in-serviced on resident-to-resident altercations. The DON said the staff should make sure there were no injuries of physical or mental distress to the residents. During an interview on 7/2/2025 at 4:27 PM, the ADM said he was not aware of verbal altercation until reported by surveyor. Resident #45 had not told anyone about the incident. The ADM said he expected his staff to report to him immediately any allegations of abuse. He said the facility put both residents on Q 15-minute checks, referred to psychiatric services and kept the residents apart. The ADM said Resident #45 cussed at Resident #53 first. He said it was confirmed that Resident #45 was the perpetrator and not Resident #53. The ADM said Resident #45 had been more sensitive lately due to the loss of a friend. Review of a policy titled Abuse/Neglect revised on 3/29/2018 indicated, .The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart.Definition .1. Abuse: Abuse is the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. 3. Verbal abuse: Any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents, or within or within their hearing distance, regardless of their age, ability to comprehend, or disability.6. Mental Abuse: Includes but not limited to, humiliation, harassment, threats of punishment or deprivation. B. Training.The facility will train through orientation and on-going in-services in issues related to abuse/neglect prohibition practices regularly. C. Prevention.1. The facility will provide the residents, families, and staff an environment free from abuse and neglect. 2. The facility will post the Customer service hotline and the Abuse Preventionist of the facility.3. All reports of abuse or suspicion of abuse/neglect or potentially criminal behavior will be investigated as per facility policy. 4. The facility will be responsible to identify, correct, and intervene in situations of possible abuse/neglect.5. All employees will sign a statement acknowledging the receipt of information notifying the employee of 1.) possible criminal liability for failure to report abuses.E. Reporting.A. If the allegation involve abuse or result in serious bodily injury, the report is to be made within 2 hours of the allegation. B. If the allegation does not involve abuse or serious bodily injury, the report must be made within 24 hours of the allegation.

Based on observation, interview and record review, the facility failed to ensure residents were free from chemical restraints (the use of medication to restrict a person's movement or behavior) that were not required to treat the residents' medical symptoms for 2 of 5 residents (Resident #114 and Resident #49) reviewed for unnecessary medications. The facility failed to ensure Resident #114 had an appropriate diagnosis related to use of Escitalopram (anti-depressant medication; is used to treat depression and generalized anxiety disorder). The facility failed to ensure Resident #114 had an appropriate diagnosis related to use of Trazodone (anti-depressant medication; is used to treat major depressive disorder). The facility failed to ensure Resident #49 had an appropriate diagnosis related to use of Buspirone (anti-anxiety medication; is used to treat certain anxiety disorders or to relieve the symptoms of anxiety). The facility failed to ensure Resident #49 had an appropriate diagnosis related to use of Depakote (anti-convulsant; is used to treat various types of seizure disorders). The facility failed to document Resident #49's behaviors related to Buspirone. Then Depakote was added 06/11/25 and 06/20/25 without adequate indication of use. These failures could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications. Findings included: 1. Record review of Resident #114's face sheet date 07/01/25 indicated Resident #114 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #114 had diagnoses including displaced intertrochanteric fracture of right femur (is a break in the upper part of the thigh bone (femur), specifically in the area between the femoral neck and the lesser trochanter, where the broken pieces have shifted out of alignment), neuromuscular dysfunction of bladder (an injury or disease interrupts the electrical signals between your nervous system and bladder function), and dementia (is a general term for a decline in mental ability severe enough to interfere with daily life). Resident #114 did not have a diagnosis of depression (is a mood disorder characterized by persistent feelings of sadness and loss of interest in activities that were once enjoyable) listed. Record review of the MDS indicated Resident #114 was admitted to the facility less than 21 days ago. No MDS for Resident #114 was completed prior to exit. Record review of Resident #114's baseline care plan dated 06/19/25 did not reflect use of an anti-depressant or a psychotropic medication (any drug that affects behavior, mood, thoughts, or perception). Record review of Resident #114's consolidated physician order dated 06/30/25 indicated:*Escitalopram Oxalate Oral Tablet 20mg, give 1 tablet by mouth at bedtime for depression. Start date 06/19/25. *Trazodone Oral Tablet 50mg, give 1 tablet by mouth at bedtime for depression. Start date 06/19/25. Record review of Resident #114's Medication Administration Record dated 06/01/25-06/30/25 indicated:*Escitalopram Oxalate Oral Tablet 20mg, give 1 tablet by mouth at bedtime for depression. Resident #114 received 12 out of 12 scheduled doses.*Trazodone Oral Tablet 50mg, give 1 tablet by mouth at bedtime for depression. Resident #114 received 12 out of 12 scheduled doses. 2. Record review of Resident #49's face sheet dated 06/30/25 indicated Resident #49 was an 84-years-old female admitted to the facility on [DATE]. Resident #49 had diagnoses including displaced posterior arch fracture of first cervical vertebra (a break in the bony ring of the first cervical vertebra, also known as the atlas), type 1 diabetes (is a chronic autoimmune disease where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas, leading to insufficient or no insulin production), hypothyroidism (is when your thyroid gland doesn't make and release enough hormone into your bloodstream), atherosclerotic heart disease (is a hardening of your arteries from plaque building up gradually inside them), and history of falling. Resident #49 did not have diagnoses of Dementia (is a general term for a decline in mental ability severe enough to interfere with daily life) or anxiety disorder (is a mental health condition characterized by excessive, uncontrollable, and often irrational worry about everyday events or activities). Record review of Resident #49's admission MDS assessment dated [DATE] indicated Resident #49 was usually understood and usually had the ability to understand others. Resident #49 had a BIMS score of 7 which indicated severe cognitive impairment. Resident #49 did not display any behavioral symptoms. Record review of Resident #49's care plan dated 06/12/25 indicated Resident #49 used anti-anxiety medications. Interventions included give anti-anxiety medications ordered by physician. Monitor /document side effects and effectiveness. Monitor/record of for target behavior symptoms and document per facility protocol. Record review of Resident #49's consolidated physician order dated 06/30/25 indicated:*Buspirone Oral Tablet 5mg, give 1 tablet by mouth three times a day for anxiety. Start date 04/10/25. Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 1 capsule by mouth two times a day for dementia with anxiety. Start date 06/11/25.*Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 1 capsule by mouth one time a day for dementia with anxiety. Start date 06/21/25.*Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 2 capsules by mouth at bedtime for dementia with anxiety (2 tabs to equal 250mg). Start date 06/20/25. Record review of Resident #49's Medication Administration Record dated 06/01/25-06/30/25 indicated:*Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 1 capsule by mouth two times a day for dementia with anxiety. Discontinued date 06/20/25. Resident #49 received 18 out of 18 doses. *Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 1 capsule by mouth one time a day for dementia with anxiety. Resident #49 received 10 out of 10 doses. *Depakote Sprinkles Oral Capsule Delayed Release 125mg, give 2 capsules by mouth at bedtime for dementia with anxiety (2 tabs to equal 250mg). Resident #49 received 9 out of 9 doses. *Buspirone Oral Tablet 5mg, give 1 tablet by mouth three times a day for anxiety. Resident #49 received 88 out of 90 doses. Resident #49 had one Yes for behavior observed on 06/11/25 at 1:00 p.m. dose. Record review of Resident #49's progress notes dated 06/02/25-07/03/25 indicated:*06/11/25 at 8:30 a.m. by LVN D, indicated, .physical behavior.in the activity room.agitated, cognitive impairment, wanders.initial treatment/new orders.ua with c&s, Depakote 125mg by mouth twice a day for dementia with anxiety.*06/11/25 at 3:08 p.m. by MA G, indicated behavior observed. *06/19/25 at 2:03 p.m. by LVN D, indicated, Received UA results with C&S showing Ecoli (Escherichia coli) and ESBL (Extended-Spectrum Beta-Lactamase) in urine.UTI (Urinary Tract Infection)*06/20/25 at 6:42 p.m. by LVN D, indicated, .Resident [#49] continues to have anxious behaviors.Yells out constantly 'help me, help me, what do I do.'.NP K notified.new order received to give Depakote Sprinkles 125mg 1 by mouth every day and 250mg at bedtime. Record review of Resident #49's ADL task sheet-Behaviors dated June 2025 indicated: *6am-2pm: 06/02/25, 06/03/25, 06/07/25, 06/08/25, 06/11/25, 06/12/25, 06/13/25, 06/18/25, 06/19/25, 06/24/25, and 06/27/25Resident #49 had eighteen shifts (6am-2pm) with no behaviors observed by a CNAs. *2pm-10pm: 06/01/25, 06/02/25, 06/04/25, 06/05/25, 06/06/25, 06/09/25 x2, 06/16/25, and 06/21/25.Resident #49 had twenty shifts (2pm-10pm) with no behaviors observed by a CNAs. *10pm-6am: 06/03/25, 06/05/25, 06/06/25, 06/11/25, 06/16/25, 06/19/25, and 06/22/25 x2.Resident #49 had twenty-one shifts (10pm-6am) with no behaviors observed by a CNAs. Unable to determine what type of behaviors Resident #49 displayed from the ADL task sheet. During an observation on 06/30/25 at 8:39 a.m., Resident #49 was asleep in her room. During an observation on 07/01/25 at 1:26 p.m., Resident #49 was in her room with the door closed. Resident #49 was sitting up in her bed hollering out for a family member. Resident #49's family member also resided in the facility. I opened Resident #49's door. Resident #49 calmed after door opened. During an observation on 07/01/25 at 2:08 p.m., Resident #49 was sitting up in her bed hollering out for a family member. Resident #49 calmed by CNA A. CNA A explained Resident #49's family member would visit after his nap. During an observation on 07/01/25 at 3:40 p.m., Resident #49 was asleep in her room. During an interview on 07/02/25 at 10:49 a.m., the ADON said, the nurses and MDS Coordinator should ensure the residents had an appropriate diagnosis for the ordered medication. She said it should be done during the drug review. She said she did not know about Resident #114's medications. She said the behavior and side effect monitoring for medications were done by the CNAs. She said the behaviors and side effect monitoring was done every shift. She said the CNAs documented on the ADL task sheet in the facility's charting system. She said Resident #49 was seen by psych service 06/05/25. She said the practitioner had given Resident #49 the diagnoses of Dementia and generalized anxiety. She said the facility had not added the diagnoses to Resident #49's diagnoses list. She said the MDS Coordinator was responsible for adding diagnoses to the resident's charts. She said she expected the nurses to document the resident's behaviors. She said the behaviors needed to be documented on the medication administration record if an order had an attached assessment and the progress note. She said Resident #49 had behaviors documented by the CNAs with interventions in the facility's charting system. She said when documentation did not support a medication changes, it could appear as if it was an unnecessary medication. She said a resident could experience a decline in ADLs if they received an unnecessary medication. She said that was not the case with Resident #49. She said Resident #49 had a decrease in appetite and NP K was notified. She said Resident #49 has refused to get out of bed lately. She said the nursing administration was responsible for ensuring the residents did not receive unnecessary medication. On 07/02/25 at 12:48 p.m., attempted to contact LVN D by phone. Contact was unsuccessful and unable to leave a message. During an interview on 07/02/25 at 12:52 p.m., RN C said the admission nurse should ensure the residents had an appropriate diagnosis for an ordered medication. She said if a medication had a diagnosis not listed in the resident's medical record, she would ask the MDS Coordinator for assistance or call the medical doctor for a diagnosis. She said the nurse should document the resident's behaviors on the medication or treatment administration record. She said if a resident was seen by psych services and new diagnoses were given, then the MDS Coordinator was responsible for adding them to the resident's chart. She said if a medication was ordered to treat behaviors not documented then it could be considered a chemical restraint. She said the medication could over sedate the resident. She said the resident could experience a decline in ADLs. During an interview on 07/02/25 at 2:28 p.m., the DON said, the admit nurse or the nurse taking the order should make sure the resident had a diagnosis for the ordered medication. She said it was important to have an appropriate diagnosis to know what the medication was treating and see if it was the right treatment for the diagnosis. She said the MDS Coordinator added diagnoses to the resident's medical record. She said it was important to add the diagnosis to the medical diagnoses list so there was a continuation of care. She said the CNAs monitored the resident's behaviors. She said the nurses documented the residents' behaviors and side effects monitoring on the weekly summary and with medication monitoring on the medication administration record. She said if a resident did not have an appropriate diagnosis or documented behavior with the medication monitoring, it could be considered an unnecessary medication. She said an unnecessary medication could make a resident drowsy. She said Resident #49 had not had a decline in her ADLs. She said the DON and ADON were responsible for ensuring the resident did not receive an unnecessary medication. During an interview on 07/02/25 at 3:25 p.m., the ADM said nursing management were responsible to make sure the residents had a diagnosis for the ordered medication. He said the CNAs and the nurses were responsible for charting behaviors. He said the nurses were responsible for adding diagnoses to the resident's diagnosis list. He said appropriate diagnoses and documented behaviors prevented poly pharmacy (is an umbrella term to describe the simultaneous use of multiple medicines by a patient for their conditions). He said nursing management was responsible for this process. He said they should monitor this process through the system in place, in the facility's charting system. Record review of a facility's Psychotropic Medication policy dated 02/12/2025 indicated, .The facility will ensure that the resident is free from chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms.Residents should only receive psychotropic medications when other nonpharmacological interventions are clinically contraindicated. A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: Anti-psychotic; Anti-depressant; Anti-anxiety.Other medications not classified in the four categories above can also affect brain activity and should not be used as a substitution for another psychotropic medication listed above, unless prescribed with a documented clinical indication consistent with accepted clinical standards of practice.Categories of medications which affect brain activity include antihistamines, anti-cholinergic medications and central nervous system agents used to treat conditions such as seizures, mood disorders, pseudobulbar affect, and muscle spasms or stiffness.The requirements pertaining to psychotropic medications in this policy apply to these types of medications when their documented use appears to be a substitution for another psychotropic medication rather than for the original or approved indication. Psychotropic medications will be administered to a resident if adequate indications for use are present.'Adequate Indications for use' refers to the identified, documented clinical rationale for administering a medication that is based upon an assessment of the resident's condition and therapeutic goals, and after any other treatments have been deemed clinically contraindicated. Diagnoses alone do not necessarily warrant the use of a psychotropic medication. Psychotropic medications may be indicated if. behavioral symptoms present a danger to the resident or others. expressions or indications of distress that are significant distress to the resident. if not clinically contraindicated, multiple non-pharmacological approaches have been attempted, but did not relieve the medical symptoms which are presenting a danger or significant distress; and/or. Each resident's drug regimen will be free from unnecessary drugs. An unnecessary drug is any drug when used. Without adequate indications for its use. Based on a comprehensive assessment of a resident, the facility will ensure that. Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record. Residents in this facility have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms. If a medication has a sedating or subduing effect on a resident and is not being administered to treat a medical symptom, the medication is acting as a chemical restraint and should not be used. The indications for initiating, maintaining, or discontinuing medication(s), as well as the use of non-pharmacological approaches are determined by evaluating the resident's physical, behavioral, mental, and psychosocial signs and symptoms to identify and rule out any underlying medical conditions, including the assessment of relative benefits and risks, and the preferences and goals for treatment. The use of non-pharmacological approaches will be attempted, unless clinically contraindicated, to minimize the need for psychotropic medications, use the lowest possible dose, or discontinue the medications. The resident's medical record will include documentation of this evaluation and the rationale for chosen treatment options.The facility will ensure that the residents' behaviors (expressions or indications of distress), which may have prompted the initiation or change in a psychotropic medication, are not: Upsetting to the resident or a safety concern to the resident or others . Due to a medical condition or problem (e.g., pain, fluid or electrolyte imbalance, infection, obstipation, medication side effect or polypharmacy) that can be expected to improve or resolve as the underlying condition is treated or the offending medication(s) are discontinued. Due to environmental stressors alone (e.g., alteration in the resident's customary location or daily routine, unfamiliar care provider, hunger or thirst, excessive noise for that individual, inadequate or inappropriate staff response), that can be addressed to improve the symptoms or maintain safety; and. Due to psychological stressors alone (e.g., loneliness, taunting, abuse), anxiety or fear stemming from misunderstanding related to his or her cognitive impairment.Monitoring and accurate documentation of the resident's response to any psychotropic medication treatment (such as, lab results, vital signs, progress notes, behavior flow sheets, medication administration records and the consultant pharmacist's drug regimen review) is essential to evaluate the ongoing effectiveness, benefits as well as risks of non-pharmacological approaches and psychotropic medications. Nurse Aides - will be cued and have the ability to report potential adverse medication effects and behaviors via Point Click Care (PCC) Point of Care Module every shift and should if observed, verbally report the observation to a licensed nurse. Any adverse effect or behavior will trigger an alert in PCC for nursing administration review. Licensed Nurses - should continually monitor for medication adverse effects and behaviors and report to the physician or their designee as needed. The Weekly Summary in Point Click Care will also cue the nurse to document and report any behaviors or medication adverse effects to the physician or their designee. Any adverse effect or behavior will trigger an alert in PCC for nursing administration review. Review of Urinary Tract Infection Induced Delirium in Elderly Patients: A Systematic Review (2022) https://pmc.ncbi.nlm.nih.gov/articles/PMC9827929/, was accessed on 07/09/25 which indicated, .UTI manifests more commonly and specifically for this age group as delirium (is a sudden and temporary state of confusion and altered awareness) or confusion in the absence of a fever. The etiology of delirium is multifactorial; the most common triggering factor of delirium is found to be an infection in 49.5% of cases (mainly due to UTIs). Delirium can be explained as a syndrome of severe neuropsychiatric disturbance resulting in a change in awareness, cognition, and fluctuation in attention in a short span due to medical conditions that cannot be described by already existing neurocognitive disorders. Escherichia coli (E. coli) is the predominant pathogen found in 33% of UTI cases. delirium is a common presentation of UTI in the elderly.

Based on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 3 of 15 residents (Resident #29, Resident #114, and Resident #117) reviewed for resident rights. 1. The facility failed to ensure Resident #29 was assisted with eating in a dignified manner on 06/30/2025. 2. The facility failed to ensure on 06/30/25, Resident #114 did not have to wait from 10:34 a.m. until 11:05 a.m., to be provided incontinence care. 3. The facility failed to ensure on 07/01/25, Resident #117 was provided incontinence care when requested. Resident #117 reported to the ADON and MA G she needed to be changed. These failures could place residents at risk for decreased quality of life, quality of care, and self-esteem. Findings included: 1. Record review of Resident #29's face sheet dated 07/02/25 indicated Resident #29 was a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #29 had diagnoses including Huntington's disease (is a hereditary neurodegenerative disorder that causes the progressive breakdown of nerve cells in the brain) and dysphagia (difficulty swallowing). Record review of Resident #29's quarterly MDS dated [DATE] indicated Resident #29 was sometimes understood and sometimes had the ability to understand others. Resident #29 was unable to complete the BIMS interview. Resident #29 had short-and-long term memory recall problem. Resident #29 had moderately impaired cognitive skills for daily decision making. Resident #29 had functional limitation in range of motion on both sides to her upper and lower extremities. Resident #29 required substantial/maximal assistance for eating. Record review of Resident #29's care plan dated 02/01/24 indicated Resident #29 had an ADL self-care performance deficit due to disease process, limited mobility, limited range of motion, and musculoskeletal impairment. Intervention included eating required staff assistance times one. During an observation on 06/30/25 at 7:40 a.m., Resident #29 was at the nursing station in a Geri chair, sitting sideways. Resident #29 was making unintelligible noises. CNA H was standing feeding Resident #29 breakfast. During an interview on 07/01/25 at 1:22 p.m., CNA H said she fed Resident #29 on 06/30/25. She said she fed Resident #29 at the nursing station. She said staff normally sat down to feed the residents. She said she was not going to pull up a chair at the nursing station to feed Resident #29 though. She said it was important to sit down when feeding a resident because it was a better angle and due to dignity. She said a resident could choke if they were fed at the wrong angle. She said she had received training on how to properly feed a resident. 2. Record review of Resident #114's face sheet date 07/01/25 indicated Resident #114 was an [AGE] year-old male admitted to the facility on [DATE]. Resident #114 had diagnoses including displaced intertrochanteric fracture of right femur (is a break in the upper part of the thigh bone (femur), specifically in the area between the femoral neck and the lesser trochanter, where the broken pieces have shifted out of alignment), neuromuscular dysfunction of bladder (an injury or disease interrupts the electrical signals between your nervous system and bladder function), and dementia (is a general term for a decline in mental ability severe enough to interfere with daily life). Record review of the MDS indicated Resident #114 was admitted to the facility less than 21 days ago. No MDS for Resident #114 was completed prior to exit. Record review of Resident #114's baseline care dated 06/19/25 indicated Resident #114 had a hip fracture. Interventions included anticipate and meet needs. Be sure call light within reach and respond promptly to all requests for assistance. During an observation on 06/30/25 at 10:34 a.m., Resident #114's call light outside his door came on. Resident #114 started banging on something and hollering out. During an observation on 06/30/25 at 11:00 a.m., Resident #114's call light outside his door was still on. During an observation on 06/30/25 at 11:05 a.m., Resident #114's call light was off and a staff member could be heard in his room changing him. During an interview and observation on 07/01/25 at 9:26 a.m., Resident #114 was lying in his bed. Resident #114 said he had to wait a while yesterday for help. He said he had needed to be changed yesterday. 3. Record review of Resident #117 face sheet dated 06/30/25 indicated Resident #117 was a [AGE] year-old female admitted to the facility on [DATE]. Resident #117 had diagnoses including type 2 diabetes mellitus (is a chronic condition characterized by the body's inability to properly use insulin, leading to high blood sugar levels), congestive heart failure (the heart can't pump enough blood), end stage renal disease (is the final stage of chronic kidney disease where the kidneys are no longer able to adequately filter waste and excess fluid from the blood), and dependence on renal dialysis (is a treatment for people whose kidneys are failing). Record review of the MDS indicated Resident #117 was admitted to the facility less than 21 days ago. No MDS for Resident #117 was completed prior to exit. Record review of Resident #117's care plan dated 06/19/25 indicated Resident #117 had an ADL self-care performance deficit. Intervention included toilet use required staff times two for assistance. During an interview on 07/01/25 at 11:57 a.m., Resident #117 was sitting up in her bed. She said she had asked the staff to change her at 7:30 a.m. She said she had still not been changed. She said it was a bowel movement because she did not urinate because of dialysis. She said she had told MA G. She said MA G said she could not change her because she was passing meds. She said someone earlier had answered the call light and told her they would get someone. She said no one came back to change her. She said she had not gotten back on the light since she told MA G. During an interview on 07/01/25 at 1:07 p.m., MA G said Resident #117 had mentioned to her around 8:00 a.m. that she needed to be changed. She said she told Resident #117 she could not be changed because the breakfast trays were out. She said the ADON had previously been in Resident #117's room before her and answered the call light. She said normally, if the meal trays were not out and a resident asked to be changed, she told a CNA. She said she also assumed the ADON had told the assigned CNA that Resident #117 needed to be changed. She said a resident should not have a delay in being changed because it could cause bed sores. She said it could also make the resident uncomfortable and feel degraded. During an interview on 07/01/25 at 1:54 p.m., the ADON said, she told CNA A after breakfast that Resident #117 needed to be changed. She said she answered Resident #117's call light sometime after breakfast. She said Resident #117 told her, she needed to be changed. She said the breakfast trays may have still been on the hall. She said she expected the CNAs to change the residents as soon as possible or within 15-20 minutes if they were busy with something else. She said if the CNAs were too busy, she and the DON would even change the residents. She said Resident #117 not being changed until 11:58 a.m. was not an appropriate timeframe for incontinent care. She said Resident #117 waiting a long time to be changed was a dignity issue and could cause skin issues. She said the charge nurses should ensure the CNAs changed the residents timely. She said she should have followed up to make sure Resident #117 had gotten changed earlier. During an interview on 07/01/25 at 2:09 p.m., CNA A said the DON told her at 12:00 p.m. that Resident #117 needed to be changed. She said she checked on Resident #117 at 9 a.m. and she said she was fine. She said Resident #117 told her she needed to be up after lunch for therapy. She said when she changed her before lunch, her bowel movement did not look like it had been there since 7:30 a.m. During an interview on 07/02/25 at 12:52 p.m., RN C said the staff should be sitting down and at eye level when feeding a resident. She said it was important to be at eye level to observe for choking and to make the resident not feel rushed. She said it could also make the resident feel childlike or looked down upon when staff stood over them. She said the charge nurses should ensure the CNAs were not standing when feeding the residents. She said the residents' call light should be answered within 5 minutes. She said waiting 30 minutes for assistance was a long time. She said when the residents had to wait a long time for assistance, it placed them at risk for falls, skin breakdown, and getting upset. During an interview on 07/02/25 at 2:07 p.m., CNA J said the residents' call lights should be answered as soon as possible. She said it was important not to wait a long time to answer the call light because it could be an emergency. She said when the residents had to wait a long time to be changed or get their call light answered, they could hurt themselves or feel ignored. During an interview on 07/02/25 at 2:28 p.m., the DON said she expected the nursing staff to sit down when feeding the residents. She said it was a dignity issue when standing while feeding a resident. She said it could make the resident feel forced fed. She said it was the nursing administration's responsibility to ensure the nursing staff were sitting when feeding a resident. She said the call light response time depended on what everyone was doing. She said if a resident had to wait an extended period, they could experience skin irritation. During an interview on 07/02/25 at 3:25 p.m., the ADM said the nursing staff should be sitting down when feeding a resident. He said sitting down promoted dignity to the resident. He said he did not know how it would make the resident feel, but it was a dignity issue. He said whoever was feeding the resident, was responsible for ensuring they sat down to feed the resident. He said the residents should be rounded on every 2 hours by the CNAs. He said he expected the call lights to be answered as quickly as possible. He said 30 mins to get assistance seemed liked a long time. He said timely assistance prevented skin breakdown. Record review on CNA H's, undated Proficiency Audit, indicated .Feeding the dependent resident.satisfactory. Record review of a facility's Resident Rights policy revised 11/28/16 indicated, .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

Based observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for 1 of 2 residents (Resident #114) reviewed for catheter care. 1. The facility failed to ensure Resident #114 had an order for his indwelling catheter (a flexible tube inserted into the bladder to drain urine). 2. The facility failed to ensure Resident #114's indwelling catheter was care planned. 3. The facility failed to ensure Resident #114's catheter bag (connected to the indwelling catheter and collects urine) was not touching the floor on 07/01/25. These failures could place residents at risk of not receiving continuity of catheter care and urinary tract infection (is a bacterial infection that affects any part of the urinary system). Findings included: Record review of Resident #114's face sheet, dated 07/01/25, indicated an [AGE] year-old male who was admitted to the facility on [DATE]. Resident #114 had diagnoses which included displaced intertrochanteric fracture of right femur (is a break in the upper part of the thigh bone [femur], specifically in the area between the femoral neck and the lesser trochanter, where the broken pieces have shifted out of alignment), neuromuscular dysfunction of bladder (an injury or disease interrupts the electrical signals between your nervous system and bladder function), and dementia (is a general term for a decline in mental ability severe enough to interfere with daily life). Record review of Resident #114's admission MDS indicated Resident #114 was admitted to the facility less than 21 days ago. There was no MDS for Resident #114 completed prior to exit.Record review of Resident #114's baseline care plan, dated 06/19/25, did not reflect a care area for an indwelling catheter. Record review of Resident #114's consolidated physician order, dated 06/30/25, did not reflect an order for an indwelling catheter or supplemental care orders. During an interview and observation on 06/30/25 at 10:12 a.m., Resident #114 was lying in bed. He said he had a catheter. The catheter tubing or catheter bag could not be visualized. During an interview and observation on 07/01/25 at 9:26 a.m., Resident #114 was lying in bed. Resident #114's catheter bag was visualized on the side of his bed. The bottom portion of Resident #114's catheter bag was touching the floor. During an interview on 07/02/25 at 10:49 a.m., the ADON said the nurses were responsible for getting an order for the resident's indwelling catheters. She said the order was important, so the nurses knew why the residents had it. She said she thought she was Resident #114's admission nurse. She said the nurses were responsible for adding the resident's indwelling catheter to the care plan. She said she did not know why Resident #114's indwelling catheter was not on his care plan because she added it to his admission nurse note. She said the information entered on the admission nurse note triggered care areas on the baseline care plan. She said Resident #114's indwelling catheter should be on his care plan to know how to care for it. She said Resident #114's catheter bag should not be touching the floor due to infection control. She said the nursing administration should ensure this process was happening. During an interview on 07/02/25 at 12:52 p.m., RN C said the admitting nurse should ensure the residents had an order for an indwelling catheter and supplemental care orders. She said the nurses should also ensure the residents had the appropriate diagnosis for the indwelling catheter. She said the admitting nurses should ensure the resident's indwelling catheter was care planned. She said the resident's catheter bag should not touch the floor. She said that placed the resident at risk for an infection. During an interview on 07/02/25 at 2:28 p.m., the DON said the admission nurse was responsible for ensuring a resident, who was admitted with an indwelling catheter, had an order for it. She said it was important for continuation of care. She said the DON and ADON should ensure the admission nurse received orders for it. She said the IDT was responsible for ensuring a resident's indwelling catheter was care planned. Resident #114's indwelling catheter should have been care planned because it was continuation of care. She said it was the IDT responsibility to ensure the team was care planning care areas. She said Resident #114's indwelling catheter should not touch the floor. She said it should not touch the floor due to infection control. She said whoever put Resident #114 in the bed should have ensured the catheter was not touching the floor. During an interview on 07/02/25 at 3:25 p.m., the ADM said nursing management was responsible for obtaining physician orders for an indwelling catheter. He said a physician order was important to make sure the indwelling catheter was appropriate. He said the nursing staff was responsible for ensuring a resident's indwelling catheter bag did not touch the floor. He said it reduced the risk of infection. Record review of the facility's, undated, Catheter Care policy indicated, .Be sure the catheter tubing and drainage bag are kept off the floor. Review the resident's plan of care daily for changes.

Based on observations, interviews, and records review, the facility failed to ensure the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #23) of 5 residents reviewed for pressure ulcers/injuries.1.The facility failed to perform complete and accurate wound care per Physician orders for Resident # 23's right ischium (a paired bone forming the lower and back part of the hip bone) on 7/1/2025 at 10:04 AM.2. The facility failed to ensure Resident #23's air mattress was dialed to the correct weight of 154.2 pounds. This failure could affect residents with skin injures and wounds and could place the residents at risk for worsening of pressure ulcers. The findings were: 1. Review of Resident #23's face sheet dated 7/2/2025 revealed a [AGE] year-old female readmitted to the facility on [DATE]. Her diagnoses included spastic quadriplegic cerebral palsy (most severe form of spastic cerebral palsy affecting all 4 limbs. It causes widespread muscle stiffness and poor motor control), dysphagia (difficulty swallowing), cognitive communication deficit (deficits refer to difficulties in communication that stem from disruptions in cognitive processes such as attention, memory and executive function), epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures caused by abnormal electrical activity in the brain), pressure ulcer of sacral region, stage 4, and pressure ulcer of right lower back, stage 4 (full-thickness tissue loss, exposing underlying structures such as muscle, tendon or bone). Review of Resident #23's quarterly MDS dated [DATE] revealed Resident #23 was sometimes understood and sometimes understood others. Resident #23 had a BIMS of 6 indicating severe cognitive impairment and was dependent for all ADL's. MDS revealed Resident #23 had 3 total pressure ulcers with 2 Stage 3 pressure ulcers that were present upon admission or reentry. Review of Resident #23's care plan initiated on 6/12/2025 revealed Resident #23 had potential for pressure ulcer development due to decreased mobility and the need for ADL assistance. Care plan revealed Stage 3 Pressure Injury to right ischium, left buttock and left inferior buttock. The goal was for Resident #23 to have intact skin, free from redness, blisters, or discoloration through review date. The interventions were to administer medications as ordered, administer treatments as ordered and monitor the effectiveness, replace loose or missing dressing as needed, assess, record and monitor wound healing at least weekly, do not massage over bony prominences and use mild cleansers for peri care and washing, and educate the resident, family and caregivers as to causes of skin breakdown including transfer, positioning requirements, importance of taking care during ambulating, mobility, good nutrition and frequent repositioning. Further care plan revealed Resident #23 needed assistance to turn, reposition at least every 2 hours, required the use of an air loss mattress and use of lifting device, draw sheet to reduce friction. Review of Resident #23's progress note dated 6/17/2025 revealed Stage 3 pressure ulcer of the right ischium full thickness (Site #22) with an area of deep fissure. The Wound Care Provider indicated the wound measured 3.1 cm x 1.5 cm x 0.1 cm with moderate amount of serous exudate[VT2] (a fluid that escapes from blood vessels into surrounding tissues, often due to inflammation or injury). Wound care orders indicated to cleanse wound with soapy water washes daily and as needed if saturated, soiled or dislodged, apply anasept (a topical solution of sodium hypochlorite that fights bacteria and prevents and treats infection caused by cuts, ulcers, or surgery) and cover with foam silicone border and faced with silver applied daily and as needed if saturated, soiled or dislodged. Peri-wound treatment ordered to apply house barrier cream daily as needed. Review of physician order listing report revised on 6/19/2025 indicated orders to right ischium (within crevice) (Site #22) was to be cleansed with soap and water, pat dry, apply collagen sheet, apply calcium alginate and cover with a dry dressing one time daily for wound healing and as needed for if dressing was soiled or dislodged. Review of progress note from Wound Care Specialty group dated 6/24/2025 indicated Resident #23 was not seen due to non-wound related hospitalization. Review of progress note from wound care specialty group dated 7/1/2025 indicated wound care orders to right ischium (Site #22) as followed: Cleanse with soap and water, apply anasept three times weekly and as needed, cover with collagen sheet and within fissure and cover with foam silicone border gauze faced with silver daily and as needed. Review of order summary report dated 7/2/2025 indicated wound care to right ischium (within crevice) start date 6/18/2025 to cleanse with soap and water, pat dry, apply collagen sheet, calcium alginate and cover with dry dressing one time daily for wound healing and as needed for if dressing was soiled or dislodged. During observation on 7/1/2025 at 10:04 AM, Treatment nurse was observed providing treatment following Wound Care Provider visit. The Treatment Nurse was observed wearing proper PPE while providing care. Nurse did not cleanse the wound to right ischium (Site #22) with soap and water. The Treatment Nurse was observed adding collagen powder to honey that was in a medication cup that was prepared on her bedside table. She mixed the collagen and honey with a sterile Q-tip, opened a 4x4 collagen sheet and placed honey/collagen mixture on the collagen sheet and then opened a calcium alginate and placed over the collagen sheet and applied to Resident #23's right ischium then secured with a white border gauze dressing. The Treatment nurse then placed a 4x4 sheet of calcium alginate folded twice and placed in the fissure area and covered with a white border gauze to secure. No anasept or house barrier cream was used during observation of care of right ischium (Site #22). During an interview on 7/1/2025 at 10:48 AM, the Treatment Nurse said she cleansed the wound with soap and water while the Physician was in the room. The nurse said she should have cleansed prior to providing the treatment and after Resident #23 rolled back on her bed. The Treatment Nurse said the Physician told her to continue with same orders. The Treatment Nurse said the Physician instructed her to pack the fissure lightly with collagen and she said she folded the dressing and lightly pressed it in the fissure after folding it twice. The dressing used in the fissure was a calcium alginate dressing and not collagen as ordered. During a telephone interview on 7/1/25 at 1:14 p.m. with the Wound Care Physician, she said the orders she has written were not followed . The Physician said the facility was on their 3rd Treatment Nurse. The Physician said Medi honey would not hurt the wound and it would increase the viscosity (a measure of a fluids resistance to deformation or flow) of the wound. She said that would not be her first choice for Resident #23's wound. The Physician said she was aware, and it had been reported that wound care orders were not followed. The Physician said she was told her orders were recommendations. The Physician said the ADON was the one who took care of the orders. The Physician said she would come to the facility and there would be new verbal orders from the Attending Physician. The Physician said calcium alginate folded and placed in the fissure wound area could cause unnecessary pressure and said you must be careful how you place it. She said Resident #23 had intermittent fungal infections. She said ideally, Resident #23 should be positioned and the wound bed cleansed and then apply the dressing. She said she was aware of the facility not having the foam dressing with silver and she did agree to the border gauze. She said the silver was an antimicrobial (an agent that kills microorganisms) for residents with greater concerns and it decreased the surface bacterial load. The Physician said the anasept (a topical solution of sodium hypochlorite that fights bacteria and prevents or treats infections) was a cleanser that was less strength than a Dakin's (a dilute sodium hypochlorite solution commonly known as bleach) solution. Physician said the resident's low air loss bed setting should be set on about 160 lbs. She said if the setting was at 200 lbs., it would be like not having an air loss mattress and would be much harder. During a telephone interview on 7/1/2025 at 1:49 PM, the Nurse Practitioner said she was familiar with Resident #23. She said Resident #23 was followed by a wound care specialty group who visited the facility. She said she expected the nurses to follow the treatment orders that the wound care specialist recommended. She said the nurses were responsible for putting in the orders and following them. During an interview on 7/1/2025 at 3:04 PM, the ADON said they review the orders from the wound care specialty group and the Attending Physician signs off on the orders. The ADON said the Physician does not change every order. During a telephone interview on 7/2/2025 at 9:06 AM, the Attending Physician returned call and said he comes to the facility 1 x monthly. He said he does assess residents with wounds when he makes his rounds. The Attending Physician said he would want the nurses following the orders recommended by the wound care specialty physician. He said he only gets involved if there was an issue. The Attending Physician said his NP would call if there was an issue. He said the ADON does not usually call him to change an order. He said he expects the orders to be followed. He said the staff do not call him because he follows the wound care specialty orders. During an interview on 7/2/2025 at 10:31 AM, RN B said he puts in the orders for referrals on his residents who have wounds. He said the Wound Care Specialty group come to the facility every Tuesday. He said he would place the orders in the EMR (electronic medical record) when the progress note with orders was completed. He said normally, it was the charge nurse who puts in the orders. He said sometimes the DON and ADON puts in the orders. He said they put the new orders on the 24-hour report. RN B said he puts the orders in on the same day or at least by end of his shift. RN B said he had not seen any incorrect wound care when he has performed care and removed dressings. He said if wound care was not performed correctly, it could cause the wound to deteriorate. He said the wound care orders should be updated on the care plan. RN B said if you put something on the wound that was not ordered, it could get worse. He said bedridden residents with wounds should be turned every 2 hours. He said not repositioning a resident could also cause the wounds to get worse. During an interview on 7/2/2025 at 12:17 PM, LVN L said she cares for Resident #23. She said she was assisting during the treatment observation. She said the Treatment Nurse had only been at the facility for a couple of weeks. LVN L said based on how the wound looked yesterday, she felt the wound was improving. LVN L said the Treatment Nurse was responsible for putting the orders in the computer. She said they all work together. LVN B said the wound care orders for Resident #23 were being followed. LVN L said the ADON put in the orders. She said the orders in the EMR and the Wound Care Progress Note with orders should match the treatment note. LVN L said the facility had plenty of wound care supplies. LVN L said the NP and Attending Physician like to be notified of any changes. She said the Attending Physician signs all the orders. LVN L said she was not sure if the Attending Physician reviewed the wound care specialty groups notes or checked the orders. During an interview on 7/2/2025 at 3:00 PM, the ADON said residents who were not on hospice with wounds were referred to wound care specialty group. ADON said it was a standing order for residents to be referred to wound care. She said the NP would provide orders until the residents were seen by Wound Care Specialist. The ADON said the facility had been without a wound care nurse since February. The ADON said she checks along with the DON and charge nurse, progress treatment notes from the wound care specialty group. The ADON said sometimes the orders are changed when they notify the NP or Physician. ADON said the NP ordered Calcium Alginate for Resident #23's wound because of the drainage. The ADON said she was pretty sure she spoke with the NP. The ADON said I think the Attending Physician signs the orders. The ADON said the order the Treatment Nurse completed was not ordered. The ADON said collagen should have been placed in the crevice, not calcium alginate. The ADON said the wound could decline if the wrong care orders were followed. The ADON said she was not sure if the wound care orders were updated on the care plan. The ADON said the facility did have a medical director and said the orders were called to the NP and she could make the determination or provide a different order. During an interview on 7/2/2025 at 3:30 PM, the DON said the facility clarified wound care orders with the Attending Physician and the NP was notified of the orders from wound care specialty group. The DON said the facility runs the orders by the NP to see if she wants to continue the orders. The DON said the specialty wound care provider requires multiple clarifications to her orders. The DON said she had spoken with the facility's regional person to discuss changing provider companies. She said the ADM would have to provide the wound care specialty group some sort of notice. The DON said she did expect the nurse to follow the orders that were written in the Treatment Administration Record. During an interview on 7/2/2025 at 4:27 PM, the ADM said he expected the nurses to follow orders written and expected care to be performed per orders in the computer. He said not providing the correct wound care would not fully treat that diagnosis and there was a potential, it could affect the wound. He said there was a potential for anything. The ADM said the wound care provider said the wound was the best it had looked. He said the wound care provider was supposed to know what they are doing. The ADM said the wound care specialty group would have 3 different orders for the wounds and said the facility frequently had to consult with the NP. The ADM said the nurse manager had spoken with the wound care specialist provider about the inconsistency of the orders. The ADM said the facility had requested other providers, but it had not happened. The ADM said the facility is currently seeking another wound care group. 2. Record Review of Resident #23's Care Plan dated 6/12/2025 reflected Resident #23 had a stage 3 pressure ulcer to her right ischium/Crevice, left buttock, and left inferior buttock. Interventions included the resident required repositioning every two hours. Resident #23's care plan also stated the resident used an air mattress. Record review of Resident #23's chart revealed her weight was 154.2 pounds. During an observation on 6/30/25 at 8:22 a.m. Resident #23 was observed lying in bed on a low air loss mattress. Resident #23's low air loss mattress was set to 200 pounds. Resident #23 was unable to verbalize if she was in discomfort. During an observation on 7/1/25 at 8:34 a.m. Resident #23's air loss mattress was set to 200 pounds. Resident #23 was unable to verbalize if she was in discomfort. During an observation on 7/1/25 at 12:26 p.m., Resident #23's left hip was positioned on a wedge. During an observation on 7/1/25 at 2:03 p.m., Resident #23's left hip was positioned on a wedge. During an observation on 7/1/25 at 3:43 p.m., Resident #23's left hip was positioned on a wedge During an observation on 7/2/25 at 8:06 a.m., Resident #23's left hip was positioned on a wedge. During an observation on 7/2/25 at 10:06 a.m., Resident #23's left hip was positioned on a wedge. During an interview on 7/2/25 at 10:35 a.m. the ADON said that a resident that had wounds and was on a low air loss mattress would need the setting on the low air loss mattress set to the resident's weight. If a resident weighed 150 pounds and the setting was at 200 pounds it would be ineffective for that resident. She said that it would not serve its purpose to support healing. During an interview on 7/2/25 at 1:18 p.m., the DON said that if a resident weighs 150 pounds and had a pressure relieving mattress, the setting of the mattress should be at 150 pounds and not at 200 pounds. She said the purpose of the pressure relieving mattress was to off load pressure and promote healing. She said that Resident #23 should be repositioned every two hours as her care plan stated. She said both of these could prevent the healing of pressure wounds. She said that nursing staff was responsible to ensure that Resident #23's wound care was in an environment to promote healing. During an interview on 7/2/25 at 1:32 p.m., the Administrator said that pressure relieving mattresses should have been set at the appropriate weight setting to promote healing. He said that nursing staff were responsible to ensure that the setting is correct. He said that residents that require repositioning should be repositioned by nursing staff as ordered. He said that residents could be placed at risk of not healing if their wound care orders were not followed. Review of a Pressure Injury: Prevention, Assessment and Treatment policy dated 5/5/25 indicated, Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. Review of a Pressure Injury: Prevention, Assessment and Treatment policy dated 5/5/25 indicated, Nursing personnel will continually aim to maintain the skin integrity, tone, turgor, and circulation to prevent breakdown, injury, and infection. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure. Determine resident's skin tolerance to pressure and develop a turning schedule; residents should be turned every two (2) hours or more often if necessary and notify the Treatment Nurse/designee of any potential problems. Review of a Pressure Injury: Prevention, assessment and Treatment policy dated 5/5/2025 indicated, Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the Physician of pressure sore and obtain and follow orders as directed by the physician. Review of Physician Services Agreement dated December 7, 2015, indicated Provider responsibilities.Perform services in accordance with accepted professional standards. (a) Perform patient consultations and follow-up care. (b) Develop care plans in partnership with facility staff. (c) Take part in Quality Assurance programs. Facility Responsibilities: .provide a dedicated nurse to round with the clinician.inform the resident's primary care provider of the clinician's recommendations within 24.Discuss recommendations/care plans with the assigned clinician on the day of grand rounds.Respect the physician-patient relationship and allow the clinician, once consulted, to provide services and procedures to such resident as determined to be medically necessary. Review of Dressing change checklist in-serviced on 6/6/2025 indicated, Verifies orders for wound treatment from TARS and chart.Preparation for dressing change.wash hands, gathers dressing change supplies for each wound according to orders for wound care.prepares a clean/dry surface for dressing change supplies.provides disposal container for soiled dressings.appropriately locks treatment cart when left unattended. Review of Skin Integrity Management dated 2003 indicated, If a wound is noted, perform an assessment, and initiate a treatment plan as soon as possible.3. Wound care should be performed as ordered by physician.

Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 15 residents (Resident #49) reviewed for ADL (activities of daily living) care. The facility failed to ensure Resident #49 received her scheduled bed baths on 06/10/25, 06/14/25, 06/17/25, 06/24/25, 06/26/25, and 06/28/25. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in feelings of poor self-esteem, decrease socialization and skin breakdown. Findings included: Record review of Resident #49's face sheet dated 06/30/25 indicated Resident #49 was an [AGE] year-old female admitted to the facility on [DATE]. Resident #49 had diagnoses including displaced posterior arch fracture of first cervical vertebra (a break in the bony ring of the first cervical vertebra, also known as the atlas), type 1 diabetes (is a chronic autoimmune disease where the body's immune system mistakenly attacks and destroys insulin-producing cells in the pancreas, leading to insufficient or no insulin production), hypothyroidism (is when your thyroid gland doesn't make and release enough hormone into your bloodstream), atherosclerotic heart disease (is a hardening of your arteries from plaque building up gradually inside them), and history of falling. Record review of Resident #49's admission MDS assessment dated [DATE] indicated Resident #49 was usually understood and usually had the ability to understand others. Resident #49 had a BIMS score of 7 which indicated severe cognitive impairment. Resident #49 did not reject care. Resident #49 required substantial/maximal assistance for shower/bathe self. Record review of Resident #49's care dated 04/08/25 indicated Resident #49 had an ADL self-care performance deficit. Intervention included bathing required staff assistance times one person. Record review of Resident #49's ADL task sheet dated June 2025 indicated:*Bathing- 06/03/25, 06/05/25, 06/07/25, 06/12/25, 06/19/25, and 06/21/25. Resident #49 received 6 out of 12 scheduled bathing's. During an observation on 06/30/25 at 8:39 a.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49 hair was in disarray and oily. During an observation on 06/30/25 at 9:41 a.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49 hair was in disarray and oily. During an observation on 07/01/25 at 12:05 p.m., Resident #49 was asleep in the bed with a neck brace on. Resident #49 hair was in disarray and oily. During an interview on 07/02/25 at 10:49 a.m., the ADON said the CNAs were responsible for providing the residents' showers and bed baths. She said the residents should receive their bed bath or shower on scheduled days and when requested. She said the showers and/or bed baths were documented in the facility's charting system under ADL bathing. She said bathing was important for the residents' dignity and skin. She said the charge nurses should ensure the CNAs were providing the residents scheduled and requested baths. She said the charge nurses should be reviewing the resident's ADL bathing sheets to ensure bathing was being done. During an interview on 07/02/25 at 12:52 p.m., RN C said the CNAs were responsible for showering the residents. She said the CNAs charted in the facility's charting system. She said the residents should receive showers or bed baths on shower days, as needed, or when requested. She said it was the residents' rights and on the residents' care plans to receive showers or bed baths. She said the bed baths or showers were important to prevent skin breakdown. She said the charge nurses were responsible for ensuring the CNAs gave the residents scheduled bed baths and showers. During an interview on 07/02/25 at 2:07 p.m., CNA J said, the CNAs were responsible for bathing the residents. She said the residents were bathed every other day and scheduled by beds. She said the CNAs charted the bathing in the facility's charting system. She said bathing was important to prevent body odor. She said the charge nurses were responsible for monitoring the CNAs on bathing the residents. During an interview on 07/02/25 at 2:28 p.m., the DON said the CNAs were responsible for bathing the residents. She said the showers or bed baths should be given as scheduled or when requested. She said the CNAs charted the bathing in the facility's charting system. She said bathing the resident was important for dignity, decrease skin irritation, and body odor. She said the charge nurses were responsible for ensuring the CNAs provided the residents their bed baths and showers. During an interview on 07/02/25 at 3:25 p.m., the ADM said the CNAs were responsible for bed baths and showers. He said the CNAs charted in the facility's charting system. He said the residents were scheduled on Monday, Wednesday, Friday or Tuesday, Thursday, Saturday or as needed. He said the scheduled bathing was important to prevent infections. He said the charge nurses should ensure the CNAs provided scheduled and as needed bathing. He said the charge nurses should monitor this process through the facility's systems in place. Record review of an undated Bath, Tub/Shower policy indicated, .Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin, and body odor to promote comfort, cleanliness, circulation, and relaxation. The frequency and type of bathing depends on resident preference, skin condition, tolerance and energy level. the aging skin can be maintained by bathing every two days or with partial bathing as needed.

Based on interview and record review the facility failed to ensure residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Resident #117) reviewed for dialysis services. 1. The facility failed to ensure the pre-dialysis assessments were completed and documented on Resident #117's dialysis communication forms on 06/25/23. 2. The facility failed to ensure the post-dialysis assessments were completed and documented on Resident #117's dialysis communication forms on 06/23/25 and 06/25/23. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of Resident #117's face sheet, dated 06/30/25, indicated Resident #117 was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #117 had diagnoses which included type 2 diabetes mellitus (is a chronic condition where the body either doesn't produce enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels), congestive heart failure (the heart can't pump enough blood), end stage renal disease (is the final stage of chronic kidney disease where the kidneys are no longer able to adequately filter waste and excess fluid from the blood), and dependence on renal dialysis (is a treatment for people whose kidneys are failing). Record review of Resident #117's consolidated physician orders, dated 06/30/25, indicated:*06/19/25 Dialysis Days Monday-Wednesday-Friday*06/20/25 Dialysis every Monday-Wednesday-Friday Record review of Resident #117's admission MDS indicated Resident #117 was admitted to the facility less than 21 days ago. No MDS for Resident #117 was completed prior to exit. Record review of Resident #117's baseline care plan, dated 06/19/25, did not reflect renal dialysis dependence. Record review of Resident #117's Dialysis Center Communication Form, dated 06/23/25, indicated pre-dialysis and dialysis information completed. The post-dialysis section was blank. Record review of Resident #117's Dialysis Center Communication Form, dated 06/25/25, indicated dialysis information completed. The pre- and post-dialysis section was blank. During an interview on 06/30/25 at 10:45 a.m., Resident #117 said she went to dialysis on Mondays, Wednesdays, and Fridays. She said she left at 3:30 p.m. or 4 p.m. She said she got back around 7 p.m. or 7:30 p.m. She said the staff did not always take her vital signs when she got back from dialysis. During an interview on 07/02/25 at 12:52 p.m., RN C said the charge nurses were responsible for filling out the pre and post dialysis section on the communication form. She said the pre dialysis information was important so the dialysis center knew how the resident was before Resident #117 arrived. She said the post dialysis was important so the facility knew how Resident #117 tolerated dialysis. She said when the vital signs were not done or placed on the dialysis communication form, issues could be missed or overlooked. During an interview on 07/02/25 at 2:13 p.m., RN B said he took care of Resident #117 on one of her dialysis's days. He said the facility had a dialysis book. He said the dialysis resident's communication forms went into to book. He said the facility's charge nurses were responsible for the pre-and-post dialysis section on the dialysis communication form. He said the pre dialysis section was important, so the dialysis center knew what to monitor for. He said the post dialysis section was important to see if there were any big fluctuation to monitor for afterwards. He said the dialysis form was a communication tool. He said issues could arise if the form was not completed. He said the DON and ADON were responsible for ensuring the nursing staff were completing the dialysis communication forms. During an interview in 07/02/25 at 2:28 p.m., the DON said she expected the charge nurses to complete the pre-and-post section of the dialysis communication form. She said the sections were important to know how the resident was before and after dialysis. She said when the sections were not done, the communication between the facility and the dialysis center was not happening. She said the DON and ADON were responsible for ensuring the nursing staff completed the dialysis communication form. During an interview on 07/02/25 at 3:25 p.m., the ADM said the charge nurses were responsible for completing the dialysis communication forms. He said the dialysis communication form was important for continuum of care. He said also the communication between the facility, and the dialysis center. He said the charge nurses were responsible for ensuring the charge nurses were completing the dialysis communication form. Record review of the facility's Dialysis policy, revised 11/2013, indicated .The facility will establish baseline information from the dialysis center with will monitor changes from the baseline. The facility will monitor departures and returns from the dialysis center. The facility will document the resident's vital signs, general appearance, orientation, and additional baseline data as needed. The resident's clinical record will be documented with this information. The date and time of the resident's return to the facility will be recorded by the nurse.

Based on observation, interview and record review the facility failed to ensure that the medication error rate of five percent or greater. The facility had a medication error rate of 6.06%, based on two errors out of 33 opportunities, which involved 2 of 5 residents (Resident #116 and Resident #118) and 1 of 2 staff reviewed for medication administration. 1. The facility failed to administer Resident # 116's correct dose of Famotidine 40 mg 1 tablet by mouth daily for gastric reflux (occurs when stomach acid flows back into the esophagus) on 7/1/2025 at 7:46 AM. 2. The facility failed to administer Resident #118's correct dose of Pepcid (Famotidine) 20 mg 2 tablets to be administered two times daily related to gastro-esophageal reflux disease without esophagitis (occurs when stomach acid flows back into the esophagus) on 7/1/2025 at 7:34 AM. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings include:1. Record review of Resident #116's face sheet, dated 7/2/2025, indicated an [AGE] year-old female, who was admitted to the facility on [DATE]. Resident #116 had diagnoses which included cerebral infarction (An ischemic stroke occurs when the blood supply to part of the brain is blocked or reduced), anemia ( a condition of low red blood cells or hemoglobin that can cause fatigue, shortness of breath and pale skin), mild cognitive impairment (a condition characterized by a slight decline in cognitive abilities such as memory and the ability to complete complex task), hypertension (a common condition where the force of the blood against the artery walls is consistently too high), and dysphagia (difficulty swallowing). Record review of Resident #116's entry MDS indicated Resident #116 was admitted to the facility less than 21 days ago. There was no MDS for Resident #116 completed prior to exit. Record review of Resident #116's order summary report, dated 6/25/2025, indicated Resident #116 was prescribed Famotidine 40 mg 1 tablet by mouth daily for gastric reflux (occurs when stomach acid flows back into the esophagus). During observation of medication pass on 7/1/2025 at 7:46 AM, MA G administered Famotidine 20 mg 1 tablet to Resident #116. 2. Record review of Resident #118's face sheet, dated 7/2/2025, indicated an [AGE] year-old male, who was admitted to the facility on [DATE]. Resident #118 had diagnoses which included protein-calorie malnutrition, Type II Diabetes without complications (a group of diseases that affect how the body uses blood sugar), hypertension (occurs when the force of blood against your artery walls are consistently too high), and dissection of descending thoracis aorta (a serious condition in which a tear occurs in the inner layer of the body's main artery).Record review of Resident #118's admission MDS, dated [DATE], indicated he was able to make self-understood and usually understood others. Resident #118 had a BIMS of 4, which indicated severe cognitive impairment. Record review of Resident #118's care plan, revised on 6/16/2025, indicated the resident had impaired cognitive function or impaired thought processes with interventions to administer medications as ordered, communicate with the resident and family regarding resident's capabilities and needs, and review medications and record possible causes of cognitive deficits such as new medication or dosage increased, anticholinergics, opioids, benzodiazepines, and drug interactions. Record review of Resident #118's order summary report, dated 7/2/2025, indicated Resident #118 was ordered Pepcid (Famotidine) 20 mg 2 tablets to be administered two times daily related to gastro-esophageal reflux disease without esophagitis (occurs when stomach acid flows back into the esophagus). During observation of medication pass on 7/1/2025 at 7:34 AM, MA G administered Famotidine 20 mg 1 tablet to Resident #118. During an interview and observation of the medication cart on 7/2/2025 at 12:43 PM, MA G said she did not realize she administered the incorrect dose of Famotidine to Resident #116 or Resident #118.During an interview on 7/2/2025 at 3:30 PM, the DON said she expected MA to administer medications as prescribed. She said she expected the MA to notify the nurse if the medication did not match the MAR (medication administration record) with the dose or number of tablets. The DON said the charge nurse was responsible for ensuring the MA administered medications as prescribed and the dose was correct. During an interview on 7/2/2025 at 4:27 PM, the ADM said he expected the MA to administer the medication as ordered. He said if the correct dose was not administered it would not be treating the diagnosis to its fullest extent. Record review of the facility's policy Medication Administration and General Guidelines, dated 3-2025, indicated, Medications are administered as prescribed, in accordance with State Regulations using good nursing principles and practices and only by persons legally authorized to do so.Procedure.1. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications.2. Medications are administered in accordance with written orders.3. The person administering medications adheres to Universal precautions, using proper hand hygiene.4. Residents are allowed to self-administer medications when specifically authorized by attending physician.16. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label.Adheres to the 6 Rights of Medication Administration: 1. Right dose. 2. Right route 3. Right Resident 4. Right Medication 5. Right time 6. Right documentation.Returns the medication to locked storage area.

Based on interviews and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 3 Residents (Resident #1) reviewed for pressure injuries. The facility failed to implement interventions to prevent Resident #1 from developing a facility acquired unstageable pressure ulcer. The facility failed to identify and treat an unstageable pressure ulcer to Resident #1's sacral area. The facility failed to identify residents who are at risk for pressure ulcer development. An IJ was identified on 2/18/2025 at 3:49 PM. The IJ template was provided to the facility on [DATE] at 3:49 PM. While the IJ was removed on 2/19/2025 at 3:30 PM, the facility remained out of compliance at a severity of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk for new development or worsening of existing pressure injuries, pain, decreased quality of life, and hospitalization . Findings included: Record review of the face sheet dated 2/13/2025 indicated Resident #1 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), paranoid schizophrenia (hallucinations, delusions, and disorganized speech), contractures of left and right knee (permanent shortening or tightening of muscles, tendons, ligaments, or skin), dementia (decline in memory, thinking, reasoning, and problem solving). Record review of the quarterly MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #1 required was completely dependent on staff for all activities of daily living. The MDS indicated Resident #1 was dependent with transfers. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #1 did not have any unhealed pressure ulcers/injuries. Record review of the discharge MDS dated [DATE] indicated Resident #1 did not have any unhealed pressure ulcers/injuries. Record review of the care plan last revised on 4/25/2023 indicated Resident #1 had the potential for pressure ulcer development due to decreased mobility, incontinence and decreased cognition with interventions that included: 1. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 2. Follow facility policies/protocols for the prevention/treatment of skin breakdown. 3. Incontinent care after each episode and apply moisture barrier. 4. Inform the resident/family/caregivers of any new skin breakdown . 6. Notify the nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care . Record review of Braden Scale for Predicting Pressure Sore Risk dated 8/4/2023 revealed Resident #1's score of 9 which indicated Resident #1 was at high risk for developing a pressure sore. Record review of Weekly Skin Assessment-V 5 dated 7/19/2024 indicated Resident #1 did not have any moisture associated skin damage or pressure, venous, arterial or diabetic ulcers. Record review of Resident #1's clinical record from 7/19/2024 to 7/25/2024 revealed Resident #1 did not have a documented skin assessment with wound measurements or description of sacral wound. Record review of the physician orders dated 7/25/2024 indicated Resident #1 had the following orders: 1. Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed with an order date of 7/23/2024 and an order start date of 7/23/2024. 2. Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement one time a day with an order date of 7/23/2024 and an order start date of 7/24/2024. Record review of the treatment administration record for July 2024 indicated Resident #1 had the following treatment: Non pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement completed on the following dates: 1. 7/23/24 completed by the ADON 2. 7/24/24 completed by the ADON and RN B 3. 7/25/24 completed by LVN A. During an interview on 2/19/2025 at 3:15 PM the ADON said she provided wound care to Resident #1 prior to her being discharged to the hospital. She said Resident #1 had moisture associated skin damage to her buttocks, but she did not see an unstageable to her sacral area. She said she must have forgotten to sign off on the treatment administration record and that was why on 7/26/2024 she signed the treatment administration record for the dates of 7/23/2024 and 7/24/2024. She said yes it had been discussed in the morning meeting that Resident #1's Responsible party called and said Resident #1 would not be returning to the facility due to Resident #1 receiving the wound while at the facility. Record review of Resident #1's nursing progress note completed on 7/26/2024 as a Late Entry for 7/22/2024 indicated the CNA C informed LVN A that she was doing care on Resident #1 and wanted LVN A to look at Resident #1's bottom. CNA C helped LVN A to assess Resident #1's bottom by rolling her on her side. Resident #1 was noted to have MASD (moisture associated skin damage) to bilateral buttocks. LVN A documented to wound bed was pink in color with no drainage noted. LVN A documented there were no signs or symptoms of infection noted. LVN A documented the edges were attached. LVN A documented he consulted the NP (nurse practitioner) about Resident #1's buttocks with recommendation noted till treatment nurse could assess. LVN A documented cleanse area with soap and water, pat dry and apply clean dry dressing. LVN A documented treatment was initiated at that time. LVN A documented he would advise treatment nurse of findings to follow up on NP (nurse practitioner) recommendation. LVN A did not document that he notified any family or family representative of the new skin breakdown or new order received from the NP (nurse practitioner). Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:32 PM the ADON documented on 7/23/2024 at 1:31 PM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Treatment Administered Daily. Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:33 PM the ADON documented on 7/23/2024 at 2:32 PM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. PRN Administration was: Effective. Dressing was changed after bath. Record review of Resident #1's nursing progress note completed on 7/23/2024 at 10:57 PM, LVN D documented she called residents family member to give update on resident with no answer. Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:34 PM the ADON documented on 7/24/2024 at 10:33 AM Non pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Wound care provided by charge nurse and ADON. Record review of CTNR Shower Sheets dated 7/24/2024 signed by CNA E indicated Resident #1 had an open area to her buttocks area. Record review of Resident #1's nursing progress note completed on 7/25/2024 at 9:49 AM LVN A documented on 7/25/2024 at 9:35 AM Resident this morning presenting with possible AMS [altered mental status]. Resident partially opening her eyes to verbal and tactile stimulus. Resident nonverbal this morning. Residents tardive dyskinesia [chronic involuntary movement disorder] is generally very active and this morning it is very mild. Resident will not squeeze my fingers on command. No facial Dropping noted. Generalized weakness noted with her extremities and trunk. Rapid shallow breathing noted . Talked to NP [nurse practitioner] and informed of residents current status with order to send to [hospital emergency room ] for eval and tx [treatment] due to AMS [altered mental status]. [family member] .notified and ok with transfer to [hospital emergency room ]. 911 initiated and resident was transported per stretcher via ambulance to [hospital emergency room ] at this time. All paperwork sent with EMS [emergency medical services] for them and ER [emergency room ]. Record review of eTransfer Form-V6 dated 7/25/2024 indicated Resident #1 was sent to the hospital for the following: Resident partially opening her eyes to verbal and tactile stimulus. Non verbal. No facial dropping noted. Generalized weakness. Will not squeeze my hands. Rapid shallow breathing noted. Sending out for possible AMS [altered mental status]. The form indicated Resident #1 had special treatments and precautions of: contact infection control precautions for an infection of the buttocks. The form indicated Resident #1 was on EBP (enhanced barrier precautions). The form indicated Resident #1 was receiving wound treatment with a current wound to the buttocks. Record review of hospital Disclosure and Consent Medical Care and Surgical Procedure dated 8/4/2024 at 12:16 PM for wound debridement indicated Resident #1's condition was infected wound of the sacral area measuring 3cm x 3.5cm x2cm that was classified as unstageable. Record review of a picture taken at the hospital dated 7/25/2024 at 7:48 PM indicated Resident #1 had an unstageable wound to the sacral area measuring 3cm x 3.5cm x 2cm. Record review of the hospital paperwork dated 7/25/2024 indicated admitting diagnosess of metabolic encephalopathy and pressure injury of sacral region, unstageable. During a phone interview on 2/12/2025 at 12:25pm with Resident #1's RP (responsible party), she said neither she nor her family members had been notified that Resident #1 had developed any kind of skin problem. She said it was not until she got to the hospital emergency room that she was notified that Resident #1 had an unstageable wound to her sacral (upper buttocks) area. She said when she saw the area she took pictures and the wound was horrible. She said she made the decision in the hospital emergency room that Resident #1 would not be returning to the facility due to the unstageable wound she had received while at the facility. During an interview on 2/12/2025 at 3:22 PM the ADON said she was not aware of Resident #1 had a wound until the day on 7/22/2024 when LVN A was notified by CNA C. She said when she saw Resident #1's bottom there was old scar tissue in the sacral area but what she treated was on the actual buttocks area and that was red with spots of blood like a scrape. She said she never saw a wound on the sacrum. She said it was possible that the necrotic tissue could have been mistaken for moisture associated skin damage tissue. She said the treatment nurse was responsible for doing weekly skin assessments. During an interview on 2/13/2025 at 10:30 AM the DON said she went and looked at Resident #1 buttocks when a CNA asked her to look at the resident because she needed her to put a new dressing on the resident. She said the wound was on the right buttock and seemed like someone had pulled her across the bed and caused the top layer of skin to come off. She said she cleaned the wound and applied calcium alginate to the wound. She said she did not remember anything being on Resident #1's left buttock. She said she only remembered applying a dressing to one buttock on the right side. She said she did not remember seeing anything to Resident #1's sacral area. She said Resident #1 had scarring due to old pressure areas that had healed. The DON said she thought the area to the sacrum could have been missed due to Resident #1's skin coloration. She said she had a conversation with one of Resident #1's family member about the resident being in the bed by 5pm and the family member wanted her up all day and she explained that it was not good for Resident #1. She said she never staged or classified Resident #1's wound. She said she would have classified the wound as MASD (moisture associated skin damage). The DON said a skin notification worksheet was not completed and did not know why. She said the treatment nurse goes to the nurse's station and looked at the 24-hour report to check for any new skin issues every day when she came to work. The DON said if a new skin area was identified and the treatment nurse was not available, the residents charge nurse was to notify the MD and put a treatment in place, if the treatment nurse was at the facility, then it was her responsibility. She said the nurse that initially identified a new wound was supposed to do measurements, but it was not done on Resident #1. She said once the treatment nurse assessed the wound then she was supposed to measure the wound, then the resident should have been seen by the Wound Care Doctor weekly and the Wound Care Doctor would then do the measurements weekly. The DON said she made rounds with the Wound Care Doctor if the treatment nurse was not at the facility and if she was there then she looked at the worst wounds. She said the Wound Care Doctor came every Wednesday to the facility. The DON said the Wound Care Doctor never saw Resident #1 and did not know why. During a phone interview on 2/13/2025 at 11:58 AM LVN A said the CNA C asked him to look at Resident #1's buttocks. He said the wound he saw was in her gluteal fold, low sacral area to the right. He said when he assessed the wound it was not bleeding and looked like moisture associated skin damage red area to him. He said to best of his knowledge he did not see anything that he could remember in the sacral area. He said he wiped and applied barrier cream to the area. He said he did not measure the wound. LVN A said he thought he remembered notifying the family member that night but did not know who it was. He said he notified the wound care nurse to look at it by putting a paper note in her box for the next day for her to address. During a telephone interview on 2/13/2025 at 12:34 PM CNA C said she had been a CNA for [AGE] years and had taken care of a lot of residents with wounds. She said she remembered reporting an open wound on the top of Resident #1's sacrum and reported it to LVN A. CNA C said on the next day when she came back to work, she did not see a dressing on Resident #1's wound. She said she took a picture of Resident #1's wound and took her phone to the nurse's station and showed it to LVN A and told him it was bad. CNA C said the wound on Resident #1 was on the upper middle crease of the residents' buttocks and it was a bad bed sore that was open with dead tissue. She said she never reported the wound to anyone else other than LVN A. During an interview on 2/13/2025 at 1:19 PM CNA E said she worked with Resident #1 prior to her discharging from the facility but was not working the day Resident #1 left the facility. She said Resident #1 had a place on her buttocks that looked like carpet burn like a little scrape on it. She said they were putting barrier cream on it. CNA E said she saw a pink area on her buttocks but never saw an area on her sacrum. During an interview on 2/13/2025 at 1:40 PM CNA F said when Resident #1 discharged from the facility she had a skin tear on her bottom. She said the wound on Resident #1's bottom looked like a burn with pus and redness. She said she had reported it to the Treatment Nurse and the Treatment Nurse was treating the wound. CNA F said it looked like the picture of the residents wound that was showed to the CNA. Said she always reports any skin issues to the nurse or treatment nurse. During a telephone interview on 2/13/2025 at 4:30 PM the Wound Care Doctor said she had never seen Resident #1. During an interview on 2/19/2025 at 9:30 AM MDS LVN said there was a morning clinical meeting every morning and the staff nurses report to the administrative nurses on any resident issues. She said she remembered LVN A said in the morning clinical meeting that he had assessed Resident #1 and she did not have any open areas. The MDS LVN said she was never notified Resident #1 had a skin issue. She said she remembered the BOM said in the morning meeting 7/26/2024 that Resident #1's family member had called said Resident #1 would not be returning to the facility due to her having an unknown wound that she had gotten while at the facility. During an interview on 2/19/2025 at 1:23 PM the DON said her expectation for pressure ulcers was for the nurse to measure, stage, notify the physician, responsible party and dietician. She said the nurse should also make sure treatment orders were in place. Said most of the nurses have gone through the wound care training course. She said LVN's cannot stage or classify a wound so either she or the Wound Care Doctor would stage it or classify the wound by the next day. She said she was not sure how the wound on Resident #1 got missed, she said all she saw was Resident #1's right buttock and did not see the unstageable wound. She said Resident #1's family called the BOM and said they were not bringing Resident #1 back due to the wound that she had received while at the facility. The DON said there was no notification to Resident #1's Responsible Party because they were not aware that Resident #1 had a wound. She said her expectation was if there was an order for a treatment, she expected it to be done and that nurses are responsible for total patient care. During an interview on 2/19/2025 at 2:02 PM the Administrator said skin assessments should be completed on admission/readmission and weekly. He said his expectation was for the nurses to identify and treat wounds per the physicians' orders and plan of care. Record review of Licensed Nurse Proficiency Audit dated 11/09/2024 indicated LVN A had shown satisfactory performance with dressing changes. Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV). 11. Director of Nursing or designee to inservice nurses and CNAs on above prevention . Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss. Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed. Stable eschar (i.e., dry, adherent, intact without erythema or fluctuance) on an ischemic limb or the heel(s) should not be removed. 7. Nursing Care Plan. 1. Identify the problem of pressure injuries on the Nursing Care Plan. 2. Under Nursing Intervention, list physician ordered treatments. 3. Staffing definitions recognize the following limitations: .When necrosis is present accurate staging of the pressure injury is not possible until the necrosis has sloughed or the wound has been debrided . Assessment of the pressure injury should also include the site, size, and W x Lx D, of the injury. Surrounding tissue, color, exudate, wound edges, sinus tracts, odor, tunneling and undermining should also be documented at least weekly and upon decline. An Immediate Jeopardy (IJ) was identified on 2/18/2025 at 3:49 PM due to the above failures. The facility Administrator was notified. The Administrator was provided with the IJ template on 2/18/2025 at 3:49 PM. The following plan of removal submitted by the facility was accepted on 2/18/2025 at 5:30 PM: Plan of Removal Problem: F686- Failure to Provide Treatment/Services to Prevent/Heal Pressure Ulcer Interventions: Resident #1 no longer resides in the facility as of 2/18/25. A head-to-toe assessment was completed on all residents as of 2/18/25 by the DON/ADON/MDS/Compliance Nurse. The MD was notified as of 2/18/25 on all residents with pressure wounds by the DON. Orders were received for treatment and implemented as of 2/18/25 by the Treatment and Charge Nurses. Weekly ulcer assessments and non-ulcer assessments were completed as of 2/18/25 to include measurements by DON/ADON/MDS/Compliance Nurse. The Dietician was notified as of 2/18/25 of all residents with pressure wounds by the DON. All residents with pressure wounds have appropriate supplements in place to promote wound healing. Reviewed and completed by the DON and Compliance Nurse as of 2/18/25. The Dietician and Physician will be notified for recommendations/orders when new or worsening pressure wounds are identified by the DON and Treatment Nurse. This will start 2/18/25. All wound care orders were reviewed as of 2/18/25 by DON, ADON, and Compliance Nurse to ensure pressure wound care recommendations are being followed appropriately for all residents. Braden Scale assessments were completed on all residents as of 2/18/25 by the Regional Compliance Nurse and DON. Resident care plans for pressure wounds and skin issues were reviewed and updated to include interventions promoting wound healing. This was completed by the Regional Compliance Nurse and DON as of 2/18/25. The Medical Director was notified of immediate jeopardy on 2/18/25 by the Administrator. An ADHOC QAPI meeting was held with the Administrator, DON, ADON, and Medical Director to discuss the immediate jeopardy and plan of removal as of 2/18/25. Administrator, DON, and ADON were in-serviced 1:1 by the Regional Compliance Nurse as of 2/18/25 on the following topics. o Pressure Injury Prevention, Assessment, staging, and Treatment Policy to include early prevention/treatment whenever a change in skin status occurs. Documentation to include measurements and staging/classifying pressure wounds appropriately with documentation of an accurate description in the weekly ulcer assessment. Completing Braden Scale assessments upon admission, readmission, and as needed to help identify when a resident might be at risk for skin breakdown. o Skin Integrity management Policy to include identifying/documenting skin issues to include staging/classifying pressure wounds appropriately and initiating an appropriate treatment plan. Also to include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing. o Notification of a Change in Condition Policy-to include notifying the physician and family/RP when a new skin issue or pressure wound has been identified with documentation in the weekly skin assessment, weekly non-pressure assessment, weekly ulcer assessment, and care plan. Also including notifying the nurse when a new skin issue has been identified. o Skin Assessment policy to include completing head-to-toe assessments upon admission/readmission and weekly to help identify/document skin issues with physician and family/RP notification and treatment orders. o Abuse and Neglect - failure to identify properly stage pressure wounds, classify skin issues, or provide treatments as ordered can be considered neglect. In-services: The following in-services were initiated by Regional Compliance Nurse, DON for all charge nurses. Any charge nurses not present or in-serviced as of 2/18/25 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completion date 2/18/25. o Pressure Injury Prevention, Assessment, staging, and Treatment Policy to include early prevention/treatment whenever a change in skin status occurs. Documentation to include measurements and staging/classifying pressure wounds appropriately with documentation of an accurate description in the weekly ulcer assessment. Completing Braden Scale assessments upon admission, readmission, and as needed to help identify when a resident might be at risk for skin breakdown. o Skin Integrity management Policy to include identifying/documenting skin issues to include staging/classifying pressure wounds appropriately and initiating an appropriate treatment plan. Also to include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing. o Notification of a Change in Condition Policy-to include notifying the physician and family/RP when a new skin issue or pressure wound has been identified with documentation in the weekly skin assessment, weekly non-pressure assessment, weekly ulcer assessment, and care plan. Also including notifying the nurse when a new skin issue has been identified. o Skin Assessment policy to include completing head-to-toe assessments upon admission/readmission and weekly to help identify/document skin issues with physician and family/RP notification and treatment orders. o Abuse and Neglect - failure to identify properly stage pressure wounds, classify skin issues, or provide treatments as ordered can be considered neglect. o The following in-services were initiated by Regional Compliance Nurse, DON for all other nursing staff and therapy. Any staff not present or in-serviced will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completed as of 2/18/25. o Notification of a Change in Condition Policy- to include notifying the nurse when a new skin issue has been identified. o Skin integrity management and pressure injury prevention, assessment, and treatment. To include interventions to help with pressure injury prevention and notifying the charge nurse when a new skin issue is identified or if a dressing is soiled or missing. The following in-services were initiated by Regional Compliance Nurse, DON for all staff. Any staff who are not present will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All agency staff or staff on leave will in serviced prior to assuming their next assignment. Completed as of 2/18/25. o Abuse and Neglect - failure to identify skin issues or provide treatments can be considered neglect. On 2/19/2025 the Surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record review of Resident #1's electronic medical record confirmed Resident #1 discharged to the hospital on 7/25/2024 and did not return to the facility. Record review of electronic head to toe assessments date 2/13/2025 through 2/18/2025 with no concerns noted. Record review of weekly ulcer and non-ulcer assessments completed 2/12/2025 through 2/18/2025 with no concerns noted. Record review of attestation dated 2/18/2025 at 3:58 PM confirmed the Dietician was notified of all residents with pressure wounds. Record review of attestation dated 2/18/2025 confirmed all residents with pressure wounds have appropriate supplements in place to promote wound healing. Record review of attestation stating the Dietician and Physician will be notified for recommendations/orders when new or worsening pressure wounds were identified. Record review of all wound care orders were reviewed by the DON, ADON, and Compliance Nurse on 2/18/2025 to ensure pressure wound care recommendations were being followed. Record review of the electronic medical record confirmed all Braden scores had been updated on 2/13/2025. Record review of the electronic medical record confirmed all resident care plans had been reviewed and updated as of 2/18/2025. Record review of AdHoc QAPI meeting minutes confirmed to discuss plan of removal as of 2/18/2025 with the following in attendance: Administrator, ADON, DON, Medical Director, HR, MDS, Dietary Manager, DOR, Activity Director, Housekeeping Supervisor, BOM, and Medical Records. Record review of inservices provided to the Administrator, DON, and ADON dated 2/12/2025 consisted of: Pressure Injury Prevention, Skin Integrity Management Policy, Skin Assessment Policy, and Abuse and Neglect. Record review of inservices provided to Charge Nurses dated 2/12/2025 and consisted of: Pressure Injury Prevention, Skin Integrity Management Policy, Notification of a Change in Condition Policy, Skin Assessment Policy, and Abuse and Neglect. Record review of inservices provided to all staff dated 2/12/2025 and consisted of: Notification of a Change in Condition Policy, Skin Integrity Management, and Abuse and Neglect. During an interview on 2/19/2025 at 12:10 PM CNA E said some wound prevention interventions consisted of: turning and repositioning every 2 hours, elevating legs, changing positions, wedges, pillows to offset pressure points, wheelchair cushions, and movement. She said she would immediately notify the charge nurse and DON of any new wounds or wounds without dressings. She said it could be considered abuse or neglect for not preventing and treating wounds. During an interview on 2/19/2025 at 12:18 PM CNA G said some wound prevention interventions consisted of: turning and repositioning every 2 hours, elevating legs, changing positions, wedges, pillows to offset pressure points, wheelchair cushions, and movement. She said she would immediately notify the charge nurse and DON of any new wounds or wounds without dressings. She said it could be considered abuse or neglect for not preventing and treating wounds.

Based on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 3 of 5 residents (Resident #3, Resident #4 and Resident #5) and reviewed for pharmacy services. The facility failed to remove discontinued controlled medications from the medication cart for Resident #3, Resident #4 and Resident #5 who had expired. The facility failed to ensure proper destruction of 71 Hydrocodone ,d+[DATE]mg, 103 Lorazepam 1mg, 17 Lorazepam 0.5mg, and 94.75ml Morphine Sulfate 100mg/5ml that were controlled medications for Resident #3, Resident #4 and Resident #5 who had expired. These failures could place residents who received medications, including narcotics at risk for not receiving the intended therapeutic effects of their prescribed medications and experiencing unintended and harmful effects of medications prescribed to others and place the facility at risk for drug diversion. Findings included: 1.Record review of facility electronic face sheet indicated Resident # 3 was an [AGE] year-old female admitted to facility on [DATE]. Resident #3's diagnoses included: malignant neoplasm of liver (liver cancer), and secondary malignant neoplasm of bone (bone cancer). Record review of Quarterly MDS dated [DATE] indicated Resident #3 had a BIMS of 14 indicating no cognitive impairment. Record review of discharge MDS dated [DATE] indicated Resident #3 had expired in the facility on [DATE]. Record Review of comprehensive care plan dated [DATE] indicated Resident # 3 had a terminal prognosis of malignant neoplasm of liver and had received hospice services with interventions that included: .Observe resident closely for signs of pain, administer pain medications as ordered, and notify physician immediately is there is breakthrough pain . Record review of physician orders for [DATE] indicated Resident #3 had an order for Hydrocodone ,d+[DATE]mg give 1 tablet every 6 hours as needed, Lorazepam 1mg give 1 tablet every 6 hours as needed, and Morphine Sulfate 100mg/5ml give 0.25ml-0.5ml every 2 hours as needed. Record review of narcotic count sheets indicated Resident #3 had 31 Hydrocodone ,d+[DATE]mg, 56 Lorazepam 1mg, and 26.75ml of Morphine Sulfate remaining at the time of Resident #3's expiration. 2.Record review of facility electronic face sheet indicated Resident #4 was an [AGE] year-old male admitted to facility on [DATE]. Resident #4's diagnoses included: metabolic encephalopathy (brain does not function properly), malignant neoplasm of lower lobe, right bronchus or lung (lung cancer), and hypertension (high blood pressure). Record review of admission MDS dated [DATE] indicated Resident #4 had a BIMS of 10 indicating moderate cognitive impairment. Record review of discharge MDS dated [DATE] indicated Resident #4 had expired in the facility on [DATE]. Record Review of comprehensive care plan dated [DATE] indicated Resident #4 had a terminal prognosis of squamous cell carcinoma and had received hospice services with interventions that included: .work with nursing staff to provide maximum comfort for the resident . Record review of physician orders for [DATE] indicated Resident #4 had an order for Hydrocodone ,d+[DATE]mg give 1 tablet every 4 hours as needed, Lorazepam 1mg give 1 tablet every 2 hours as needed, and Morphine Sulfate 100mg/5ml give 1ml every hour as needed. Record review of narcotic count sheets indicated Resident #4 had 40 Hydrocodone ,d+[DATE]mg, 30 Lorazepam 1mg, 17 Lorazepam 0.5mg, and 44ml of Morphine Sulfate remaining at the time of Resident #4's expiration. 3.Record review of facility electronic face sheet indicated Resident #5 was an [AGE] year-old male admitted to facility on [DATE]. Resident #5's diagnoses included: atrial fibrillation (irregular heartbeat), malignant neoplasm of prostate (prostate cancer), and dementia (decline in mental ability). Record review of admission MDS dated [DATE] indicated Resident #5 had a BIMS of 04 indicating severe cognitive impairment. Record review of discharge MDS dated [DATE] indicated Resident #5 had expired in the facility on [DATE]. Record Review of comprehensive care plan dated [DATE] indicated Resident #4 had a terminal prognosis and had received hospice services with interventions that included: .if receiving hospice services, work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met . Record review of physician orders for [DATE] indicated Resident #3 had an order for Lorazepam 1mg give 1 tablet every 6 hours as needed, Morphine Sulfate 20mg/ml give 0.25ml every 2 hours as needed, and Morphine Sulfate 20mg/ml give 0.5ml every 2 hours as needed. Record review of narcotic count sheets indicated Resident #5 had 17 Lorazepam 1mg, and 24ml of Morphine Sulfate remaining at the time of Resident #5's expiration. During an interview on [DATE] at 12:21 PM LVN H said when a resident had expired, they count the residents remaining narcotics with the hospice nurse. She said she counted the remaining narcotics the night Resident #3 and Resident #4 expired with the hospice nurse and then locked the medications in the cart to give to the DON. She said the next evening on [DATE] when she came in to work and counted the cart with LVN A he told her he had thinned out the cart and turned the medication in with the count sheets to the DON. She said the hospice sheets were still on the cart in the back of the book, but the narcotic count sheets were missing from the book. She said the following day [DATE] the DON called her and woke her up asking where the narcotics where and she told her that LVN A had said he had thinned the cart out and turned them in to the DON. During a phone interview on [DATE] at 11:58 AM LVN A said he had been passing pills and was tired and frustrated that day, so he decided to lighten his load by destroying the expired residents' medications. He said he wasted the medication in the 100-hall guest room bathroom. LVN A said he poured the medications in a cup and then flushed them in the toilet. LVN A said he had been a nurse for [AGE] years and knew he was supposed to give the medication to the DON and the Pharmacist was supposed to destroy them. He said in hindsight he knew it was not his best idea. Said he was suspended and terminated. He said he had worked for the facility on and off for ,d+[DATE] years and had never destroyed medications before. He said the facility had in the past educated him on the proper way to destroy medications. During an interview on [DATE] at 1:23 PM the DON said on Tuesday [DATE], she went to get the expired residents narcotics out the medication cart. She said LVN H told her they were not on the cart and LVN A had said he gave them to the DON to destroy. She said she did not remember LVN A giving her the medications but went and checked her locked medication cabinets for medications in case she had forgotten but did not find the medications. She said she called LVN A he told her that he had destroyed the medications by flushing them down the toilet in the family room bathroom because he needed space on the cart. The DON said LVN A told her he had the count sheets in his personal bag and needed to find someone to sign with him that he had destroyed the medications. She said she told LVN A he was not going to find anyone to sign with him if they had not witnessed the destruction. She said LVN A did return the count sheets to the facility. She said LVN A told her he just was not thinking straight. The DON said she called and reported the incident to the Administrator immediately and LVN A was suspended and ultimately terminated. She said her expectation was for the nurses to turn in medications to her to be destroyed with the pharmacy consultant. During an interview on [DATE] at 2:02 PM the Administrator said his expectation was for nurses to turn in all discontinued narcotic medications to the DON for destruction with the pharmacy consultant. During an interview on [DATE] at 2:02 PM the Administrator said when he spoke with LVN A he asked him to take a drug test. He said when the results of the drug test where positive LVN A told him he had prescriptions for the positives on the drug test. He said he asked LVN A to provide the prescriptions to the facility, but LVN A never provided any prescriptions. He said LVN A was suspended and ultimately terminated. The Administrator said the expectation for drug destruction would be for the nurses to hand over discontinued narcotics to the DON. He said the DON and the pharmacy consultant should reconcile the drugs and then destroy them according to facility policy. Record review of a urine drug screen dated [DATE] for LVN A indicated positive for cocaine, opiates, codeine, and hydrocodone. Record review of facility policy Discontinued Medications undated indicated: 1. The nurse that received the order to discontinue a medication is responsible for: .Removing the medication from the medication storage, filling out the form to be attached to the medication that discontinued, if applicable, personally giving the form and medication to the DON or ADON . Record review of facility policy Drug Destruction Policy dated [DATE], indicated: It is the policy of this facility to destroy dangerous and controlled medications according to the State of Texas law . 2. Drugs to be destroyed will be destroyed under the supervision of a consultant pharmacist and at least one of the following: Director of Nursing, Assistant Director of Nursing, or Administrator. 3. Nursing staff will submit to Director of Nursing any medication and any applicable log that has expired, been discontinued by physician or that had been prescribed to a resident who no longer resides at the facility. 4. The nurse submitting the discontinued medication, will verify along with the Director of Nursing that the amount of medication remaining matches the log. After verification, both the nurse and the Director of Nursing will sign the log. 5. The nurse will make a copy of the signed log and provide to the administrator. The Director of Nursing will maintain the original log and medication .

Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 3 residents (Residents #2) reviewed for care plans. The facility failed to implement Resident #2's care plan by not changing the dressing to her diabetic ulcer on the left second toe daily. On 2/12/2025 Resident #2's dressing was dated for 2/9/2025. This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs. Findings include: Record review of a face sheet for Resident #2 dated 2/18/2025 indicated that Resident #2 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: diastolic congestive heart failure (left ventricle of the heart cannot relax normally), protein calorie malnutrition (reduced availability of nutrients), type 2 diabetes mellitus (high blood sugar levels). Record review of an Admission MDS assessment dated [DATE] for Resident #2 indicated she had a BIMS score of 13, indicating intact cognition. Section M of same MDS assessment indicated that she was at risk of developing pressure ulcers/injuries and Resident #2 did not have any diabetic foot ulcers. Record review of a care plan for Resident #2 dated 2/13/2025 indicated Resident #2 had a diabetic ulcer to left second toe with interventions that included: Administer treatments as ordered and monitor for effectiveness. Record review of physician orders for Resident #2 dated 1/17/2025 indicated: Left foot 2nd toe-cleanse area with N/S [normal saline] pat dry apply silvasorb gel to wound with [NAME] peri-wound cover with dry foam and secure with tape PRN [as needed] soiled/dislodgement one time a day. Record review of the treatment administration record dated 2/18/2025 indicated Resident #2 had not received treatment to the left foot 2nd toe on 2/9/2025, 2/10/2025, and 2/11/2025. Record review of physician's progress note dated 2/6/2025 indicated: Patient here with her [family member] very concerned that her mother is not getting good care for her left second toe. She states the bandage is not changed initially . During an observation and interview on 2/12/2025 at 10:10 AM with Resident #2's family member said she was concerned that Resident #2 was not getting wound per the physician's orders. She said on 2/12/2025 Resident #2's dressing to the left foot 2nd toe had not been changed since 2/9/2025. She said Resident #2's dressing changes had not been getting changed daily as ordered. She said she had addressed the issue with the ADON previously. Observation of Resident #2's left foot 2nd toe revealed a dressing dated 2/9/25. During an interview on 2/19/2025 at 1:23 PM the DON said she did not know why Resident #2's treatment to her left 2nd toe had not been done. She said by not having her treatment done per the physician's orders could cause the residents wound to become worse. During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for all wound care to be done as per the physician's orders. He said it just was not done on Resident #2. He said he was told the treatment nurse was out sick but the charge nurse should have completed the wound care. He said by not receiving the wound care per physician orders and the care plan it could cause the wound to become worse. During an interview on 2/19/2025 at 3:15 PM the ADON said she did not know why the wound care had not been completed on Resident #2. Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification . 6. Nursing Action/Rationale: 1. Prevention: The nurse can assist in the prevention of pressure injuries by performing the following nursing interventions: Note: Add any interventions to care plan . 3. Keep bed clean, dry and free of wrinkles. 4. Encourage physical activity that stimulates circulation such as active and passive range of motion exercises. 5. Maintain body alignment with support for body parts; pillows, cradles, pads, heel/elbow protectors, and mattresses can be used to help relieve pressure . 9. Assess for early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet. 10. Treatment Nurse/designee or Director of Nursing will assess site and evaluate for appropriate stage as listed in this procedure. Notify physician; obtain an order and monitor site daily. Sign off on treatment sheet any treatment completed (i.e., Stage I through Stage IV) .

Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #1) of three residents reviewed for a change of condition. The facility failed to notify the responsible party or family of a change in condition for Resident #1 after finding a new wound on her buttocks on 7/22/2024. This failure could affect residents by placing them at risk for a delay in medical treatment, worsening in condition. Findings included: Record review of the face sheet dated 2/13/2025 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), paranoid schizophrenia (hallucinations, delusions, and disorganized speech), contractures of left and right knee (permanent shortening or tightening of muscles, tendons, ligaments, or skin), dementia (decline in memory, thinking, reasoning, and problem solving). Record review of the face sheet dated 2/13/2025 indicated Resident #1's daughter was her responsible party with a phone number and a directive to please text the daughter. Record review of the quarterly MDS dated [DATE] indicated Resident #1 usually understood others and was usually understood by others. The MDS indicated Resident #1 had a BIMS score of 03 which indicated severe cognitive impairment. The MDS indicated Resident #1 required was completely dependent on staff for all activities of daily living. The MDS indicated Resident #1 was dependent with transfers. The MDS indicated Resident #1 was at risk for developing pressure ulcers/injuries. The MDS indicated Resident #1 did not have any unhealed pressure ulcers/injuries. Record review of the discharge MDS dated [DATE] indicated Resident #1 did not have any unhealed pressure ulcers/injuries. Record review of the care plan last revised on 8/05/2024 indicated Resident #1 had the potential for pressure ulcer development due to decreased mobility, incontinence and decreased cognition with interventions that included: 1. Educate the resident/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning. 2. Follow facility policies/protocols for the prevention/treatment of skin breakdown. 3. Incontinent care after each episode and apply moisture barrier. 4. Inform the resident/family/caregivers of any new skin breakdown . 6. Notify the nurse immediately of any new areas of skin breakdown: Open area, Redness, Blisters, Bruises, discoloration noted during bath or daily care . Record review of the physician orders dated 7/25/2024 indicated Resident #1 had an order to: 1. Non-pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed with an order date of 7/23/2024 and an order start date of 7/23/2024. 2. Non-pressure-left and right buttocks-cleanse area with normal saline pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement one time a day with an order date of 7/23/24 and an order start date of 7/24/2024. Record review of Braden Scale for Predicting Pressure Sore Risk dated 8/4/2023 revealed Resident #1's score of 9 which indicated Resident #1 was at high risk for developing a pressure sore. Record review of Weekly Skin Assessment-V 5 dated 7/19/2024 indicated Resident #1 did not have any moisture associated skin damage or pressure, venous, arterial, or diabetic ulcers. Record review of eTransfer Form-V6 dated 7/25/2024 indicated Resident #1 was sent to the hospital for the following: Resident partially opening her eyes to verbal and tactile stimulus. Non verbal. No facial dropping noted. Generalized weakness. Will not squeeze my hands. Rapid shallow breathing noted. Sending out for possible AMS [altered mental status]. The form indicated Resident #1 had special treatments and precautions of: contact infection control precautions for an infection of the buttocks. The form indicated Resident #1 was on EBP (enhanced barrier precautions). The form indicated Resident #1 was receiving wound treatment with a current wound to the buttocks. The form indicated Resident #1's responsible party (daughter) was notified on 7/25/2024 at 9:30 AM of the transfer. Record review of Resident #1's nursing progress note completed on 7/26/2024 as a Late Entry for 7/22/2024 indicated the CNA C informed LVN A that she was doing care on Resident #1 and wanted LVN A to look at Resident #1's bottom. CNA C helped LVN A to assess Resident #1's bottom by rolling her on her side. Resident #1 was noted to have MASD (moisture associated skin damage) to bilateral buttocks. LVN A documented to wound bed was pink in color with no drainage noted. LVN A documented there were no signs or symptoms of infection noted. LVN A documented the edges were attached. LVN A documented he consulted the NP (nurse practitioner) about Resident #1's buttocks with recommendation noted till treatment nurse could assess. LVN A documented cleanse area with soap and water, pat dry and apply clean dry dressing. LVN A documented treatment was initiated at that time. LVN A documented he would advise treatment nurse of findings to follow up on NP (nurse practitioner) recommendation. Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:32 PM the ADON documented on 7/23/2024 at 1:31 PM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Treatment Administered Daily. Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:33 PM the ADON documented on 7/23/2024 at 2:32 PM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. PRN Administration was: Effective. Dressing was changed after bath. Record review of Resident #1's nursing progress note completed on 7/23/2024 at 10:57 PM, LVN D documented she called residents daughter to give update on resident with no answer. Record review of Resident #1's nursing progress note completed on 7/26/2024 at 1:34 PM the ADON documented on 7/24/2024 at 10:33 AM Non-pressure-left and right buttocks-cleanse area with N/S [normal saline] pat dry apply calcium alginate and cover with a dry dressing daily PRN soiled/dislodgement as needed. Wound care provided by charge nurse and ADON. Record review of Resident #1's nursing progress note completed on 7/25/2024 at 9:49 AM LVN A documented on 7/25/2024 at 9:35 AM Resident this morning presenting with possible AMS [altered mental status]. Resident partially opening her eyes to verbal and tactile stimulus. Resident nonverbal this morning. Residents' tardive dyskinesia [chronic involuntary movement disorder] is generally very active and this morning it is very mild. Resident will not squeeze my fingers on command. No facial Dropping noted. Generalized weakness noted with her extremities and trunk. Rapid shallow breathing noted . Talked to NP [nurse practitioner] and informed of resident's current status with order to send to [hospital emergency room ] for eval and tx [treatment] due to AMS [altered mental status]. Daughter .notified and ok with transfer to [hospital emergency room ]. 911 initiated and resident was transported per stretcher via ambulance to [hospital emergency room ] at this time. All paperwork sent with EMS [emergency medical services] for them and ER [emergency room ]. During a phone interview on 2/12/2025 at 12:25pm with Resident #1's RP (responsible party), she said neither she nor her sister had been notified that Resident #1 had developed any kind of skin problem. She said it was not until she got to the hospital emergency room that she was notified that Resident #1 had an unstageable wound to her sacral (upper buttocks) area. During an interview on 2/12/2025 at 3:22 PM the ADON said she was not aware of Resident #1 had a wound until the day on 7/22/2024 when LVN A was notified by CNA C. She said she never notified Resident #1's responsible party or any family. During an interview on 2/13/2025 at 10:30 AM the DON said if a new skin area was identified and the treatment nurse was not available, the residents charge nurse was to notify the MD and Responsible. During a phone interview on 2/13/2025 at 11:58 AM LVN A said he thought he remembered notifying the daughter that night but didn't know who it was that he talked to. He said he notified the wound care nurse to look at it by putting a paper note in her box for the next day for her to address. During an interview on 2/19/2025 at 2:02 PM the Administrator said his expectation was for the nurses to notify the resident's responsible party. Record review of the facility policy Notify the Physician of Change in Status revised on March 11, 2013, indicated: .5. The resident's family member or legal guardian should be notified of significant change in resident's status unless the resident has specified otherwise. Record review of the facilities policy Pressure Injury: Prevention, Assessment and Treatment revised on 8/12/2016 indicated: 3. Upon assessment and identification of a pressure sore the staff nurse will notify the treatment nurse/designee. The treatment nurse/designee will: 1. Notify the physician of pressure sore and obtain and follow any orders as directed by the physician. 2. Notify family and dietary department. Document notification .

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 16 residents reviewed for pain. (Resident #203) 1.The facility failed to effectively manage Resident #203's pain. 2.The facility failed to ensure Resident #203's low air loss mattress was plugged in, functioning, and fully inflated to prevent pain. 3.The facility failed to ensure LVN B notified Resident #203's physician after a family member requested a medication change to manage his pain related to muscle spasms. These failures could result in residents experiencing unnecessary pain and a decreased quality of life. Findings included: Record review of Resident #203's face sheet dated 6/04/24 indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #203 had diagnoses which included stage 4 pressure ulcer to sacrum (most severe pressure ulcer to bottom of spine, full thickness skin loss, may be muscle, bone tendon, or joint involvement), incomplete C5-C7 quadriplegia (paralysis or weakness in all four limbs, but with some ability to move, feel sensations, or control automatic body processes), reflex neuropathic bladder (nerves and muscles that control the bladder do not work properly and causes difficulty urinating), benign prostatic hyperplasia with lower urinary tract symptoms (prostate enlarges and results in difficulty urinating), resistance to multiple antimicrobial drugs, depression (persistent sadness), insomnia (hard to fall asleep, stay asleep, or get quality sleep), cystostomy (opening into gallbladder to drain fluid), and pain. Record review of Resident #203's hospital history and physical dated 4/30/24 revealed he had incomplete Quadriplegia with a history of muscle spasms and pain, and he should continue as needed medications for spasms and pain control. Record review of Resident #203's admission MDS revealed it had not been completed prior to survey exit. Record review of Resident #203's care plan initiated on 5/28/24 indicated: Resident #203 had a potential for uncontrolled pain with interventions which included anticipate the resident's need for pain relief and respond immediately to any complaint of pain; evaluate the effectiveness of pain interventions with alleviating symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition; and notify physician if interventions were unsuccessful or if the current complaint was a significant change from resident's past experience of pain. Resident #203 had peripheral vascular disease (narrowed blood vessels reduce blood flow to the limbs causing leg pain) with interventions which included to monitor/document/report to physician as needed for any signs or symptoms of complications of extremities such as pain. Resident #203 had a pressure ulcer or potential for pressure ulcer development with interventions which included to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Resident #203 required antidepressant medication with interventions which included to monitor/document/report to physician as needed of depression unaltered by antidepressant meds with behaviors of sad, irritable, anger, never satisfied, crying, negative mood/comments, and agitation. Record review of Resident #203's Order Summary Report dated 6/04/24 revealed orders for Gabapentin 300 mg one capsule by mouth two times daily for neuropathy (nerve pain) with a start date of 5/28/24, Methocarbamol 500 mg one tablet by mouth four times a day for muscle relaxer related to Quadriplegia with a start date of 5/28/24, Tylenol 325 mg two tablets by mouth every four hours as needed for pain or fever with a start date of 5/28/24, May have pressure relieving mattress every shift for wound with a start date of 5/28/24, and Norco 10/325 mg one by mouth every six hours for pain routinely with a start date of 5/29/24. Record review of Resident #203's MAR dated 5/01/24-5/31/24 and MAR dated 6/01/24-6/30/24 revealed the above medications were administered as ordered. Record review of Resident #203's Pain-MDS dated [DATE] revealed he experienced pain almost constantly and the pain frequently affected his sleep and almost constantly interfered with his activities of daily living. Record review of Resident #203's pain level summary dated 5/28/24-6/05/24 revealed he had pain values from 0 to 7 on a 1-10 scale (1 being the least pain to 10 being the worst pain). Resident #203's pain level on 6/03/24 was a 4 at 11:59 AM, a 7 at 2:05 PM, a 7 at 5:04 PM, and a 5 at 8:56 PM. Record review of Resident #203's NP visit note dated 5/29/24 revealed the resident stated he could move both lower extremities but chose not to because with movement muscle spasms would follow. There was a new order to change Resident #203's Norco to 10/325 mg by mouth every six hours scheduled. Record review of Resident #203's progress notes dated 5/28/24-6/03/24 revealed on 5/29/24, LVN M received new orders to change his Norco 10/325 mg every six hours to routinely. On 5/30/24, LVN B documented he continued to complain of pain upon turning and repositioning and getting weight. On 5/31/24, LVN B documented Resident #203 was known to holler for a while when treatments were done. On 6/02/24, RN N documented Resident #203 had a low air loss mattress in place and the resident was receiving routine pain medication and reported it was effective. There was no documentation of Resident #203's continued complaints of pain being reported to the physician. There was no documentation related to Resident #203's family member requesting a different medication for his pain related to leg spasms from LVN B. During an observation on 6/03/24 beginning at 11:16 AM, the surveyor entered Resident #203's room while LVN G and CNA E were still in the resident's room after performing wound care. CNA E repositioned Resident #203's pillow. Resident #203 was hollering out that he was having severe pain and he felt like he was lying on a board. LVN G told Resident #203 it was just the wound vac (wound dressing and tubing attached to a machine that pulls a vacuum to assist in the closure and drainage of wounds), but the resident continued to holler out saying it had never felt like that before and to please look back there (his bottom). LVN G asked CNA E to roll the resident over so she could look under Resident #203. CNA E rolled the resident toward her while LVN G looked under the resident and again told him it was just the wound vac. Resident #203 was then propped up his on right side with pillows under his left back. LVN G said she would tell Resident #203's nurse and see if he could have a pain pill. During an observation and interview on 6/03/24 beginning at 11:21 AM, Resident #203 said he was having severe pain on his bottom, and he felt like he was lying on a board. Resident #203 said he had never had it feel like that before. Resident #203 said with tears in his eyes, he was not crazy, and something was wrong. Resident #203 continued to holler out in pain and asked the surveyor to please do something, because it had never felt like that before. Resident #203 said he had been in the facility for about a week. Resident #203 had a low air loss mattress (prevents and treats pressure wounds) and it was not operating and there were no lights on the control box to indicate it was on. The power the cord of the low air loss mattress was unplugged from the wall and was lying across the top of the bed frame at the head of the bed . During an observation and interview on 6/03/24 beginning at 11:52 AM, with surveyor intervention, RN F accompanied the surveyor to Resident #203's room and she said LVN G had told her Resident #203 was having pain and she was going to get him a pain pill. While entering Resident #203's room, he continued to holler out that it was killing him, and he felt like he was lying on a board on his back. RN F put on gloves and rolled Resident #203 over to his right side and ran her gloved hand under him and looked under him. RN F told Resident #203 there was nothing under him except the wound vac to his bottom. RN F then repositioned Resident #203 with pillows and told him she would get him a pain pill. With surveyor intervention, RN F was asked if the low air loss mattress was functioning. RN F looked at the low air loss mattress control box and she said it was not on and she found the cord/plug that was lying at the head of the bed on the bed frame. RN F had to unwrap the cord from under the bed and plugged it in to the electrical plug and turned it on at the control box. RN F said it would take a few minutes for the low air loss mattress to re-inflate. RN F told Resident #203 she was going to get his pain medication. During an observation and interview on 6/04/24 at 5:01 PM, Resident #203 said after the air mattress re-inflated yesterday, it helped his pain level tremendously. Resident #203 said he felt like he was lying on a board, and he said the therapist told him the mattress was not inflated and he was lying on the steel frame. Resident #203 thanked the surveyor for bringing it to the facility's attention and getting it turned back on. Resident #203 said he had only had that feeling of lying on a board after the nurse did his wound care yesterday (6/03/24). Resident #203 continued to have right leg spasms and would holler out and would speak to his leg when it would start to spasm and said please, please, don't do it, don't do it as he rubbed his right leg. Resident #203 said he has had leg spasms and chronic pain for a long time. Resident #203 said he wished they could find something to help the pain with his muscle spasms or if they could just cut his right leg off, but they would not do it. During an interview on 6/03/24 at 12:02 PM, RN F brought Resident #203 a pain pill and said if the treatment nurse had let her know she was going to change his wound vac, she could have gotten him pain meds before the wound care to help prevent pain. RN F said the purpose of the low air loss mattress was to relieve pressure and if it was not plugged in, it could cause increased pressure to Resident #203's wounds. RN F said Resident #203 usually hollered out and complained of pain, but she felt his pain had gotten better. RN F said she thought they probably accidently unplugged his low air loss mattress when they were doing his wound care earlier and did not realize it. During an interview 6/05/24 at 1:50 PM, CNA H said she had worked at the facility for fourteen years. CNA H said it was just her second day to take care of Resident #203. CNA H said Resident #203 was in pain all the time and he had muscle spasms and hollered while she provided care. CNA H said she had not told the nurse anything about Resident #203's pain because she felt the nurse should already know. CNA H said Resident #203 mainly hurts when they moved him. CNA H said she would let Resident #203 do most of the positioning himself as much as he could, and it seemed easier on him. During an interview on 6/05/24 at 2:04 PM, LVN G said she had worked at the facility for eleven years and had been the treatment nurse for two years. LVN G said Resident #203 came into the facility hollering and complaining of pain and legs spams. LVN G said Resident #203 took routine pain medications. LVN G said she was positioning Resident #203 when the surveyor came into Resident #203's room on 6/03/24 and Resident #203 was complaining about being on a board. LVN G said she had already checked under him for anything that could cause him pain and she did not find anything other than the wound vac dressing on the wound to his sacrum she had just changed. LVN G said they did not do anything to unplug the low air loss mattress while performing Resident #203's wound care. LVN G said she did not know how the low air loss mattress became unplugged. LVN G said she knew there was air in the mattress because she put her hand on it when she checked under Resident #203. LVN G said the low air loss mattress had air in it and she did not hear a hiss like it was losing air. LVN G said if the air deflation level was very low, it could have made Resident #203 feel like he was lying on a rail, but she did not think it was that deflated. LVN G said everything they did for Resident #203 hurt him. LVN G said when she could not determine why Resident #203 was hurting, she reported to RN F and told her Resident #203 needed something for pain. LVN G said not addressing pain could make the resident feel hopeless, lose trust, have anger, depression, and a multitude of negative thought processes. During an interview on 6/05/24 at 2:26 PM, RN F said she had worked at the facility for approximately a year as needed. RN F said Resident #203 had a pressure wound on his sacrum with a wound vac dressing. RN F said Resident #203 was awake, alert, and oriented. RN F said Resident #203 could follow a verbal pain scale and he had a low pain tolerance. RN F said if residents complained of pain, she would look for the cause of pain, check to see what medications they had for pain, and use alterative pain management methods such as redirection. RN F said if the resident was awake, alert, and oriented, the resident would know what they wanted. RN F said she would notify the physician for new or changed orders if what they were doing was not working or managing the resident's pain. RN F said Resident #203's low air loss mattress not being plugged in on 6/03/24 could have contributed to his pain level, but she did not feel it was completely deflated and it still had air in it when she checked under him. RN F said pain management was important to keep the resident as comfortable as possible. RN F said if pain was not controlled, the resident could start losing functions. RN F said if the resident's pain was not managed effectively, the resident could have extreme pain and irritably and it could cause psychological issues such as not eating, decline in functions, and they could become depressed. During an interview on 6/05/24 at 2:43 PM, LVN B said she had worked at the facility since September 2023 and normally worked the day shift. LVN B said Resident #203 was receiving round the clock pain medications. LVN B said Resident #203 complained of pain all the time and hollered out even when just touching the bed and he seemed to do it worse when his family was in the room. LVN B said they tried to reposition him, got him a longer bed, and gave pain medications routinely to manage Resident #203's pain and thought he had not complained as much since. LVN B said Resident #203 usually just complained when they provided care. LVN B said Resident #203 said he had spasms to his legs. LVN B said Resident #203's family member wanted him to have a different medication for his leg spasms. LVN B said the family member told her the name of the medication they wanted to change to, but LVN B did not remember the name of the medication. LVN B said she told the family member she (LVN B) would have to talk to the physician about it to obtain an order for the medication. LVN B said the family member asked her about wanting the medication for his pain from the muscle spasms changed about 3-4 days ago. LVN B said she had not talked to the physician and had forgotten all about it . LVN B said if the low air mattress was not plugged in, it could make a difference in the how the resident felt. LVN B said pain management was important to manage. LVN B said if pain was not managed effectively, then it could affect the resident's behavior, they could become more irritable and complain. During an interview on 6/05/24 at 3:01 PM, CNA E said she had worked at the facility full-time for approximately three months, but she had worked at the facility for about ten years as needed. CNA E said Resident #203 hollers out in pain a lot. CNA E said if she did anything to Resident #203, he would holler out in pain. During an interview on 6/05/24 at 3:19 PM, the ADON said when a resident reported pain, they could give medications, provide alternative measures, and then go back in 45 minutes to evaluate if the resident had relief from pain. The ADON said if there was no relief, then they should notify the physician for new or changed orders. The ADON said pain management could cause a lot of problems in the resident such as they could stop eating, change in behaviors, and unable to sleep. The ADON said she did not know why the physician had not been notified related to Resident #203's continued pain and muscle spasms, but the ADON said the physician would be notified as soon as she was done with the surveyor. During an interview on 6/05/24 at 3:41 PM, the ADM said he would expect residents' pain to be managed. The ADM said Resident #203 was a new resident and he felt Resident #203's pain was being managed. The ADM said he had visited with Resident #203 a lot and the ADM said he would not say his pain was out of control. The ADM said he had talked to RN F, and she had told him Resident #203 was not on the bed frame and the low air loss mattress was not deflated when it was not plugged in. The ADM said he did not feel Resident #203 had a negative effect because they were managing his pain with routine pain medications. Record review of the facility's In-service Attendance Record dated 6/01/24 with the subject of Monitoring for pain/pain management revealed . pain assessments should be ongoing . individualized and documented so that all involved in the patient's care understand the pain problem . asking patient's to describe their pain using words would guide staff to the appropriate interventions for specific pain types . patients may have more than one type of pain . and it said to see attached sheets and the Pain Management, Assessment Scale policy was attached to the in-service. The Inservice Attendance Record was signed by LVN G, RN F, and CNA E. Record review of the facility's policy titled Pain Management, Assessment Scale with a revised date of May 25, 2016 revealed . pain was a subjective sensation of discomfort derived from multiple sensory nerve interactions generated by physical, chemical, biological, or psychological stimuli . complaints of pain would be assessed accordingly by the nurse and effectively managed through prescribed medications, and comfort measures, and all available resources of the facility . talk with the resident about pain and assess for pain relief after interventions . monitor for effectiveness of pain interventions .

Based on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed for quality of care. (Resident # 1) The facility did not: * administer Resident #1's physician prescribed medication prior to allowing him to sign out and leave the facility; *provide medications to Resident #1 with written or oral instructions on how to administer the medications for the period of time he would be away from the facility; *assess Resident #1's ability to care for himself when out of the facility; *assess the residents' behavior and develop an individualized comprehensive care plan for his impaired judgement and repeated unrealistic expressed desire to leave the facility and go see his wife. Resident #1 left the facility with his roommate's family to travel to a city approximately 3 hours away to visit his wife. The resident experienced [CONDITION(S)] in route and died . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury and death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, initially admitted on [DATE] , readmitted [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment with a BIMS of 9. The assessment indicated he understood with clear comprehension, had no behaviors and required supervision with ADL care. The resident had range of motion limitation in both lower extremities and used a wheelchair for mobility. A care plan dated [DATE] and last reviewed [DATE] indicated the following: *Resident #1 was at risk for complications related to hypertension with interventions including: administer antihypertensive medications as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * Resident #1 had CHF (congestive heart failure) and was at risk for SOB (shortness of breath), chest pain, increased [CONDITION(S)] (fluid retention), increased blood pressure as evidenced by pulmonary [CONDITION(S)] (fluid in lungs), [CONDITION(S)] of extremities (legs and arms), pain and apprehension. Interventions included: administer medications for CHF per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Resident #1 was at risk for dehydration as evidenced by use of a diuretic with interventions to assess, document and notify the physician as needed for skin turgor, urine output and dry cracked lip; monitor for elevated temperature, blood pressure, constipation and report to the physician any abnormalities occurring. *Resident #1 wished to remain a full code. Interventions included: staff will start CPR should [CONDITION(S)] occur and/or breathing independently cease, call 911 and transport to ER; staff to notify MD (physician) and RP (responsible party) of any changes in condition. * Resident #1 was at risk for complications related to [CONDITION(S)] (a high amount of fat in the blood) with interventions including: administer medication as ordered by the physician (Atorvastatin), monitor for effectiveness and side effects of medication, document and notify physician as needed. *Resident #1 was at risk for complications and injury related to anticoagulation/antiplatelet therapy with interventions including: assess, document and report to physician as needed for abnormal or unexplained bleeding, bruising, ecchymosis, petechiae, purpura and tinnitus, administer medication per physician orders, monitor effectiveness (coumadin, aspirin) .protect me from injury by avoiding sudden movements, bumps when transferring or providing care . *Resident #1 had cognitive impairment with long and short-term memory loss and poor recall due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *The care plan did not address the residents commitment to leaving the facility to see his wife, impaired judgment and repeated attempts to get visitors and staff to take him to see his wife. The initial social service history form dated [DATE] indicated Resident #1 was admitted from the hospital and needed skilled care. The resident previously resided in a skilled nursing facility with his wife. The note indicated the residents behavior led their children to separate the resident from his wife and the wife remained in a SNF in another city (did not specify a specific behavior). Social worker note indicated the resident while there had no prior mental health history or hospitalization s. A behavioral health diagnostic assessment dated [DATE] completed by a psychologist/psychiatrist/ counseling agency indicated Resident #1 was tearful and stated I brought it on myself. I wrote down on a piece of paper I'm going to kill my wife and myself because we're not going to be abused. The assessment indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated Resident #1's cognitive assessment needed to be monitored as there were indicators of an incipient (beginning) dementia process. Resident #1 was oriented to person, place and situation with confusion around the date. Psychological services note dated [DATE] indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated the resident had mild cognitive decline and his judgement was moderately impaired. The intervention was to assist with decreasing negative emotion to improve clarity of thought, especially around decision making. The note indicated the resident said he was trying to get out of the facility so he could care for his wife. The note indicated the resident expressed anger towards the facility because he believed they withheld information until the last minute which allowed them to control his life. The note indicated the resident was committed to discharging and taking care of his wife and was resistant to interventions with a single mindedness to be with his wife. The note indicated the resident dismissed reality of interference by his children and the need for a resource in fulfilling his plan. The note indicated cognitive fluctuations posed a guarded prognosis. The note indicated the plan was to facilitate realistic planning around living situation and relationship with wife. A review of clinic records dated [DATE] indicated Resident #1 visited the device clinic for his pacemaker checkup. It was noted the dual-chamber pacemaker pulse generator triggered ERI (elective replacement indication triggered when device is nearing end of life) and previously triggered ERI on ,d+[DATE] and had gone unnoticed. The note indicated the resident was pacemaker dependent (a risk of serious injury or death from sudden pacemaker failure). The resident was admitted for an urgent pulse generator change out for [DATE]. A nursing note dated [DATE] at 11:51 a.m. indicated the resident returned from the hospital via ambulance due to pacemaker replacement. An undated sign out/ sign in sheet indicated Resident #1 signed out on [DATE] at 9:00 a.m. A nursing note dated [DATE] at 2:27 p.m., late entry Completed by LVN B indicated Resident #1 and his roommate left with the roommates brother. The note indicated LVN A witnessed the resident in the front seat secured with seat belt. Consolidated physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] #1 was to receive the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] *Pantoprazole (used to treat acid reflux) 40 mg at 5:30 a.m. *Sucralfate (used to treat and prevent ulcers) 1 gm at 7 a.m. *Lexapro (used to treat depression) 10 mg daily at 8 a.m. *Ferrous Sulfate (iron) 325 mg daily at 8 a.m. *Busiprone HCL (used to treat anxiety) 10 mg 3 times daily at 8 a.m., 2 p.m. and 8 p.m. *Hydralazine (used to treat high blood pressure) 100 mg tab every 8 hours at 8 a.m., 2 p.m. and 8 p.m. with instructions to hold if SBP (systolic blood pressure) is less than 100 or DPB (diastolic blood pressure) is less than 60. *Aspirin 81 mg daily at 9 a.m. *Lasix (used to treat and prevent fluid build-up) 40 mg daily at 9 a.m. *Potassium Chloride extended release 10 mg daily at 9 a.m. *Amlodipine [MEDICATION(S)] (used to treat high blood pressure) 10 mg daily at 9 a.m. with instructions to hold if SBP (systolic blood pressure) is less than 100 or DPB (diastolic blood pressure) is less than 60. *Losartan potassium (used to treat high blood pressure) 100 mg daily at 9 a.m. with instructions to hold if SBP (systolic blood pressure) is less than 100 or DPB (diastolic blood pressure) is less than 60. *Carvedilol (used to treat congestive heart failure) 12.5 mg 2 times daily at 9 a.m. and 9 p.m. with instructions to hold if SBP (systolic blood pressure) is less than 100 or DPB (diastolic blood pressure) is less than 60. *Coumadin (blood thinner) 7 mg at 5 p.m. *Atorvastatin (used to treat high cholesterol) 40 mg at 9 p.m. During a telephone interview on [DATE] at 12:12 p.m., MA C said she did not administer Resident #1's morning medications on the morning medication pass on [DATE]. MA C said she inaccurately documented the resident received his medication on the medication administration record. She said she was the only medication aide working that day and was overwhelmed. She said on the morning of [DATE], she looked for Resident #1 to administer his medications and could not locate him. She said she told LVN B she could not locate the resident and was told the resident had left the facility. During a telephone interview on [DATE] at 5:52 p.m. LVN B said on Saturday ([DATE]) around 7:30 p.m. or 8 p.m. Resident #1 said he had a secret. LVN B said the resident told her he was going to see his wife and that his roommate was going to take him. She said she did not tell anyone about the residents' plan. She said she was aware of the family history and the circumstance of the resident's separation from his wife. She said she knew the residents' daughter outside of work. LVN B said she was able to redirect the resident and told him she would have to call his daughter if he were to leave the facility. LVN B said Resident #1 told her that he would leave in the morning. LVN B said she told the resident she would still be working in the morning so he would still have to see her to sign out and she would have to call his daughter and notify her before he could leave the facility. LVN B said the next morning ([DATE]) she saw the resident roll by the nurses station and asked if he was upset with her and the resident said he was not worried about that. LVN B said that was the last time she saw the resident that day. LVN B said she received a phone call from Resident #1's daughter asking her why they let the resident leave the facility. LVN B said she told the daughter the resident was in the facility, but would go verify. LVN B said she searched for the resident and LVN A told her Resident #1 had signed out and left with his roommate and his family. LVN B said she explained to the daughter the resident had 24 hours to get back into the facility before he had to be placed back on the isolation unit. LVN B said the resident never returned to the facility. She said the resident always made his own decisions and had not been deemed incompetent. LVN B said ever since she knew the resident he had always said he was going to see his wife but this time he actually did it. LVN B said she did not think the resident would actually leave the facility. LVN B said the resident did not receive any of his morning medications because MA C came to her searching for the resident to give him his medication after he left. LVN B said the resident did not take any of his medications with him for the day because she was at her medication cart administering medications when LVN A told her the resident had left the facility. She said she did not give Resident #1 any medications to take with him. During a telephone interview on [DATE] at 3:10 p.m., LVN A said he was on the 300 hall administering medications and Resident #1 rolled up and asked if he minded getting the sign out book for him. LVN A said he asked the resident where he was going and the resident said he was going to see his wife. LVN A said he asked the resident how he was going to get there and he said he paid his roommates brother in law to drive him. LVN A said he asked the resident if he discussed leaving with LVN B, who was the residents charge nurse. He said the resident said not to bother her. LVN A said the resident signed himself out and put the date and time. LVN A said he explained to the resident that by signing the form he was responsible for himself in the community. He said he asked the driver where they were going and he said (a city approximately 3 hours away) and they would be back some time that day ([DATE]). LVN A said he told them the resident had to be back in the facility before 12 midnight. LVN A said he was not aware of the time frame Resident #1 would be out of the facility. LVN A said he notified LVN B that the resident had left the facility, and by then Resident #1's daughter called the facility and questioned him about allowing the resident to sign out. LVN A said he explained to her the resident had the right to sign himself out. LVN A said the resident was not assigned to him and he did not check to see if the resident had received his medications for the day. LVN A said if the resident was assigned to him he would had made sure the resident got his morning medications and any medications he may have needed for the time he was to be out of the facility. LVN A said he was not aware of Resident #1 having any behaviors and had no direction on what to do if the resident requested to leave to go see his wife. He said he felt the resident was safe and was competent to make his own decisions. He said he did know Resident #1 had previously written in a personal journal that he wanted to kill himself and his wife. A police department incident report dated [DATE] indicated Resident #1's roommates family called 911 at 10:37:52 to report the death of Resident #1. A nursing note dated [DATE] at 11:33 a.m., completed by LVN B indicated an officer from another city called and said Resident #1 was in the back seat with no pulse present. LVN B informed officer to transfer resident to the nearest hospital. The note indicated the resident was in route to Dallas to see wife. Hospital records dated [DATE] indicated the resident was brought to the hospital emergency department on [DATE] at 11:14 a.m. via ambulance. The record indicated the chief complaint was [CONDITION(S)]. The record indicated the [CONDITION(S)] was witnessed in the car by a friend who thought Resident #1 was asleep. The record indicated the resident could not be aroused when they stopped for gas and 911 was called. The record indicated Resident #1 was last seen awake 1.5 hours prior to calling 911. Upon EMS arrival the resident was unresponsive and his pulse was absent. The record indicated the resident expired due to [CONDITION(S)]. During a telephone interview on [DATE] at 1:23 p.m., Resident #1s daughter said prior to [DATE] the facility repeatedly called her when the resident wanted to go see his wife. She said she told the staff to ignore the resident and to not let him leave the facility. She said she did not receive a call from the facility on [DATE] when the resident left the facility. She said the resident called her and told her he was on his way to see his wife. She said she called the facility and was told the resident signed himself out. She said she later received a call from the hospital notifying her the resident was deceased . She said prior to moving to the facility, the resident was living at a different facility with his wife. She said an aide at his previous facility, found his open journal on his bed and discovered he had written in his journal he was going to kill himself and his wife. She said the resident had it in his head his wife was cheating on him because male staff were providing peri-care for her. She said the resident was banned from going back to that facility. She said the residents wife still resided at the facility. During a telephone interview on [DATE] at 12:35 p.m., a family member of Resident #1s roommate said on Friday ([DATE]) she spoke with Resident #1 over the phone and he asked if he could be taken to see his wife in (a town approximately 3 hours away). She said her husband and the resident made an arrangement to go Sunday ([DATE]). She said that was the first time she had ever spoken to Resident #1. She said they picked up Resident #1 and his roommate on Sunday. She said the resident was rolled out to the car and her husband and the aide assisted Resident #1 into the front seat of the car. She said she was not provided any medical history about the resident and was not provided any medication for Resident #1. She said they made one stop before heading out. She said they were all making small talk. She said Resident #1 abruptly stopped talking and his head dropped down. She said she asked Resident #1's roommate if the resident had sleeping issues, and Resident # 1's roommate replied he was tired and to let him sleep. She said a few minutes later the resident had a foul smell, and they had to air out the car by letting the windows down. She said her husband tried to awaken Resident #1 and his roommate nudged him from the back seat and the resident did not awake. She said she called his named and touched the back of the residents neck (she was seated behind Resident #1) and the resident was cold. She said they hit a pothole in the road and the residents body slumped down in the seat. She said told her husband to pull over because Resident #1 had expired. She said they pulled over at a gas station and called 911. She said the facility did not inform her of any of Resident #1's medical conditions and if she had known, she would have never taken him to see his wife. She said she felt if the facility allowed the resident to sign out, he was healthy enough to travel. She said she did not ask about Resident #1s health conditions. She said the facility did not tell her the resident could not go see his wife. During a telephone interview on [DATE] at 5:26 p.m., the social worker said Resident #1 had the right to leave the facility. She said the resident scored a ,d+[DATE] (no cognitive impairment) on his most recent BIMS assessment and had no POA or guardianship. The social worker said she was aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said his wife's children or wife and children wanted them separated. She said the resident had no current behaviors. During an interview on [DATE] at 11:36 a.m., the social worker said had mistakenly said the resident had a BIMS of 15 and the resident actually had a BIMS of 5 (severe cognitive impairment). She said a BIMS of 5 and above was high functioning. She said the resident did not have short term or long-term memory loss. She said the resident did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said 3 weeks ago he said his wife had a stroke and he needed to go see her. The social worker said she called the daughter about the residents' concerns and was told his wife did not have a stroke. During an interview on [DATE] 3:24 p.m., The social work said she called Resident #1s daughter when the resident requested to go see his wife. She said Resident #1s daughter did not provide her with any direction as what they were to do. The social worker said she just redirected the resident. The social worker said she asked the daughter if he could go back to the facility and she was informed his wife's children felt very strongly about him staying separated from her. She said she did make a referral for psychological services to help him. She said she was not aware the resident was allegedly banned from the nursing facility his wife resided. During an interview on [DATE] at 11:54 a.m., the DON said she was aware the family did not want the resident to go see his wife but did not know why. The DON said the resident always asked staff to take him to see his wife and offered to pay staff. She said the resident had this behavior since he was admitted . The DON said she did not need to care plan the resident wanting to see his wife, because the resident was able to make his own decision. She said the resident was not an elopement or wander risk. During an interview on [DATE] at 10:47 a.m. RN F said she was new to the MDS position and was not sure of how the care planning and care conferences operated. LVN K said she was the regional MDS nurse and was unsure how this facility did their care planning and care conferences. She said all the facilities did things differently. She said she was training RN F to provide the MDS scheduled to the social worker who would then schedule all the care conferences. She said she could not speak on how the care planning was done at the facility, but the care planning should have been completed by the social worker. During an interview on [DATE] at 10:52a.m., the social worker said the MDS nurse was responsible for the care plans. She said they had been without an MDS nurse for several months. She said the MDS coordinator was responsible for the care conferences and documented any issues or changes related to resident care and services. The social worker said all departments were present during the care conferences and would review/ update the care plan as needed. The social worker said over the past 2 or 3 months they had no care conferences due to not having an MDS nurse and COVID-19. She said she did not know when they were going to resume. She said her role was to make the appointments for the care conferences with families, responsible parties, and residents. The social worker said care conferences were scheduled for annually, admission, quarterly, 30 days, and as needed. During an interview on [DATE] 11:50 a.m., NP said the resident was capable of making his own decisions. She said the resident was alert and oriented. The NP said she felt the resident was safe to sign himself out of the facility as long as he received all of his medication. The NP said she was not aware the resident had not received his medications prior to leaving the facility. The NP said she expected all residents to receive their medication for the day when they went out on pass. During an interview on [DATE] at 2:53 p.m., DON said she was not aware of why Resident #1 was not allowed to see his wife. She said she was not aware the resident was banned from his previous facility. She said the resident would always just say he wanted to see wife. She said Resident #1s roommate told her on [DATE], that on Friday ([DATE]) Resident #1 told him he was dying and wanted to see his wife before he died . During an interview on [DATE] at 11:32 a.m., the administrator said Resident #1 had a right to go see his wife, he said the resident had a BIMS of ,d+[DATE] and it was his right to sign himself out of the facility. He said he was aware that the resident had signed out with another family. He said the resident did not have any health issues that made him unsafe to leave on pass. He said he was not aware of the resident being banned from the facility his wife was located. He said all he knew was what the resident told him which was that he was separated from his wife against his will. The signing Resident out policy updated ,d+[DATE] indicated all residents leaving the premises must be signed out .2. A sign-out register is located at each nurse station. Registers must indicate the residents expected time of return. 3.medications that must be administered while the resident is out will be given to the resident/person signing the resident out. 4. Written and /or oral instructions on when and how to administer the medications will be provided to the resident or to the person signing the resident out. Only medications that must be administered while the resident is out will be passed .6. Staff observing a resident leaving the premises, and having doubts about the resident being properly signed out should notify their supervisor at once. 7. Restrictions noted on the residents chart concerning who may not sign the resident out must be honored unless otherwise prohibited by the facility policy or state/federal law governing such releases .10. Inquiries concerning the signing out of residents should be referred to the Director of nursing services or the administrator. A review of the facility care plan policy revised ,d+[DATE] indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functions needs is developed and implemented for each resident .8. The comprehensive, person centered care plan will: .b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .g. incorporate identified problem areas. H. incorporate risk factors associated with identified problems . m. aide in preventing or reducing decline in the residents' functional status and;/or functional levels . A review of the Goals and objective, care plans policy revised ,d+[DATE] indicated the care plan goals and objective are derived from information contained on the residents comprehensive assessment and: a. are residents oriented, are behaviorally stated, are measurable; and contain timetables to meet the residents needs in accordance with the comprehensive assessment. The administrator was notified on [DATE] 12:19 p.m., that an IJ situation was identified related to quality of care due to the above failure. The administrator was provided the IJ template on [DATE] at 12:21 p.m. The facility's Plan of Removal was accepted on [DATE] 6:45 p.m., and included the following interventions: 1.Notify the medical director of the IJ status. MD notified per DON on [DATE]. 2.Notify the regional director of clinical services of the IJ status. Notified per administrator on [DATE]. 3. Notify the area administrator of the IJ status. Notified per administrator on [DATE]. 4. Resident #1 no longer resides in the facility. 5. Facility will determine if any Residents are signed out on pass/ therapeutic leave at this time.- No residents were signed out on pass/ therapeutic leave at this time. Completed [DATE] 6. Licensed nursing staff will be provided education by the DON/ADON regarding the following procedures for Residents who are going out of the facility out on pass or therapeutic leave: Residents who are signing out on pass should be assessed by licensed nurse on duty prior to leaving the facility. Ask the resident the expected time for return and have residents/ responsible party complete the sign in/sign out entry sheet, Medications that may be scheduled while resident is out of the facility will be provided to the resident and or/ person signing them out, The nurse on duty for an assigned resident going out of the facility will provide written or oral instructions regarding medication administration, An entry will be made in the residents record of the education and medication provided to the resident or responsible party. The DON/Designee will be notified of any issues related to the residents request and/ or sign out situation. Reviewed signing residents out policy with licensed nurse, Reviewed signing resident out policy with licensed nurses, Reviewed sign in/ sign out sheet with licensed nurses, Reviewed release of responsibility for medications, Education started per DON on [DATE] at 5:50p.m. Nurses who are not on duty will be notified to come to the facility for educations by the ADON/Designee. A nurse will not be allowed to start their shifts until education has been completed. All education was completed on [DATE] at 5:05p.m. Nurses who are not on duty will be notified to come to the facility for education by the ADON/Designee. A nurse will not be allowed to start until education had been completed. 7. Licensed nursing staff will be provided education by the facility DON/ AON regarding the safety of vulnerable residents who may make decisions that are not safe: If a resident chooses to do something that may pose a significant risk to their health and safety the nurse on duty has reason to believe that a resident decision could put them at risk, the nurse will provide education to the resident regarding potential risks related to their decision. The nurse will utilize evaluation and assessment processes of the resident to identify any potential risk related to their decision. The residents family or responsible party will be notified by the nurse of the residents decision and protentional risk associated with the decision. An entry will be made in the residents record the education provided to the residents or responsible party. A care planning conference may be scheduled if necessary to discuss and attempt to resolve any issues or concerns. The DON/ Designee will be notified of any issues related to the residents request and/ or sign out situation. Education started per DON on [DATE] at 5:50p.m. Nurses who are not on duty will be notified to come to the facility for educations by the ADON/Designee. A nurse will not be allowed to start their shifts until education had been completed. 8. Compliance to be monitored through: A review of the 24 hours report, residents EMR, sign in/ sign out sheet, release of responsibility for medications by nursing management on during clinical meetings with corrective actions taken for identified concerns Findings will be submitted to the facility QAPI committee for review and additional audits if indicated. 9. Educations will be provided to the facility nursing management and QAPI committee members on compliance monitoring procedures by regional director of clinical services. Completed [DATE] at 2:10p.m. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: During interviews with 12 staff (DON, 1 RN, 6 LVNs, 3 CNAs,) the staff were successfully able to communicate the procedure for signing out/ signing in residents: During an interview on [DATE] 9:00 a.m. LVN B said they were to assess the residents prior to them leaving the facility. She said they were to make sure the resident had enough medications for the time they would be out of the facility. She said they were to call the DON and the police is she felt a resident was not safe leaving the facility. She said they were to also notify the residents family or responsible party when a resident left the facility. She said when they sign out the are to come the form: time and date they left, how long they will be gone. She said they were to document in the residents records. She said they were to provide education to th [TRUNCATED

Based on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet residents mental and psychological needs1 of 3 residents reviewed for comprehensive resident assessment . (Resident # 1) The facility did not develop and implement an individualized comprehensive care plan for Resident #1 to address: *his impaired judgment and repeated unrealistic expressed desire to leave the facility and go see his wife; *a plan to facilitate a safe and adequately supervised method to visit his wife; *a plan to assist the resident with adjustment to the nursing home and absence from his wife; *the identification of Resident #1 as a vulnerable resident and at risk for making decisions that placed his health and safety at risk; An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of injury and death. Findings included: A face sheet dated [DATE] indicated Resident #1 was [AGE] years old, initially admitted on [DATE] , readmitted [DATE], and had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An MDS dated [DATE] indicated Resident #1 had moderate cognitive impairment with a BIMS of 9. The assessment indicated he understood with clear comprehension, had no behaviors and required supervision with ADL care. The resident had range of motion limitation in both lower extremities and used a wheelchair for mobility. A care plan dated [DATE] and last reviewed [DATE] indicated the following: *Resident #1 was at risk for complications related to hypertension with interventions including: administer antihypertensive medications as per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . * Resident #1 had CHF (congestive heart failure) and was at risk for SOB (shortness of breath), chest pain, increased [CONDITION(S)] (fluid retention), increased blood pressure as evidenced by pulmonary [CONDITION(S)] (fluid in lungs), [CONDITION(S)] of extremities (legs and arms), pain and apprehension. Interventions included: administer medications for CHF per physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . *Resident #1 was at risk for dehydration as evidenced by use of a diuretic with interventions to assess, document and notify the physician as needed for skin turgor, urine output and dry cracked lip; monitor for elevated temperature, blood pressure, constipation and report to the physician any abnormalities occurring. *Resident #1 has some cognitive loss and at times includes supervision with ADLs. *Resident #1 wished to remain a full code. Interventions included: staff will start CPR should [CONDITION(S)] occur and/or breathing independently cease, call 911 and transport to ER; staff to notify MD (physician) and RP (responsible party) of any changes in condition. * Resident #1 was at risk for complications related to [CONDITION(S)] (a high amount of fat in the blood) with interventions including: administer medication as ordered by the physician (Atorvastatin), monitor for effectiveness and side effects of medication, document and notify physician as needed. *Resident #1 was at risk for complications and injury related to anticoagulation/antiplatelet therapy with interventions including: assess, document and report to physician as needed for abnormal or unexplained bleeding, bruising, ecchymosis, petechiae, purpura and tinnitus, administer medication per physician orders, monitor effectiveness (coumadin, aspirin) .protect me from injury by avoiding sudden movements, bumps when transferring or providing care . *Resident #1 had cognitive impairment with long and short-term memory loss and poor recall due to diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An Intervention was: he would be explained all procedures in terms or gestures that can understand prior to assisting with care issues daily. The care plan did not address the residents commitment to leaving the facility to see his wife, impaired judgment and repeated attempts to get visitors and staff to take him to see his wife. During an interview on [DATE] at 10:47 a.m. RN F said she was new to the MDS position and was not sure of how the care planning and care conferences operated. LVN K said she was the regional MDS nurse and was unsure how this facility did their care planning and care conferences. She said all the facilities did things differently. She said she was training RN F to provide the MDS scheduled to the social worker who would then schedule all the care conferences. She said she could not speak on how the care planning was done at the facility, but the care planning should have been completed by the social worker. During an interview on [DATE] at 10:52a.m., the social worker said the MDS nurse was responsible for the care plans. She said they had been without an MDS nurse for several months. She said the MDS coordinator was responsible for the care conferences and documented any issues or changes related to resident care and services. The social worker said all departments were present during the care conferences and would review/ update the care plan as needed. The social worker said over the past 2 or 3 months they had no care conferences due to not having an MDS nurse and COVID-19. She said she did not know when they were going to resume. She said her role was to make the appointments for the care conferences with families, responsible parties, and residents. The social worker said care conferences were scheduled for annually, admission, quarterly, 30 days, and as needed. The initial social service history form dated [DATE] indicated Resident #1 was admitted from the hospital and needed skilled care. The resident previously resided in a skilled nursing facility with his wife. The note indicated the residents behavior led their children to separate the resident from his wife and the wife remained in a SNF in another city (did not specify a specific behavior). Social worker note indicated the resident while there had no prior mental health history or hospitalization s. A behavioral health diagnostic assessment dated [DATE] completed by a psychologist/psychiatrist/ counseling agency indicated Resident #1 was tearful and stated I brought it on myself. I wrote down on a piece of paper I'm going to kill my wife and myself because we're not going to be abused. The assessment indicated the resident's diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The assessment indicated Resident #1's cognitive assessment needed to be monitored as there were indicators of an incipient (beginning) dementia process. Resident #1 was oriented to person, place and situation with confusion around the date. Psychological services note dated [DATE] indicated the resident had a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The note indicated the resident had mild cognitive decline and his judgement was moderately impaired. The intervention was to assist with decreasing negative emotion to improve clarity of thought, especially around decision making. The note indicated the resident said he was trying to get out of the facility so he could care for his wife. The note indicated the resident expressed anger towards the facility because he believed they withheld information until the last minute which allowed them to control his life. The note indicated the resident was committed to discharging and taking care of his wife and was resistant to interventions with a single mindedness to be with his wife. The note indicated the resident dismissed reality of interference by his children and the need for a resource in fulfilling his plan. The note indicated cognitive fluctuations posed a guarded prognosis. The note indicated the plan was to facilitate realistic planning around living situation and relationship with wife. A review of clinic records dated [DATE] indicated Resident #1 visited the device clinic for his pacemaker checkup. It was noted the dual-chamber pacemaker pulse generator triggered ERI (elective replacement indication triggered when device is nearing end of life) and previously triggered ERI on ,d+[DATE] and had gone unnoticed. The note indicated the resident was pacemaker dependent (a risk of serious injury or death from sudden pacemaker failure). The resident was admitted for an urgent pulse generator change out for [DATE]. A nursing note dated [DATE] at 11:51 a.m. indicated the resident returned from the hospital via ambulance due to pacemaker replacement. An undated sign out/ sign in sheet indicated Resident #1 signed out on [DATE] at 9:00 a.m. A nursing note dated [DATE] at 2:27 p.m., late entry Completed by LVN B indicated Resident #1 and his roommate left with the roommates brother. The note indicated LVN A witnessed the resident in the front seat secured with seat belt. During a telephone interview on [DATE] at 5:52 p.m. LVN B said on Saturday ([DATE]) around 7:30 p.m. or 8 p.m. Resident #1 said he had a secret. LVN B said the resident told her he was going to see his wife and that his roommate was going to take him. She said she did not tell anyone about the residents' plan. She said she was aware of the residents family history and the circumstance of his separation from his wife due to knowing his daughter outside of work. LVN B said she was able to redirect the resident and told Resident #1 she would have to call his daughter if he were to leave the facility. LVN B said Resident #1 told her that he would leave in the morning. LVN B said she told the resident she would still be working in the morning so he would still have to see her to sign out and she would have to call his daughter and notify her before he could leave the facility. LVN B said the next morning ([DATE]) she saw the resident roll by the nurses station and asked if he was upset with her and the resident said he was not worried about that. LVN B said that was the last time she saw the resident that day. LVN B said she received a phone call from Resident #1s daughter asking her why they left the resident leave the facility. LVN B said she told the daughter the resident was in the facility, but would go verify. LVN B said she searched for the resident and LVN A told her Resident #1 had signed out and left with his roommate and his family. LVN B said she explained to the daughter the resident had 24 hours to get back into the facility before he had to be placed back on the isolation unit. LVN B said the resident never returned to the facility. LVN B said she did not know why the daughter would not let him leave the facility to go see his wife. She said she felt the resident was competent and could make his own decisions. She said the resident had always made his own decisions and had not been deemed incompetent. LVN B said ever since she knew the resident he had always said he was going to see his wife but this time he actually did it. LVN B said she did not think the resident would actually leave the facility. LVN B said the residents did not receive any of his morning medications because MA C came to her searching for the resident to give him his medication after he left. LVN B said the resident did not take any of his medications with him for the day because she was on her medication cart when LVN A told her he had left the facility. During a telephone interview on [DATE] at 3:10 p.m., LVN A said he was on the 300 hall on the medication cart and Resident #1 rolled up and asked if he minded getting the sign out book for him. LVN A said he asked the resident where he was going and the resident said he was going to see his wife. LVN A said he asked the resident how he was going to get there and he said he paid his roommates brother in law to drive him. LVN A said he asked the resident if he discussed leaving with LVN B, who was the residents charge nurse. He said the resident said do not bother her. LVN A said the resident signed himself out and put the date and time. LVN A said he explained to the resident that by signing the form he was responsible for himself in the community. He said he asked the driver where they were going and he said (a city approximately 3 hours away) and they would be back some time that day ([DATE]). LVN A said he told them the resident had to be back in the facility before 12 midnight. LVN A said he was not aware of the time frame Resident #1 would be out of the facility. LVN A said he notified LVN B that the resident had left the facility, and by then Resident #1s daughter called the facility and questioned him about allowing the resident to sign out. LVN A said he explained to her the resident had the right to sign himself out. LVN A said the resident was not assigned to him and he did not check to see if the residents had received his medications of for the day. LVN A said if the resident was assigned to him he would had made sure the resident got his morning medications and any medications they may have needed for the time they were out of the facility. LVN A said he was not aware of Resident #1 having any behaviors and had no directions on what to if he requested to leave to go see his wife. He said he felt the resident was safe and was competent to make his own decisions. LVN A said he knew Resident #1s wife lived in the same facility had lived prior. He said he was not aware the resident was allegedly banned from leaving the facility. He said he did know Resident #1 wrote in a personal journal that he wanted to kill himself and his wife and the family and the facility got involved. A police department incident report dated [DATE] indicated Resident #1s roommates family called 911 at 10:37:52 to report death of Resident #1. A nursing note dated [DATE] at 11:33 a.m., completed by LVN B indicated officer from another city called and said Resident #1 was in the back seat with no pulse present. LVN B informed officer to transfer resident to the nearest hospital to be pronounce death. LVN B called daughter and ADON was aware of changes. The resident was in route to Dallas to see wife. Hospital records dated [DATE] indicated the resident was brought to the hospital emergency department on [DATE] at 11:14 a.m. via ambulance. The record indicated the chief complaint was [CONDITION(S)]. The record indicated the cardiac arrested was witnessed in the car by a friend who thought Resident #1 was asleep. The record indicated the resident could not be aroused when they stopped for gas and 911 was called. The record indicated Resident #1 was last seen awake 1.5 hours prior to calling 911. Upon EMS arrival the resident was unresponsive and his pulse was absent. The record indicated the resident expired do to [CONDITION(S)]. During a telephone interview on [DATE] at 1:23 p.m., Resident #1s daughter said prior to [DATE] the facility repeatedly called her when the resident wanted to go see his wife. She said she told the staff to ignore the resident. She said she did not receive a call from the facility on [DATE] when the resident left the facility. She said the resident called her and told her he was on his way to see his wife. She said she called the facility and was told the resident signed himself out. She said she later received a call from the hospital notifying her the resident was deceased . She said prior to moving to the facility, the resident was living at a different facility with his wife. She said an aide at his previous facility, found his opened journal on his bed and discovered he had written in his journal he was going to kill himself and his wife. She said the resident had it in his head his wife was cheating on him because male staff were providing peri-care for her. She said the resident was banned from going back to that facility. She said the residents wife still resided at the facility. During a telephone interview on [DATE] at 12:35 p.m., a family member of Resident #1s roommate said on Friday ([DATE]) she spoke with Resident #1 over the phone and he asked if he could be taken to see his wife in (a town approximately 3 hours away). She said her husband and the resident made an arrangement to go Sunday ([DATE]). She said that was the first time she had ever spoken to Resident #1. She said they picked them up on Sunday and the resident was rolled out to the car and her husband and the aide assisted Resident #1 into the front seat of the car. She said she was not provided any medical history about the resident and the residents was not provided any medication. She said they made one stop before heading to out. She said they were all making small talk. She said Resident #1 abruptly stopped talking at the and his head dropped down. She said she asked Resident #1s roommate if the resident had sleeping issues, and Resident # 1s roommate replied he was tired and to let him sleep. She said a few minutes later the resident had a foul smell, and they had to air out the car by letting the windows down. She said her husband tried to wake him and Resident #1s roommate nudged him from the back seat and the resident did not awake. She said she called his named and touched the back of the residents neck (she was seated behind Resident #1) and the resident was cold. She said they hit a pot hole in the road and the residents body slumped down in the seat. She said told her husband to pull over because Resident #1 had expired. She said they pulled over at a gas station and called 911. She said the facility did not inform her of any of Resident #1's medical conditions and if she had known, she would have never taken him to see his wife. She said she felt if the facility allowed the resident to sign out, he was healthy enough to travel. She said she did not ask about Resident #1s health conditions. She said the facility did not tell her the resident could not go see his wife. During a telephone interview on [DATE] at 5:26 p.m., the social worker said Resident #1 had the right to leave the facility. She said the resident scored a ,d+[DATE] (no cognitive impairment) on his most recent BIMS assessment and had no POA or guardianship. The social worker said she was aware the resident had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . She said his wife's children or wife and children wanted them separated. She said the resident had no current behaviors. During an interview on [DATE] at 11:36 a.m., the social worker said had mistakenly said the resident had a BIMS of 15 and the resident actually had a BIMS of 5 (severe cognitive impairment). She said a BIMS of 5 and above was high functioning. She said the resident did not have short term or long-term memory loss. She said the resident did have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . She said 3 weeks ago he said his wife had a stroke and he needed to go see her. The social worker said she called the daughter about the residents' concerns and was told his wife did not have a stroke. During an interview on [DATE] 3:24 p.m., The social work said she called Resident #1s daughter when the resident requested to go see his wife. She said Resident #1s daughter did not provide her with any direction as what they were to do. The social worker said she just redirected the resident. The social worker said she asked the daughter if he could go back to the facility and she was informed his wife's children felt very strongly about him staying separated from her. She said she did make a referral for psychological services to help him. She said she was not aware the resident was allegedly banned from the nursing facility his wife resided. During an interview on [DATE] at 11:54 a.m., the DON said she was aware the family did not want the resident to go see his wife but did not know why. The DON said the resident always asked staff to take him to see his wife and offered to pay staff. She said the resident had this behavior since he was admitted . The DON said she did not need to care plan the resident wanting to see his wife, because the resident was able to make his own decision. She said the resident was not an elopement or wander risk. During an interview on [DATE] 11:50 a.m., NP said the resident was capable of making his own decisions. She said the resident was alert and oriented. The NP said she felt the resident was safe to sign himself out of the facility as long as he received all of his medication. The NP said she was not aware the resident had not received his medications prior to leaving the facility. The NP said she expected all residents to receive their medication for the day when they went out on pass. During an interview on [DATE] at 2:53 p.m., DON said she was not aware of why Resident #1 was not allowed to see his wife. She said she was not aware the resident was banned from his previous facility. She said the resident would always just say he wanted to see wife. She said Resident #1s roommate told her on [DATE], that on Friday ([DATE]) Resident #1 told him he was dying and wanted to see his wife before he died . During an interview on [DATE] at 11:32 a.m., the administrator said Resident #1 had a right to go see his wife, he said the resident had a BIMS of ,d+[DATE] and it was his right to sign himself out of the facility. He said he was aware that the resident had signed out with another family. He said the resident did not have any health issues that made him unsafe to leave on pass. He said he was not aware of the resident being banned from the facility his wife was located. He said all he knew was what the resident told him which was that he was separated from his wife against his will. A review of the Care plan, comprehensive person-centered policy revised ,d+[DATE] indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the residents physical, psychological and functions needs is developed and implemented for each resident .8. The comprehensive, person centered care plan will: .b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing .g. incorporate identified problem areas. H. incorporate risk factors associated with identified problems . m. aide in preventing or reducing decline in the residents' functional status and;/or functional levels . 14. The interdisciplinary team must review and update the care plan: a. when a significant change occurs in the residents condition, when a desired outcome is not met, during a readmission from a hospital stay, and at least quarterly. A review of the Goals and objective, care plans policy revised ,d+[DATE] indicated the care plan goals and objective are derived from information contained om the residents comprehensive assessment and: a. are residents oriented, are behaviorally stated, are measurable; and contain timetables to meet the residents needs in accordance with the comprehensive assessment. The DON was notified on [DATE] at 2:31 p.m., that an IJ situation was identified due to the above failure. The DON was provided the IJ template on [DATE] at 2:32 p.m. The facility's plan of removal was accepted on [DATE] at 1:58 p.m., and included the following: 1. Notified the Medical Director for Immediate Jeopardy status. Physician notified per the DON on [DATE] at 2:47p.m. 2. Notified Regional Director of Clinical Services of Immediate Jeopardy Status, who was notified per Administrator on [DATE] at 2:45p.m. 3. Notified the Area Administrator/Regional Director of Operations of Immediate Jeopardy status, notified per administrator on [DATE] at 2:43p.m. Regional director of operations notified on [DATE] at 2:53p.m. 4. Resident #1 no longer reside in the facility. 5. Facility will conduct audit of Resident's Care Plan Schedule. Completed [DATE] at 2:15p.m. 6. The facility Interdisciplinary Care Plan Team was provided education by the facility DON regarding requirements for measurable objectives in Comprehensive Care Plans and timely updating procedures. A schedule will be developed by the MDS Coordinator and letters will be sent out by the social worker. Completed [DATE] at 10:30a.m. 7. The facility Interdisciplinary Care Team was provided education by the Regional Director of Clinical Services on Care Plans. a. Care planning-interdisciplinary Team b. Care Plan Comprehensive Person- Centered c. Goals and Objectives, Care plans d. Resident Participation-Assessment/Care Plans e. Using the Care plan f. Roles of Staff Members- i. MDS Coordinator to send out Care Plan Calendar every week and monthly ii. Social Services is to notify resident/ responsible party and schedule Care Plan Conferences. iii. Social services will notify the rest of IDT od scheduled care plan conferences in a leadership meeting. iv. Each IDT Member will complete review care plans related to identified needs from assigned MDS coding responses. g. Routine scheduled care plans are scheduled every Thursday beginning at 10am unless an alternate schedule is indicated to accommodate Resident and or Responsible party. h. Care plans are due on admission, quarterly, with an identified change of condition, and on an annual basis. i. Care Plan Calendars provided for April-[DATE] MDS Coordinator will continue to update calendar and notify the IDT of any changes. Completed [DATE] 5:30p.m. 8. Compliance will be monitored thorough: a. Review of care plans as weekly schedule per schedule by IDT with corrective actions taken for identified concerns. b. Findings will be submitted to the facility QAPI Committee on a monitoring basis or review and additional audits if indicated. 9. Education will be provided to the facility Interdisciplinary Care Plan Team on compliance monitoring procedures by the Regional Director of Clinical Services. Completed [DATE] at 5:30p.m. 10. Interdisciplinary Care Plan Team provided education on development and completion of individualized (person centered) care plans based on MDS assessment, resident wishes, assessment of resident strengths, needs and any personal or cultural preferences. In corporate resident's personal and cultural preferences and develop a plan of care with measurable goals. Any areas of concerns that are identified during resident assessments will be evaluated before any interventions will be added to the care plan. The Activity director will be in-serviced when she returns on [DATE]. Completed [DATE] at 12:35p.m. On [DATE] the surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Conducting interview with 7 staff (Social worker, Administrator, DM, therapist, and 3 RN) During an interview on [DATE] at 3:14p.m., the therapy director said she was to address the residents individual needs as it related to therapy disciplines. She said the care plans and meetings needed to be completed timely. She said IDT meetings were to be every Thursday at 10a.m She said they were to be completed annually, quarterly, significant change, and as needed. She said the MDS was to provide them with a schedule and they were to follow that schedule unless it had been updated. During an interview on [DATE] at 3:18p.m., RN S said she was responsible for making sure the care plans are carried out and to ensure the care plan meetings were happing ever Thursday by 10:30a.m. She said she was to help the social worker call the families and make arrangements for the IDT meetings. She said if a responsible party could not attend at the scheduled time then she was to ensure it could reschedule around a time best for them. She said the MDS and care plans were to be completed and reviewed annually, quarterly, significant change, and as needed and that care plans were individualized and person centered. During an interview on [DATE] at 3:22p.m., RN F said she was do make a weekly MDS schedule and hand it out during the morning meeting. She said if she needed to update the schedule she would provide all the IDT member with an updated calendar as needed. She said the care plan meeting are every Thursday at 10:30a.m., or depending on when the family could make it. She said the care plans to were to be individualized and specific to the resident. She said she completed an audit on all the charts and had her work cut out for her. She said updating and resolving the care plans during the IDT meeting with make it easier process to keep all information current. She said all IDT member were to sign the care plan once they updated it. During an interview on [DATE] at 3:28p.m., the DM said IDT meeting were to be completed annually, quarterly, significant change, and as needed. She said the MDS coordinator was to provide them with a schedule and they were to follow that schedule unless it had been updated. She said each discipline was responsible for making changes to the care plan as it related to their department and sign saying it had been reviewed/ Resolved and dated. She said they did not have to wait until the next care plan meeting if a resident had a significant change of condition, they could call a meeting and discuss the situation as needed. She said they also had to make sure the care plans were person centered. During an interview on [DATE] at 3:35p.m., the administrator said his roll to make sure the compliance was held up on the care plans. He said he was to ensure care plans were held as scheduled and as needed. He said the MDS nurse was to provide all IDT member with a schedule and was responsible for keeping it updated. He said the social worker was to mail out letters and contact the families notifying them of the times scheduled and she was responsible for ensure families were accommodated if they needed to meet another day or time. He said the meetings were held on Thursday at 10:00a.m. He said if he found negative finding while monitoring compliance then he will get it addressed and place the issue in QA, monthly until resolved. He said the audit of all resident charts were completed and they will be working on the care plans. He said all the department supervisors were aware of their roles when it came to care plans and IDT meetings. During a telephone interview on [DATE] at 3:37p.m. the social worker said her role was to notify the resident and families of the scheduled IDT meetings and make sure adjustments were made if a responsible party was unable to meet at the time of the schedule meeting time. She said the IDT meetings were to start around 10:30a.m She said they could meet as need if an issue arose that was not scheduled. She said the MDS nurse will try to give a 30-day notice. During a telephone interview on [DATE] at 3:41p.m., the DON said she in-services everyone on Friday and what their duties were for IDT, MDS, and Care plans. She said she then re-in serviced them today about making sure the care plans were person centered. The DON said her role was to make sure MDS nurse gave a calendar and gave report on any [TRUNCATED]

Based on observation, interview and record review, the facility failed to provide the necessary treatment and services, based on a comprehensive assessment and in accordance with professional standards of practice, to prevent pressure injuries development and promote healing for 1 of 8 residents reviewed for pressure injuries. (Resident # 4) The facility did not reposition Resident #4 while he was in his wheelchair and did not place Resident #4's [DEVICE] dressing on his stage 4 sacral pressure injury for approximately 4 ½ hours after he returned from the wound clinic. The resident developed a new facility acquired unstageable pressure injury on his left hip. This failure could place 8 residents with pressure injuries at risk for the development and worsening of pressure injuries. Findings included: Physician orders [REDACTED].#4 was readmitted [DATE], was [AGE] years old with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Change dressing every Monday, Wednesday, and Friday. If the resident was sitting in the wheelchair, he needed to do buttock lifts every 15 minutes. The order indicated he needed to stay off his buttocks as much as possible. A Braden Risk Assessment Report dated 1/3/18 indicated Resident #4 was a moderate risk for the development of pressure injuries. A care plan initiated 1/10/18 indicated Resident #4 had a problem identified as a stage 2 pressure injury of the sacrum. It was updated 1/26/18 to indicate the resident had deterioration of his sacral pressure injury to a stage 4. The care plan for Resident #4 was not updated to include the wound care center intervention (from 3/6/18) of repositioning the resident with buttocks lift every 15 minutes while up in wheelchair or to limit his time up in the wheelchair as ordered. An MDS dated [DATE] indicated Resident #4 had moderately impaired cognition, unclear speech, and was usually understood and usually understood others. He required extensive assistance of 2 staff for bed mobility, transfer, and toileting. An indwelling catheter was in place and he was always incontinent of bowel. He had 1 unstageable pressure injury measuring 6.3 cm x 3.7 cm x 1.5 cm with slough present. A wound assessment report dated 4/23/18 indicated Resident #4 developed a new unstageable pressure injury on his left hip measuring 2 cm x 2 cm x 0 cm with slough over 95% of the surface area. A care plan initiated on 2/8/18 with a review date of 5/3/18 indicated Resident #4 was at risk for developing pressure injuries related to a Braden score of 18 or below, poor nutritional status, dry skin, immobility due to pain, incontinence, [MEDICAL CONDITION], and disease process. Interventions did not include repositioning the resident with buttock lifts every 15 minutes while he was up in his wheelchair or to limit the time he was up in the wheelchair. A wound and skin status report sheet dated 5/8/18 indicated Resident #4's unstageable pressure injury on his left hip measured 1.90 cm x 1.50 cm x 0.00 with 90% slough/eschar covering the wound bed. A wound care clinic report dated 5/8/18 indicated a treatment order change for Resident #4's left trochanter (hip) wound: Medi-honey gel to his left hip wound. Change daily. Cover with a gauze or a band-aid. The wound care report did not include measurements or a description of the pressure injury. A wound care clinic assessment dated [DATE] at 9:00 a.m. indicated Resident #4's stage 4 pressure injury on the sacrum area measured 6.3 cm x 1.5 cm x 1.5 cm. The onset date of the wound was 1/12/18. Physician orders [REDACTED].#4's treatment of [REDACTED]. Change dressing every Monday, Wednesday, and Friday. If the resident was sitting in the wheelchair, he needed to do buttock lifts every 15 minutes. The order indicated he needed to stay off his buttocks as much as possible. An emergency transport notification dated 5/11/18 at 9:39 a.m. indicated Resident #4 returned to the facility from wound care on 5/8/18 at 11:07 a.m. During an observation on 5/8/18 at 11:30 a.m., Resident #4 was seated in a wheelchair in front of the nursing station after returning from the wound care clinic. There was a wound vac and tubing hanging on the wheelchair, but it was not connected to anything. During an observation on 5/8/18 at 12:05 p.m., Resident #4 was seated in a wheelchair in the dining room. During an observation on 5/8/18 at 12:16 p.m. Resident #4 was seated in a wheelchair in the dining room and was spoon-fed a pureed diet. Resident #4 was not repositioned or offloaded off of his buttocks every 15 minutes while he was in his wheelchair. During an interview on 5/9/18 at 3:30 p.m., MA G said after lunch (on 5/8/18) she took Resident #4 outside while he was up in his wheelchair. She said she did not reposition Resident #4 in the wheelchair every 15 minutes and had not been instructed to do so. MA G said she knew he should be turned while in the bed every two hours. During an observation on 5/8/18 at 2:22 p.m., Resident #4 was transferred to bed from his wheelchair and placed onto his back. During an observation and interview on 5/8/18 at 3:36 p.m., the wound care nurse said she was distracted and did not put the wound vac on Resident #4 when he returned from the wound care clinic. She said she normally put the wound vac on soon after he came back from wound care. Resident #4 was repositioned onto his left side off his back and a sacral dressing was in place to the sacral area. There was no wound vac attached. The wound care nurse removed the dressing applied at the wound care center and performed wound care to the sacral ulcer and applied the wound vac. Resident #4 was repositioned onto his right side and a dressing was removed from the left hip area. After the wound care nurse cleaned the left hip pressure injury, the wound bed was covered with yellow slough and measured 1.90 cm x 1.50 cm x 0.00 cm. During an interview on 05/09/18 09:11 a.m., Resident #4 said staff were not turning him at night. He said he had not refused to be repositioned in bed or in a wheelchair. He was not sure how long he had the pressure injury to his tailbone. During an interview on 5/10/18 at 10:11 a.m., CNA K said she worked with Resident #4 in the evenings. She said she turned him from side to side every 2 hours while in bed and would reposition him every 2 hours while up in a wheelchair. CNA K said she did not do buttocks lifts every 15 minutes while Resident #4 was in his wheelchair, she had not been instructed to do so. During an interview on 5/11/18 at 10:27 a.m., the DON said the wound care clinic sent orders back to the facility after seeing Resident #4. She said if Resident #4 had orders to have buttock lifts every 15 minutes the orders should be followed. During an interview on 5/11/18 at 3:55 p.m., the administrator said staff should follow physician orders [REDACTED]. A Pressure Ulcer Risk Assessment with a revision date of September, 2013 indicated the following: .General Guidelines 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues . According to the National Pressure Ulcer Advisory Panel, http://www.npuap.org/resources/educational-and-clinical-resources, reviewed 5/24/18, Pressure Injury: A pressure injury is localized damage to the skin and underlying soft tissue usually over a bony prominence or related to a medical or other device. The injury can present as intact skin or an open ulcer and may be painful. The injury occurs as a result of intense and/or prolonged pressure or pressure in combination with shear. The tolerance of soft tissue for pressure and shear may also be affected by microclimate, nutrition, perfusion, co-morbidities and condition of the soft tissue. .Stage 4 Pressure Injury: Full-thickness skin and tissue loss Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible. If slough or eschar obscures the extent of tissue loss this is an Unstageable Pressure Injury. .Unstageable Pressure Injury: Obscured full-thickness skin and tissue loss Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. If slough or eschar is removed, a Stage 3 or Stage 4 pressure injury will be revealed . The CMS 672 dated 5/8/18 indicated 8 residents had pressure injuries.

Based on observation, interview, and record review, the facility failed to provide adequate supervision and assistance devices for 1 of 6 residents reviewed for accidents and supervision. (Resident # 1) Resident #1, who had a history of [REDACTED]. An Immediate Jeopardy was identified that existed from 07/03/16 to 07/08/16. This was determined to be past non-compliance. The facility implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place 3 residents who were at high risk for elopement at risk of injury or death. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The orders indicated the resident was to have a wander guard (device worn by a resident that triggers an alarm if the resident exits through selected doors) for safety, that was initiated on 01/18/16. A nursing admission assessment dated [DATE] indicated Resident #1 had a history of [REDACTED]. An elopement risk assessment dated [DATE] indicated Resident #1 had a [DIAGNOSES REDACTED]. The assessment indicated Resident #1 was living at home with his sister. Resident #1's sister reported the resident would attempt to leave the house and had no safety awareness, so she and her sister had to sit with him constantly prior to his admission to the facility. The assessment also indicated Resident #1 had a wander guard and staff would monitor his behavior. A social service note dated 01/20/16 indicated Resident #1 stayed at another nursing facility for two days prior to admittance on 01/18/16. Because he was a wanderer, he could not return back to the previous facility. The most recent MDS dated [DATE] indicated Resident #1 had moderately impaired cognition, had exhibited behaviors of wandering on a daily basis, was independent with walking in his room, and he required supervision when walking in the corridor. A nursing care plan dated 04/16/16 indicated Resident #1 was at high risk for elopement and required the use of a wander guard. Interventions included monitoring the wander guard placement, check functioning of the wander guard daily on the 6-2 shift, maintaining an updated photograph of the resident every 6 months, and allow safe wandering. The care plan also indicated Resident #1 had cognitive impairment and would wander out of the exit doors, if no one was watching. An additional intervention dated 07/14/16 indicated Resident #1 would have one-on-one sitters at his bedside and were to know the resident's whereabouts at all times. An incident report dated 03/14/16 at 7:00 p.m. indicated Resident #1 left the facility, and was walking around outside, by the front door. Resident #1 was encouraged to stay inside the facility for safety reasons. There were no visible injuries noted. The investigation indicated Resident #1 was observed by staff walking around by the front door. Resident #1 stated he was just outside. A wander guard was placed on the resident for safety. A social services note dated 03/16/16 indicated Resident #1 wandered up and down the halls and into other residents' rooms, apparently looking for food and a restroom. The note indicated the resident was able to get outside, but was easily redirected back into the building. A nursing note dated 04/04/16 at 7:30 p.m., indicated Resident #1 was agitated and said he was leaving. Resident #1 continued to ambulate within the facility. At 8:00 p.m. Resident #1 exited through the Hall 500 door, setting off the alarm. The resident went to the parking lot and was redirected by the staff. His wander guard was in place, but no additional safety measures were implemented. An incident report dated 04/10/16 at 4:00 p.m. indicated Resident #1 exited the facility front door and walked to the end of the sidewalk before the staff got to him. The staff assisted Resident #1 back inside the facility. The resident was very confused and agitated stating, I'm looking for my car to go home. Post-incident action indicated Resident #1's wander guard was checked and was working properly. The report indicated the front door would open if the handle was held down, even with the wander guard in place. No additional safety measures were implemented. An incident report dated 04/10/16 at 8:30 p.m. indicated Resident #1 was at the front exit door, with the door alarm sounding off. The nurse rushed to the resident, who became combative, and did not want to go back in the facility. After much encouragement, the resident went back inside the facility. Post-incident actions included observation of the resident and ensuring the safety alarm was in place. A narrative of the investigation indicated the staff said the resident was possibly sun downing, and was looking for a car. The staff redirected him to the parlor and his room, but the resident continued to look for a car. The wander guard was in place, but no additional safety measures were implemented. An incident report dated 04/10/16 at 8:40 p.m. indicated a CNA reported Resident #1 was outside the building, and she brought him back inside. The resident expressed his desire to leave the facility. The staff tried to reassure the resident and reminded him of the need for safety. The staff were to continue to monitor the resident and ensure all current safety measures were in progress. The narrative indicated Resident #1's sister took him out on pass, and upon his return he became agitated, wanting to leave. The plan indicated staff were to continue to redirect the resident and continue use of the wander guard. An incident report dated 04/15/16 at 10:30 p.m. indicated a CNA reported Resident #1 had stepped outside, then was assisted back inside the facility by staff. Staff would continue to monitor the resident's whereabouts, and his safety alarm was in place. The narrative indicated Resident #1 continued to wander, and his wander guard was in use. The staff was to continue visual checks, and provide diverse activities. An incident report dated 04/20/16 at 7:30 p.m. indicated a CNA reported Resident #1 went outside the facility and staff escorted him back inside the building. The resident was encouraged not to leave the facility without supervision. Staff were to continue monitoring Resident #1's location to ensure safety, and a safety alarm was in place. The narrative indicated Resident #1 learned to lean on the exit doors for 15 seconds to make them release. The staff were to continue to use the wander guard and to redirect the resident away from the doors. No additional safety measures were implemented. A nursing note dated 04/20/16 at 11:52 p.m., indicated a CNA reported Resident #1 went outside the facility and was escorted back in the building by staff. Staff encouraged Resident #1 not to leave the facility without supervision. During an interview on 07/19/16 at 2:10 p.m., CNA J said she could not recall where she found Resident #1 during the incidents on 04/10/16 or 04/20/16. She said she could not remember any details. She said Resident #1 constantly wanders around the facility and indicated he was fast. CNA J said due to the resident being a high risk of elopement, the staff would check on him more often than the other residents. She said Resident #1 had a wander guard in place and the doors would activate when he approached them and staff were to immediately respond to the alarms. A nursing note dated 06/12/16 at 10:30 a.m., indicated Resident #1 was very anxious, pacing the floor, and wandering around, on and off other units. Resident #1 got out the front door and the resident was found at the side of the building. The resident was assisted back inside the facility. The resident seemed to calm down, and the staff continued to monitor the resident. An incident report dated 06/12/16 at 11:00 a.m. indicated Resident #1 went out the front door and was found on the side of the facility. The wander guard was checked to ensure it was working properly, and the resident was kept in sight for safety. Resident #1's wander guard was functioning properly, and staff were to continue to monitor and redirect the resident. Stop signs, implemented to remind the resident not to exit the facility, were near the doors. During an interview on 07/19/16 at 10:40 a.m., LVN H said on 6/12/16, she was caring for Resident #1. She said during that shift Resident #1 was pacing up and down the halls of the facility. She said she heard the wander guard alarm go off at the main entrance. LVN H said she went to the door, could not see anyone, so she walked outside. She said another resident was sitting outside on the front patio and indicated Resident #1 went around the building. She said she ran around the side of the building towards the dumpsters and found Resident #1 walking towards the back of the building. LVN H said she was afraid Resident #1 was going to fall since he had an unsteady gait and had to run to catch him. She said Resident #1 knew to hold down the door bar and it would automatically open within a few seconds, even if the wander guard system was activated. She said she kept the resident with her at the nursing station the remainder of her shift. An incident report dated 06/15/16 at 8:00 p.m. indicated Resident #1 went outside the building, and staff assisted the resident back inside the facility. The report indicated Resident #1 went outside four times after the initial time that evening, and each time the resident was assisted back inside the building. The staff closely monitored Resident #1's whereabouts, and encouraged the resident not to go outside without assistance due to personal safety, and the wander guard was in place. The resident's wander guard was functioning properly, and staff were to continue to monitor and redirect the resident, and the stop signs remained in use on the doors. The resident was agitated. An incident report dated 06/28/16 at 7:00 p.m. indicated Resident #1 went outside. The staff intervened and assisted Resident #1 back inside the facility. The staff were to continue to closely monitor the resident and ensure the wander guard was in place. The investigation narrative indicated the resident's wander guard was functioning properly. The staff were to continue to monitor and redirect the resident, and the stop signs remained in use on the doors. An incident report dated 07/03/16 at 7:20 a.m. indicated the local police department called the facility at approximately 7:10 a.m.; and reported they picked up Resident #1 and he had been in their custody for over an hour. Resident #1 was brought back to the facility, escorted by a police officer, at approximately 7:20 a.m. The nurse conducted an assessment and noted a 2 cm by 2 cm abrasion on Resident #1's right knee and a 4 cm by 0.5 cm abrasion on his left elbow. All exit doors were checked against the resident's wander guard and were working. Resident #1 had a staff member sitting with him at that time and was placed on 15 minute checks. The investigation narrative indicated the resident's wander guard was functioning properly. Staff were to continue to monitor and redirect the resident, and the stop signs remained in use on the doors. A nursing note dated 07/03/16 at 7:20 a.m., indicated Resident #1 eloped from the facility, was found by the local police department and returned to the facility. The police officer reported Resident #1 was picked up around 5:30 a.m. walking on the road. An assessment was completed and Resident #1 was noted to have abrasions on his left arm and left knee. First aid was administered and the physician was notified of the incident. Resident #1's wander guard and all exit doors were checked and were functioning properly. A staff member was assigned to sit with the resident at that time. The staff were to continue to closely monitor Resident #1 throughout the shift. During an interview on 07/18/16 at 5:50 a.m., LVN A said she worked on 07/03/16, the night Resident #1 eloped from the facility. She said around 5:00 a.m., the staff were finishing up their final rounds and getting ready for the 6-2 shift to come in. She said she last saw Resident #1 around 4:00 a.m. walking down the hallway. She said she did not hear any alarms go off from that time until the end of the shift at 6:00 a.m. LVN A said Resident #1 had previously attempted to exit the facility, and the staff were aware they should monitor his whereabouts. During an interview on 07/18/16 at 5:56 a.m., LVN B said she was caring for Resident #1 on 07/03/16, the night he eloped from the facility. She said he attempted to exit the building numerous times, and each time the alarm was activated. LVN B said this particular time, there was no alarm activated. She said she last saw Resident #1 around 4:30 a.m. walking on Hall 100. She said Resident #1 had a wander guard in place and staff were reminded to monitor the resident due to his previous attempts to elope from the facility. She said the wander guards were checked daily on the 6-2 shift and was unsure why the alarm did not activate on 07/03/16. LVN B said she was unaware Resident #1 was not in the facility when she left after her shift that morning. She said she was later called by the DON and notified Resident #1 was found by the local police department, as the resident was walking down the road. She said between the times of 5:00 a.m. and 5:30 a.m., the staff were usually making their final rounds. She said she did not recall if anyone was located at the nursing station that morning. LVN B said Resident #1 would often attempt to elope during the late evening hours. She said she did not document which doors the resident exited in each incident, but indicated he usually would go out the main entrance. She said she could not specifically remember if the alarms were activated during those specific incidents, but indicated they must have, if the staff knew he was going outside. During an interview on 07/18/16 at 10:20 a.m., Resident #1 said he remembered getting out of the facility and walking down the street. The resident said he thought he went out the back door, where they go smoke. Resident #1 said he goes out any door he sees. He said on the night in question; he did not see anyone at the nursing station, and he was going home. During an interview on 07/18/16 at 1:15 p.m., the administrator said the local police department called around 7:00 a.m. on 07/03/16 and notified the staff they had picked up Resident #1 while he was walking down the street around 5:34 a.m. She said she used a map and identified the resident was less than a mile away from the facility when the police picked him up. She said once Resident #1 was returned to the facility, a staff member was assigned to sit with Resident #1 24/7 and the high frequency alarms were installed to the doors on Halls 200, 300, 400, and 500. The administrator said they had attempted to transfer Resident #1 to another facility with a secure unit, but they would not accept him. During an interview on 07/18/16 at 6:05 a.m., CNA C said Resident #1 was walking up and down all the halls on 07/02/16 and 07/03/16, the night and morning of his elopement. She said he was walking down Hall 200 around 4:30 or 5:00 a.m. when she last saw him. She said she was making her last rounds during that time and did not hear any alarms. CNA C said Resident #1 had a wander guard in place and the alarms would normally activate when he approached the doors. She said the staff were aware to closely monitor his whereabouts. She said since the incident, Resident #1 had 24 hour sitters. During an interview on 07/18/16 at 8:00 a.m., MA D said Resident #1 wandered around the facility, but she had not witnessed him attempt to exit the building. She said she was aware he required close supervision and indicated Resident #1 was normally asleep in his room or lying on the couch in the parlor watching television. During an interview on 07/18/16 at 8:10 a.m., RA E said she was assigned to check the wander guard system daily on the 6-2 shift. She said she checked each door equipped with the wander guard alarms (Hall 100, main lobby entrance, and the parlor exit) and checked the residents' wander guard bracelets. RA E said the other exits (Hall 200, 300, 400, and 500) required a key code to exit, and if pushed, they would alarm. She said the doors had recently been equipped with high frequency alarms, after Resident #1 eloped from the facility. RA E said she checked Resident #1's bracelet on the day prior to the interview, and it was functioning correctly. She said the bracelet activated the alarm when he was returned to the facility by the police officer. During an interview on 07/18/16 at 11:15 a.m., CNA F said she worked on 07/03/16, the night Resident #1 eloped from the facility. She said she last saw the resident around 3:00 a.m., lying on the couch in the parlor. She said everyone was making their final rounds for the shift between 5:00 a.m. and 5:30 a.m. CNA F said she did not remember anyone being at the nursing station and did not recall hearing any alarms during that time frame. She said there was another incident around 8:00 p.m. on the last Thursday of June where she found Resident #1 walking outside the building in the parking lot. CNA F said she had worked the day shift that day and left the facility. She said she returned to pick up some things when she noticed the resident in the parking lot. She said there were two other ladies outside and she had asked if they let him out the door. CNA F said the ladies said they did not let him out and indicated they witnessed him walk from around the back of the building. She said she was able to talk Resident #1 into going back inside with her, and assisted him inside the building. CNA F said she did not hear any alarms at that time when they entered the building. She said she walked the resident to the nursing station and notified the nurse. She said the staff did not appear to be looking for the resident or act like they knew he was outside. She said the staff were aware Resident #1 attempted to elope and were to monitor his whereabouts. During an interview on 07/18/16 at 12:26 p.m., LVN G said 07/03/16, the local police department called around 7:00 a.m. and said they picked up Resident #1 while he was walking down the road. She said she had not made her rounds on Hall 500, where Resident #1 resided before the police called. She said the police officer said he picked the resident up around 5:30 a.m. approximately 0.6 miles from the facility, on a road that was normally busy during daytime hours. LVN G said when the police officer arrived to the facility with Resident #1, the main entrance was activated by the resident's wander guard bracelet and the resident was smiling. She said RA E checked the bracelet again to ensure it was functioning, once the resident was inside the building. LVN G said she conducted an assessment and noted Resident #1 had abrasions on his right elbow and left knee. She said she asked the resident if he had fallen. She said this incident was not the first time Resident #1 attempted to leave the facility. She said he would usually attempt to leave during the evening hours. LVN G said since Resident #1 was at a high risk for elopement, the staff would monitor his whereabouts every hour. LVN G said Resident #1 knew if he leaned against the door bar for a few seconds, the door would automatically open. She said the facility installed the high frequency alarms after the resident eloped because the staff could not hear the key pad alarms. During an interview on 07/18/16 at 11:30 a.m., the maintenance supervisor said prior to Resident #1's elopement, he checked the doors weekly to ensure they were functioning properly. He said after the incident, he was assigned to check them daily. He said the high frequency alarms were installed after Resident #1 eloped from the facility. The maintenance supervisor said the exit doors on Halls 200, 300, 400, and 500 required a key code to exit, but would also alarm if the door was opened without the proper code. He said the alarm was not very loud and hard to hear if the staff were at the end of another hall. He said that was why the facility installed the high frequency alarms on 07/08/16. During an interview on 07/18/16 at 1:10 p.m., the DON said she was not sure why Resident #1 was transferred to their facility. She said she could not recall if they were informed the resident wandered prior to him being admitted to the facility. She said at first, Resident #1 was wandering up and down the halls looking for food or the restroom. The DON said later, the resident's sister took him out on pass and it seemed to make the resident more confused. She said after the sister took him out, the resident attempted to exit the facility stating he needed to go home or he was trying to find his car. She said at that time, a wander guard was placed. The DON said he would normally attempt to exit through the Hall 500 exit, which led out into the facility parking lot; or he would attempt to exit out the facility main entrance. She said the staff would attempt to bring the resident to his room, redirect him with activities, or see if he was looking for something in particular. The DON said the facility installed Velcro stop signs in front of the doors on Halls 200, 300, 400, and 500 in an attempt to help remind the resident not to go out the door. She said she could not recall when the stop signs were installed. The DON said the staff would often use the exit doors on the end of the halls, and indicated Resident #1 may have followed someone outside without their knowledge. She said if that was the case, there would not have been an alarm activated as the wander guard system was located only on the entrance, parlor, and Hall 100 doors. She said she in-serviced the staff not to use the hall doors as exits on 07/09/16. The DON said there was nothing else specifically done prior to the incident on 07/03/16. She said on 07/03/16, the local police department called and notified the staff they had picked Resident #1 up while he was walking down the street and were bringing him back to the facility. She said once Resident #1 was returned to the facility, a staff member was assigned to sit with Resident #1 24/7 and the high frequency alarms were installed to the doors on Halls 200, 300, 400, and 500. The DON indicated there was now a wander guard book kept at the nursing station where they maintained photographs and information about 3 residents who had wander guards and were at risk for elopement. It was determined these failures placed Resident #1 in an Immediate Jeopardy (IJ) situation from 07/03/16 to 07/08/16. The facility took the following actions to correct the non-compliance on 07/08/16: Exit Access test operation of door and locks sheets dated 07/08/16 thru 07/18/16 indicated the high frequency alarms were tested on a daily basis. During an interview on 07/18/16 at 10:20 a.m., CNA K said she was assigned to closely monitor Resident #1. She said she was to go where ever the resident wandered and encourage the resident not to elope. She said she documented the resident's whereabouts every 15 minutes. During observations on 07/18/16 and 07/19/16, Resident #1 was observed ambulating throughout the facility with an assigned staff member present at all times. When the resident would approach the doors, the wander guard system would activate, locking the doors and initiating an alarm. During an observation on 07/18/16 at 11:30 a.m., Halls 200, 300, 400, and 500 were noted with Velcro stop signs across the door frame, key pad locks, and high frequency alarms. When activated, all alarms were functional. Hall 100, the parlor exit, and the main entrance were noted with the wander guard system in place and activated when Resident #1 approached them. The following in-services had been performed: -07/03/16 staff are to make walking rounds during shift report to ensure all residents are in the building. -07/03/16 staff are to check wander guards on the residents at the beginning of the shift and ensure there is a physician order. -07/03/16 the door alarms have to be reset if the generator restarts, the fire alarm is activated, or the lights flicker. -07/06/16 an incident report must be completed each time a resident attempts to elope, noting the time and which door the resident attempted to exit. The elopement risk assessment must be updated. -07/06/16 how to operate the enunciator panel. -07/09/16 all nurses are to check the exit doors at the beginning of each shift and document on the 24 hour report. -07/09/16 when the alarms sounds, each employee is responsible to look and see who is trying to exit the building. Alarms will have to be turned off with a key at the nursing station. -07/11/16 how to check the doors to ensure they are secure in 5 easy steps. Fifteen minute surveillance program sheets dated 07/03/16 at 7:30 a.m. thru 07/18/16 at 5:45 a.m. indicated Resident #1's whereabouts were noted every 15 minutes. A signaling device testing calendar dated 01/1/16 thru 07/18/16 indicated Resident #1's wander guard bracelet was tested on a daily basis. A wandering unsafe resident policy dated 2001 indicated the facility would strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are risk for elopement. The policy also indicated the staff will institute a detailed monitoring plan, as indicated for residents who are assessed to have a high risk of elopement of other unsafe behavior. An undated list provided by the DON on 07/18/16 indicated there were 3 residents at risk for elopement.

Based on interview and record review, the facility failed to consult the physician immediately for changes in condition for 1 of 6 residents reviewed for changes in condition. (Resident #2) The facility did not consult with the physician for 2 days following Resident #2's exhibiting non-verbal signs of pain, 4 days after she slid from her wheelchair on 07/01/16, landing on her side. X-ray results 6 days later indicated Resident #2 had a fractured right hip. This failure could place 41 residents with dementia at risk for not receiving care and treatment to meet their needs. Findings included: Physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, required assistance with bed mobility and transfers, used a wheelchair for mobility, and had recent falls since her admission. The MDS indicated Resident #2 was unable to make herself understood and exhibited behaviors. A care plan dated 05/19/16 indicated Resident #2 required assistance with activities of daily living, bed mobility, and transfers. The care plan also indicated Resident #2 had poor safety awareness, increased risk of falls, and used a wheelchair for mobility. Interventions included monitoring for any pain, redness or swelling; and document any changes and notify the physician. An Incident Report dated 07/01/16 indicated Resident #2's husband was pushing the resident to her room and she slid out of her wheelchair. Old injuries from her previous falls were noted, including bruising on her face, orbital sockets and bruising on her left hip. The nurse practitioner was notified of the incident. The narrative of investigation indicated Resident #2 was confused and disoriented, did not follow directions, and became agitated easily. A nursing note dated 07/01/16 at 6:00 p.m. indicated Resident #2's husband was pushing her back to her room when the resident slid out of her wheelchair. No new injuries were noted. There were old injuries from Resident #2's previous falls noted during the assessment. The nurse practitioner was present at the facility and was notified of the incident. The nursing note indicated the nurse would continue to monitor the resident. During an interview on 07/18/16 at 11:15 a.m., CNA F said she cared for Resident #2 after her fall on 07/01/16. She said she was uncertain of the exact date, but remembered she and CNA P were providing incontinent care for Resident #2 and she was screaming and moaning during the procedure. She said CNA P said she thought Resident #2 had a broken hip and immediately went to tell the charge nurse. CNA F said she was unable to remember what charge nurse was notified of this incident. A nursing note dated 07/06/16 at 9:00 a.m. indicated CNA L was transferring Resident #2 when she bit the aide on her left arm. The physician and husband were notified of the incident. During an interview on 07/19/16 at 10:40 a.m., LVN Q said she cared for Resident #2 on 07/02/16 thru 07/04/16, and noted no changes in her condition. She said she did not exhibit any increased behaviors, pain, or decreased range of motion. She said she was off a few days and when she returned on 07/07/16, Resident #2 was noted to have non-verbal indicators of pain and a slumped posture to one side while sitting in her wheelchair. LVN Q said she administered Resident #2's [MEDICATION NAME] as ordered for pain and notified the physician. She said an order for [REDACTED]. An SBAR report dated 07/07/16 indicated Resident #2 exhibited extreme facial grimacing, decreased range of motion, and appeared to have a broken hip. The report also indicated Resident #2 had a fall within the week and the condition was made worse by movement. An x-ray report dated 07/07/16 at 2:31 p.m., indicated Resident #2 had bruising with acute pain post-fall and indicated an acute right femoral neck fracture was detected. A history and physical from a local hospital dated 07/07/16 indicated Resident #2 had a right femoral neck fracture that had probably been present for a week because her history of a fall a week ago. During an interview on 07/19/16 at 11:00 a.m., CNA L said she cared for Resident #2 a few days after her fall on 07/01/16. She said there was another incident where Resident #2 rolled off of her mattress, which was directly on the floor, and onto the adjacent mat on the floor. She said the resident acted as if she was in pain, and she and CNA N notified LVN K. CNA L said she was unsure the exact day this incident occurred. She said on 07/06/16 Resident #2 bit her during a transfer. She said Resident #2 had not bitten her before. She said while the resident was sitting in her wheelchair, she was squirming around and kept saying she felt like she was having a baby. She said she notified LVN K, but was not sure what was done. A written statement dated 07/08/16 indicated CNA L reported she and another aide were attempting to get Resident #2 out of bed. She said the resident was irritated so they left her alone for a few minutes. When they returned and provided incontinent care, Resident #2 was not complaining of pain, but bit CNA L on the elbow when they tried to move her. During an interview on 07/19/16 at 11:15 a.m., CNA M said she cared for Resident #2 after her fall on 07/01/16. She said she and CNA P were getting Resident #2 up for her shower on 07/05/16 and the resident was crying and screaming during the transfer. She said Resident #2 would often scream out or cry, but indicated this instance was different and appeared as if Resident #2 was in pain. She said she and CNA P transported the resident to the shower room and noted a large bruise on her right hip when they removed the gown. CNA M said they reported Resident #2 was in pain and had a large bruise on her right hip to LVN K. She said LVN K looked at the bruise and stated she already knew about it. CNA M said she was not sure if LVN K notified the physician. An undated written statement indicated on 07/06/16 CNA P reported she and another CNA were getting Resident #2 up, noticed her bruising, and indicated the resident was screaming. CNA P indicated she went to get the nurse, LVN K, and was told she already knew about the bruising. A written statement dated 07/14/16 indicated LVN K reported Resident #2 had a normal day with no pain or distress noted. The statement indicated the aide took Resident #2 to the shower and notified her of a bruise on the left hip. The nurse indicated she told the aide it was an old bruise and was yellow and slightly blue in color. During an interview on 07/19/16 at 1:50 p.m., the ADON said Resident #2 had a fall on 07/01/16. She said it was her understanding there were no changes noted until 07/07/16. She said she was off a few days and was not notified Resident #2 had a change until 07/07/16. She said the DON conducted an investigation. The ADON, after reading the written statements, said LVN K should have assessed the resident even if she was already aware of the bruise on her hip. She said if Resident #2 had exhibited signs of increased pain, the physician should have been notified since she had a recent fall. The ADON said Resident #2 had not bitten any of the staff, and indicated that could have been a sign of distress while the CNA was transferring her. During an interview on 07/19/16 at 2:17 p.m., the administrator said she was told on 07/01/16, Resident #2 slid out of her wheelchair while her husband was pushing her back to her room. She said the staff reported Resident #2 did not have any changes until 07/07/16 when she exhibited signs of increased pain and decreased range of motion. She said the charge nurse notified the physician, who ordered the x-ray, which revealed a right [MEDICAL CONDITION]. The administrator said the DON called and spoke with the resident's husband, and he said Resident #2 did land on her side, but could not remember which side. She said after reviewing the written statements provided by LVN K, she understood that she actually assessed the resident's bruise. The administrator said based on the statement on 07/06/16, she could not determine if LVN K assessed the resident. She said if the nurse assessed Resident #2 and found the resident to have an increased level of pain, she would have expected the nurse to notify the physician for further instruction. During an interview on 07/19/16 at 3:06 p.m., the nurse practitioner said she was in the facility when Resident #2 slid from her wheelchair on 07/01/16. She said she did not go to assess the resident because the charge nurse said the resident had no injuries. She said she was notified on 07/07/16 Resident #2 exhibited increased pain and she ordered an x-ray to rule out any fractures. The nurse practitioner said the x-ray revealed a fractured right hip and the resident was sent to the emergency room for further evaluation. She said if the charge nurse was notified prior to 07/07/16 of Resident #2 exhibiting increased pain or distress, she would have expected the nurse to assess the resident and notify her immediately. An acute condition changes clinical protocol dated 2005 indicated .the nursing staff and the physician would discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. A pain assessment and management policy dated 2001 indicated the staff would . observe the resident for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain include: verbal such as groaning, crying, screaming; and behavioral such as resisting care, irritability, depression, and decreased participation in usual activities. The policy also indicated the nursing staff should document the level of pain, status of pain, and effectiveness of interventions. The policy continued to indicate the following would be reported to the physician or practitioner: significant changes in the level of the resident ' s pain and prolonged, unrelieved pain despite care plan interventions. A charting and documentation policy dated 2001 indicated . all incidents, accidents, or changes in resident's condition must be recorded. A hand written notation added and documented for 72 hours (3 days). The CMS 672 dated 07/18/16 indicated 41 residents with the [DIAGNOSES REDACTED].

Based on interview, and record review, the facility failed to provide the necessary care and services to maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 6 residents reviewed for pain. (Resident # 2) The facility did not implement interventions for 2 days after Resident #2 exhibited non-verbal signs of pain, 4 days following an incident when she slid from her wheelchair, and landed on her side. X-ray results indicated she had sustained a fractured right hip and a right femoral neck fracture. This failure could place 41 residents with dementia at risk for unrelieved pain, discomfort, decreased quality of life, not receiving care and treatment to meet their needs. Findings included: Physician orders [REDACTED].#2 was [AGE] years old, admitted on [DATE] with [DIAGNOSES REDACTED]. The most recent MDS dated [DATE] indicated Resident #2 had moderately impaired cognition, required assistance with bed mobility and transfers, used a wheelchair for mobility, and had recent falls since her admission. The MDS indicated Resident #2 was unable to make herself understood and exhibited behaviors. A care plan dated 05/19/16 indicated Resident #2 required assistance with activities of daily living, bed mobility, and transfers. The care plan also indicated Resident #2 had poor safety awareness, increased risk of falls, and used a wheelchair for mobility. Interventions included monitoring for any pain, redness or swelling; and document any changes and notify the physician. An Incident Report dated 07/01/16 indicated Resident #2's husband was pushing the resident to her room and she slid out of her wheelchair. Old injuries from her previous falls were noted, including bruising on her face, orbital sockets and bruising on her left hip. The nurse practitioner was notified of the incident. The Narrative of investigation indicated Resident #2 was confused and disoriented, did not follow directions, and became agitated easily. The incident report did not address if Resident #2 had any injuries or complained of pain with this particular incident. A nursing note dated 07/01/16 at 6:00 p.m. indicated Resident #2's husband was pushing her back to her room when the resident slid out of her wheelchair. No new injuries were noted. There were old injuries from Resident #2's previous falls noted during the assessment. The nurse practitioner was present at the facility and was notified of the incident. The nursing note indicated the nurse would continue to monitor the resident. During an interview on 07/19/16 at 11:15 a.m., CNA M said she cared for Resident #2 after her fall on 07/01/16. She said she and CNA P were getting Resident #2 up for her shower on 07/05/16 and the resident was crying and screaming during the transfer. She said Resident #2 would often scream out or cry, but indicated this instance was different and appeared as if Resident #2 was in pain. She said she and CNA P transported the resident to the shower room and noted a large bruise on her right hip when they removed the gown. CNA M said they reported Resident #2 was in pain and had a large bruise on her right hip to LVN K. She said LVN K looked at the bruise and stated she already knew about it. CNA M said she was not sure if LVN K notified the physician. An undated written statement indicated on 07/06/16 CNA P reported she and another CNA were getting Resident #2 up, noticed her bruising, and indicated the resident was screaming. CNA P indicated she went to get LVN K, and was told she already knew about the bruising. A nursing note dated 07/06/16 at 9:00 a.m. indicated CNA L was transferring Resident #2 when she bit the aide on her left arm. The physician and husband were notified of the incident. During an interview on 07/19/16 at 11:00 a.m., CNA L said she cared for Resident #2 a few days after her fall on 07/01/16. She said there was another incident where Resident #2 had rolled off of her mattress, which directly on the floor, and onto the adjacent mat on the floor. She said the resident acted as if she was in pain, and she and CNA N notified LVN K. CNA L said she was unsure the exact day this incident occurred. She said on 07/06/16 Resident #2 bit her during a transfer. She said Resident #2 had not bitten her before. She said while the resident was sitting in her wheelchair, she was squirming around and kept saying she felt like she was having a baby. She said she notified LVN K, but was not sure what was done. During an interview on 07/19/16 at 1:50 p.m., the ADON said Resident #2 had not bitten any of the staff, and indicated that could have been a sign of distress while the CNA was transferring her. During an interview on 07/18/16 at 11:15 a.m., CNA F said she cared for Resident #2 after her fall on 07/01/16. She said she was uncertain of the exact date, but remembered she and CNA P were providing incontinent care for Resident #2 and she was screaming and moaning during the procedure. She said CNA P said she thought Resident #2 had a broken hip and immediately went to tell the charge nurse. CNA F said she was unable to remember what charge nurse was notified of this incident. An SBAR report dated 07/07/16 indicated Resident #2 exhibited extreme facial grimacing, decreased range of motion, and appeared to have a broken hip. The report also indicated Resident #2 had a fall within the week and the condition was made worse by movement. An x-ray dated 07/07/16 at 2:31 p.m., indicated Resident #2 had bruising with acute pain post-fall and indicated an acute right femoral neck fracture was detected. A MAR indicated [REDACTED]. A history and physical from a local hospital dated 07/07/16 indicated Resident #2 had a right femoral neck fracture that was probably present for a week because her history of a fall a week ago. A written statement dated 07/08/16 indicated CNA L reported she and another aide were attempting to get Resident #2 out of bed. She said the resident was irritated so they left her alone for a few minutes. When they returned and provided incontinent care, Resident #2 was not complaining of pain, but bit CNA L on the elbow when they tried to move her. A written statement dated 07/14/16 indicated LVN K reported Resident #2 had a normal day with no pain or distress noted. The statement indicated the aide took Resident #2 to the shower and notified her of a bruise on the left hip. The nurse indicated she told the aide it was an old bruise and was yellow and slightly blue in color. A written statement dated 07/08/16 indicated CNA M reported she and CNA P provided Resident #2 with a shower, and noticed bruises on her left side. She indicated they notified the charge nurse, LVN K, and she indicated she had already seen all the bruises on Resident #2. During an interview on 07/19/16 at 10:40 a.m., LVN Q said she cared for Resident #2 07/02/16 thru 07/04/16, and noted no changes in her condition. She said she did not exhibit any increased behaviors, pain, or decreased range of motion. She said she was off a few days and when she returned on 07/07/16, Resident #2 was noted to have non-verbal indicators of pain and a slumped posture to one side while sitting in her wheelchair. LVN Q said she administered Resident #2's [MEDICATION NAME] as ordered for pain and notified the physician. She said an order for [REDACTED]. During an interview on 07/19/16 at 1:50 p.m., the ADON said Resident #2 had a fall on 07/01/16. She said it was her understanding there were no changes noted until 07/07/16. She said she was off a few days and was not notified Resident #2 had a change until 07/07/16. She said the DON conducted an investigation. The ADON said after reading the written statements, she said LVN K should have assessed the resident even if she was already aware of the bruise on her hip. She said if Resident #2 had exhibited signs of increased pain, the physician should have been notified since she had a recent fall. During an interview on 07/19/16 at 2:17 p.m., the administrator said she was told on 07/01/16, Resident #2 slid out of her wheelchair while her husband was pushing her back to her room. She said the staff reported Resident #2 did not have any changes until 07/07/16 when she exhibited signs of increased pain and decreased range of motion. She said the charge nurse notified the physician, who ordered an x-ray, which revealed a right [MEDICAL CONDITION]. The administrator said the DON called and spoke with the resident's husband, and he said Resident #2 did land on her side, but could not remember which side. During an interview on 07/19/16 at 3:06 p.m., the nurse practitioner said she was in the facility when Resident #2 slid from her wheelchair on 07/01/16. She said she did not go to assess the resident because the charge nurse said the resident had no injuries. She said she was notified on 07/07/16 Resident #2 exhibited increased pain and she ordered an x-ray to rule out any fractures. The nurse practitioner said the x-ray revealed a fractured right hip and the resident was sent to the emergency room for further evaluation. She said if the charge nurse was notified prior to 07/07/16 of Resident #2 exhibiting increased pain or distress, she would have expected the nurse to assess the resident and to be notified immediately. An acute condition changes clinical protocol dated 2005 indicated .the nursing staff and the physician would discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. A pain assessment and management policy dated 2001 indicated the staff would .observe the resident for physiologic and behavioral (non-verbal) signs of pain. Possible behavioral signs of pain include: verbal such as groaning, crying, screaming; and behavioral such as resisting care, irritability, depression, and decreased participation in usual activities. The policy also indicated the nursing staff should document the level of pain, status of pain, and effectiveness of interventions. The policy continued to indicate the following would be reported to the physician or practitioner: significant changes in the level of the resident's pain and prolonged, unrelieved pain despite care plan interventions. A charting and documentation policy dated 2001 indicated . all incidents, accidents, or changes in resident's condition must be recorded. A hand written notation added and documented for 72 hours (3 days). The CMS 672 dated 07/18/16 indicated 41 residents with the [DIAGNOSES REDACTED].

Based on observation, interview, and record review, the facility failed to accurately assess, plan and intervene to provide pain relief for 2 of 2 residents reviewed for dental services. (Resident #s: 1 and 2) Resident # 1 experienced dental pain. A dental examination dated 3/19/14 recommended a surgical extraction of a tooth. Resident #1 did not have funding for the procedure. The facility did not evaluate and assess their interventions to ensure pain control Resident #2 experienced dental pain. Resident #1 did not have funding for dental services. The facility did not evaluate and assess their interventions to ensure pain control This failure could place 25 residents who had payment sources other than Medicare or Medicaid at risk for pain, decreased quality of life and weight loss. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. A SW assessment dated [DATE] indicated Resident #1 had dental concerns. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact. She required set up assist with eating. A dietician note dated 1/31/14 indicated Resident #1 was observed to eat a meal and reported problems chewing, due to poor teeth. The note indicated Resident #1 said she was trying to lose weight. The dietician noted the SW would address the need for a dental referral. A care plan dated 2/6/14 indicated Resident # 1 was at risk for nutrition or hydration deficit as evidenced by chewing problems. Resident #1 had missing/broken teeth, oral pain and depression. The care plan interventions were to " ...assess oral cavity and obtain dental consult as needed ... " Social service notes indicated the following: *2/25/14- Resident #1 was at the nurse station and reported dental pain. The resident had swelling around a broken tooth in the gum. The social worker informed the nurse she needed something for pain. The note indicated paperwork was completed for a dental referral. *3/4/14 - Resident #1 continued to complain of dental pain. She was ordered pain medication. The SW would follow up on the dental referral. *3/13/14- the dental company said Resident #1 would have to pay private pay for any dental service. A physician progress notes [REDACTED].#1 complained of a sore on the upper right gum and wanted medication. The sore was described as a small red area on the right gum about a black tooth gum line. The small area had a red circle around it, with a white center. The note indicated Resident #1 said she had a dental appointment scheduled. The note indicated Resident #1 needed a good mouthwash cleanser. The recommendation was to use [MEDICATION NAME] mouthwash at bedtime for tooth decay. A physician order [REDACTED].# 1 was to receive [MEDICATION NAME] mouthwash 10 milligram (mg) at bedtime. A dental examination dated 3/19/14 indicated charges for Resident # 1, to have a surgical extraction of a tooth at a 50 percent discount totaled $286.98. The contract indicated the facility would be responsible for the cost. The contract was signed by the administrator on 3/19/14. A nursing note dated 3/25/14 indicated Resident # 1 complained of mouth pain. Resident #1 said " ... is there something you can give me to help ..." The nurse practitioner was notified and ordered [MEDICATION NAME] oral suspension 10 mg, swish and swallow, three times a day for 7 days. Resident #1 was administered [MEDICATION NAME] 10/325 to relieve pain. Mobile dental completed dental x-rays for Resident #1 on 3/21/14. A physician order [REDACTED].#1 was to have [MEDICATION NAME] 10 mg three times daily for seven days. An order dated 3/26/14 indicated Resident #1 had a [DIAGNOSES REDACTED]. A nursing note dated 4/3/14 indicated Resident #1's physician order [REDACTED]. An oral assessment indicated no redness. A social service note dated 4/10/14 indicated on 4/9/14 the administrator was reminded of Resident #1's need for dental services. The note indicated Resident #1 continued to be in significant pain and was not eating well. The administrator said corporate was aware and had not responded to the request to pay for dental services. During an interview on 4/10/15 at 2:49 p.m., LVN A said Resident #1 complained of pain in her mouth last week. She did not assess to see if there were any issues. The resident had completed [MEDICATION NAME] swish and swallow for mouth pain. During an interview on 4/10/14 at 3:00 p.m., ADON/RN B said Resident # 1 had not complained of mouth pain to her. She said the SW had mentioned in morning meeting a few times Resident #1 had mouth pain. ADON/RN B said she wrote an order for [REDACTED]. During an observation and interview on 4/10/14 at 3:25 p.m., Resident # 1 opened her mouth and her front teeth were yellowed and broken. The two or three front teeth were broken and barely visibly on the gum line. She took her fingers and pulled her lips back. She had one solitary tooth on the left side that was black and brown. She became tearful and said that it caused her pain almost constantly. She said she thought it was swollen and infected. Resident #1 said the facility was supposed to be doing something to help her get her teeth pulled. She said every time she mentioned it to someone they said they were working on it. She said yesterday, she could not eat. Resident #1 said she tried to eat some meat, but it was too hard for her to chew it. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #1 did not have Medicaid and was considered full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said neither Resident #1 nor her family could afford the cost of dental services. The SW said Resident # 1 complained of tooth pain almost daily and it had started to affect her ability to eat. During an interview on 4/10/14 at 3:44 p.m., ADON/RN B said she assessed Resident # 1's mouth, after surveyor intervention. She said her gums were red, a little swollen and inflamed. There was no smell. She said Resident #1 appeared to have trouble opening her mouth and indicated that started last week. ADON/RN B said Resident #1 said she was in pain. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident # 1 needed dental services. He said he signed the necessary paperwork, presented it to corporate office at least two months ago, with no response. 2. Physician orders [REDACTED].# 2 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A dietary note dated 1/17/14 indicated Resident #2 had missing teeth and complained about not being able to chew certain foods because of his missing teeth. The resident was served a soft sandwich on his lunch and dinner tray. The note indicated Resident #2 had a desire to lose weight. His current weight was 217 pounds. Social service notes indicated the following: *1/28/14- indicated the administrator was asked again regarding the facility paying for Resident #2's dental costs. The administrator said he had not heard anything, but would e-mail corporate again today. Resident #2 continued to have pain and weight loss. *3/31/14- indicated Resident #2 had poor dentition with missing teeth. The resident continued to report pain. The paperwork necessary for the facility to pay to have the teeth extracted had been done. " We are continuing to wait on corporate to approval. " Nursing note dated 4/7/14 indicated Resident #2 was sent to the hospital due to complaints of pain to his scrotum. Social services note dated 4/9/14 indicated Resident #2 was scheduled for surgery to have stones removed from his urethra. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #2 did not have Medicaid and was considered full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said Resident #2 and his family could not afford the cost of dental services. The SW said she submitted Resident #2's dental paperwork to the administrator for approval and it had been a couple of months and they were still waiting. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident #2 needed dental services. He said he signed necessary paperwork, presented it to corporate office for Resident #1's dental work, about a month ago with no response. The facility information sheet dated 4/10/14 indicated 25 residents had payment sources other than Medicare or Medicaid.

Based on observation, interview, and record review, the facility failed to obtain dental services for 2 of 2 residents reviewed for dental services. (Resident #s: 1 and 2) Resident #s: 1 and 2 did not receive necessary dental interventions to relieve their dental pain. Resident #s: 1 and 2 complained of gum and teeth pain and discomfort for at least a month. This failure could place 25 residents who had payment sources other than Medicare or Medicaid at risk for pain, decreased quality of life and weight loss. Findings included: 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. A SW assessment dated [DATE] indicated Resident #1 had dental concerns. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact. She required set up assist with eating. A dietician note dated 1/31/14 indicated Resident #1 was observed to eat a meal and reported problems chewing, due to poor teeth. The note indicated Resident #1 said she was trying to lose weight. The dietician noted the SW would address the need for a dental referral. A care plan dated 2/6/14 indicated Resident # 1 was at risk for nutrition or hydration deficit as evidenced by chewing problems. Resident #1 had missing/broken teeth, oral pain and depression. The care plan interventions were to " ...assess oral cavity and obtain dental consult as needed ... " Social service notes indicated the following: *2/25/14- Resident #1 was at the nurse station and reported dental pain. The resident had swelling around a broken tooth in the gum. The social worker informed the nurse she needed something for pain. The note indicated paperwork was completed for a dental referral. *3/4/14 - Resident #1 continued to complain of dental pain. She was ordered pain medication. The social worker would follow up on the dental referral. *3/13/14- the dental company said Resident #1 would have to pay private pay for any dental service. A physician progress notes [REDACTED].#1 complained of a sore on the upper right gum and wanted medication. The sore was described as a small red area on the right gum about a black tooth gum line. The small area had a red circle around it, with a white center. The note indicated Resident #1 said she had a dental appointment scheduled. The note indicated Resident #1 needed a good mouthwash cleanser. The recommendation was to use [MEDICATION NAME] mouthwash at bedtime for tooth decay. A physician order [REDACTED].# 1 was to receive [MEDICATION NAME] mouthwash 10 milligram (mg) at bedtime. A dental examination dated 3/19/14 indicated charges for Resident # 1, to have a surgical extraction of a tooth at a 50 percent discount totaled $286.98. The contract indicated the facility would be responsible for the cost. The contract was signed by the administrator on 3/19/14. A nursing note dated 3/25/14 indicated Resident # 1 complained of mouth pain. Resident #1 said " ... is there something you can give me to help ..." The nurse practitioner was notified and ordered [MEDICATION NAME] oral suspension 10 mg, swish and swallow, three times a day for 7 days. Resident #1 was administered [MEDICATION NAME] 10/325 to relieve pain. Mobile dental completed dental x-rays for Resident #1 on 3/21/14. A physician order [REDACTED].#1 was to have [MEDICATION NAME] 10 mg three times daily for seven days. An order dated 3/26/14 indicated Resident #1 [DIAGNOSES REDACTED]. A nursing note dated 4/3/14 indicated Resident #1's physician order [REDACTED]. An oral assessment indicated no redness. A social service note dated 4/10/14 indicated on 4/9/14 the administrator was reminded of Resident #1's need for dental services. The note indicated Resident #1 continued to be in significant pain and was not eating well. The administrator said corporate was aware and had not responded to the request to pay for dental services. During an interview on 4/10/15 at 2:49 p.m., LVN A said Resident #1 complained of pain in her mouth last week. She did not assess to see if there were any issues. The resident had completed [MEDICATION NAME] swish and swallow for mouth pain. During an interview on 4/10/14 at 3:00 p.m., ADON/RN B said Resident # 1 had not complained of mouth pain to her. She said the SW had mentioned in morning meeting a few times Resident #1 had mouth pain. ADON/RN B said she wrote an order for [REDACTED]. During an observation and interview on 4/10/14 at 3:25 p.m., Resident # 1 opened her mouth and her front teeth were yellowed and broken. The two or three front teeth were broken and barely visibly on the gum line. She took her fingers and pulled her lips back. She had one solitary tooth on the left side that was black and brown. She became tearful and said that it caused her pain almost constantly. She said she thought it was swollen and infected. Resident #1 said the facility was supposed to be doing something to help her get her teeth pulled. She said every time she mentioned it to someone they said they were working on it. She said yesterday, she could not eat. Resident #1 said she tried to eat some meat, but it was too hard for her to chew it. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #1 did not have Medicaid and was considered a full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said neither Resident #1 nor her family could afford the cost of dental services. The SW said Resident # 1 complained of tooth pain almost daily and it had started to affect her ability to eat. During an interview on 4/10/14 at 3:44 p.m., ADON/RN B said she assessed Resident # 1's mouth, after surveyor intervention. She said her gums were red, a little swollen and inflamed. There was no smell. She said Resident #1 appeared to have trouble opening her mouth and indicated that started last week. ADON/RN B said Resident #1 said she was in pain. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident # 1 needed dental services. He said he signed the necessary paperwork, presented it to corporate office at least two months ago, with no response. 2. Physician orders [REDACTED].# 2 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A dietary note dated 1/17/14 indicated Resident #2 had missing teeth and complained about not being able to chew certain foods because of his missing teeth. The resident was served a soft sandwich on his lunch and dinner tray. The note indicated Resident #2 had a desire to lose weight. His current weight was 217 pounds. Social service notes indicated the following: *1/28/14- indicated the administrator was asked again regarding the facility paying for Resident #2 ' s dental costs. The administrator said he had not heard anything, but would e-mail corporate again today. Resident #2 continued to have pain and weight loss. *3/31/14- indicated Resident #2 had poor dentition with missing teeth. The resident continued to report pain. The paperwork necessary for the facility to pay to have the teeth extracted had been done. " We are continuing to wait on corporate to approval. " Nursing note dated 4/7/14 indicated Resident #2 was sent to the hospital due to complaints of pain to his scrotum. Social services note dated 4/9/14 indicated Resident #2 was scheduled for surgery to have stones removed from his urethra. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #2 did not have Medicaid and was considered full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said Resident #2 and his family could not afford the cost of dental services. The SW said she submitted Resident #2's dental paperwork to the administrator for approval and it had been a couple of months and they were still waiting. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident #2 needed dental services. He said he signed necessary paperwork, presented it to corporate office for Resident #1's dental work, about a month ago with no response. The facility information sheet dated 4/10/14 indicated 25 residents had payment sources other than Medicare or Medicaid.

Based on observation, interview and record review, the administrator and corporate administration failed to ensure the facility's resources were managed effectively to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 2 of 2 residents (Resident #s 1 and 2) reviewed for dental services, and vendors were paid timely to prevent services from being discontinued. Resident #s 1 and 2 needed dental services. The corporate administration did not respond to a requested need for financial assistance for dental services. Resident #s 1 and 2 complained of gum and teeth pain and discomfort for at least a month. Administration did not pay for trash service, which led to service being discontinued. Corporate administration did not pay financial obligations timely. This failure could place the census of 84 residents at risk of not receiving care and services needed to maintain their highest potential and residing in an unsanitary and unsafe environment. Findings included: 1. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #s: 1 and 2 did not have Medicaid and were considered full vendors or private pay. She said the residents did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said neither Resident #1 or Resident #2 nor their families could afford the cost of dental services. The SW said Resident # 1 complained of tooth pain almost daily and it had started to affect her ability to eat. She said Resident #2 needed dental services as well. She said paperwork was submitted to the administrator for approval and it had been a couple of months and they were still waiting. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident # 1 needed dental services. He said he signed the necessary paperwork, presented it to corporate office at least two months ago, with no response. The administrator said it had been at least two months with Resident # 2 and about a month with Resident #1. During an interview on 4/10/14 at 1:18 p.m., the administrator said the trash pickup was suspended due to non- payment. He said facility bills were computer generated and paid through corporate office. He said the pest control company and the plumber were not paid until today. The administrator said there were some issues with the heating pump, but the plumbing company would not come until they were paid. The administrator said local bills did not get paid timely. He said the laboratory company had been partially paid. He said bills were submitted to corporate office, but were not paid on time. The administrator said there was apparently some brake down in the system. He said he did not think corporate office was without funds, but there was a problem with accounts payable. The administrator said he was resigning. 1. Physician orders [REDACTED].#1 was [AGE] years old, admitted [DATE], with [DIAGNOSES REDACTED]. The resident had an order for [REDACTED]. A SW assessment dated [DATE] indicated Resident #1 had dental concerns. The most recent MDS dated [DATE] indicated Resident #1 was cognitively intact and required set up assist with eating. A dietician note dated 1/31/14 indicated Resident #1 was observed to eat a meal and reported problems chewing, due to poor teeth. The note indicated Resident #1 said she was trying to lose weight. The dietician noted the SW would address the need for a dental referral. A care plan dated 2/6/14 indicated Resident # 1 was at risk for nutrition or hydration deficit as evidenced by chewing problems. Resident #1 had missing/broken teeth, oral pain and depression. The care plan interventions were to "assess oral cavity and obtain dental consult as needed ". Social service notes indicated the following: *2/25/14- Resident #1 was at the nurse station and reported dental pain. The resident had swelling around a broken tooth in the gum. The social worker informed the nurse she needed something for pain. The note indicated paperwork was completed for a dental referral. *3/4/14 - Resident #1 continued to complain of dental pain. She was ordered pain medication. The SW would follow up on the dental referral. *3/13/14- the dental company said Resident #1 would have to pay private pay for any dental service. A physician progress notes [REDACTED].#1 complained of a sore on the upper right gum and wanted medication. The sore was described as a small red area on the right gum about a black tooth gum line. The small area had a red circle around it, with a white center. The note indicated Resident #1 said she had a dental appointment scheduled. The note indicated Resident #1 needed a good mouthwash cleanser. The recommendation was to use [MEDICATION NAME] mouthwash at bedtime for tooth decay. A physician order [REDACTED].# 1 was to receive [MEDICATION NAME] mouthwash 10 milligram (mg) at bedtime. A dental examination dated 3/19/14 indicated charges for Resident # 1, to have a surgical extraction of a tooth at a 50 percent discount totaled $286.98. The contract indicated the facility would be responsible for the cost. The contract was signed by the administrator on 3/19/14. A nursing note dated 3/25/14 indicated Resident # 1 complained of mouth pain. Resident #1 said " ... is there something you can give me to help ..." The nurse practitioner was notified and ordered [MEDICATION NAME] oral suspension 10 mg, swish and swallow, three times a day for 7 days. Resident #1 was administered [MEDICATION NAME] 10/325 to relieve pain. Mobile dental completed dental x-rays for Resident #1 on 3/21/14. A physician order [REDACTED].#1 was to have [MEDICATION NAME] 10 mg three times daily for seven days. An order dated 3/26/14 indicated Resident #1 had a [DIAGNOSES REDACTED]. A nursing note dated 4/3/14 indicated Resident #1's physician order [REDACTED]. An oral assessment indicated no redness. A social service note dated 4/10/14 indicated on 4/9/14 the administrator was reminded of Resident #1's need for dental services. The note indicated Resident #1 continued to be in significant pain and was not eating well. The administrator said corporate was aware and had not responded to the request to pay for dental services. During an interview on 4/10/15 at 2:49 p.m., LVN A said Resident #1 complained of pain in her mouth last week. She did not assess to see if there were any issues. The resident had completed [MEDICATION NAME] swish and swallow for mouth pain. During an interview on 4/10/14 at 3:00 p.m., ADON/RN B said Resident # 1 had not complained of mouth pain to her. She said the SW had mentioned in morning meeting a few times Resident #1 had mouth pain. ADON/RN B said she wrote an order for [REDACTED]. During an observation and interview on 4/10/14 at 3:25 p.m., Resident # 1 opened her mouth and her front teeth were yellowed and broken. The two or three front teeth were broken and barely visibly on the gum line. She took her fingers and pulled her lips back. She had one solitary tooth on the left side that was black and brown. She became tearful and said that it caused her pain almost constantly. She said she thought it was swollen and infected. Resident #1 said the facility was supposed to be doing something to help her get her teeth pulled. She said every time she mentioned it to someone they said they were working on it. She said yesterday, she could not eat. Resident #1 said she tried to eat some meat, but it was too hard for her to chew it. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #1 did not have Medicaid and was considered full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said neither Resident #1 nor her family could afford the cost of dental services. The SW said Resident # 1 complained of tooth pain almost daily and it had started to affect her ability to eat. During an interview on 4/10/14 at 3:44 p.m., ADON/RN B said she assessed Resident # 1's mouth, after surveyor intervention. She said her gums were red, a little swollen and inflamed. There was no smell. She said Resident #1 appeared to have trouble opening her mouth and indicated that started last week. ADON/RN B said Resident #1 said she was in pain. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident # 1 needed dental services. He said he signed the necessary paperwork, presented it to corporate office at least two months ago, with no response. 2. Physician orders [REDACTED].# 2 was a [AGE] year old male admitted on [DATE] with [DIAGNOSES REDACTED]. A dietary note dated 1/17/14 indicated Resident #2 had missing teeth and complained about not being able to chew certain foods because of his missing teeth. The resident was served a soft sandwich on his lunch and dinner tray. The note indicated Resident #2 had a desire to lose weight. His current weight was 217 pounds. Social service notes indicated the following: *1/28/14- indicated the administrator was asked again regarding the facility paying for Resident #2's dental costs. The administrator said he had not heard anything, but would e-mail corporate again today. Resident #2 continued to have pain and weight loss. *3/31/14- indicated Resident #2 had poor dentition with missing teeth. The resident continued to report pain. The paperwork necessary for the facility to pay to have the teeth extracted had been done. "We are continuing to wait on corporate to approval. " Nursing note dated 4/7/14 indicated Resident #2 was sent to the hospital due to complaints of pain to his scrotum. Social services note dated 4/9/14 indicated Resident #2 was scheduled for surgery to have stones removed from his urethra. During an interview on 4/10/14 at 2:15 p.m., the SW said Resident #2 did not have Medicaid and was considered full vendor or private pay. She said the resident did not have dental coverage services covered by Medicaid and had to pay out of pocket. She said Resident #2 and his family could not afford the cost of dental services. The SW said she submitted Resident #2's dental paperwork to the administrator for approval and it had been a couple of months and they were still waiting. During an interview on 4/10/14 at 4:40 p.m., the administrator said he was aware Resident #2 needed dental services. He said he signed necessary paperwork, presented it to corporate office for Resident #1's dental work, about a month ago with no response. 3. During an interview on 4/10/14 at 12:10 p.m., the DON said the vendors for pest control and trash pickup were not paid. She said trash pickup was stopped, due to non- payment. During an observation on 4/10/14 at 1:08 p.m., the DON the two trash bends were full. About 30 to 35 bags of trash were stacked against the fence, by the bends. There were also two different stacks of boxes by the bends as well. The DON said they had nowhere else to put the trash the bends were full. During an interview on 4/10/14 at 1:18 p.m., the administrator said the trash pickup was suspended due to non- payment. He said facility bills were computer generated and paid through corporate office. He said the pest control company and the plumber were not paid until today. The administrator said there were some issues with the heating pump, but the plumbing company would not come until they were paid. The administrator said local bills did not get paid timely. He said the laboratory company had been partially paid. He said bills were submitted to corporate office, but were not paid on time. The administrator said there was apparently some brake down in the system. He said he did not think corporate office was without funds, but there was a problem with accounts payable. The administrator said he was resigning. During an interview on 4/10/14 at 1:34 p.m., the regional director of operations said he had been in his position for 4 weeks. He said he did not know what the issue was with paying the bills because the company did not appear to be short of money. A bill from the laboratory services vendor indicated services provided from 10/31/13 to present had a total outstanding balance of $4093.43 A plumbing bill with charges from 11/21/13 through 3/13/14 indicated a balance of more than 30 days past due of 3,211.95 and more than 90 to 60 days past due of 1,533.73 and over 90 days past due of 1,498.11. The total amount past due was 6,243.79. The bill was paid in full on 4/10/14. A pest control log sheet dated 3/4/14 indicated treatments was completed and would continue pending payments. A bill from the pest control company dated back to 11/5/13 indicated a balance due of $1,663.20. A check for the balance was dated 4/9/14. A letter regarding consolidated billing from the hospital dated 12/4/13 indicated a past due amount of $148.71. The letter documented if not paid in 30 days the facility would be charged $1560.00. A memo dated 4/8/14 indicated a check was being cut for the hospital regarding the bill dated 12/4/13. During an interview on 4/10/14 at 4:04 p.m., the administrator said he received a call yesterday form a local hospital threatening to file a complaint with CMS regarding an unpaid bill. He said apparently the facility owed $182 that had not been paid from some time back and it was now $1500. He said the bill was paid on 4/9/14. The facility information sheet dated 4/10/14 indicated a census of 84.