Every finding on record at Highland Place Rehab and Nursing Center

Based on record reviews and interviews, the facility failed to ensure a resident received adequate assistance to prevent an avoidable accident for 1 (#7) of 1 resident reviewed for accidents by failing to implement two person assist intervention during ADL care.The deficient practice resulted in actual harm for Resident #7 on 08/10/2026 at approximately 4:45 p.m. when Resident #7 fell out of bed while receiving ADL care by one staff member. Resident #7's MDS assessment and comprehensive care plan indicated Resident #7 was dependent with ADLs and mobility and required two person assist. S15CNA reported Resident #7 was receiving pericare related to Resident #7's large bowel movement. S15CNA reported she turned around to get wipes and when she turned back around Resident #7 was sliding off the bed from the large amount of the bowel movement. Resident #7's legs were off the bed and she slid to the floor. S11LPN reported Resident #7 had a laceration to the left side of the head and was transported to a local emergency room for further evaluation. Review of Resident #7's hospital record revealed in part, Resident #7 was admitted to a local hospital on [DATE] with diagnosis, including but not limited to, subarachnoid hemorrhage.Findings:Review of Resident #7's medical record revealed an admit date of 09/10/2024 with diagnoses including, but not limited to, dementia with agitation, unspecified convulsions, and muscle wasting and atrophy of left and right shoulder. Further review of Resident #7's medical record revealed Resident #7 was transferred to a local hospital on [DATE] and had not returned to the facility. Review of Resident #7's quarterly MDS assessment with ARD of 07/27/2026 revealed in part, a BIMS was not conducted related to Resident #7 was rarely/never understood. Further review of Resident #7's quarterly MDS assessment with ARD of 07/27/2026 revealed in part, Resident #7 was dependent with all ADLs and mobility.Review of Resident #7's care plan dated August 2026 revealed in part, Resident #7 was dependent on 2 person assist with toileting/incontinence care, bed mobility, and bathing.Review of Resident #7's progress note dated 08/10/2026 at 4:45 p.m. by S11LPN revealed in part, Resident #7 was in bed receiving ADL care, rolled out of bed to the floor, and had an abrasion to left side of scalp which was cleaned and covered with gauze. Resident #7's doctor/nurse practitioner and family were notified and Resident #7 was transported to a local emergency room. Review of Resident #7's hospital record revealed in part, an admission date of 08/10/2026 with diagnoses including, but not limited to, subarachnoid hemorrhage.Review of facility's incident report dated 08/10/2026 for Resident #7 revealed in part, nurse was called to room by CNA stating Resident #7 rolled out of bed to the floor during ADL care. Further review of facility's incident report dated 08/10/2026 revealed in part, an intervention of educate staff on following the care plan for total care residents.Review of facility's performance improvement plan dated 08/10/2026 revealed in part, S15CNA interviewed, in-serviced, and suspended pending investigation.Review of S15CNA's personnel record revealed in part, an orientation competency assessment form dated 04/30/2026 with documentation S15CNA was able to verbalize how to access/use a resident's plan of care.During a telephone interview on 08/12/2026 at 3:18 p.m., S15CNA reported on 08/10/2026 she had gone into Resident #7's room to bathe her because Resident #7 was going out of the facility to have her peg tube reinserted. S15CNA reported she had loosened Resident #7's brief and noticed Resident #7 had a large bowel movement. S15CNA reported she turned around to get wipes for Resident #7 and when she turned back around, Resident #7 was sliding off the bed from the large amount of the bowel movement. Resident #7's legs were off the bed and she slid to the floor. S15CNA did not respond to questions regarding the position of the resident in the bed when ADL care was started. S15CNA reported she did not have any other staff member in Resident #7's room assisting with ADL care. S15CNA reported she did not know Resident #7 required 2 person assist with ADLs because she had not looked at Resident #7's plan of care. S15CNA confirmed she was suspended on 08/10/2026 and as of 08/12/2026 had not returned to work.During a telephone interview on 08/12/2026 at 3:38 p.m., S11LPN reported on 08/10/2026 after 4:00 p.m., S15CNA called her to Resident #7's room. S11LPN reported when she entered Resident #7's room, Resident #7 was on the floor. S11LPN reported Resident #7 was lifted back to bed by 4 staff members including herself and S15CNA. S11LPN reported Resident #7 was observed to have blood in her hair on the left side of her head. S11LPN reported once Resident #7's hair was moved out of the way, a laceration was observed on the left side of Resident #7's head. S11LPN reported the laceration to Resident #7's head was covered with gauze and secured with kerlix rolled gauze. S11LPN confirmed Resident #7 required assist of 2 persons with ADL care. S11LPN reported administration, Resident #7's nurse practitioner and Resident #7's responsible party was notified. S11LPN reported Resident #7 was transported to local emergency room.During an interview on 08/12/2026 at 3:55 p.m., S1Administrator reported Resident #7's fall incident was reported on 08/10/2026 to administration. S1Administrator reported the facility started an investigation into Resident #7's fall incident on 08/10/2026 in which it was determined S15CNA was providing care to Resident #7 without assistance from a second staff member as Resident #7 was care planned for. S1Administrator reported S15CNA was removed from providing care, attended in-service which included following resident's plan of care and dependent residents require two person assist. S1Administrator reported the facility interviewed and suspended S15CNA on 08/10/2026. S1Administrator reported the facility is still working on corrective actions. S1Administrator reported the facility is currently working on corrective actions for S15CNA if/when S15CNA returns to work. S1Administrator reported thus far, the facility has determined S15CNA will have to reorient for at least 3 days with a senior CNA and will have to demonstrate how to access a resident's plan of care to determine how much assist a resident requires. S1Administrator confirmed the facility's correction plan was not complete but included all CNAs will have to demonstrate and not simply verbalize how to access a resident's plan of care during competency assessments.

Based on record reviews and interview the facility failed to complete the Skilled Nursing Facility Beneficiary Notice of non-coverage SNF ABN form as required. This deficient practice was identified for 2 (#25, #141) of 3 residents reviewed for Beneficiary Protection Notification.Findings: Review of Resident #25's Beneficiary Notification Review form revealed the facility initiated Resident #25's discharge from Medicare Part A Services when the benefit days were not exhausted and failed to complete and provide SNF ABN Form to Resident #25 and/or representative. Review of Resident #141's SNF Beneficiary Notification Review form revealed the facility initiated Resident #141's discharge from Medicare Part A Services when the benefit days were not exhausted and failed to complete and provide SNF ABN Form to Resident #141 and/or representative. During an interview on 08/10/2026 at 4:20 p.m. S14 Social Services reported Resident #25 was discharged from Part A on 06/11/2026, remained in the facility for Long Term Care, and confirmed she did not have any documentation a SNF ABN Form had been completed for Resident #25. S14 Social Services further reported Resident #141 was discharged from Part A on 06/22/2026 when her therapy goals were met, remained in the facility for Long Term Care and confirmed she did not have any documentation a SNF ABN had been completed for Resident #141.

Based on record reviews and interview, the facility failed to ensure MDS assessments were completed and transmitted timely for 2 (#73 and #84) of 2 sampled residents reviewed for resident assessment. Findings:Resident #73Review of Resident #73's discharge MDS, with an ARD of 03/24/2026, revealed in part a status of in progress. Further review of Resident #73's discharge MDS failed to reveal the assessment had been transmitted.Resident #84Review of Resident #84's discharge MDS, with an ARD of 04/06/2026, revealed in part a status of in progress. Further review of Resident #73's discharge MDS failed to reveal the assessment had been transmitted.During an interview on 08/11/2026 at 2:00 p.m., S4 MDS Director confirmed Resident #73 and Resident #84's discharge MDS assessments had not been completed and transmitted and should have been.

Based on record reviews and interviews, the facility failed to coordinate assessment with the PASARR program by failing to refer residents with newly evident or possible serious mental disorder, intellectual disability, or related conditions for review by the State-designated Level II authority for 2 (#4, #14) of 4 residents reviewed for PASARR. Findings: Resident #4 Review of Resident #4's medical record revealed in part diagnosis of major depressive disorder and delusional disorder with diagnosis date of 03/31/2025. Further review of Resident #4's medical record failed to reveal a Level II PASARR had been completed for Resident #4. During an interview on 08/11/2026 at 3:50 p.m., S1Administrator confirmed the facility had not obtained a Level II PASARR for Resident #4. Resident #14 Review of Resident #14's medical record revealed an admit date of 12/11/2026. Resident #14 had a diagnosis of delusional disorders and failed to reveal a Level II PASARR being completed for Resident #14. During an interview on 08/11/2026 at 1:05 p.m., S14Social Services confirmed Resident #14 had a diagnosis of delusional disorder dated 12/11/2025 and a Level II PASARR was not completed.

Based on record reviews, observations and interviews, the facility failed to ensure each resident received the care and treatment in accordance with professional standards of practice for 2(#15 and #16) of 2 residents reviewed for positioning and/or mobility. The facility failed to -1. Provide restorative service for Resident #15 by not placing a roll in the resident's left hand and not applying a splinting device to the resident's left knee in accordance with the physician's order and/or the comprehensive plan of care.2. Provide restorative services for Resident #16 by not placing a roll in the resident's right hand and not applying bilateral multi-podus boots on the resident's feet in accordance with the physician's orders and/or the comprehensive plan of care.Findings:Review of the facility's Activities of Daily Living Maintain Abilities policy dated 03/2026 revealed in part.Policy: It is the policy of the facility to specify the responsibility to create and sustain an environment that humanizes and individualizes each resident's quality of life by ensuring all staff, across all shifts and departments, understand the principles of quality of life, and honor and support these principles for each resident, and that the care and services provided are person-centered, and honor and support each resident's preferences, choices, values and beliefs to achieve and or assist the resident in attaining the highest physical abilities.Procedures: The facility will ensure a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. Resident #15Review of Resident #15's medical record reveal diagnosis in part, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and left non-dominant hand, muscle wasting and atrophy not elsewhere classified, left/right lower leg, contracture of left wrist, elbow, and hand.Review of Resident # 15's physician order revealed an order dated 12/20/2025: Resident to attend restorative nursing program for splinting of left knee and left hand 6 times a week for 5 hours per day as tolerated. Further review revealed an order dated 08/14/2018: Place carrot/rolled washcloth to left palm while awake every day and evening for prophylactic skin care.Review of resident #15's Comprehensive Plan of Care revealed the resident to attend restorative nursing program for contracture and limited range of motion to left knee. Interventions is for staff to apply splint and monitor for altered skin.Review of Resident #15's Comprehensive Plan of Care revealed the resident is to receive assistance to ADL self-care performance deficit related to quadriplegia, CVA with hemiparesis. Interventions is for staff to place carrot/rolled washcloth to left palm while awake.Observation on 08/11/2026 at 9:45 a.m. of Resident #15 failed to reveal a rolled washcloth to the left hand and splinting to left knee.Observation on 08/11/2026 at 2:40 p.m. of Resident #15 failed to reveal a rolled washcloth to the left hand and splinting to left knee.Observation on 08/12/2026 at 8:15 a.m. of Resident #15 failed to reveal a rolled washcloth to the left hand and splinting to left knee.During an interview on 08/12/2026 at 8:20 a.m. S16 LPN verified Resident #15 did not have a rolled washcloth to the left hand and splinting of left knee in place. Further confirmed the restorative CNA is responsible for applying assistive/splinting devices.During an interview on 08/12/2026 at 8:25 a.m. S3 CNA Supervisor reported the CNA can place assistive/splinting devices if an order is received to do so. S3 CNA Supervisor confirmed there was no task on the Kardex for the CNA to place splinting/assistive device on Resident #15.During an interview on 08/12/2026 at 8:35 a.m. S10 CNA reported Resident #15 did not receive restorative services. Resident #16Review of Resident #16's current physician orders revealed an order dated 03/07/2026 resident to attend restorative nursing program for right hand and bilateral (multi-podus) splinting 6 times a week for 6-8 hours per day as tolerated.Review of Resident #16's August 2026 MAR/TAR failed to reveal any documentation the right hand roll or multi-podus boots had been used.Review of Resident #16's Tasks Kardex failed to reveal a task for the CNA to place a right hand roll or the multi-podus boots on the resident's feet.Review of Resident #16's most recent completed MDS revealed section GG indicated Resident #16 had functional limitation in range of motion. Resident #16 was dependent for oral hygiene, toileting hygiene, and shower/bath, upper and lower body dressing.Review of Resident #16's Comprehensive Plan of Care revealed the resident to attend restorative nursing program for bilateral feet splinting and right hand roll splinting 6 times a week for up to 4 hours per day as tolerated. Interventions is for staff to apply splint and monitor for altered skin.Observation on 08/10/2026 at 10:00 a.m. revealed Resident #16 did not have a roll in the right hand and no multi-podus boots was on the resident's feet.Observation on 08/11/2026 at 11:05 a.m. revealed Resident #16 did not have a roll in the right hand. Further observation revealed no multi-podus boots was on the resident's feet. Resident #16's multi-podus boots were in the resident's cabinet.Observations on 08/11/2026 at 2:10 p.m. with S3 CNA Supervisor acknowledge Resident #16 did not have a right hand roll or multi-podus boots on the feet. S3 CNA Supervisor reported the MDS nurses are over restorative care. S3 CNA Supervisor reported the regular CNAs can place the hand roll in the resident hand but the restorative CNAs are responsible for placing the multi-podus boots on the resident feet. During an interview on 08/11/2026 at 3:00 p.m. S4 MDS Director reported Resident #16 went out to the hospital and the physician order to place a roll in the right hand and put the multi-podus boots on never got put on the kardex for the CNAs to do. S4 MDS Director reported the orders really should have been discontinued when Resident #16 returned to the facility.During an interview on 08/11/2026 at 3:10 p.m. S5 Restorative CNA confirmed she would be the CNA to place the roll in Resident #16's right hand and put the multi-podus boots on. S5 Restorative CNA confirmed these tasks were not on Resident #16's kardex and she was not aware the resident needed restorative services.

Based on record review, observations and interview, the facility failed to ensure 2 (#55, #212) out of 2 residents reviewed for respiratory care were provided such care, consistent with professional standards of practice. The facility failed toChange Resident #55's and Resident #212's respiratory equipment weekly; Properly store Resident #55's and Resident #212's respiratory equipment to prevent contamination.Findings:Review of the facility's Respiratory Therapy Equipment Policy dated 02/2026 revealed in part:PurposeThe purpose of this procedure is to provide guidelines to help prevent nosocomial infections associated with respiratory therapy equipment, including ventilators, and to prevent transmission of infections to residents and staff.Procedure Guidelines:Oxygen Administration:5. Change oxygen cannulas and tubing every 7 days and date.6. Keep oxygen cannulas and tubing used PRN in a plastic bag when not in use.7. Wash filters from oxygen concentrators weekly. Rinse and squeeze dry.Medication Nebulizers/Continuous Aerosol:7. Store circuit in plastic bag, marked with date and resident's name, between uses.9. Discard administration set-up every 7 days. Date new tubing. Resident #55Review of Resident #55's medical record revealed an admission date on 12/18/2012 and diagnoses including, in part, hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting right dominant side and post covid-19 condition.Review of Resident #55's physician orders revealed an order dated 07/17/2026 for Albuterol Sulfate Inhalation Nebulization Solution 1.25 MG/3ML (Albuterol Sulfate); 1 vial inhale orally via nebulizer every 8 hours as needed for coughing.Observation on 08/10/2026 at 8:15 a.m. revealed Resident #55's nebulizing face mask on Resident #55's bedside table, unbagged. Observation on 08/10/2026 1:15 p.m. revealed Resident #55's nebulizing face mask on Resident #55's bedside table, unbagged.During an interview on 08/11/2026 at 11:25 a.m. at Resident #55's bedside, S9 CNA confirmed Resident #55's nebulizing face mask on Resident #55's bedside table was unbagged and dated 07/14/2026.During an interview on 08/11/2026 at 11:26 a.m. at Resident #55's bedside S10, CNA confirmed resident's respiratory equipment should be stored in a bag when not in use. During an interview on 08/11/2026 at 11:30 a.m. S11 LPN reported resident respiratory equipment should be stored in a bag when not in use. Resident # 212Review of Resident #212's medical record revealed an admission date on 07/22/2026 and diagnoses including, in part, Chronic Obstructive Pulmonary Disease, essential primary hypertension, muscle weakness- generalized, and unsteadiness on feet.Review of Resident #212's physician orders revealed an order dated of 07/23/2026 for Ipratropium-Albuterol Inhalation Solution 0.5-2.5 (3) MG/3ML (Ipratropium-Albuterol)-3 ml inhale orally four times a day for COPD. Further review revealed an order dated 07/22/2026 for oxygen at 2 liters per nasal cannula continuous. Observation on 08/11/2026 at 10:00 a.m. revealed Resident #212's nebulizing face mask on Resident #212's bedside table in a bag labeled with the date of 07/23/2026. Further observation revealed Resident #212's nasal cannula tubing sitting in the seat of Resident #212's wheelchair attached to an oxygen concentrator unbagged. During an interview on 08/11/2026 at 11:30 a.m. S11 LPN- confirmed Resident #212's nebulizing mask bag was dated 07/23/2026. Also confirmed respiratory supplies should be changed and dated weekly. During an interview on 08/11/2026 at 11:35 a.m. S11 LPN confirmed Resident#212's nasal cannula was in the seat of Resident #212's wheelchair unbagged. S11 LPN also confirmed all respiratory supplies should be bagged when not in use. During an interview on 08/11/2026 at 11:40 a.m. S12 Corporate Nurse confirmed respiratory equipment should be changed weekly, dated, and stored in a bag when not in use.

Based on record reviews and interviews, the facility failed to ensure 2 (#2, #19) out of 5 residents were free of unnecessary medications. The facility failed to:Monitor Resident #2 for bleeding while receiving an anticoagulant.Monitor Resident #19 for edema while receiving a diuretic.Ensure psychotropic medication administration consents were obtained for Resident #19.Findings:Resident #2Review of Resident #2's medical record revealed an admit date of 01/27/2026 with the following diagnoses, including in part: chronic atrial fibrillation. Review of Resident #2's physician's orders revealed an order dated 06/11/2026 for Eliquis oral tablet 5mg (Apixaban) give 1 tablet by mouth two times a day for atrial fibrillation. During an interview on 08/12/2026 at 10:20 a.m. S13 Unit Manager acknowledged Resident #2 was receiving an anticoagulant and was not monitored for bleeding. Resident #19Review of Resident #19's medical record revealed an admit date of 12/30/2025 with the following diagnoses, including in part: insomnia unspecified, depression unspecified, bipolar disorder unspecified, anxiety disorder and hypertensive heart disease with heart failure.Review of Resident #19's physician's orders revealed the following orders:06/25/2026 - Spironolactone oral tablet 25 mg give 1 tablet by mouth one time a day for hypertension and congestive heart failure.05/29/2026 - Lexapro oral tablet 20 mg (Escitalopram Oxalate) give 1 tablet by mouth one time a day for major depressive disorder.05/04/2026 - Doxepin Hydrochloride oral capsule 10 mg give 1 capsule by mouth at bedtime for insomnia.04/23/2026 - Buspirone Hydrochloride oral tablet 15 mg give 1 tablet by mouth two times a day for generalized anxiety disorder.03/25/2026 - Remeron oral tablet 15 mg (Mirtazapine) give 0.5 tablet by mouth at bedtime for insomnia.03/10/2026 - Latuda oral tablet 20 mg (Lurasidone HCl) give 1 tablet by mouth one time a day related to bipolar disorder unspecified.Review of Resident #19's medical record failed to reveal psychotropic medication consents for Lexapro, Doxepin, Buspirone, Remeron, and Latuda.Review of Resident #19's July 2026/August 2026 medication administration record and electronic task log failed to reveal documentation of monitoring for edema. During an interview on 08/12/2026 at 10:20 a.m. S2 Unit Manager acknowledged Resident #2 was receiving a diuretic and was not being monitored for edema. During an interview on 08/12/2026 at 2:30 p.m. S13 DON acknowledged Resident #19's psychotropic medication administration consents were not completed for Lexapro, Doxepin, Buspirone, and Latuda.

Based on record review and interviews, the facility failed to provide documentation of measures to prevent the growth of Legionella/Legionnaire's and other opportunistic waterborne pathogens in the facility's water systems.Findings: Review of the facility's Legionnaire's Disease policy reviewed 08/10/2026 failed to reveal the facility's specific assessment for areas at risk and/or the facility's specific measures to prevent growth of other opportunistic waterborne pathogens. Review of the water temperature checks document for dates 06/11/2026 through 08/10/2026 revealed document review failed to contain any monitoring for Legionella and other opportunistic waterborne pathogens. Review of the facility's charted representation of the water system at [facility name] map provided by S1 DON failed to reveal information on the facility's specific assessment for areas at risk and/or the facility's specific measures or for Legionella and other opportunistic waterborne pathogens. During an interview on 08/11/2026 at 12:53 p.m. S6 Maintenance Supervisor reported he is responsible for water temperature monitoring including for Legionella prevention. S6 Maintenance Supervisor reported he was unaware of a policy or guideline for Legionella prevention and monitoring.During an interview on 08/12/2026 at 11:17 a.m. S1 Administrator confirmed the Legionnaire's Disease policy did not contain information for the facility's specific assessment for areas at risk and/or the facility's specific measures to prevent growth.

Based on record review and interviews, the facility failed to implement a comprehensive person centered care plan for Resident #163. The facility failed to provide two person assistance during ADL care for 1 (#163) out 57 sampled residents' records reviewed. Findings:Review of the facility's Accommodation of Needs policy dated 03/2026 revealed in part:Procedure:2. The care plan is to be updated with the level of assistance required to meet the needs of the resident for activities of daily living (ADLs) such as bed mobility, transfers, toileting, incontinence care, eating, etc.Review of Resident #163's medical record revealed Resident #163 was admitted on [DATE] with diagnoses including, in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and unspecified abnormalities of gait and mobility.Review of Resident #163's Quarterly MDS assessment dated [DATE] revealed, in part, resident was dependent for rolling left and right. Review of Resident #163's care plan revealed, in part, Resident #163 required a two person assist for rolling left and right.During a telephone interview on 08/11/2026 at 4:47 p.m., S7 CNA reported on 07/23/2026 she was doing peri-care on Resident #163 without a second person to assist and rolled Resident #163 on left side. S7 CNA confirmed Resident #163 was a two person assist for positioning and should have had another staff member to assist with ADL care.During an interview on 08/11/2026 at 4:15 p.m., S8 LPN confirmed she entered Resident #163's room on 07/23/2026 at approximately 3:00 p.m. and found S7 CNA performing peri care on Resident #163 without another staff member to assist. S8 LPN further confirmed resident was a two person assist for positioning.During an interview on 08/12/2026 at 11:17 a.m., S2 DON confirmed Resident #163 was a two person assist for positioning on 07/23/2026 and S7 CNA should not have started care alone on Resident #163.

Based on record reviews, observations and interviews, the facility failed to ensure residents with pressure injuries received necessary treatment and services consistent with professional standards of practice to promote healing for 2 (#1and #3) residents of 3 sampled residents. The facility failed to ensure:1. Resident #1's right lateral ankle pressure injury remained free of moisture and 2. EBP signage was in place for Resident #1 and Resident #3. Findings: Review of the facility's undated Enhanced Barrier Precautions policy revealed in part: Enhanced Barrier Precautions expand the use of PPE beyond situations in which exposure to blood and body fluids is anticipated and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing.All residents with any of the following conditions should use enhanced barrier precautions:2. Wounds and/or indwelling medical devices (e.g., central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status who reside on a unit or wing where a resident known to be infected or colonized with a novel or targeted MDRO resides. Resident #1 Review of Resident #1 's medical record revealed an admit date of 03/03/2025 with diagnoses including in part, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, Type 2 Diabetes, and mild protein-calorie malnutrition. Review of Resident #1's Annual MDS assessment dated [DATE] revealed a BIMS was not conducted as Resident #1 was never understood. Resident #1 was totally dependent on staff and required physical assistance for bathing and transfers. Review of Resident #1's Comprehensive Care Plan revealed in part, Resident #1 was care planned for EBP for wounds. Review of Resident #1's medical record revealed the following wound assessments and treatment recommendations by S2Wound Care NP in part: 04/07/2026 Stage 3 right lateral ankle pressure injury with a status of stable and measured 2.5 cm x 3 cm x 0.2 cm. Treatment Recommendations: Clean with 0.125% Dakin's solution, apply Calcium alginate, Collagen with silver (Ag) and Silicone super-absorbent dressing. Change 3 times per week, Tuesday/Thursday/Saturday and as needed if dislodged, saturated, or soiled. 4/14/2026 Stage 3 right lateral ankle pressure injury with a status of subsequent-worsening and measured 3 cm x 2.5 cm x 0.2 cm with Undermining from 12 o'clock to 3 o'clock, 0.7 cm. Treatment Recommendations: Clean with 0.125% Dakin's solution, apply Collagen with silver (Ag), Calcium Alginate with Silver (Ag) and Silicone super-absorbent dressing. Change 3 times per week, Tuesday/Thursday/Saturday and as needed if dislodged, saturated, or soiled. Review of S2Wound Care NP's 04/14/2026 progress note revealed an addendum related to the decline of Resident #1's right lateral ankle injury which revealed in part: An addendum has been made to the existing progress note due to documented events that occurred after this morning's assessment. I was contacted by S1Administrator who stated one of Resident #1's family members had concerns regarding wound, deterioration, and status of Resident #1's current wounds. At this morning's assessment, it was noted Resident #1 had a wound deterioration to the right lateral ankle as the granulation tissue appeared frail. The granulation tissue to Resident #1's right lateral ankle was noted to be less robust beefy red tissue and overall less healthy. A change in Resident #1's plan of care was made. Silver collagen was added to stimulate the wound bed and to decrease any bioburden. This afternoon, a conference call was held with Resident #1's family member. During the call, I (S2Wound Care NP) explained to Resident #1's family member the characteristics of the right lateral ankle wound deterioration. Please note prior to the call it was reported that Resident #1's family member had assisted Resident #1 to shower over the weekend. During the call, I explained to Resident #1's family member that excess moisture from showering can cause a tissue change or wound deterioration. An observation on 05/11/2026 at 11:00 a.m. revealed Resident #1's room failed to have EBP signage in place. During an interview on 05/11/2026 at 11:05 a.m., S3CNA acknowledged Resident #1's room did not have EBP signage in place and should have. During an interview on 05/11/2026 at 11:10 a.m., S4LPN acknowledged Resident #1's room did not have EBP signage in place and should have had. During an interview on 05/12/2026 at 9:30 a.m., S2Wound Care NP reported the wound assessment on 04/14/2026 revealed Resident #1's right lateral ankle pressure injury had changes she could not understand. S2Wound Care NP reported Resident #1's right lateral ankle pressure injury was mushy and frail. S2Wound Care NP further reported on the afternoon, 04/14/2026 she was notified by the facility Resident #1's family member had showered Resident #1 over the weekend. S2Wound Care NP further reported the changes to Resident #1's right lateral ankle were consistent with getting wet. S2Wound Care NP confirmed moisture to a wound bed could causes frailness and a decline. S2Wound Care NP acknowledged residents with pressure injuries should not be showered. During an interview on 05/12/2026 at 3:30 p.m., S5RN reported the shower incident occurred on 04/05/2026 around 2:00 p.m. S5RN reported Resident #1's family member wanted Resident #1 to have a shower. S5RN reported she brought the shower chair into Resident #1's room and she and Resident #1's family member transferred Resident #1 to the shower chair. S5RN reported Resident #1's wounds did not have dressings in place and she secured a plastic bag only to Resident #1's right lateral ankle wound. S5RN reported she proceeded to take Resident #1 into the shower room and showered Resident #1. S5RN reported after the shower she transported Resident #1 back to the room and applied wound care cleaner and a dry dressing to all of Resident #1's wounds. S5RN acknowledged the plastic bag around Resident #1's right ankle had collected a little water. S5RN reported she did not report or document the shower incident and stated she did not think showering Resident #1 was a big deal. S5RN further reported she did not know a major decline could result by a wound getting wet. During an interview on 05/12/2026 at 4:10 p.m., S1Administrator reported S5RN should not have showered Resident #1 with open wounds. During a telephone interview on 05/13/2026 at 11:40 a.m., S2Wound Care NP stated Bottom line, Resident #1 should have never been put in the shower. This set Resident #1 up for bacteria. Resident #3Review of Resident #3 's medical record revealed an admit date of 02/20/2024 with a diagnosis including in part, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. Review of Resident #3's Quarterly MDS assessment dated [DATE] revealed a BIMS was not conducted as Resident #3 was never understood. Resident #3 was totally dependent on staff and required physical assistance for bathing and transfers. Review of Resident #3's Comprehensive Care Plan revealed Resident #3 was care planned for EBP for wounds. An observation on 05/11/2026 at 11:50 a.m. revealed Resident #3 awake and lying in bed resting with visible wound care bandages to heels bilaterally. Further observation failed to reveal EBP signage was in place. During an interview on 05/11/2026 at 11:05 a.m., S3CNA acknowledged Resident #3 was on EBP related to his wounds. S3CNA furthered acknowledged there was no EBP signage on Resident's #3 door and should have been. During an interview on 05/11/2026 at 11:10 a.m., S4LPN confirmed Resident #3 was on EBP. S4LPN further confirmed no EBP signage was in place and should have been.

Based on record review, observation and interviews, the facility failed to follow procedures to ensure a resident received pain medication to be administered as ordered for 1 (Resident #2) of 6 sampled residents. The facility failed to provide effective pain management due to the resident's scheduled morphine not being available. The deficient practice resulted in an actual harm for Resident #2 on 11/27/2025 at 8:10 p.m. when Resident #2 received a prn (as needed) dose of Oxycodone-acetaminophen 10-325 mg (milligram) po (by mouth) for a pain level of 10 which had a follow-up status of ineffective. The facility had ran out of Resident #2's Morphine Sulfate (controlled substance) narcotic pain medication ordered for the administration of 30 mg 2 tablets for a total of 60 mg po q (every) eight hours. Resident #2's last documented dose of scheduled Morphine was on 11/26/2025 at 2:00 p.m. S3Unit Manager failed to follow up on the narcotic medication refill request for Resident #2's Morphine prior to and after Resident #2 ran out of scheduled Morphine. Resident #2 missed 3 consecutive doses of scheduled Morphine prior to transfer to a local ER (Emergency Room). Resident #2 received Oxycodone-acetaminophen 10-325 mg on 11/26/2025 at 8:55 p.m. for pain for a pain level of 9 which included a follow-up status of effective and on 11/27/2025 at 6:22 a.m. for pain for a pain level of 7 which included a follow-up status of effective. Resident #2 received Tylenol 650 mg po on 11/27/2025 at 5:40 p.m. with no pain level documented which included a follow-up status of ineffective. Resident #2 received an additional dose of prn oxycodone-acetaminophen 10-325 mg po on 11/27/2025 at 8:10 p.m. for a pain level of 10 which included a follow-up status of ineffective. Resident #2 reported he needed his Morphine for chronic pain and the alternate pain medications were not working. Resident #2 reported his body takes some time to feel the effects of not getting his scheduled Morphine and stated the pain was worsening, so I had to go to the ER. Reported when he left for the ER his headache pain level was a 7 out of 10. Resident #2 was transferred to the ER on [DATE] at 9:21 p.m. for complaints of severe headache, nausea and ineffective pain control. Findings: Review of the facility's Pain Management policy dated 09/2025 revealed in part:Policy: The intent of the facility to ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan and the resident's choices, related to pain management.Procedure: The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.Review of the facility's Pain Documentation in eMAR (Electronic Medication Administration Record) for PRN Pain Medications policy dated 09/2025 revealed in part: Policy: It is the policy of this center to review pain needs by asking the resident for the verbal pain scale .Procedure:1. Explain to the resident/resident representative that the purpose of the documentation and pain rating scale is to aid the nurses and physicians in controlling and managing the resident's current pain level.2. Explain to the resident to rate the current pain level on a scale from 0 to 10, where 0 is no pain and 10 is the worst pain imaginable. (Remember the resident's report of pain is subjective; their pain rating is what they say it is. Ask the resident to select a number that best describes how they feel at the time of observation.)4. Pain should be observed and recorded in eMAR prior to PRN pain intervention and after pain intervention, to ensure pain interventions are managing pain.Note: Both pharmacological and non-pharmacological considerations should be made for pain.Pharmacological: When considering drug therapy for managing pain, there are three basic concepts to review:1. By mouth (most convenient and cost-effective route of administration).2. By the clock (rather than PRN or as needed) allows each analgesic dose to achieve constant pain control.3. By the ladder:a. Start with non-opioid analgesic drugs such as acetaminophen, aspirin or other non-steroidal anti-inflammatory drugs.b. If pain remains unrelieved, opioids may be added. These include codeine, hydrocodone, oxycodone and low dose morphine.c. For severe pain unrelieved by above steps, consider opioids such as morphine, oxycodone, hydromorphone and fentanyl.Review of the facility's Ordering and Receiving Controlled Medications policy dated 01/2023 revealed in part: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances and medications classified as controlled substances by state law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center, in accordance with federal and state laws and regulations. Review of Resident #2's medical record revealed an admit date of 09/08/2022 with a re-admit date of 09/09/2025. Further review of Resident #2's medical record revealed diagnoses which included in part, other incomplete lesion at T7-T10 level of thoracic spinal cord, sequela, fistula of stomach and duodenum, and chronic pain syndrome. Review of Resident #2's admission MDS (Minimum Data Set) assessment dated [DATE] revealed in part a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. Further review of Resident #2's admission MDS assessment revealed Resident #2 received scheduled and prn pain medications for pain management. Further review of Resident #2's admission MDS assessment dated [DATE] revealed Resident #2's worst pain experienced in the past 5 days was rated a 10 on a 0-10 pain scale.Review of Resident #2's current care plan revealed in part, Resident #2 had a focus of potential for pain and discomfort related to muscle spasm, fistula of stomach and duodenum, and chronic pain syndrome created on 09/10/2025 with interventions to assess for pain every shift and administer analgesics per physician orders. Review of Resident #2's current physician orders revealed in part: 09/21/2025 Morphine Sulfate oral tablet 30 mg, give 2 tablets po q 8 hours related to pain. 11/04/2025 Oxycodone-acetaminophen oral tablet 10-325 mg, give 1 tablet by mouth every 8 hours prn for pain.05/11/2023 acetaminophen 325 mg, give 2 tablets po q 4 hours prn for mild pain or breakthrough pain.Review of Resident #2's November 2025 eMAR revealed in part, Resident #2's last documented dose of scheduled Morphine was on 11/26/2025 at 2:00 p.m. Further review revealed Resident #2 failed to receive his scheduled dose of Morphine Sulfate 60 mg on 11/26/2025 at 10:00 p.m. and had a documented pain level of 9. Resident #2 failed to receive his scheduled doses of Morphine Sulfate of 60 mg on 11/27/2025 at 6:00 a.m. and 11/27/2025 at 2:00 p.m. with no levels of pain documented. Further review of Resident #2's November 2025 eMAR revealed Resident #2 was receiving the following prn pain medications:11/26/2025 at 8:55 p.m. Oxycodone-acetaminophen 10-325 mg for pain for a pain level of 9 and included a follow-up status of effective. 11/27/2025 at 6:22 a.m. Oxycodone-acetaminophen 10-325 mg for pain for a pain level of 7 and included a follow-up status of effective. 11/27/2025 at 12:08 p.m. Oxycodone-acetaminophen 10-325 mg for pain for a pain level of 9 pain and included a follow-up status of unknown. 11/27/2025 at 5:40 p.m. Tylenol 650 mg po with no pain level documented and included a follow-up status of ineffective.11/27/2025 at 8:10 p.m. Oxycodone-acetaminophen 10-325 mg po for a pain level of 10 with a follow-up status of ineffective. Review of Resident #2's interdisciplinary notes revealed in part:S4RN (Registered Nurse) documented on 11/26/2025 at 9:23 p.m. Morphine Sulfate tablet 30 mg give 2 tablets by mouth q 8 hours was not administered due to medication not in, a request for refill was sent on 11/25/2025 and physician stated a hard script was sent to the pharmacy on 11/26/2025.S7LPN (Licensed Practical Nurse) documented on 11/27/2025 at 6:53 a.m. Morphine Sulfate tablet 30 mg give 2 tablets by mouth q 8 hours was not administered due to not available and on order from the pharmacy.S8LPN documented on 11/27/2025 at 3:07 p.m. Morphine Sulfate tablet 30 mg give 2 tablets by mouth q 8 hours was not administered due to medication on order.S9LPN documented on 11/27/2025 at 8:29 p.m. Resident #2 complained of severe headache and is demanding to go out to _____ hospital ER. B/P (blood pressure) 154/94, P (pulse rate) 105, R (respiratory rate) 22.notified on-call NP (Nurse Practitioner).Further review of Resident #2's interdisciplinary notes revealed Resident #2 was transferred to the ER on [DATE] at 9:21 p.m. and was subsequently admitted to the hospital.Review of Resident 2#'s medical record, revealed a provider note dated 11/27/2025 which read in part: The nurse called in regard to this patient (Resident #2). presenting with severe headache and nausea. History is provided by nursing staff. Resident #2 reports severe headache and nausea and is requesting transfer to the ER. Resident #2 took Tylenol earlier today without relief. Resident #2 was administered Percocet (oxycodone) at 1800 (6:00 p.m.), but reports that his symptoms persist. Resident #2 is currently out of morphine. Resident #2's family has called requesting that he be sent to the ER. by: S11NP. Further review of Resident #2's medical record revealed a Controlled Substances Refill Request for S10MD (Medical Doctor) dated 11/25/2025 and revealed in part, a refill request for Resident #2's scheduled Morphine Sulfate of 30 mg (give 2 tablets) q 8 hours was faxed on 11/25/2025 at 10:51 p.m. by S4RN with a total amount of medication on hand of four. Further review revealed a receipt response from S10MD was selected as via fax notification with the fax number provided. During an interview on 12/02/2025 at 2:40 p.m., S4RN reported she sent a refill request via fax to S10MD when she noted Resident #2 had two doses of scheduled Morphine remaining. S4RN reported she also made a follow-up call to S10MD on 11/26/2025 because Resident #2 was out of Morphine and reported Resident #2 complained of a migraine headache. S4RN further reported S10MD said he sent a hard script to the pharmacy for Resident #2's Morphine refill and she (S4RN) needed to call the pharmacy and not him (S10MD). S4RN acknowledged she did not call the pharmacy. During an observation of Resident #2's narcotic drawer with S2DON (Director of Nursing) on 12/02/2025 at 3:00 p.m., Resident #2's narcotic count failed to reveal Morphine 30 mg tablets were in stock for Resident #2. During an interview on 12/02/2025 at 3:00 p.m., S2DON confirmed Resident #2 received his last dose of scheduled Morphine on 11/26/2025 at 1:52 p.m. and went out to the ER on [DATE] at 9:21 p.m. S2DON acknowledged Resident #2 missed 3 consecutive doses of scheduled Morphine and should not have. During a telephone interview on 12/02/2025 at 4:00 p.m., Resident #2, who remained hospitalized due to other medical conditions, reported he went to the ER on [DATE] for a migraine headache, nausea, and bed sore pain. Resident #2 reported the facility had been out of his Morphine for a day and a half and this was not the first time his doctor had let his Morphine run out. Resident #2 further reported he needed his Morphine for chronic pain and the alternate pain medications were not working. Resident #2 reported his body takes some time to feel the effects of not getting his scheduled Morphine and stated the pain was worsening, so I had to go to the ER. Reported when he left for the ER his headache pain level was a 7 out of 10. During an interview on 12/02/2025 at 4:30 p.m., S3Unit Manager reported floor nurses began faxing Morphine refill requests to S10MD beginning 11/24/2025 and continued through 11/26/2025. S3Unit Manager reported when she called the pharmacy just now on 12/02/2025, the pharmacist reported the last refill request for Resident #2's Morphine was received on 10/24/2025. During an interview on 12/02/2025 at 4:35 p.m., S2DON reported the nursing staff should have called the pharmacy to follow-up why Morphine had not been refilled instead of continuing to fax requests to the physician. During an interview on 12/03/2025 at 9:30 a.m., S12CNA (Certified Nursing Assistant) reported she regularly cared for Resident #2 who was noncompliant with ADL (activities of daily living) care and positioning but did not complain of pain much at all. During a telephone interview on 12/03/2025 at 9:55 a.m., S9LPN reported she was the nurse taking care of Resident #2 on 11/27/2025 during the evening shift. S9LPN reported when she arrived to work on 11/27/2025 she was informed Resident #2 wanted to go out to the ER. S9LPN reported when she went on initial rounds, Resident #2 complained of a severe headache and would let her know when he was ready to go to the ER. S9LPN reported Resident #2 had been on Morphine so long and stated I felt it worked best for him. S9LPN reported she had administered Resident #2 other prn pain medications including Tylenol but Resident #2 had responded prn pain doses were in-effective prior to leaving for ER. S9LPN reported a little bit later into the shift, Resident #2 stated he was still hurting and wanted to go to ER now. S9LPN reported she had received calls from Resident #2's family members requesting transport to the ER. S9LPN reported she notified the on-call NP, Resident #2 was out of his Morphine, complained of a severe headache and requested to go to the ER. S9LPN further reported she had faxed a refill request for Resident #2's Morphine on the early morning of 11/25/2025 prior to leaving for 2 days off because Resident #2 was getting low on doses of Morphine. S9LPN reported when she returned on 11/27/2025, the facility had not received Resident #2's refill of Morphine. During a telephone interview on 12/03/2025 at 10:50 a.m., S10MD reported he remembered receiving a refill request on either 11/24/2025 or 11/25/2025 regarding Resident #2's Morphine refill request. S10MD reported he was not aware until yesterday, 12/02/2025, that Resident #2's refill request had not been received by the pharmacy. S10MD reported upon looking into the electronic health system (EHS), S10MD verified Resident #2's last refill received by the pharmacy was on 10/24/2025. S10MD reported he remembered changing the refill request date in the EHS system to either 11/24/2025 or 11/25/2025 but could not see verification in the EHS system that a November refill request had been submitted to or received by the pharmacy. S10MD reported Resident #2 had significant wounds and a worker's related injury and received scheduled Morphine for chronic pain. S10MD acknowledged Resident #2's morphine failed to get refilled in a timely manner. S10MD reported nursing staff could have called S13NP or left him a message. S10MD further reported the narcotic refill process was as stated, I (S10MD) have asked the nurses to fax these refill requests but sometimes they fax, sometimes they text and sometimes they call for refills, but faxing works best. During an interview on 12/03/2025 at 11:10 a.m., S1Administrator reported she was just made aware yesterday, 12/02/2025, the facility had ran out of Resident #2's scheduled Morphine and Resident #2 was transferred to the ER. S1Administrator reported the facility's process for narcotic medication refills included the nurse to submit a refill request before a resident runs out of any medication and should have seven days of resident's medication on hand when process begins. S1Administrator further reported nursing staff should follow chain of command and notify the Unit Manager when a refill has not been obtained timely, who would then notify the DON or the Administrator to get involved if needed. S1Administrator acknowledged the S3Unit Manager failed to inform the DON Resident #2 was out of Morphine and reported there was a failure of communication. During a telephone interview on 12/03/2025 at 11:50 a.m. S11NP reported she received a call from Resident #2's nurse on 11/27/2025 who reported Resident #2 was complaining of a severe headache, was out of Morphine and the prn pain medications were not working. S11NP reported she initially wanted to give Resident #2's prn pain medication more time to take affect but was told by the nurse the family wanted Resident #2 to go to the ER. S11NP reported she was not aware Resident #2 had missed 3 consecutive doses of Morphine and acknowledged this could affect his pain level because Resident #2 takes Morphine chronically (scheduled). During an interview on 12/03/2025 at 12:00 p.m., S4RN reported the refill request form that she had previously faxed to S10MD had not come back as received and Resident #2 was almost out of his Morphine on 11/26/2025. S4RN reported she selected for S10MD to fax back a confirmation of receipt and the facility's fax number was provided. S4RN reported she was advised by S3Unit Manger to call S13NP. S4RN reported when she called, S13NP informed her (S4RN) that she did not manage chronic pain and advised her to call S10MD. S4RN reported she telephoned S10MD who told me to call the pharmacy. S4RN reported that she did not call the pharmacy because she had informed S3Unit Manager. During an interview on 12/03/2025 at 12:15 p.m., S3Unit Manager reported she was informed by S4RN on 11/26/2025 that Resident #2 was almost out of his Morphine and the request had been faxed but never confirmed as received. S3Unit Manager reported she told S4RN to call S13NP who had S4RN call S10MD. S3Unit Manager Reported S4RN came to her and told her S10MD advised to call the pharmacy. S3Unit Manager acknowledged neither of them called the pharmacy and reported she was busy handling other things. S3Unit Manager reported the facility's pharmacy was off-site and the facility received two runs daily, one in the evening and one around midnight. S3Unit Manager reported she stayed over on 11/26/2025 until the evening pharmacy delivery arrived and Resident #2's Morphine had not been delivered. S3Unit Manager reported she did not notify the pharmacy, the physician or administrative staff Resident #2 was out of Morphine. S3Unit Manager acknowledged Resident #2 would not receive the 11/26/2025 10:00 p.m. scheduled dose of Morphine and confirmed she knowingly left the facility that night. S3Unit Manager reported when she returned on the morning of 11/27/2025, she was informed by staff Resident #2's Morphine had not come in on the midnight run and Resident #2 missed his 6:00 a.m. dose of scheduled Morphine on 11/27/2025. S3Unit Manager reported she did not notify the pharmacy, physician or administrative staff Resident #2 was out of his Morphine and had missed 2 consecutive doses. S3Unit Manager reported later that afternoon on 11/27/2025, she checked on Resident #2 and Resident #2 was lying in bed with a sheet over his head and did not want the lights on. S3Unit Manager reported Resident #2 complained of a migraine headache and was not happy the facility was out of his Morphine. S3Unit Manager reported she left on 11/27/2025 prior to Resident #2 going out to the ER and was aware at this time, Resident #2 had missed a 3rd dose or scheduled Morphine. S3Unit Manager acknowledged she failed to follow-up when Resident #2 ran out of scheduled Morphine and should have. During an interview on 12/03/2025 at 12:25 p.m., S2DON reported she worked on 11/27/2025 and had not been notified by staff the facility had ran out of Resident #2's scheduled Morphine. S2DON reported the S3Unit Manager should have notified her and did not. During an interview on 12/03/2025 at 12:30 p.m., S1Administrator reported S3Unit Manager failed to notify the proper channels when the facility ran out of Resident #2's Morphine. S1Administrator further reported there was a lack of communication by S3Unit Manager to properly request and follow-up on narcotic refills. During an interview on 12/04/2025 at 8:30 a.m., S1Administrator and S2DON acknowledged Resident #2 did not receive his scheduled Morphine for 3 consecutive doses prior to transfer to the ER and should have.

Based on record review and interviews, the provider failed to ensure a plan of care had been developed and implemented for 2 (#1 and #5) of 6 (#1, #2,#3,#4 #5 #6) residents whose care plans were reviewed by:1. Failing to develop a plan of care for the use of a PICC (peripheral inserted central catheter) line for Resident #1 and Resident #5.2. Failing to administer Resident #1 intravenous antibiotic medication as ordered and failing to provide restorative care for Resident #5 as ordered.Findings: 1.Resident #1Review of Resident #1's medical record revealed an admit date of 09/17/2025 with a diagnosis of but not limited to sepsis unspecified organism, Bacterial infection, type 2 diabetes with other circulatory problems, polyneuropathy, and non-pressure chronic ulcer of the feet.Review of Resident #1's MDS (Minimum Data Set) dated 09/23/2025 revealed a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. Review of Resident 1's medical record revealed Resident #1 was admitted to the facility with a PICC line in his left arm. Review of Resident #1's Comprehensive Care Plan failed to reveal a problem and approaches reflecting use of a PICC line for the administration of IV (intravenous) antibiotics. During an interview on 12/20/2025 at 3:15p.m. S5 MDS Director confirmed Resident #1's Comprehensive Care Plan failed to have a problem and approaches reflecting the use of a PICC line for the administration of IV antibiotics. Resident #5Review of Resident 5's medical record revealed an admit date of 10/07/2025 with a diagnosis of but not limited to muscle wasting and atrophy, right shoulder non-surgical orthopedic/muscle, cachexia, moderate protein-calorie malnutrition, other pleural conditions, other disorders of lung pulmonary cavity lesion, shortness of breath, other specified disorders of the bladder and dysphagia oropharyngeal phase.Review of Resident #5's admission MDS (Minimum Data Set) dated 10/13/2025 revealed a BIMS (Brief Interview Mental Status) score of 15 indicating intact cognition. Review of Resident 5's medical record revealed Resident #5 was admitted to the facility with a PICC line was located in his left jugular vein and had to be sent back out to the transferring facility for replacement to his right upper inner arm. Review of Resident #1's Comprehensive Care Plan failed to reveal a problem and approaches reflecting use of a PICC line for the administration of IV (intravenous) antibiotics. During an interview on 12/02/2025 at 3:30 p.m. S5 MDS Director confirmed Resident #5's Comprehensive Care Plan failed to have a problem and approaches reflecting the use of a PICC line for the administration of IV antibiotics.2.Resident #1Review of Resident #1's September 2025 Physician's Orders revealed an order for Cefepime HCL intravenous solution 2 GM (grams)/100 ml (milliliters) every 8 hours intravenously for osteomyelitis until 10/22/2025.Review of Resident #1's September 2025 Medication Administration Record failed to reveal documentation of the administration of Cefepime IV solution on 09/19/2025 10 p.m. dose and 09/24/2025 2:00 p.m. dose. During a phone interview on 12/02/2025 at 9:00 a.m. Resident #1 reported the nurses at the facility did not administer IV antibiotic medication properly. Further reported Resident #1 was not given the IV antibiotics three times a day.During an interview on 12/02/2025 at 2:00 p.m. S2 DON (Director of Nursing) confirmed Resident #1's IV antibiotics were not documented as administered 09/19/2025 10 p.m. dose and 09/24/2025 2:00 p.m. dose. S2 DON confirmed Resident #1's IV antibiotics should have been administered as ordered by the physician.Resident #5 Review of resident #5 current Physician's orders revealed an order dated 11/20/2025, Resident to attend restorative nursing program for active/ active assist range of motion to bilateral upper and lower extremities 6 times a week for a minimum of 15 minutes for session as tolerated. During an interview on 12/01/2025 at 1:30 p.m. resident #5 reported he had not received restorative services. During an interview on 12/02/2025 at 3:20 p.m. S6 Restorative Aide reported restorative services for resident #5 had not been started. S6 Restorative Aide reported the MDS nurses place a resident on the restorative aide schedule so that they can be seen and resident #5 was not placed on their schedule.During an interview on 12/02/2025 at 3:30 p.m. S5 MDS Director confirmed Resident #5 did not have restorative services, she reported it had been overlooked.

Based on record review, observation, and interview, the facility failed ensure a resident's Percutaneous Endoscopic Gastrostomy (PEG) tube (a soft, plastic feeding tube that goes into the stomach used to provide nutrition when oral intake is inadequate) feeding was not administered while a resident was in a flat position for 1 (#4) of 6 (#1, #2, #3, #4, #5 and #6) sampled residents. Findings: Review of the facility's Feeding Systems (Artificial) policy dated 06/2025 revealed in part:Purpose: The purpose of this procedure is to provide guidelines for the safe administration of tube feedings.Procedure Guidelines2. Continuous Feeding:b. If not contraindicated, elevate the head of the bed thirty to forty-five degrees (30-45 degrees) for duration of feeding and for one (1) hour after administration. Review of Resident #4's medical record revealed an admit date of 04/17/2025 with diagnoses including in part focal traumatic brain injury with loss of consciousness of unspecified duration and attention to gastrostomy. Review of Resident #4's quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part a BIMS (Brief Interview of Mental Status) was not performed as Resident #4 was rarely/never understood. Review of Resident #4's quarterly MDS revealed Resident #4 had a feeding tube in place.Review of Resident #4's physician orders revealed in part:08/21/2025 Enteral feed every shift, Jevity 1.5 at 55 cc (cubic centimeter) per hour per peg pump continuously.11/28/2025 Tube: elevate head of bed 30-45 degrees at all times during feeding and one hour after feeding is stopped. Review of Resident #4's current care plan revealed in part, Resident #4 required peg tube feedings and to elevate the head of bed 30-45 degrees at all times during feeding and one hour after feeding is stopped. An observation on 12/01/2025 at 2:55 p.m. revealed Resident #4 lying supine in bed with Jevity 1.5 infusing at 55 cc per hour per peg pump. Further observation revealed Resident #4's head of bed was in a flat position and not elevated. During an interview on 12/01/2025 at 3:00 p.m., S2DON (Director of Nursing) and S1Administrator acknowledged Resident #4 was lying on her back and the head of bed was not elevated while tube feeding was in process. S2DON reported the head of bed should be elevated at 30 degrees during tube feeding infusion and was not.

Based on record reviews and interviews the facility failed to ensure 1 (#165) of 5 (#5, #7, #14, #158, and #165) residents or resident's representatives reviewed for unnecessary medications were informed of risk and benefits, treatment alternatives or other options of psychotropic medications prior to administration. Findings: Review of facility's Psychotropic Medication Use and Chemical Restraints Policy dated 06/2025 revealed, in part:Purpose .This policy promotes safe, appropriate, and individualized use of psychotropic medications in nursing home residents.Policy StatementIt is the policy of this facility to prohibit the use of psychotropic medications as chemical restraints for staff convenience or disciplinary purposes. Psychotropic drugs will only be used: To treat a specific, documented condition diagnosed by a licensed practitioner, and As part of a comprehensive, person-centered care plan. Psychotropic Medication: Any drug that affects brain activity associated with mental processes and behavior. This includes but is not limited to Antipsychotics, Antidepressants, Anxiolytics (anti-anxiety agents) and Hypnotics (sedatives). The prescribing practitioner must document the resident's diagnosis or condition, risks and benefits discussed with the resident or representative, and non-pharmacological alternatives attempted.Informed ConsentObtain informed consent from the resident or legal representative.Prior to administration: Provide written and verbal education on medication purpose, potential benefits and risks, and alternatives (including non-drug interventions) Document consent in the medical record.Prohibited UsesPsychotropic medications must not be used: Without informed consent Review of Resident #165's face sheet revealed an admission date of 01/07/2025 with the following diagnoses but not limited to bipolar disorder, current episode depressed, severe with psychotic features, major depressive disorder, and altered mental status. Review of Resident #165's July 2025 Physician Orders revealed: 06/19/2025: Trazadone HCl (hydrochloride) Oral Tablet 50 MG (milligram); Give 0.5 tablet by mouth at bedtime for insomnia 06/18/2025: Cymbalta Oral Capsule Delayed Release Particles 60 MG; Give 1 capsule by mouth two times a day for major depressive disorder06/07/2025: Buspirone HCl Oral Tablet 10 MG; Give 1 tablet by mouth two times a day for generalized anxiety disorder05/27/2025: Mirtazapine Oral Tablet 30 MG; Give 1 tablet by mouth at bedtime related to major depressive disorder 03/31/2025: Anti-anxiety Medication use: Observe resident closely for significant side effect monitoring every shift 01/07/2025: Psych meds: monitor behaviors: physical aggression, yelling, cursing, biting, kicking, scratching, resisting care, exit seeking behavior or other behaviors every shift. 01/7/2025: EPS (Extrapyramidal symptoms): Monitor for EPS every shift. 01/7/2025: Psych meds: monitor side effects every shift. 01/8/2025: Hydroxyzine HCl Oral Tablet 25 MG; Give 1 tablet by mouth every 8 hours as needed for itchingReview of Resident #165's Quarterly MDS (Minimum Data Sets) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) of 10 indicating moderate impaired cognition. Review of Resident #165's MDS dated [DATE] revealed little interest or pleasure and poor appetite or overeating in doing things for 7-11 days of the look back period (over the last 2 weeks), feeling down, depressed, or hopeless for 2-6 days of look back period (over the last 2 weeks). Further review of Resident #165's MDS dated [DATE] revealed verbal behavioral symptoms directed toward others occurred for 1 to 3 days and other behavioral symptoms not directed toward others occurred 1 to 3 days for the past 2 weeks of the look back period. Review of Resident #165's MDS dated [DATE] Medications section revealed Resident #165 received during the last 2 weeks of the look back period revealed Antidepressant, Anticoagulant, Antibiotic, Hypoglycemic (including insulin), Anticonvulsant, and Antipsychotic medications during the last 2 weeks of look back period. Review of Resident #165's Care Plan revealed resident uses antidepressant medication related to insomnia, depression with interventions to educate the resident/family/caregivers about risks, benefits and the side effects and/or toxic symptoms of anti-depressant drugs being given, give antidepressant medications ordered by physician. Monitor/document side effects and effectiveness.Review of Resident #165's EHR (Electronic Health Record) failed to reveal informed consents were obtained before administration of psychotropic medications. During an interview on 07/24/2025 at 9:00 a.m. S1 Administrator presented the facility policy and confirmed informed consents were not obtained before administration of psychotropic medications.

Based on record reviews, observations and interviews the facility failed to act promptly to concerns presented in the resident council meetings. The deficient practice affected 4 (#37, #139, #170, #178) of 7 (#37, #45, #139, #170, #173, #174, #178) residents interviewed for resident care and life in the facility. The deficient practice had the potential to affect the total census of 176 residents in the facility. Findings:Review of the facility's grievance policy with a revision date of 6/2025 revealed:INTENT: It is the policy of the facility to allow the resident and or legal representative to voice a grievance in such a manner to acknowledge and respect resident rights.PROCEDURE:1. The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC (Long Term Care) facility stay.2. The resident has the right to and the facility will make prompt efforts by the facility to resolve grievances the resident may have, in accordance with this paragraph.4. The designated professional will maintain the facility Grievance Program.5. All residents, staff, and visitors will have access to the professional designated to manage the Grievance Program, Grievance Officer. 8. The facility will establish a grievance policy to ensure the prompt resolution of all grievances regarding the residents' rights.9. Upon request, the facility will give a copy of the grievance policy to the resident. The grievance policy must include:a. Notifying resident individually or through postings in prominent locations throughout the facility of the right to file grievances orally (meaning spoken) or in writing; the right to file grievances anonymously; the contact information of the grievance official with whom a grievance can be filed, that is, his or her name, business address (mailing and email) and business phone number, a reasonable expected time frame for completing the review of the grievance, the right to obtain a written decision regarding his or her grievance, and the contact information of independent entities with whom grievances may be filed, that is, the pertinent State agency, Quality Improvement Organization, State Survey Agency and State Long-Term Care Ombudsman program or protection and advocacy system; b. Identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions, leading any necessary investigations by the facility, maintaining the confidentiality of all information associated with grievances, for example, the identity of the resident for those grievances submitted anonymously, issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations;c. As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated;d. Consistent with 5483.12(c)(1), immediately reporting all alleged violations involving neglect, abuse, including injuries of unknown source, and/or misappropriation of resident property, by anyone furnishing services on behalf of the provider, to the administrator of the provider, and as required by State law;e. Ensuring that all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns(s), a statement as to whether the grievance was confirmed or not confirmed, any corrective action taken or to be taken by the facility as a result of the grievance, and the date the written decision was issued;f. Taking appropriate corrective action in accordance with State law if the alleged violation of the residents' rights is confirmed by the facility or if an outside entity having jurisdiction, such as the State Survey Agency, Quality Improvement Organization, or local law enforcement agency confirms a violation for any of these residents' rights within its area of responsibility.Review of the Resident Council Meeting Minutes held on [DATE], [DATE], [DATE], and [DATE] revealed discussions of missing clothes among the residents with no resolution.During an interview on [DATE] at 2:12 p.m. Resident #178 reported missing items such as missing clothes to the facility and no one will do anything. Review of Resident #178's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 12 indicating moderate cognition.During an interview on [DATE] at 2:13 p.m. Resident #139 reported hair grease going missing to the nurses and CNAs (Certified Nursing Assistant) and nothing gets done. Resident #139 further reported it does not do any good to report things missing because nothing gets done about it and there is no resolution and no replacements.nothing. Resident #139 further reported she will see other resident's wearing her clothes and she can't just go take it off of them. Resident #139 reported pants and shirts missing in the last 6 months and no one does anything about it. Resident #139 reported feeling aggravated. Review of Resident #139's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 12 indicating moderate cognition.During an interview on [DATE] at 2:14 p.m. Resident #37 reported underwear missing within the last 2 months and they were never replaced. Resident #37 reported the missing items to S26 Social Service and S25 Laundry Supervisor.Review of Resident #37's record revealed a Quarterly MDS (Minimum Data Sets) dated [DATE] with a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognitionDuring an interview on [DATE] at 2:15 p.m. Resident #170 reported laundry goes missing all the time. Resident #170 further reported within the last 3 months he reported his laundry missing to CNAs and the nursing staff and the facility will not resolve the issue. Review of Resident #170's record revealed a Quarterly MDS dated [DATE] with a BIMS score of 15 indicating intact cognition. During an interview on [DATE] at 2:21 p.m. S27 Housekeeping reported the laundry was horrible and unorganized, residents clothing items go missing all the time. S27 House Keeping has observed CNAs gather laundry from residents' rooms and take them to the laundry area. S27 Housekeeping reported the laundry was so unorganized and that was why residents' laundry was missing. An observation on [DATE] at 2:00 p.m. revealed at least 4 large unorganized racks of laundry and blankets and a barrel with large amounts of laundry piled up over the top. During an interview on [DATE] at 2:00 p.m. S25 Housekeeping and Laundry Supervisor reported items should be labeled before being sent to the laundry. S25 Laundry Supervisor reported if items were washed and not labeled, they were placed in the missing clothes section. S25 Housekeeping and Laundry Supervisor reported some resident families donate their deceased family member's clothes and they were also placed in the same pile as the missing clothes pile. S25 Housekeeping and Laundry Supervisor reported if a resident needed a shirt, they pulled from the missing clothes pile and a shirt would be picked out for them to wear. S25 Housekeeping and Laundry Supervisor confirmed he was not aware of Resident #37's missing underwear, Resident #139's, Resident #170's and Resident #178's missing any clothing. S25 Housekeeping and Laundry Supervisor reported there was not a list of missing clothing items which included a date the items went missing. S25 Housekeeping Laundry Supervisor reported the donated pile of clothes was mixed with the missing clothes pile. During an interview on [DATE] at 2:24 p.m. S26 Social Service reported the CNAs and nursing staff should label all clothing upon admit and as they receive personal items. S26 Social Service reported items should be found in a reasonable amount of time which is about 3 days. S26 reported if missing items are not found, a Grievance form should be filled out with missing items listed and the facility will replace the missing items. S26 Social Service was not aware of missing items from Resident #37, Resident #139, Resident #170, or Resident #178.

Based on observations and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 4 (#50, #88, #91, #110) of 11 (#35, #50, #56, #68, #88, #91, #110, #128, #158, #179 #189) residents reviewed for environment. The facility failed to: 1. provide a clean room and a closet door for Resident #110.2. provide linens that were in good repair for all residents. (This had the ability to affect 176 residents residing in the facility.)3. provide the required furnishings in each resident room. The facility failed to provided a chair for Resident #88 and #91.4. provide a clean uncluttered room for Resident #50, Resident #50's clothes were stored on the floor. Findings: Resident #50 Review of Resident #50’s medical record revealed an admit date of 06/26/2025 with the following diagnoses, including in part: unspecified fracture of upper end of right humerus/subsequent encounter with routine healing, unsteadiness on feet, and cognitive communication deficit. Observation on 07/21/2025 at 8:05 a.m. revealed Resident #50's clothing in a box on the floor next to the bed and on clothing on the bathroom floor. During an interview on 07/21/2025 at 8:25 a.m. S6 CNA (Certified Nursing Assistant) acknowledged the clothes in the box and on the bathroom floor should not be there. Resident #91 Review of Resident #91’s medical record revealed an admit date of 09/13/2023 with the following diagnoses, including in part: Hypertension, depression, respiratory failure, and nutrition malnutrition. Further observation revealed a Quarterly MDS (Minimum Data Set) dated 06/19/2025 with a BIMS (Brief Interview for Mental Status) score of 14 indicating intact cognition. An observation on 07/23/2025 at 1:00 p.m. revealed Resident #91 shared a room with one other resident and had one metal fold out chair in her room labeled with her roommate’s name. Further observation failed to reveal Resident #91 had a chair to sit in or for visitors to sit in. During an interview on 07/23/2025 at 1:00 p.m. Resident #91 reported when her daughter visited, she had to sit on the edge of Resident #91's bed during the visit because there was not a chair for her to sit in. Resident #88 Observation on 07/21/2023 at 9:30 a.m. revealed Resident #88 was in a shared room with no chairs for residents or visitors to sit. During an interview on 07/21/2023 at 9:30 a.m. Resident #88 acknowledged there were no chairs to sit in the resident shared room and reported sitting on the side of the bed when wanting to sit up. Resident #88 reported his mother stood up during a visit with him and his grandmother sat on the foot of his bed. Review of Resident #88's face sheet revealed an admission date of 02/22/2023 with the following diagnoses but not limited to major depressive disorder, history of falling, pyogenic arthritis, polyneuropathy, contracture of left knee, and pain in left knee. Review of Resident #88's Quarterly MDS (Minimum Data Sets) dated 05/15/2025 revealed a BIMS (Brief Interview of Mental Status) of 14 indicating cognitively intact. Resident #110 Observation on 07/21/2025 at 8:30 a.m. revealed Resident #110's floor was sticky with dark brown colored dirt and residue in the corners and on the base boards of the room, further review revealed Resident #110's closet did not have a door in place. Review of Resident #110's Quarterly MDS (Minimum Data Set) dated 05/22/2025 revealed Resident #110 was assessed to have a BIMS score of 8 indicating moderately impaired cognition. During an interview on 07/21/2025 at 9:16 a.m. Resident #110 reported the closet did not have a door when he was admitted to the facility several months ago and he did not know when the floor was mopped last. During an interview on 07/22/2025 at 2:45 p.m. S22 Maintenance Director confirmed Resident #110 should have had a closet door in place and Resident #110's floor should have been cleaned daily. During an interview on 07/24/2025 at 3:00 p.m. S1 Administrator confirmed each resident should have had a chair in their room. Observations on 07/22/2025 at 11:50 a.m. during a tour of the laundry completed with S25 Housekeeping and Laundry Supervisor revealed bed sheets, pillowcases are worn thin and discolored (yellowish and tan stains). Further observation of the facility’s blankets revealed they were in very poor condition thin, discolored, felt scratchy.

Based on record review and interview the facility failed to provide the required documents to 1 (#110) of 1 (#110) resident and or resident representative who was transferred out of the facility for treatment. The facility failed to provide Resident #110 a copy of the facility's bed hold policy when transferred out of the facility. Findings: Review of Resident #110's medical record revealed an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025 with diagnoses of but not limited to hyperkalemia, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, essential hypertension and osteoarthritis.Review of Resident #1's medical record revealed Resident #110 was transferred to a hospital for treatment of hyperkalemia on 01/16/2025 and 02/13/2025.Review of Resident #110's medical record failed to reveal any documentation of the bed hold policy being provided to Resident #110 or Resident #110's representative when transferred to a hospital for treatment on 01/16/2025 and 02/13/2025. During an interview on 07/23/2025 at 2:15 p.m. S1 Administrator confirmed the facility's bed hold policy had not been provided to Resident #110 or Resident #110's representative when transferred to the hospital for treatment on 01/16/2025 and 02/13/2025.

Based on record review and interview, the facitiy failed to ensure resident assessments were encoded, transmitted and completed for 1 (#81) of 3 (#81, #130, #183) residents reviewed for resident assessments.Findings: Review of Resident #81's medical records revealed an admit date of 02/05/2025 and discharge date of 03/14/2025 with the following diagnoses, including in part: heart failure unspecified and type 2 diabetes mellitus without complications. Review of Resdient #81's MDS (Minimal Data Set) Assessments failed to reveal a discharge assessemnt. During an interview on 07/23/2025 at 2:30 p.m. S3 MDS Nurse acknowledged Discharge MDS Assessment was not completed until today.

Based on record reviews and interviews, the facility failed to develop and implement a baseline care plan for 2 (#110, #188) out of 63 total sampled residents reviewed. Findings: Resident #110 Review of Resident #110’s medical record revealed an initial admit date of 11/06/2025 and a re-admission date of 02/16/2025 with diagnoses of but not limited to hyperkalemia, unspecified dementia, unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic kidney disease, essential hypertension and osteoarthritis. Review of Resident #110's medical record failed to reveal a baseline care plan had been completed when Resident #110 was admitted on [DATE] and re-admitted on [DATE]. During an interview on 07/22/2025 at 1:00 p.m. S3 MDS (Minimum Data Set) Nurse confirmed a baseline care plan was not completed when Resident #110 was admitted on [DATE] and re-admitted on [DATE] and should have been. Resident #188 Review of Resident #188’s medical record revealed an admit date of 07/11/2025 with the following diagnoses, including in part: malignant neoplasm of upper lobe/left bronchus or lung, acute and chronic respiratory failure with hypoxia, chronic obstructive pulmonary disease, and unspecified pleural effusion not elsewhere classified. Review of Resident #188’s medical records failed to reveal the baseline plan of care was completed upon admission. During an interview on 07/24/2025 at 2:30 p.m. S3 MDS Nurse acknowledged a baseline care plan was not developed for Resident #188 and should have been.

Based on record review and interview, the facility failed to provide services according to the written plan of care for 1 (#14) of 5 (#5, #7, #14, #158, and #165) reviewed for unnecessary medications. The facility failed to ensure Resident #14's lab were obtained as ordered by the physician. Findings: Review of Resident #14's face sheet revealed an initial admission date of 12/15/2023 and a re-entry admission date of 02/10/2025 with the following diagnoses, but not limited to schizoaffective disorder, bipolar type, dementia without behavioral disturbances, psychophysiological insomnia, and anxiety disorder. Review of Resident #14's July 2025 Physician Orders revealed an order dated 06/02/2025: biannual labs: CBC (complete blood count), CMP (comprehensive metabolic panel), hemoglobin A1C, TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin for June and December.Review of Resident #14's Quarterly MDS (Minimum Data Sets) dated 04/30/2025 revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating cognitively intact. Further review of Resident #14's MDS review of medications received during the last 7 days of the look back period revealed administration of antipsychotic, antidepressant, antiplatelet, hypoglycemic and anticonvulsant. Review of Resident #14's EHR (Electronic Health Record) failed to reveal lab for TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin were obtained as ordered. During an interview on 07/22/2025 at 10:30 a.m. S1 Administrator confirmed lab for TSH (thyroid stimulating hormone), lipid, B12, folate, Vitamin D, Magnesium, Thiamine and Iron panel with ferritin were obtained as ordered.

Based on interviews and record reviews the facility failed to protect the residents' right to be free from sexual abuse and psychosocial harm from another resident for 3 (Resident #1, #6, #7) of 7 (Resident #1, #2, #3, #4, #5, #6, and #7) sampled residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed, in his hand playing with it. The facility staff did not separate Resident #2 from the other residents in the shared room. Resident #2 remained in the shared room throughout the night and part of the following day with Residents #1, #6 and #7. S1 Administrator was made aware of the abuse on 12/27/2024 at approximately 8:00 a.m. when Resident #1 came to her office and reported Resident #2 had exposed himself. S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/30/2025 at 2:45 p.m. The Immediate Jeopardy was removed on 01/31/2025 at 12:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to the exit. Findings: Abuse Prevention Policy (dated 9/5/16 and reviewed 11/15/22) Policy Statement: Standards: The resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The resident has the right to be free from mistreatment, neglect and misappropriation of property. Facility has a zero-tolerance Abuse Standard regarding all proven allegations of verbal, sexual, physical, and mental, neglect Action Prevention: The abuse coordinator in the facility is the administrator. Reports of allegations or suspected abuse, neglect or exploitation including those involving taking photograph and video recording, using any type of equipment such as cameras, smart phones, and any other electronic devices of resident and his or her personal space on social media will be reported immediately to: Facility abuse coordinator, DON, State Agencies, Local Ombudsman office. 5. Protect: Resident Protection after alleged Abuse, Neglect and Exploitation, taking, keep, share and distribute of unauthorized photograph of resident and his/her personal space in social media. It is the responsibility of all staff to provide a safe environment for the residents. Resident care and treatments shall be monitored by all staff, on an ongoing basis, so that residents are free from abuse, neglect, or mistreatment. Care will be monitored so that the resident's care plan is followed. Examples of ways to protect a resident from harm during an investigation of abuse, neglect and exploitation may include but not limited to: a) Temporary (less than 24 hours) separation from other residents if a resident's behavior poses a threat of abuse or violence. b) Temporary or permanent room or roommate change, where incompatibility creates the potential for abuse (follow change or room or roommate procedures) e) Temporary one-on-one supervision of a resident f) Engage a resident in diversionary activities g) Reassignment of nursing staff duties h) Time off for nursing staff i) Involve clergy, social services and counselors, as appropriate Resident #1 Resident #1 was readmitted to the facility on [DATE] from a local hospital with diagnoses, which included in part, unspecified paraplegia, anxiety disorder, depression and post-traumatic stress disorder. Review of Resident #1's most recent Quarterly MDS (Minimum Data Set) assessment dated [DATE] revealed in part, Resident #1 had a BIMS (Brief Interview of Mental Status) score of 15 indicating cognition was intact. Resident #1 was a paraplegic and used a wheelchair for mobility. Resident #1 required extensive assistance from 1-2 staff with bed mobility, transfers, and toileting. Review of Resident #1's comprehensive care plan revealed Resident #1 was care planned for the use of anti-anxiety medications relate to anxiety disorder and PTSD (Post Traumatic Stress Disorder). Some of the interventions are to give anti-anxiety medications ordered by physician and monitor/document side effects and effectiveness. Resident #1 was subject to an unwanted sexual advancement from resident #2. Residents #6 and #7 resided in the shared resident room at the time of the event and were not protected. Review of 2 videos from Resident #1's personal cell phone revealed: First video (dated 12/27/2024) with a start time of 2:38 a.m. - lasting 40 seconds: Resident #2 was standing at Resident #1's bedside facing Resident #1 while Resident #1 was lying in bed. Resident #2 was wearing a light blue denim button shirt unbuttoned with a black shirt underneath; black pants; red/black checkered underwear; underwear and pants pulled below his genitals; genitals fully exposed; Resident #2's right hand was on his own genitals. Resident #2's face fully visible in video. Resident #1 can be heard stating: Get the f--- away from me; gone cuz gone. Second video (dated 12/27/2024) moments after the first video lasting 1 min, 32 seconds: Resident #1 can be heard stating: Get your b -- ch a-- back; Get away [NAME] a--; Drop that sh--, drop that b--ch. Can hear a female voice (presumably staff) approach Resident #1 and then Resident #1 was heard saying: I didn't see him at first, I was looking at my phone, he snuck up on me; Tell her what you did; b--ch a-- tried to grab me; b--ch a-- was playing with his dick; he was standing over me asking if I'm crippled; right there by my bed looking at my phone; I was sitting on my bed and he tried to grab me because I'm crippled. At the end of the first video and throughout second video, the video was unsteady as Resident #1 was transferring himself from his bed to his wheelchair trying to move away from Resident #2. Review of Resident #2's admission photograph revealed the same clothing and face of Resident #2 in the video. Review of the Behavior Note dated 12/27/2024 at 3:09 a.m. by S5 RN (Registered Nurse) documented Resident #1 in hallway swinging his wheelchair arms at his roommate, Resident #2, saying, Tell them what you did B____ a___ n____! Tell them what you did. This nurse re-directed resident to calm down and go outside to get some air. Resident #2 Review of Resident #2's medical record revealed an admitted [DATE] and a discharge date of [DATE] with the following diagnoses which included: Hypo-osmolality and hyponatremia (primary diagnosis); effusion, left wrist; chronic viral hepatitis C; cognitive communication deficit; and cannabis use, unspecified. Review of Resident #2's MDS assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) of 6 which indicated severe cognitive impairment. Further review revealed Resident #2 was independent with indoor mobility. Resident #2 was marked as not using any devices such as a wheelchair, lift, or walker. Resident #6 Review of Resident #6's medical record revealed an admitted [DATE] with diagnoses which included: Stroke, hemiplegia unspecified and cerebral vascular disease. Review of Resident #6's Quarterly MDS assessment dated [DATE] revealed a BIMS of 14 which indicated intact cognition and used a wheelchair for mobility. Resident #7 Review of Resident #7's medical record revealed an admitted [DATE] with diagnoses which included: chronic obstructive pulmonary disease, syncope, type 2 diabetes, and heart failure. Review of Resident #7's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 14 which indicated cognition was intact. Further review revealed Resident #7 had no range of motion impairment for bilateral lower or upper extremities. Resident #7 was independent with activities of daily living. Both Resident #6 and Resident #7 were interviewed on 01/30/2025 and denied knowledge of the incident on 12/27/2024. During an interview on 01/28/2025 at 2:00 p.m. Resident #1 reported he had PTSD and staff did not even check on him after the incident. Resident #1 reported staff told him to go outside and get some fresh air. Resident #1 reported the staff called it an argument, staff did not believe him. Resident #1 reported S2 DON said he was exaggerating and the accused resident remained in their room until after 12:00 p.m. the next day. Resident #1 reported the incident occurred on 12/27/2024 in their shared resident room while 2 other residents were in the room. During an interview on 01/28/2025 at 4:25 p.m. Resident #1 reported around 3:00 a.m. on 12/27/2024 one of his roommates, Resident #2, grabbed him by his upper arms and shoulders and he had to wrestle with him to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed and in his hand playing with it. Resident #1 reported after the incident Resident #2 remained in the room with him. Resident #1 reported he was told to leave the room. Resident #1 reported he was not moved to another room until around noon on 12/27/2024 after his mother and his family came and moved his things to the first floor. Resident #1 reported the police attempted to interview him but he did not talk with them because he felt like no one cared. Resident #1 reported no one checked on him or asked if he was ok. Resident #1 reported it was like no one believed him. During a phone interview on 01/28/2025 at 3:45 p.m., S5 RN reported she worked on the night of the incident with Resident #1 and Resident #2. S5 RN reported she did not see the incident but heard Resident #1 yelling. S5 RN reported Resident #2 was standing over Resident #1 when she entered the room. S5 RN further reported Resident #1 stated Resident #2 was exposing himself. Resident #2 had no previous behaviors that she was aware of. S5 RN reported no facility employee remained with Resident #2 after the incident and Resident #2 did not receive one-on-one care after the incident. S5 RN confirmed Resident #2 remained in the room with Residents #1, #6 and #7 after the allegation of the sexual abuse was made. S5 RN reported before she left at the end of her shift around 7:00 a.m. Resident #2 remained in the same room with Residents #1, #6 and #7. During an interview on 01/28/2025 at 4:00 p.m., S6 ADON (Assistant Director of Nursing) reported she became aware of the incident around 3:00 a.m. on 12/27/2024 by S5 RN. S6 ADON reported when she checked on Resident #1 the morning of 12/27/2024, she saw Resident #1 coming out of the doorway of his room and Resident #2 was still in the room in the bed. S6 ADON reported Resident #2 did not say or do anything. S6 ADON reported Resident #2 was evaluated and sent to a local behavior hospital on 12/27/2024. S6 ADON reported she could not find documentation Resident #2 was placed with one-on-one monitoring after the incident. S6 ADON reported Resident #1 was still upset about Resident #2 exposing himself. S6 ADON reported Resident #1 was moved to the first floor around 12 noon on 12/27/2024. During an interview on 01/29/2025 at 9:07 a.m. S2 DON reported he was out sick the week of 12/27/2024 when the incident occurred. S2 DON reported Resident #2 should have been placed with one-on-one care after the incident and that would have been found in Resident #2's notes or the shift report notes. S2 DON was unable to provide any documentation that Resident #2 was placed on one-on-one monitoring after the incident occurred. During an interview on 01/29/2025 at 9:26 a.m. S1 Administrator reported on 12/27/2024 at 8:00 a.m. Resident #1 came to her office and reported Resident #2 had exposed himself to him during the early morning hours. S1 Administrator confirmed she was not notified of the incident until Resident #1 told her. S1 Administrator reported she should have been notified immediately and called S5 RN to find out the details about the incident with Resident #1 and Resident #2. S1 Administrator reported S5 RN got Resident #1 calmed down and Resident #2 was in bed and there were no issues. S1 Administrator confirmed Resident #1 and Resident #2 were in the same room with Resident #6 and Resident #7 until Resident #1 was moved later in the day on 12/27/2024. During an interview on 01/29/2025 at 12:50 p.m., S1 Administrator confirmed the facility did not have documentation of Resident #2 receiving one-on-one supervision after the incident on 12/27/2024 involving Resident #1 and Resident #2. During an interview on 01/29/2025 at 9:50 a.m. S7 SSD (Social Service Director) reported on 12/27/2024 she was instructed by S2 DON that she needed to do a trauma assessment for Resident #1. S7 SSD reported she was told very little about why the trauma assessment was needed. S7 SSD reported she was only made aware something had happened and she did not know what occurred. S7 SSD reported Resident #1 was emotional. S7 SSD reported Resident #1 was already being seen by their psych NP (Psychiatric Nurse Practitioner) for his diagnosis of PTSD. Review of S9 Psych NP Follow-up evaluations notes dated 01/13/2025 revealed documentation of Resident #1's recent exacerbation of PTSD. Resident #1 reported recent exacerbation of PTSD symptoms after another resident at the facility reportedly exposed himself in front of him. Resident #1 reports that the other resident was lingering around him, causing his obsessive thoughts/anxiety. Resident #1 was now reporting hypervigilance and persistence of obsessive thoughts. Resident #1 also reported increase anxiety, currently taking clonazepam 0.5 mg (milligram) twice daily for anxiety treatment. Resident #1 stated increased depressive symptoms as well, currently taking Cymbalta 30 mg twice daily for depression/anxiety. During an interview on 01/29/2025 at 3:45 p.m., S9 Psych NP reported he had seen Resident #1 a few times after the incident on 12/27/2024. S9 Psych NP reported Resident #1 had PTSD due to gunshot wounds. S9 Psych NP reported Resident #1 had shown exacerbation of his PTSD and he was working with Resident #1 trying to adjust his medications. During an interview on 01/30/2025 at 10:30 a.m. S5 RN reported on 12/27/2024 she did not suspect abuse between Resident #1 and Resident #2 because she did not see it. S5 RN reported she placed a phone call to S6 ADON immediately after the incident because S6 ADON was on call for administration. S5 RN reported S6 ADON instructed her to separate them with no other instruction given. S5 RN reported she further informed S6 ADON that the situation had deescalated and both had calmed down. S5 RN reported she separated Resident #1 and Resident #2 by telling Resident #1 to go out and get some fresh air. S5 RN reported Resident #2 remained in the room along with the 2 other residents (Residents #6, and #7). S5 RN reported Resident #2 had an unsteady gait but could walk. S5 RN admitted telling Resident #1 that Resident #2 was probably using his urinal. When S5 RN was asked if Resident #2 went to the bathroom on his own, she verified Resident #2 was able to go to the bathroom on his own without assistance and he did not use a urinal. S5 RN further reported the other 2 residents, #6 and #7, remained in the room asleep during the incident and were unaware of the incident. S5 RN confirmed S6 ADON did not ask specific questions about the incident. S5 RN confirmed there was no other staff in the resident room when she left at the end of her shift at 7:00 a.m. S5 RN further reported at the end of her shift Resident #1 had returned to the shared resident room and was in his bed, Resident #2 was in his bed and the other 2 residents remained in bed. The facility's Plan of Removal: Resident #1 was the victim at the time of the event on 12/27/024 at 2:38 a.m. The perpetrator, Resident #2, was discharged from the center on 12/27/2024 at 6:08 p.m. Roommates, Resident #6 and Resident #7 had the potential to be affected since they were in the room at the time of the event and afterwards until the aggressor was discharged . To address the psychosocial/sexual abuse aspect of Resident #1, the Social Services Director completed Trauma Assessments on 12/27/2024, 12/30/2024, 01/02/2025 and 01/03/2025. The psychiatric nurse practitioner assessed Resident #1 on 12/30/2024 and 01/13/2025 to address psychiatric issues after the incident. Resident #1 will continue to see the psychiatric nurse practitioner on a monthly basis and as needed for any psychiatric concerns. Resident and staff interviews started 01/30/2025 and are in progress to identify any other residents who may have the potential to be affected. 1. Any allegation of abuse - the center must follow the abuse/neglect policy to protect residents, effective 01/30/2025. 2. If an abuse allegation is made, the abuse aggressor will be place on one-on-one with the behavior monitoring which will continue until cleared by a medical provider or until discharged , effective 01/20/2025. 3. The Administrator and DON are responsible for ensuring that all aspects of the abuse/neglect policy are carried out and that all components, such as one-on-one documentation and behavior monitoring, are implemented, effective 01/30/2025. 4. Administrator and Director of Nursing (DON) have been educated on abuse/neglect, the abuse/neglect policy to indicate reporting timeframes, and following all administration and reporting requirements for abuse/neglect and the follow-up of handling abuse/neglect allegations. This education occurred on 01/30/2025 by the RN, Chief Nursing Officer. 5. Residents #6 and #7 have had trauma assessments completed on 01/30/2025 by the Social Services Director. Education started immediately on 01/30/2025 (see attached) to include 100% of staff and contract staff. This education will include the abuse/neglect policy with timeframes and will include initiation of the one-on-one with behavior monitoring form. The mode of education will be verbal in person via staff meeting as well as a voice and text message communication blast. The voice and text message blast communication were sent out by the Regional Administrator. The in-person staff meetings for education were/is being completed by the following staff members: RN, Director of Nursing; Associate Director of Nursing; and RN, Assistant Director of Nursing. All education was initiated on 01/30/2025 and will continue daily until 100% is achieved. No one will work until education has been validated as received. The Nursing Home Administrator or Designee will review all sign-in sheets/electronic documentation of text message communication blasts against the staff roster and contract staff roster on 01/30/2025. This will be continue until it is completed, no later than 02/03/2025. If any further staff are awaiting education, these staff will not work until their education completion has been validated. All new hires will receive this education prior to working. Ad hoc QAPI (Quality Assurance and Performance Improvement) was held on 01/31/2025 at 5:30 p.m. with Nursing Home Administrator, Director of Nursing, Management Nurses, Department Heads, Medical Director, and a floor staff licensed nurse and certified nursing assistant to discuss the systemic changes of facility practice. Starting the week of 02/03/2025, the center social service director or designee will interview five residents weekly for four weeks to ask about abuse and follow up. The abuse interview monitoring process will continue after the initial four weeks monthly for three months. The results of these audits will be brought to the quality assurance/performance improvement committee to ensure all processes are followed and to ensure continued compliance. If it is determined that processes are not followed, the center will perform a 100% re-education of all staff and follow up directly with the responsible at the time of the incident. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: The IJ situation was removed at 12:15 p.m. on 01/31/2025.

Based on interviews and record reviews, the facility failed to be administered in a manner that enabled its resources to be used effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well-being for 1 (Resident #1) of 7 (#1, #2, #3, #4, #4, #5, #6, and #7) residents. The deficient practice resulted in an Immediate Jeopardy on 12/27/2024 at approximately 2:38 a.m., when Resident #1 was approached at his bedside by Resident #2 with Resident #2's penis exposed playing with himself. Residents #6 and #7 resided in the shared resident room at the time of the event. Resident #1 was verbal and his cognition was intact. Resident #1 reported Resident #2 grabbed him by his upper arms and shoulders and he had to wrestle with Resident #2 to get away. Resident #1 reported Resident #2 asked him if he was gay and had his penis exposed, in his hand playing with it. The facility staff did not separate Resident #2 from the other residents in the shared room. Resident #2 remained in the shared room throughout the night and part of the following day with Residents #1, #6 and #7. S1 Administrator was made aware of the abuse on 12/27/2024 at approximately 8:00 a.m. when Resident #1 came to her office and reported Resident #2 had exposed himself. S1 Administrator and S2 DON (Director of Nursing) were notified of the Immediate Jeopardy on 01/30/2025m at 2:45 p.m. The Immediate Jeopardy was removed on 01/31/2025 at 12:15 p.m. The facility implemented an accepted Plan of Removal as confirmed through onsite observations, interviews and record reviews prior to exit. Findings: Cross Reference F600 During a phone interview on 01/28/2025 at 3:45 p.m., S5 RN (Registered Nurse) reported no facility employee remained with Resident #2 after the incident on 12/27/2024 and Resident #2 did not receive one-on-one care after the incident. S5 RN confirmed Resident #2 remained in the room with Residents #1, #6 and #7 after the allegation of the sexual abuse was made. S5 RN reported before she left at the end of her shift around 7:00 a.m. Resident #2 remained in the same room with Residents #1, #6 and #7. During an interview on 01/28/2025 at 4:00 p.m., S6 ADON (Assistant Director of Nursing) reported she became aware of the incident around 3:00 a.m. on 12/27/2024 by S5 RN. S6 ADON reported when she checked on Resident #1 the morning of 12/27/2024, she saw Resident #1 coming out of the doorway of his room and Resident #2 was still in the room in the bed. S6 ADON reported Resident #2 did not say or do anything. S6 ADON reported she could not find documentation Resident #2 was placed with one-on-one monitoring after the incident. During an interview on 01/29/2025 at 9:07 a.m. S2 DON reported Resident #2 should have been placed with one-on-one care after the incident and that would have been found in Resident #2's notes or the shift report notes. S2 DON was unable to provide any documentation that Resident #2 was placed on one-on-one monitoring after the incident occurred. During an interview on 01/30/2025 at 10:30 a.m. S5 RN confirmed there was no other staff in the resident room when she left at the end of her shift at 7:00 a.m. on 12/28/2024. S5 RN further reported at the end of her shift, Resident #1 had returned to the shared resident room and was in his bed, Resident #2 was in his bed and the other 2 residents remained in bed. During an interview on 01/29/2025 at 9:26 a.m. S1 Administrator reported on 12/27/2024 at 8:00 a.m. Resident #1 came to her office and reported Resident #2 had exposed himself to him during the early morning hours. S1 Administrator confirmed she was not notified of the incident until Resident #1 told her. S1 Administrator reported she should have been notified immediately and called S5 RN to find out the details about the incident with Resident #1 and Resident #2. S1 Administrator confirmed Resident #1 and Resident #2 were in the same room with Resident #6 and Resident #7 until Resident #1 was moved later in the day on 12/27/2024. During an interview on 01/29/2025 at 12:50 p.m., S1 Administrator confirmed the facility did not have documentation of Resident #2 receiving one-on-one supervision after the incident on 12/27/2024 involving Resident #1 and Resident #2. During an interview on 01/30/2025 at 9:56 a.m. S2 DON reported he was responsible for overseeing all staff are trained on the abuse/neglect policy including recognizing signs, investigations, protection, and reporting procedures. During an interview on 01/30/2025 at 9:56 a.m. S1 Administrator acknowledged she was responsible for providing oversite of the facility's abuse/neglect policy including reporting timeframes, one on one monitoring and making sure staff was educated on the necessary steps to ensure the safety and well-being of all resident. The facility's Plan of Removal: Resident #1 was the victim at the time of the event on 12/27/024 at 2:38 a.m. The perpetrator, Resident #2, was discharged from the center on 12/27/2024 at 6:08 p.m. Roommates, Resident #6 and Resident #7 had the potential to be affected since they were in the room at the time of the event and afterwards until the aggressor was discharged . Resident and staff interviews started 01/30/2025 and are in progress to identify any other residents who may have the potential to be affected. 1. Any allegation of abuse - the center must follow the abuse/neglect policy to protect residents, effective 01/30/2025. 2. If an abuse allegation is made, the abuse aggressor will be place on one-on-one with the behavior monitoring which will continue until cleared by a medical provider or until discharged , effective 01/20/2025. 3. The Administrator and DON are responsible for ensuring that all aspects of the abuse/neglect policy are carried out and that all components, such as one-on-one documentation and behavior monitoring, are implemented, effective 01/30/2025. 4. Administrator and Director of Nursing (DON) have been educated on abuse/neglect, the abuse/neglect policy to indicate reporting timeframes, and following all administration and reporting requirements for abuse/neglect and the follow-up of handling abuse/neglect allegations. This education occurred on 01/30/2025 by the RN, Chief Nursing Officer. 5. Residents #6 and #7 have had trauma assessments completed on 01/30/2025 by the Social Services Director. Education started immediately on 01/30/2025 (see attached) to include 100% of staff and contract staff. This education will include the abuse/neglect policy with timeframes and will include initiation of the one-on-one with behavior monitoring form. The mode of education will be verbal in person via staff meeting as well as a voice and text message communication blast. The voice and text message blast communication were sent out by the Regional Administrator. The in-person staff meetings for education were/is being completed by the following staff members: RN, Director of Nursing; Associate Director of Nursing; and RN, Assistant Director of Nursing. All education was initiated on 01/30/2025 and will continue daily until 100% is achieved. No one will work until this education has been validated as received. All new hires will receive this education prior to working. Ad hoc QAPI (Quality Assurance and Performance Improvement) was held on 01/31/2025 at 5:30 p.m. with Nursing Home Administrator, Director of Nursing, Management Nurses, Department Heads, Medical Director, and a floor staff licensed nurse and certified nursing assistant to discuss the systemic changes of facility practice. Starting the week of 02/03/2025, the center social service director or designee will interview five residents weekly for four weeks to ask about abuse and follow up. The abuse interview monitoring process will continue after the initial four weeks monthly for three months. The results of these audits will be brought to the quality assurance/performance improvement committee to ensure all processes are followed and to ensure continued compliance. If it is determined that processes are not followed, the center will perform a 100% re-education of all staff and follow up directly with the responsible at the time of the incident. Administrative oversight of the process will be completed by the Nursing Home Administrator and the Director of Nursing. As of 01/30/2025 and ongoing, the Regional Director Clinical Operations will provide oversight of the Nursing Home Administrator and Director of Nursing administrative oversight by reviewing and providing feedback on allegations of abuse and providing further supervision and training as needed. Date Facility Asserts the Likelihood for Serious Harm to Any Recipient No Longer Exists: 01/30/2025.

Based on record review and interviews, the facility failed to ensure pain management was provided to a resident who required such services, consistent with professional standards of practice for 1 (#4) of 5 (#1, #2, #3, #4, and #5) sampled residents reviewed for pain. The facility failed to ensure Resident #4, who reported pain after a post-surgery wound, received medication or interventions to alleviate pain. The deficient practice resulted in an actual harm for Resident #4 on 01/10/2025 at approximately 6:00 p.m. when Resident #4 requested pain medication for her post-surgical wound. Resident #4 requested Tylenol on the evening shift from S3 LPN (Licensed Practical Nurse). S3 LPN told Resident #4 she could not give her anything for pain. Resident #4 called 911 as a result of not getting pain medication. Resident #4 was eventually admitted to the hospital ER (emergency room ) for acute pain on 01/10/2024 where she received 2 doses of Dilaudid for acute pain. Findings: Pain Policy: Pain management Program dated 04/2022. Policy: The facility shall provide adequate management of pain to ensure that residents attain or maintain the highest practicable physical, mental, and psychosocial well-being. Procedure: 1. Evaluate the resident for pain upon admission, to include prior use of pain medication 2. Behavioral signs and symptoms that may suggest the presence of pain include but are not limited to: d. Resisting care, striking out. f. Fidgeting, increased or recurring restlessness. g. Facial expressions: grimacing, frowning, fear, grinding of teeth h. Change in behavior: depressed mood, decreased participation in usual activities of daily living k. Sighing, groaning, crying, breathing heavily 3. Assessment and evaluation by the appropriate members of the interdisciplinary team may include: a. Asking the patient to rate the intensity of his/her pain using a numerical scale or a verbal or visual descriptor that is appropriate and preferred by the resident. h. Current prescribed pain medications, dosages and frequency 7. Non-pharmacological pain management interventions include but are not limited to: a. Adjusting room temp b. Smoothing linens c. Turning and repositioning to comfortable position d. Loosen any constrictive bandage or device e. Apply splinting (e.g., pillow or folded blanket) f. Physical modalities (e.g., cold compress, warm shower or bath) g. Exercises to address stiffness h. Cognitive/behavioral interventions (e.g., music, diversions, pain education) Review of facility policy dated 04/2022 and titled Pain Management Program, revealed the policy did not address the administration of pain medication, as ordered. Review of the Resident #4's medical record revealed an admitted date of 01/09/2025, with diagnoses that included, in part: Encounter for orthopedic aftercare flowing surgical amputation; acquires absence of other right toe(s); acute osteomyelitis, right ankle and foot; severe sepsis without septic shock; encounter for surgical aftercare following surgery on the circulatory system; atherosclerosis of native arteries of extremities with gangrene, right leg; peripheral vascular disease; and malignant neoplasm of endometrium. Review of Resident #4's Medicare 5 day MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 15 indicating intact cognition. Review of the Discharge MDS assessment dated [DATE] revealed Resident #4 was independent with eating, toileting hygiene and shower/bathing. Review of Resident #4's admission pain assessment on 01/09/2025 revealed resident was marked as having mild pain in the last 5 days. Review of the progress notes revealed, in part, on 01/10/2025 at 8:21 p.m. Resident #4 came to the nurses' station inquiring about pain medication which there was a problem with the medication prescription. Several attempts were made to correct the problems with no success. Review of the progress notes revealed, in part, on 01/10/2025 at 8:50 p.m. Resident #4 was transferred to a local hospital per ambulance per stretcher. Review of Resident #4's hospital medical records revealed an admitted [DATE] at 9:19 p.m. with acute pain and discharge date of [DATE]. Further review revealed Resident #4 received 2 doses of Dilaudid (pain medication) on 01/10/2025 after being admitted to the hospital. Resident #4 was discharged home from the hospital on 01/13/2025. During an interview on 01/30/2025 at 2:50 p.m. S3 LPN recalled she worked on 01/10/2025 on the 3P-11P shift and cared for Resident #4. S3 LPN reported Resident #4 knew the staff were working on getting her pain prescription filled. S3 LPN confirmed Resident #4 did ask for a pain pill and S3 LPN explained she didn't have anything for pain. S3 LPN reported she did not ask Resident #4 what her pain level was because she was trying to send her out to the hospital per Resident #4's request, but acknowledged Resident #4 was in pain. S3 LPN further reported she could have had Tylenol but Resident #4 did not ask for it (Tylenol). When asked if Resident #4 refused Tylenol, S3 LPN replied I guess you could say that. S3 LPN reviewed the January 2025 MAR (Medication Administration Record) and confirmed Resident #4 did not receive anything for pain during her 3P-11P shift on 01/10/2025. When the surveyor reviewed the January 2025 MAR with S3 LPN and asked why there was not a documented pain level on 01/10/2025 during her 3P-11P shift, S3 LPN reported Resident #4 was discharged before med pass time and that was why a pain assessment was not done on 01/10/2025 on the 3P-11P shift. During a phone interview on 02/04/2025 at 12:20 p.m. Resident #4 reported she was admitted to the facility on [DATE]. She was not in great pain at the time of admit; but, she liked to keep her pain under control. Resident #4 reported she asked S3 LPN on 01/10/2025 at 6:00 p.m. for Tylenol. Resident #4 reported S3 LPN told her she could not get anything until orders were put in. Resident #4 reported she had pain at her surgical site from having metatarsals removed, and pain in her knees and her hips. Resident #4 reported, ultimately, she ended up with nothing for pain. Resident #4 reported S3 LPN triggered her and made her get irate when she told her she could not have anything for pain. Resident #4 reported feeling mad at the end. At this point, Resident #4 reported she was done with S3 LPN and called 911 to take her to the hospital. Resident #4 reported S3 LPN triggered her and it caused me to jump over the moon; she caused me to get irate. Resident #4 reported around 8:00 p.m. on 01/10/2025 the ambulance service picked her up from the facility and took her to the ER per her request because she had not received anything for pain and she was in pain. When the surveyor asked about Resident #4's pain level at the time she left the facility, on a scale of 0-10, Resident #4 reported her pain level was about a 6. During an interview on 01/30/2025 at 3:10 p.m. S2 DON (Director of Nursing) acknowledged Resident #4 did not receive pain medication and should have received something for pain.

Based on record reviews and interviews, the provider failed to ensure residents received adequate supervision and to prevent elopement for 1 (#140) out of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. S21 LPN failed to notify appropriate staff during the night shift on 05/06/2023 when Resident #140 was not observed. On 05/07/2023, Resident #140 was located at 9:02 a.m. at his home, which is located 6.1 miles from the facility, and had been missing from the facility for 18 hours. Resident #140 returned to the facility on [DATE] at 10:25 a.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Provider's Elopement Policy dated 09/21/2017 revealed in part: Policy interpretation and implementation: It is the standard of this health care center that appropriate procedures exist in the case of a missing resident. A missing resident is defined as a resident who has left the facility grounds without being signed out on pass. Standard of Practice: Step 1. Should an employee discover that a resident is missing from the facility, he/she should notify the charge nurse. The charge nurses will: b) make a thorough search of the building (s) and premises. If not located within 15 minutes; c) notify the administrator and the director of nursing services; d) notify the resident's representative; notify the attending physician; notify the law enforcement officials; i) make an extensive search of the surrounding area. Step 2. At any time in which a resident is determined missing, the items below should be strictly followed: A. alert - the supervisor/charge nurse will alert all other personnel by paging Dr. Wander and location (including unit, floor, and room number). B. Search - a search of the immediate area (buildings) will be initiated under the director of the nursing shift supervisor/charge nurse. All rooms will be searched (including locked rooms) The nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking areas, etc.) Review of Resident #140's Medical Records revealed an admitted [DATE] with the following diagnoses, in part: hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, traumatic subdural hemorrhage with loss of consciousness of unspecified duration/subsequent encounter, history of falling, chronic obstructive pulmonary disease, paroxysmal atrial fibrillation, hypertension heart failure, and anemia. Review of Resident #140's MDS (Minimum Data Set) Assessment's dated 05/03/2023 and 05/09/2023 revealed BIMS (Brief Interview for Mental Status) of 09 (moderately impaired cognition). Review of Resident #140's Care Plan revealed the following problems, in part: At risk for falls related to gait/balance problems, right hemiplegia, and history of falls. Review of Resident #140's Nurses' Notes revealed the following entries: 05/07/2023 18:14 - Incident Note - Writer noted last charted documentation was at approx. 2200 and that meds were given at approx. 2000. Writer noted that administrative staff and resident's sister arrived to this facility and after further search, that resident had gone home to his house all per administrative staff report. Administrative staff also informed writer that resident will be returning back to this facility via facility transport and to get a wander guard placed on resident as soon as possible and to do a thorough assessment. Review of Resident #140's Progress Noted dated 05/07/2023 12:06 - Skilled Evaluation - Late entry: Safety concerns - note resident did elope on 5/06 - 5/07 was found at his house by police. Review of SIMS (Statewide Incident Management System) report dated 05/12/2023 revealed the resident was seen on video surveillance going out the door at 3:25 p.m. on 05/06/2023. At 9:02 a.m., sister received call from her husband that resident was located at his home sitting on the porch Transportation arrived at the facility at 10:25 a.m. with resident. Review of Resident #140's Physical Therapy (PT) Evaluation & Plan of Treatment dated 05/03/2023 revealed: Reason for referral - Patient is a [AGE] year old with recent hospitalization status following acute CVA (cerebral vascular accident) with hemorrhage. Patient exhibits new onset of decrease in strength, decrease in functional mobility, reduced ability to safely ambulate and reduced balance indicating the need for physical therapy to improve dynamic balance, increase functional activity tolerance, increase lower extremity range of motion and strength, facilitate with all functional mobility, increase independence with gait and promote safety awareness Additional abilities/Underlying impairments - Cardiopulmonary: standing duration = 1-3 minutes/standing supported; Coordination: gross motor coordination impaired; Cognition safety awareness impaired. Functional Assessment - Gait: distance level surfaces 200 feet; assistive device rolling walker; Gait analysis: patient exhibits knee wobble and occasional inadequate toe clearance which are associated with the underlying cause of muscle paralysis/weakness and lack of/impaired coordination. Impressions: Clinical impressions - Patient presents to physical therapy with deficits in bilateral lower extremity strength, gross motor coordination, balance deficit, safety awareness, trunk stability, postural awareness, and reduced functional activity tolerance limiting patient's safety and functional mobility . Evaluation Summary - clinical decision making - moderate complexity. Review of Resident #140's Elopement Evaluations revealed on admit of 05/02/23 - score of 0 (score > 1 = at risk for elopement). Review of S21 LPN's personnel file revealed she received elopement training during orientation on 04/05/2023. Review of Facility's In-Service Records revealed an in-service on elopement was conducted on 04/02/2023. Review of Resident #140's May and June 2023 Medication Administration Record's revealed wander guard was checked every shift. During an interview on 06/06/2023 at 4:20 p.m. S7 CNA (certified nurse assistant) reported she was working the 3-11 shift when Resident #140 eloped. S7 CNA further reported she was on the hall and noticed him walking with his cane going towards the front of the facility. S7 CNA confirmed she did not observe Resident #140 again but later noticed he was not in his room. S7 CNA further acknowledged she notified S20 Agency LPN that she had not seen Resident #140 in a while, he was not in his room and he did not eat his dinner because his tray was untouched. S7 CNA reported she did not know if the nurse looked for him or not but assumed he would do something about it. During a telephone interview on 06/07/2023 at 8:00 a.m. Resident #140's sister reported he was there for rehab following a stroke and was not able to walk well. She further reported Resident #140 told her he fell after he left the facility. During an interview on 06/07/2023 at 8:05 a.m. S8 PT confirmed Resident #140's could only walk 200 feet and required stand-by assistance. S8 PT further reported Resident #140 had safety awareness needs and needed supervision. S8 PT confirmed at the time of the elopement Resident #140 was using a single point cane he had brought from home and was not safe enough to walk by himself. During an interview on 06/07/2023 at 8:10 a.m. S4 Social Services reported Resident #140 walks really slow and purposefully. S4 Social Services further reported he requested a wheelchair to take home because he said he would feel safer having it. During an interview on 06/07/2023 at 8:15 a.m. S9 CNA reported Resident #140 used both a wheelchair and a cane depending on how he was feeling. S9 CNA acknowledged when he did use his cane he was a little unsteady. During an interview on 06/07/2023 at 8:16 a.m. S10 CNA reported Resident #140 used cane and that he was unsteady when walking. During an interview on 06/07/3023 at 8:17 a.m. S11 CNA reported Resident #140 was a little wobbly when walking. During an interview on 06/07/2023 at 8:20 a.m. S6 LPN reported Resident #140 was slightly unsteady and sometimes would use his wheelchair to get around. S6 LPN indicated she was unsure Resident #140 would be capable of walking a long distance outside the facility. During an interview on 06/07/2023 at 8:25 a.m. Resident #140 reported the day he left the facility he walked outside and went to the stop sign. Resident #140 confirmed he then walked somewhere near the food stamp office and someone gave him a ride home. Resident #140 indicated he was very tired after walking that far. During an interview on 06/07/2023 at 8:35 a.m. S1 Administrator reported she was notified on 05/07/2023 Resident #140 was missing when the day shift nurse discovered he had not been observed during the night shift. S1 Administrator reported Resident #140 told her he left because he was worried about his house and wanted to check on it. She further reported he told her it was daylight when he left, he walked to the bus stop but there was no bus, and ended up somewhere near the food stamp office. She reported he told her he got a ride with someone he did not know and that person took him straight to his house and he paid him. S1 Administrator reported she asked Resident #140 if he fell and he told her no but they observed small areas on the base of his palms. S1 Administrator verified video surveillance showed Resident #140 left the facility at 3:25 p.m. unsupervised and returned on the morning of 05/06/23 to the facility. S1 Administrator acknowledged both S20 Agency LPN and S21 LPN did not report Resident #140 was not observed during their shifts on 05/06/2023 and did not follow the elopement policy. She further reported and produced documentation S20 Agency Nurse, S21 LPN and S32 Receptionist received elopement training prior to the incident on 5/06/2023. S1 Administrator further acknowledged the receptionist on duty 05/06/2023 was not looking at the front door when Resident #140 left the facility and should have been. S1 Administrator provided documentation Resident #140's wander guard is checked every shift. Review of Resident #140's Progress Notes revealed Nurse's Note dated 05/07/2023 19:13 - at approximately 10:34 a.m .Writer proceeded to thoroughly assess resident at bedside and placed on his wander guard to left ankle .neurochecks WNL (within normal limits) .skin intact with scant-small red bruising to bilateral palms of hand .Writer has educated resident to please notify staff for any needs and assistance getting up and use of call light and he voiced understanding . On 05/07/2023 the facility implemented the following actions to correct the deficient practice with completion on 05/26/2023. Immediate Actions: 1. Resident assessed by staff upon return, interviewed. 2. Entry door was switched from a from a 12 hour night locking mode to a 24 hours a day locking mode schedule 3. Receptionist was counseled and re-educated 4. S20 Agency Nurse - notified agency of incident and placed nurse on do not return list. Reported nurse to LPN (licensed practical nurse) board. 5. S21 LPN night shift nurse - suspended pending investigation. After investigation, was terminated and reported to board. 6. Ad Hoc meeting with Medical Director, Director of Nursing and [NAME] President Clinical. Reviewed investigation and actions. 7. A complete root cause analysis and investigation. 8. Trauma Assessment completed on resident with no adverse actions noted. Re-educated resident and sister (Responsible Person) on leave of absence procedure. Systemic Actions: 1. Staff re-education on elopement of resident policy and code alert - Dr. Wander (staff on leave of absence will not return to duty until in-serviced on elopement of resident policy). Education is on-going. 2. Agency staff received education on elopement of resident policy and code alert - Dr. Wander. Agency staff were educated prior to working. 3. Resident meeting to review and re-educate leave of absence procedure. Re-education and missing resident drills ongoing. Two table top elopement scenarios were conducted. Monitoring: 1. Initiated audit of assessments to ensure residents are safe and correct placement. 2. Administrator makes random rounds throughout the facility quizzing staff on the process when a resident elopes.

Based on record reviews and interviews the facility failed to be administered to in a manner that used its resources efficiently to ensure staff supervised residents to prevent elopement for 1 (#140) of 1 (#140) residents reviewed for wandering. This failed practice led to an immediate jeopardy situation for Resident #140, which began on 05/06/2023 at 3:25 p.m. when he exited the facility, attempted to walk home and received a ride from a person unknown to him. S20 Agency LPN (licensed practical nurse) failed to notify the appropriate staff after he had not observed Resident #140 after administering four o'clock medications on the evening shift of 05/06/2023. S21 LPN failed to notify the appropriate staff when S20 Agency LPN reported Resident #140 had not been seen after four o'clock. S21 LPN failed to notify appropriate staff during the night shift on 05/06/2023 when Resident #140 was not observed. On 05/07/2023, Resident #140 was located at 9:02 a.m. at his home, which is located 6.1 miles from the facility, and had been missing from the facility for 18 hours. Resident #140 returned to the facility on [DATE] at 10:25 a.m. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Cross refer to 689. Provider's Elopement Policy dated 09/21/2017 revealed in part: Policy interpretation and implementation: It is the standard of this health care center that appropriate procedures exist in the case of a missing resident. A missing resident is defined as a resident who has left the facility grounds without being signed out on pass. Standard of Practice: Step 1. Should an employee discover that a resident is missing from the facility, he/she should notify the charge nurse. The charge nurses will: b) make a thorough search of the building (s) and premises. If not located within 15 minutes; c) notify the administrator and the director of nursing services; d) notify the resident's representative; notify the attending physician; notify the law enforcement officials; i) make an extensive search of the surrounding area. Step 2. At any time in which a resident is determined missing, the items below should be strictly followed: A. alert - the supervisor/charge nurse will alert all other personnel by paging Dr. Wander and location (including unit, floor, and room number). B. Search - a search of the immediate area (buildings) will be initiated under the director of the nursing shift supervisor/charge nurse> All rooms will be searched (including locked rooms) The nursing shift supervisor/charge nurse will designate staff to search the area surrounding the building, as appropriate (patio, parking areas, etc.) Review of Resident #140's Elopement Evaluations revealed on admit of 05/02/23 - score of 0 (score > 1 = at risk for elopement). Review of S21 LPN's personnel file revealed she received elopement training during orientation on 04/05/2023. Review of Facility's In-Service Records revealed an in-service on elopement was conducted on 4/02/2023. Review of Resident #140's May and June 2023 Medication Administration Record's revealed wander guard was checked every shift. During an interview on 06/07/2023 at 8:35 a.m. S1 Administrator reported she was notified on 05/07/2023 Resident #140 was missing when the day shift nurse discovered he had not been observed during the night shift. S1 Administrator reported Resident #140 told her he left because he was worried about his house and wanted to check on it. She further reported he told her it was daylight when he left, he walked to the bus stop but there was no bus, and ended up somewhere near the food stamp office. She reported he told her he got a ride with someone he did not know and that person took him straight to his house and he paid him. S1 Administrator reported she asked Resident #140 if he fell and he told her no but they observed small areas on the base of his palms. S1 Administrator verified video surveillance showed Resident #140 left the facility at 3:25 p.m. unsupervised and returned on the morning of 05/06/23 to the facility. S1 Administrator acknowledged both S20 Agency LPN and S21 LPN did not report Resident #140 was not observed during their shifts on 05/06/2023 and did not follow the elopement policy. She further reported and produced documentation S20 Agency Nurse, S21 LPN and S32 Receptionist received elopement training prior to the incident on 5/06/2023. S1 Administrator further acknowledged the receptionist on duty 05/06/2023 was not looking at the front door when Resident #140 left the facility and should have been. S1 Administrator provided documentation Resident #140's wander guard is checked every shift. On 05/07/2023 the facility implemented the following actions to correct the deficient practice with completion on 05/26/2023. Immediate Actions: 1. Resident assessed by staff upon return, interviewed. 2. Entry door was switched from a from a 12 hour night locking mode to a 24 hours a day locking mode schedule 3. Receptionist was counseled and re-educated 4. S20 Agency Nurse - notified agency of incident and placed nurse on do not return list. Reported nurse to LPN (licensed practical nurse) board. 5. S21 LPN night shift nurse - suspended pending investigation. After investigation, was terminated and reported to board. 6. Ad Hoc meeting with Medical Director, Director of Nursing and [NAME] President Clinical. Reviewed investigation and actions. 7. A complete root cause analysis and investigation. 8. Trauma Assessment completed on resident with no adverse actions noted. Re-educated resident and sister (Responsible Person) on leave of absence procedure. Systemic Actions: 1. Staff re-education on elopement of resident policy and code alert - Dr. Wander (staff on leave of absence will not return to duty until in-serviced on elopement of resident policy). Education is on-going. 2. Agency staff received education on elopement of resident policy and code alert - Dr. Wander. Agency staff were educated prior to working. 3. Resident meeting to review and re-educate leave of absence procedure. Re-education and missing resident drills ongoing. Two table top elopement scenarios were conducted. Monitoring: 1. Initiated audit of assessments to ensure residents are safe and correct placement. 2. Administrator makes random rounds throughout the facility quizzing staff on the process when a resident elopes.

Based on record reviews, interviews and observation, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #1) of 5 sampled residents (Residents #1, #2, #3, #4, #5) who received nutrition via a PEG (percutaneous endoscopic gastrostomy) tube. There were 33 residents in the facility with orders for feeding via gastrostomy tube. This deficient practice resulted in an actual harm for Resident #1 on 5/27/19 when the nursing staff replaced resident #1's PEG tube and failed to confirm tube placement with aspiration of gastric contents and x-ray before re-starting the tube feeding. On 5/27/19, the resident was observed to be in distress with a distended abdomen, indications of pain, a blood pressure of 89/57, and a pulse of 123. The residents tube feeding was stopped and the resident was transferred to a local hospital on [DATE]. The resident required emergency surgery on 5/28/19 for malfunction of the PEG tube, free fluid in the pelvis,[MEDICAL CONDITION] due to unspecified organism, abdominal pain, [MEDICAL CONDITION] and shortness of breath. The facility implemented corrective actions which were completed prior to the State Agency's investigation, thus it was determined to be a Past Noncompliance citation. Findings: Review of the facility's Gastrostomy Tube Replacement policy revealed in part the following: 1) Obtain Physician order [REDACTED]. 12) Insert the replacement GTube gently thru the existing GTube tract into the stomach and inflate the internal retention balloon with the pre-filled syringe per manufacturers recommended guidelines. 13) Check the position of the replaced GTube by aspiration of gastric content. 15) Obtain an abdominal X-ray to verify placement 16) Document the insertion technique, date and time, placement check, type and size of tube and any other pertinent information in the Nurse's Notes and on the MAR (medication administration record). 17) Resume feedings after the GTube placement has been verified by X-ray. 18) Be alert to signs of tube displacement such as abdominal distention, shortness of breath, [MEDICAL CONDITION] congestion, and [MEDICAL CONDITION] Review of the facility's Gastrostomy, Checking Placement of Gastrostomy Feeding Tube Policy revealed in part the following: 3) Place stethoscope over abdomen. Inject 30ml. of air into the stomach; listen for a swish of air. 4) Slowly aspirate stomach contents. Review of Resident #1's e-chart revealed an admitted [DATE] and [DIAGNOSES REDACTED]. Review of resident #1's physician orders [REDACTED]. 1/25/19-NPO 1/25/19-Tube: check tube placement by aspiration of gastric contents/auscultation with stethoscope and injection of approximately 30ml (milliliters) of air listening for a swish sound. Perform before initiation of feeding/flushing and prior to medication administration or at least every shift 1/25/19-tube: if tube becomes dislodged, LPN (Licensed Practical Nurse) is to insert foley of equivalent size, no further than 6 inches into stoma site to keep open. Do not inflate bulb. Check for placement. Tape tubing to abdomen. 3/4/19-enteral feed every shift related to dysphagia following cerebral infarction-glucerna 1.5 at 60cc/hr (cubic centimeters/hour) per peg per pump continuously. 5/27/19 at 1:30 PM-KUB (A kidney, ureter, and bladder X-ray that may be performed to assess the abdominal area) one time only for PEG tube Placement. 5/27/19 at 5:00 PM-Verify Placement of enteral feeding tube prior to use 5/28/19 at 4:15 AM-Send to ER (emergency room ) Review of resident #1's progress notes revealed the following notes: 5/27/19 at 10:46 AM-Incident note by S4 LPN-called into Resident #1's room stating PEG tube had come out. After assessing resident, PEG tube had become dislodged with balloon deflated. 14 French foley catheter placed into site to hold placement. Placement checked. Taped foley down to abdomen to hold in place. RN (Registered Nurse) on duty notified. 5/27/19 at 11:55 AM Nurses Note by S3 RN/ADON (Registered Nurse/Assistant Director of Nursing)-notified by Resident #1's nurse 14 French (FR) Enteral feeding tube found dislodged with bulb intact. Nurse immediately placed a 14 FR Foley catheter in to keep stoma open. Writer cleaned site, removed 14F foley and easily placed a 16 French Enteral feeding tube. No drainage noted. Resident tolerated procedure well. Placement checked by auscultation. Will verify placement by KUB prior to use. 5/27/19 at 4:25 PM Nurses Note by S3 RN/ADON - Resident #1's nurse stated KUB to verify placement of enteral feeding was completed. Radiology report is not yet available. Resident's nurse attempted to evaluate placement by auscultation and was not able to push air through enteral feeding. With this writers attempt to reassess, also was not able to push air through tube even after repositioning. Deflated balloon and inserted a different 16 French enteral feeding tube. Secured balloon with 10ml (milliliters) normal saline and secured bumper. Able successfully push 20ml air and assess placement with auscultation. KUB will again be ordered to confirm placement of enteral feeding tube. Tube will not be used until report available. 5/27/19 at 4:48 PM-Nurses Note by S4 LPN- Peg tube has been replaced by RN on duty. Still awaiting KUB for placement. Will continue to monitor resident. 5/27/19 at 11:45 PM-Nurses Note by S5 LPN Writer called to room per CNA (Certified Nursing Assistant) due to resident having a hard abdomen and appearing to be in distress. Writer entered room to find resident lying in bed with mouth open, abdomen hard to the touch, feeding was placed on hold per aid. Writer disconnected feeding from resident and turned machine off. Vitals Taken: O2 (oxygen) 93, BP (blood pressure) 89/57, P 123, temperature 99.4. Call then placed to __ imaging due to not having KUB results on hand from previous order. The second KUB was not done as ordered. Writer explained situation to x-ray tech and told tech to come out and do second KUB now. Call placed to ADON due to KUB not being completed was told by ADON to send resident to ER via order from Nurse Practitioner (NP). Call placed to __Ambulance to transport resident. 5/28/19 at 2:30 AM-late entry- (created 5/29/19 at 6:01 AM)-KUB completed via __imaging. Resident transported to local emergency room ambulance. Review of S4 LPN's witness statement dated 5/28/19 at 12:15 PM revealed S4 LPN checked resident #1's tube placement with air, heard swishing sound, and started feeding on 5/27/19 at 11:15 PM without seeing results of KUB and without calling the Nurse Practitioner or doctor. Further review revealed S4 LPN stated she did not follow the facility policy to wait for results, okay from the NP or MD (Medical Doctor). Review of S6 CNA's witness statement dated 5/29/19 at 1:09 PM revealed she came to work at 10:50 PM for the 11-7 shift, did rounds at 11:20 PM, found Resident #1 around 11:45 PM-12:00 AM with mouth open, stomach hard at top and pointed at stomach, put feeding on hold and notified nurse. Review of S3 RN/ADON's witness statement dated 5/29/19 at 12 PM revealed she replaced resident's PEG tube x 2, placed orders for KUB and reminded S4 LPN to follow up with x-ray for results. Was notified on 5/28/19 at 1:58 AM by 11-7 S5 LPN that resident's abdomen was found to be distended, feeding was running and turned off by S6 CNA, no KUB results; 5/28/19 at 2:48 AM received call the resident was being transported out by ambulance; 5/28/19 10:25AM called hospital and was informed by staff CNA the resident was in surgery and will be admitted to ICU (Intensive Care Unit). Review of Resident #1's hospital Physician Discharge Summary dated 6/3/19 revealed the following: admitted : 5/28/19 discharge date [DATE] Admission [DIAGNOSES REDACTED]. Discharge [DIAGNOSES REDACTED]. Indication for Admission: Dislodged Gtube with free abdominal air and fluid s/p emergent exploration. Hospital Course: presented with fevers, [MEDICAL CONDITION](fast heart rate), [MEDICAL CONDITION] (low blood pressure). Patient nonverbal. Patient found to have septic shock with malpositioned G tube. Imaging done showed free air and free fluid. Emergent exploratory laparoscopy was done 5/28/19. Patient found to have 1 Liter tube feeds within abdomen which was suctioned out and irrigated with normal saline. Separate Gastric tube was created with prior injury being resected. Observation on 6/13/19 at 1:40 PM revealed resident #1 awake, alert, non-verbal due to trach, appropriate responses to questions and simple commands. HOB elevated about 45 degrees, tube feeding in progress at 50cc/hr per feeding pump. During an interview on 6/13/19 at 1:40 PM Resident #1 was non-verbal, but nodded head when asked if he remembered being sent to the hospital. Resident further nodded his head yes and pointed to his abdomen when asked if he had been in pain when he was sent to the hospital. During an interview on 6/13/19 at 2:55 PM S4 LPN confirmed she restarted resident #1's feeding without having x-ray confirmation of tube placement and without notifying the MD or nurse practitioner of no results. S4 LPN further agreed she should have waited for the x-ray results or called the MD, and acknowledged she did not follow facility policy. During an interview on 6/13/19 at 3:15 PM S5 LPN confirmed a KUB had been performed to confirm Resident #1's first PEG tube placement, but not the second PEG tube placement. S5 LPN stated she was notified by S6 CNA around 11:45 PM on 5/27/19 that something was wrong with Resident #1, he was not himself, his abdomen was hard and he was pointing to it. S5 LPN stated S6 CNA had already put Resident #1's feeding on hold to give him a shower. S5 LPN stated she found Resident #1 with mouth open, didn't look right and disconnected the PEG tube from the feeding tubing. S5 LPN stated she notified S3 RN/ADON Resident #1's abdomen was distended, feeding had been running when found by the CNA but was currently turned off, and no x-ray results of 2nd [DEVICE] placement could be found. S5 LPN sent Resident #1 to the emergency room for evaluation. During an interview on 6/13/19 at 3:25 PM S3 RN/ADON confirmed she had replaced resident #1's PEG tube two separate times on 5/27/19. S3 RN/ADON stated after the second PEG tube replacement she auscultated for air and heard a faint swoosh, aspirated but was not able to aspirate gastric contents. S3 RN/ADON stated she had S4 LPN put in order for KUB. S3 RN/ADON stated she was notified in the middle of the night that Resident #1's feeding had been restarted and he was found to have a distended abdomen and was in pain. S3 RN/ADON confirmed S5 LPN told her the 2nd KUB had never been done. S3 RN/ADON stated NP instructed to send Resident #1 to the emergency room . During a telephone interview on 6/14/19 at 9:20 AM S6 CNA stated on the evening of 5/27/19 at 11:45 PM Resident #1 just didn't look right, his mouth was open and he was not his usual self. S6 CNA stated she asked him if he was ok and he started pointed to his abdomen. When she pulled his covers back, she noticed his abdomen was hard. S6 CNA stated his tube feeding was running so she put the pump on hold and notified S5 LPN. During an interview on 6/14/19 at 1:05 PM S2 RN/DON (Registered Nurse/Director of Nursing) confirmed S4 LPN did not follow-up to ensure an x-ray had been performed to confirm resident #1's PEG tube placement. S2 RN/DON confirmed S4 LPN did not confirm tube placement with verification of gastric contents and x-ray or notify resident #1's MD or nurse practitioner before starting resident #1's tube feeding. S2 RN/DON further confirmed S4 LPN did not follow the facility's policy and procedures for Gastrostomy Tube Replacement. During an interview on 6/13/19 at 4:20 PM S2 RN/DON stated a corrective action plan was put in place that included random checks with S4 LPN, re-training of S4 LPN every 60-90 days for 1 year, and re-training of all nurses on the Gastrostomy Tube Replacement policy. Stated nurses are now to place an order for [REDACTED]. During an interview on 6/13/19 at 4:25 PM S1 Administrator stated the facility was now only ordering and keeping in stock [DEVICE]s that have a radiopaque tip so the tip will show up on x-ray to facilitate confirmation of placement. S1 Administrator stated the QAPI committee formulated a plan of correction and will continue to monitor staff for compliance. During the survey process, in interviews with S3RN, S4LPN, S5LPN, and S7LPN they all indicated they were aware that tube feedings could not be resumed until placement had been confirmed by an X-Ray. These nurses also confirmed that they had received additional training on the facility's Gastrostomy Tube Replacement Policy. The facility has implemented the following actions to correct the deficient practice from 5/27/19: 1) Retraining of all nursing staff on Gastrostomy Tube Replacement Policy with last inservice completed 6/12/19 2) Disciplinary action and a plan for random observations of S4 LPN and scheduled re-training for S4 LPN every 3 months for 1 year. 3) Procedure on ordering and following up with x-ray company until results received. 4) Order to be placed with all PEG tube replacements to hold feedings and medications until placement confirmed by x-ray. 5) Documentation of communication with x-ray company and agencies participating in care of residents. 6). Identified and implemented corrective measures into the facility's Quality Assurance and Performance Improvement plan.

Based on observations, record reviews, and interviews the facility failed to ensure the resident's environment was free from accident hazards for 20 (#186, #2, #68, #84, #38, #99, #227, #127, #124, #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, #20) cognitively impaired residents, who resided in the facility's locked dementia unit, who were identified to have access to in room water with temperatures of 130 degrees F (Fahrenheit) out of 52 (#186, #2, #57, #112, #93, #30, #7, #68, #84, #120, #38, #195, #99, #31, #101, #102, #149, #227, #88, #127, #124, #187, #32, #110, #134, #86, #58, #140, #203, #45, #205, #13, #128, #107, #164, #53, #1, #104, #188, #171, #196, #98, #213, #6, #17, #129, #150, #131, #20, #118, #170, #75) residents residing on the locked dementia unit out of a total facility census of 186 residents. The facility failed to: 1. Ensure maintenance staff did not change hot water temperatures to a level greater than 120 degrees F. 2. Ensure a system was in place to monitor and ensure water temperatures in resident's rooms were maintained at a level to prevent residents from being burned. 3. Ensure their hot water system was functioning properly to ensure safe water temperatures were maintained throughout the facility. The Immediate Jeopardy began on 10/5/15 at 8:30 a.m. when S2 Maintenance Supervisor increased the water temperature of the boiler to accommodate the kitchen dishwashing/disinfecting water temperatures and to provide hot water to the residents for bathing. The facility failed to monitor the hot water temperatures to ensure regulation and the water temperatures were found at 130 degrees F at the bathroom faucets on the 3rd Floor Dementia Unit. The Immediate Jeopardy continued for the following residents residing on the 3rd Floor Dementia Unit: #186, #2, #68, #84, #38, #99, #227, #127, #124, #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, and #20. The facility's Administrator S1 was informed of the Immediate Jeopardy on 10/5/15 at 5:50 p.m. The Immediate Jeopardy was removed on 10/6/15 at 3:30 p.m. when observations and record reviews revealed the following immediate Plan of Removal was implemented: 1. Director of Nursing immediately turned off hot water to each resident room on the 3rd Floor Dementia Unit. 2. Temperatures were checked in each room on the 3rd Floor Dementia Unit and recorded. 3. The 3rd Floor Dementia Unit has had temperatures monitored continuously since identification of the increased water temperatures utilizing a designated monitor. 4. Boiler temperatures have been adjusted in response to the readings, and at current time, have been stable for several hours. 5. Staff was in-serviced immediately in order to prevent any injury to residents due to increased water temperatures. 6. New plumbing company experienced with nursing facilities in the area was contacted to assess the water system. 7. Temperatures were checked in each room of the building and recorded. 8. Vice President of Plant Maintenance was contacted and will arrive at 12:00 p.m. on 10/6/15 to troubleshoot the water system and provide guidance to the facility. (Determination of possible problem with the mixing valve, but plumber will advise corrective action to fix water system). 9. Any readings above 120 degrees will be immediately reported to S1 Administrator for instructions. 10. S1 Administrator will review the temperatures each shift and a trend will be developed. 11. Monitoring will continue 24 hours/day until the plumbing evaluation and work was completed. After removal of the immediate jeopardy, the facility further implemented the following revisions to correct the deficient practice: 1. Plumbing company in facility 10/8/15 and disconnected the hot water heater that supplied the laundry as it was determined the water line was also connected to the main lines to the facility and water from the laundry was backing up into the main line causing increase in temperatures. 2. Plumbing company determined the mixing valves were also not functioning as they were designed to and were replaced as well. 3. Temperature monitors will continue to monitor the 3rd Floor Dementia Unit until 72 hours of in-range temperatures have been achieved. If temperatures not achieved after plumber leaves today (10/8/15), the plumber will be enlisted to continue working until the problem is alleviated. 4. Once 72 hours of in-range temperatures are achieved, temperatures will be checked twice each shift in each room on the 3rd Floor Dementia Unit until temperatures have been in range for 3 weeks. 5. After temperatures have been within range for 3 weeks, temperatures will be checked once each day except Saturday and Sunday unless CQI Committee determines that system is safe, at which time the facility will revert back to the original policy. 6. Going forward, water temperatures will be a regular part of facility's Continuous Quality Improvement (CQI) process, and administrator/designee will review water temperatures each month during CQI, and will herself randomly check temperatures and enter results into the CQI minutes. The deficient practice continued at a scope and severity of second level pattern. Findings: Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed the following under Time and Temperature Relationship to Severe Burns: Water Temperature Time for a third degree burn to occur 155 degrees F 1 Second 148 degrees F 2 Seconds 140 degrees F 5 Seconds 133 degrees F 15 Seconds 127 degrees F 1 Minute 124 degrees F 3 Minutes 120 degrees F 5 Minutes 100 degrees F Safe temperature for bathing Further review revealed the following under High Risk Groups: 1. Older Adults - Older adults, like young children, have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. 2. People with disabilities or special needs - Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. Observations on 10/5/15 from 2:30 p.m. to 3:30 p.m. revealed resident bathroom water temperatures on the 3rd Floor Dementia Unit to show a reading of 130 degrees F utilizing the surveyor's thermometer. Further observations during this time revealed residents were wandering up and down the 300 Hall and going into other resident ' s rooms. Observations further revealed residents wandering back and forth in and out of their own rooms. Facility staff at this time was assisting other residents and/or administering medications during the times the wandering residents were going in and out of rooms where the hot water was located. Observation on 10/5/15 at 4:10 p.m. S2 Maintenance Supervisor arrived to the 3rd Floor Dementia Unit with the facility thermometer. Observation on 10/5/15 of the water temperatures in resident #30 and #8's shared bathroom revealed a hot water temperature of 130 degrees F. Further observation with S2 Maintenance Supervisor revealed the water temperature in resident #128's bathroom revealed a hot water temperature of 130 degrees F. During an interview on 10/5/15 at 4:15 p.m. S2 Maintenance Supervisor was asked to check the hot water temperatures in all resident bathrooms on the 3rd Floor Dementia Unit. S2 Maintenance Supervisor stated there was no need to check all of the rooms because they were all on the same hot water system and would all have a reading of 130 degrees F. S2 Maintenance Supervisor stated he would adjust the water temperature on the boiler around 10 degrees F each morning to ensure enough hot water for resident bathing and for the kitchen to have hot enough water to meet their requirements for the dishwashing machine to disinfect the dishes. S2 Maintenance Supervisor stated once the baths were completed and the dishes were done being washed either him or one of his workers would turn the water back down around 10 degrees. S2 Maintenance Supervisor stated the worker who was supposed to have adjusted the water temperature on the boiler back down either did not decrease the water temperature enough or forgot to go back and turn it down. S2 Maintenance Supervisor stated he monitored the readings on the gauges coming out of the boilers and also completed random water checks in a couple of resident rooms on each floor daily. S2 Maintenance Supervisor stated he did not recheck the water temperatures in resident rooms once he adjusted and readjusted the hot water temperatures coming off the boiler. During an interview on 10/5/15 at 4:50 p.m. S3 Unit Manager and S4 CNA stated resident #186, #2, #68, #84, #38, #99, #227, #127, and #124 were all cognitively impaired residents on the 3rd Floor Dementia Unit Hall A who would have access to the hot water and were able to use the water if needed. During an interview on 10/5/15 at 5:00 p.m. S5 CNA stated resident #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, and #20 were all residents who were cognitively impaired on the 3rd Floor Dementia Unit Hall B. S5 CNA stated the above residents had access to the hot water and able to turn on the faucet if water was needed. During an interview on 10/5/15 at 5:10 p.m. S1 Administrator was notified upon her return to the facility of the hot water temperatures on the 3rd Floor Dementia Unit being 130 degrees F. S1 Administrator was also informed at this time that S2 Maintenance Supervisor had been manually adjusting the hot water up and down to ensure residents had hot water for bathing and the kitchen had hot water for cleaning dishes. S1 Administrator stated at this time that she was not aware of the S2 Maintenance Supervisor had been manually adjusting the hot water temperatures at the boiler and although she was not sure what the facility's policy was regarding maintaining water temperatures within normal ranges that she was sure adjusting the boiler was not part of the policy. Review of the Water Temperature Readings Log dated 6/28/15 to 10/5/15 revealed documentation that water temperature readings must be recorded from 2 locations per day. Review of the Water Temperature Readings Log revealed no water temperature had been monitored on the following dates: 7/13/15, 7/17/15, 7/20/15, 7/21/15, 7/24/15, 7/27/15, 7/30/15, 8/4/15, 8/10/15, 8/24/15, 9/7/15, 9/8/15, 9/14/15, 9/21/15, 9/24/15, 9/25/15, 9/28/15, and 10/5/15. Review of the Water Temperature Reading Log also had no documentation of temperatures on Saturdays or Sundays. Further review revealed on 9/16/15 a reading of 129 degrees F was recorded for room 212 at 11:32 a.m. Review revealed no documentation as to what was done to correct the increased temperature at that time. During an interview on 10/5/15 at 5:20 p.m. S2 Maintenance Supervisor stated he had rechecked the hot water temperatures on the 3rd Floor Dementia Unit and they were reading around 115 degrees F. S2 Maintenance Supervisor stated he did not have to adjust the temperature down on the boiler, but had let the water run through the lines to clear. S2 Maintenance Supervisor stated the way the facility's hot water system was set up was that the two hot water tanks were outside the facility and susceptible to the outside ambient temperatures and that was why he had to adjust the temperature of the water at the boiler as he had been doing. S2 Maintenance Supervisor stated the hot water system was set up as one system and the hot water started on the 1st Floor of the facility and then upwards until reaching the 4th Floor. S2 Maintenance Supervisor stated once all floors had hot water available, and then before 1st Floor would have hot water again all the floors above would have to use what was available. S2 Maintenance Supervisor further stated the resident on the locked unit did not use as much hot water as the other floors and that would cause water to sit in the lines and could be part of the increased temperatures on the 3rd Floor Dementia Unit. S2 Maintenance Supervisor agreed that there were several days that the water temperatures were not monitored and he was not sure why not. Review of a Resident Responses Analyzer form provided by the facility revealed the following residents with the Brief Interview for Mental Status (BIMS) score for cognition were listed as follows for the 3rd Floor Dementia Unit: (BIMS score ranges from 00-15 with 15 indicating resident is cognitive) Resident #186's BIMS score=2 Resident #2's BIMS score=3 Resident #68's BIMS score=3 Resident #227's BIMS score=3 Resident #127's BIMS score=11 Resident #107's BIMS score=11 Resident #164's BIMS score=10 Resident #171's BIMS score=3 Resident #6's BIMS score=9 Resident #129's BIMS score=7 Resident #150's BIMS score=9 Resident #131's BIMS score=7 Resident #20's BIMS score=12 Review of the facility's Incident Logs dated January 1, 2015 to October 5, 2015 revealed no incidents documented that residents in the facility had suffered burns due to hot water. During an interview on 10/6/15 at 9:30 a.m. S1 Administrator stated she had a plumber coming to the facility, which was experienced with nursing facilities, to check out the hot water system and fix any problems identified. S1 Administrator stated she would let us know what the plumber found once the problem was identified. S1 Administrator stated until all of the work is completed she had staff checking each resident's hot water temperatures constantly. S1 Administrator stated when the staff member had documented the temperatures on the entire 3rd Floor Dementia Unit they would start back at the first room and continue to each room in a constant cycle. Observations on 10/6/15 at 10:00 a.m. revealed multiple residents with access to the hot water remained in their room and a couple of residents were wandering up and down the hall and in and out of resident rooms where the hot water was located and would have access to the hot water. Observations revealed staff present in the day area finishing up breakfast and/or providing care for other residents and the nursing staff continued to administer morning medications. During an interview on 10/6/15 at 1:30 p.m. S1 Administrator stated the plumber had identified that both mixing valves were not working correctly and that was why the water was not being regulated accurately. S1 Administrator stated the plumber also identified the way the laundry system was connected that the water from the laundry that was not being used was being pulled back into the main lines and that water temperature was around 150 degrees and then the mixing valves not working correctly couldn't regulate the system to ensure the water stayed at a range of 120 degrees F or below. S1 Administrator stated the plumber had ordered the mixing valves and would be back to the facility on [DATE] to replace them if he was able to get them delivered timely. During an interview on 10/7/15 at 11:30 a.m. S1 Administrator stated the plumber would be at the facility around 3:00 p.m. with the mixing valves and begin the work on fixing the water system. S1 Administrator was informed at this time that the surveyor needed to speak with the plumber the facility had hired to complete the work once he returned to the facility. During an interview on 10/7/15 at 4:00 p.m., with S1 Administrator and the facility's Vice President of Plant Maintenance present, the plumber was interviewed regarding the facility's hot water system. During the interview, the plumber stated he assessed the facility's hot water system and it was determined that both mixing valves were not functioning properly. The plumber further stated he identified a problem with the facility's laundry and the hot water tank that supplied them. The plumber stated it was believed that the laundry was on its own system so the water temperature could be 150 degrees F for washing laundry, but when he observed the system it was noted the way the last plumber connected the pipes that the laundry hot water tank was also connected to the main system. The plumber stated that meant when the water for laundry was not being used it would flow back into the main system at 150 degrees F and once that water was jaded in the pipes the mixing valves were not working properly and was not able to send enough cold water to the lines to decrease the temperature where it needed to be. During further interview, when asked about S2 Maintenance Supervisor adjusting the water temperature at the boiler, the plumber stated the first sign that the mixing valves are not functioning properly is when someone has to make adjustments manually. The plumber agreed S2 Maintenance Supervisor should have know the mixing valves were not working correctly once he began having to make adjustments to keep hot water at specific times. The plumber was asked about S2 Maintenance Supervisor obtaining readings from the temperature gauges coming off of the water heaters and he agreed with the mixing valves not working properly that the gauges might not read correctly either. The plumber stated he would be back at the facility with his crew on the morning of 10/8/15 and would first disconnect the laundry hot water tank from the main system and that would most likely fix the hot water issue immediately. The plumber stated he would then replace the mixing valves out and was also going to put new gauges on the tanks. The plumber stated the work should be completed 10/8/15, but was going to be completed in separate stages to ensure the residents did not lose their access to water. During an interview on 10/7/15 at 4:15 p.m. S1 Administrator and Vice President of Plant Maintenance agreed, with the plumber that the facility hired to complete the work, S2 Maintenance Supervisor should have known the mixing valves were not working properly and further agreed that S2 Maintenance Supervisor should not have been relying on the gauge readings as much as he should have been checking the water temperatures in more resident rooms. S1 Administrator further agreed S2 Maintenance Supervisor should have been monitoring resident water temperatures more frequently with each time he had to manually change the temperatures on the boiler and not just the once daily rounds that would be made to check the temperatures. S1 Administrator agreed S2 Maintenance Supervisor should have informed her that he was having to make manual changes to the hot water system, but did not.

Based on observations, record reviews, and interviews the facility failed to be administered in a manner that used resources effectively and efficiently for 20 (#186, #2, #68, #84, #38, #99, #227, #127, #124, #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, #20) cognitively impaired residents, who resided in the facility's locked dementia care unit, who were identified to have access to in room water with temperatures of 130 degrees F (Fahrenheit) out of 52 (#186, #2, #57, #112, #93, #30, #7, #68, #84, #120, #38, #195, #99, #31, #101, #102, #149, #227, #88, #127, #124, #187, #32, #110, #134, #86, #58, #140, #203, #45, #205, #13, #128, #107, #164, #53, #1, #104, #188, #171, #196, #98, #213, #6, #17, #129, #150, #131, #20, #118, #170, #75) residents residing on the locked dementia care unit of a total facility census of 186 residents. The Administration failed to: 1. Ensure a system was in place to monitor and ensure water temperatures in resident's rooms were maintained at a level to prevent residents from being burned. 2. Ensure the facility had a policy developed and implemented to ensure the facility's hot water system was monitored and functioning properly to ensure safe water temperatures were maintained throughout the facility. The Immediate Jeopardy began on 10/5/15 at 8:30 a.m. when S2 Maintenance Supervisor increased the water temperature of the boiler to accommodate the kitchen dishwashing/disinfecting water temperatures and to provide hot water to the residents for bathing. The facility failed to monitor the hot water temperatures to ensure regulation and the water temperatures were found at 130 degrees F at the bathroom faucets on the 3rd floor dementia care unit. The Immediate Jeopardy continued for the following residents residing on the 3rd floor dementia care unit: #186, #2, #68, #84, #38, #99, #227, #127, #124, #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, and #20. The facility's Administrator S1 was informed of the Immediate Jeopardy on 10/5/15 at 5:50 p.m. The Immediate Jeopardy was removed on 10/6/15 at 3:30 p.m. when observations and record reviews revealed the following immediate Plan of Removal was implemented: 1. Director of Nursing immediately turned off hot water to each resident room on the 3rd Floor Dementia Unit. 2. Temperatures were checked in each room on the 3rd Floor Dementia Unit and recorded. 3. The 3rd Floor Dementia Unit has had temperatures monitored continuously since identification of the increased water temperatures utilizing a designated monitor. 4. Boiler temperatures have been adjusted in response to the readings, and at current time, have been stable for several hours. 5. Staff was in-serviced immediately in order to prevent any injury to residents due to increased water temperatures. 6. New plumbing company experienced with nursing facilities in the area was contacted to assess the water system. 7. Temperatures were checked in each room of the building and recorded. 8. Vice President of Plant Operations was contacted and will arrive at 12:00 p.m. on 10/6/15 to troubleshoot the water system and provide guidance to the facility. (Determination of possible problem with the mixing valve, but plumber will advise corrective action to fix water system). 9. Any readings above 120 degrees will be immediately reported to S1 Administrator for instructions. 10. S1 Administrator will review the temperatures each shift and a trend will be developed. 11. Monitoring will continue 24 hours/day until the plumbing evaluation and work was completed. After removal of the immediate jeopardy, the facility further implemented the following revisions to correct the deficient practice: 1. Plumbing company in facility 10/8/15 and disconnected the hot water heater that supplied the laundry as it was determined the water line was also connected to the main lines to the facility and water from the laundry was backing up into the main line causing increase in temperatures. 2. Plumbing company determined the mixing valves were also not functioning as they were designed to and were replaced as well. 3. Temperature monitors will continue to monitor the 3rd Floor Dementia Unit until 72 hours of in-range temperatures have been achieved. If temperatures not achieved after plumber leaves today (10/8/15), the plumber will be enlisted to continue working until the problem is alleviated. 4. Once 72 hours of in-range temperatures are achieved, temperatures will be checked twice each shift in each room on the 3rd Floor Dementia Unit until temperatures have been in range for 3 weeks. 5. After temperatures have been within range for 3 weeks, temperatures will be checked once each day except Saturday and Sunday unless CQI Committee determines that system is safe, at which time the facility will revert back to the original policy. 6. Going forward, water temperatures will be a regular part of facility's CQI process, and administrator/designee will review water temperatures each month during CQI, and will herself randomly check temperatures and enter results into CQI minutes. The deficient practice continued at a scope and severity of second level pattern. Findings: Review of the American Burn Association Scald Injury Prevention Educator's Guide revealed the following under Time and Temperature Relationship to Severe Burns: Water Temperature Time for a third degree burn to occur 155 degrees F 1 Second 148 degrees F 2 Seconds 140 degrees F 5 Seconds 133 degrees F 15 Seconds 127 degrees F 1 Minute 124 degrees F 3 Minutes 120 degrees F 5 Minutes 100 degrees F Safe temperature for bathing Further review revealed the following under High Risk Groups: 1. Older Adults - Older adults, like young children, have thinner skin so hot liquids cause [MEDICAL CONDITION] even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults. Older adults may also have conditions that make them more prone to falls in the bathtub or shower or while carrying hot liquids. 2. People with disabilities or special needs - Individuals who may have physical, mental, or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds. The disability may be permanent or temporary due to illness or injury and vary in severity from minor to total dependency on others. Sensory impairments can result in decreased sensation, especially to the hands and feet, so the person may not realize if something is too hot. Changes in a person's intellect, perception, memory, judgment, or awareness may hinder the person's ability to recognize a dangerous situation (such as a tub filled with scalding water) or respond appropriately to remove themselves from danger. Observations on 10/5/15 from 2:30 p.m. to 3:30 p.m. revealed resident bathroom water temperatures on the 3rd Floor Dementia Unit to show a reading of 130 degrees F utilizing the surveyor's thermometer. Observation on 10/5/15 at 4:10 p.m. S2 Maintenance Supervisor arrived to the 3rd Floor Dementia Unit with the facility thermometer. Observation on 10/5/15 of the water temperatures in resident #30 and #8's shared bathroom revealed a hot water temperature of 130 degrees F. Further observation with S2 Maintenance Supervisor revealed the water temperature in resident #128's bathroom revealed a hot water temperature of 130 degrees F. During an interview on 10/5/15 at 4:15 p.m. S2 Maintenance Supervisor was asked to check the hot water temperatures in all resident bathrooms on the 3rd Floor Dementia Unit. S2 Maintenance Supervisor stated there was no need to check all of the rooms because they were all on the same hot water system and would all have a reading of 130 degrees F. S2 Maintenance Supervisor stated he would adjust the water temperature on the boiler around 10 degrees F each morning to ensure enough hot water for resident bathing and for the kitchen to have hot enough water to meet their requirements for the dishwashing machine to disinfect the dishes. S2 Maintenance Supervisor stated once the baths were completed and the dishes were done being washed either him or one of his workers would turn the water back down around 10 degrees. S2 Maintenance Supervisor stated the worker who was supposed to have adjusted the water temperature on the boiler back down either did not decrease the water temperature enough or forgot to go back and turn it down. S2 Maintenance Supervisor stated he monitored the readings on the gauges coming out of the boilers and also completed random water checks in a couple of resident rooms on each floor daily. S2 Maintenance Supervisor stated he did not recheck the water temperatures in resident rooms once he adjusted and readjusted the hot water temperatures coming off the boiler. During an interview on 10/5/15 at 4:50 p.m. S3 Unit Manager and S4 CNA stated resident #186, #2, #68, #84, #38, #99, #227, #127, and #124 were all cognitively impaired residents on the 3rd Floor Dementia Unit Hall A who would have access to the hot water and were able to use the water if needed. During an interview on 10/5/15 at 5:00 p.m. S5 CNA stated resident #203, #45, #107, #164, #171, #98, #6, #129, #150, #131, and #20 were all residents who were cognitively impaired on the 3rd Floor Dementia Unit Hall B. S5 CNA stated the above residents had access to the hot water and able to turn on the faucet if water was needed. During an interview on 10/5/15 at 5:10 p.m. S1 Administrator was notified upon her return to the facility of the hot water temperatures on the 3rd Floor Dementia Unit being 130 degrees F. S1 Administrator was also informed at this time that S2 Maintenance Supervisor had been manually adjusting the hot water up and down to ensure residents had hot water for bathing and the kitchen had hot water for cleaning dishes. S1 Administrator stated at this time that she was not aware of the S2 Maintenance Supervisor had been manually adjusting the hot water temperatures at the boiler and although she was not sure what the facility's policy was regarding maintaining water temperatures within normal ranges that she was sure adjusting the boiler was not part of the policy. Review of the Water Temperature Readings Log dated 6/28/15 to 10/5/15 revealed documentation that water temperature readings must be recorded from 2 locations per day. Review of the Water Temperature Readings Log revealed no water temperature had been monitored on the following dates: 7/13/15, 7/17/15, 7/20/15, 7/21/15, 7/24/15, 7/27/15, 7/30/15, 8/4/15, 8/10/15, 8/24/15, 9/7/15, 9/8/15, 9/14/15, 9/21/15, 9/24/15, 9/25/15, 9/28/15, and 10/5/15. Review of the Water Temperature Reading Log also had no documentation of temperatures on Saturdays or Sundays. Further review revealed on 9/16/15 a reading of 129 degrees F was recorded for room [ROOM NUMBER] at 11:32 a.m. Review revealed no documentation as to what was done to correct the increased temperature at that time. During an interview on 10/5/15 at 5:20 p.m. S2 Maintenance Supervisor stated he had rechecked the hot water temperatures on the 3rd Floor Dementia Unit and they were reading around 115 degrees F. S2 Maintenance Supervisor stated he did not have to adjust the temperature down on the boiler, but had let the water run through the lines to clear. S2 Maintenance Supervisor stated the way the facility's hot water system was set up was that the two hot water tanks were outside the facility and susceptible to the outside ambient temperatures and that was why he had to adjust the temperature of the water at the boiler as he had been doing. S2 Maintenance Supervisor stated the hot water system was set up as one system and the hot water started on the 1st Floor of the facility and then upwards until reaching the 4th Floor. S2 Maintenance Supervisor stated once all floors had hot water available, and then before 1st Floor would have hot water again all the floors above would have to use what was available. S2 Maintenance Supervisor further stated the resident on the locked unit did not use as much hot water as the other floors and that would cause water to sit in the lines and could be part of the increased temperatures on the 3rd Floor Dementia Unit. S2 Maintenance Supervisor agreed that there were several days that the water temperatures were not monitored and he was not sure why not. During an interview on 10/6/15 at 9:30 a.m. S1 Administrator stated she had a plumber coming to the facility, which was experienced with nursing facilities, to check out the hot water system and fix any problems identified. S1 Administrator stated she would let us know what the plumber found once the problem was identified. S1 Administrator stated until all of the work is completed she had staff checking each resident's hot water temperatures constantly. S1 Administrator stated when the staff member had documented the temperatures on the entire 3rd Floor Dementia Unit they would start back at the first room and continue to each room in a constant cycle. During an interview on 10/6/15 at 1:30 p.m. S1 Administrator stated the plumber had identified that both mixing valves were not working correctly and that was why the water was not being regulated accurately. S1 Administrator stated the plumber also identified the way the laundry system was connected that the water from the laundry that was not being used was being pulled back into the main lines and that water temperature was around 150 degrees and then the mixing valves not working correctly couldn't regulate the system to ensure the water stayed at a range of 120 degrees F or below. S1 Administrator stated the plumber had ordered the mixing valves and would be back to the facility on [DATE] to replace them if he was able to get them delivered timely. During an interview on 10/7/15 at 4:15 p.m. S1 Administrator and Vice President of Plant Operations agreed, with the plumber that the facility hired to complete the work, S2 Maintenance Supervisor should have known the mixing valves were not working properly and further agreed that S2 Maintenance Supervisor should not have been relying on the gauge readings as much as he should have been checking the water temperatures in more resident rooms. S1 Administrator further agreed S2 Maintenance Supervisor should have been monitoring resident water temperatures more frequently with each time he had to manually change the temperatures on the boiler and not just the once daily rounds that would be made to check the temperatures. S1 Administrator agreed S2 Maintenance Supervisor should have informed her that he was having to make manual changes to the hot water system, but did not. S1 Administrator stated had she been informed during the daily morning Quality Assurance meeting she could have had the problem identified and fixed, but her staff did not inform her that this was happening. S1 Administrator stated regardless whether she was notified of the issues by S2 Maintenance Supervisor she should have made an effort to ensure there were no problems with the facility's hot water system and that she was overall responsible for every aspect of what occurred at the facility.

Based on record reviews, interviews, and the facility Policy Manual, the facility failed to ensure resident's rights were executed by failing to implement the Advance Directive to initiate CPR (Cardio [MEDICAL CONDITION] Resuscitation). The facility failed to initiate CPR for 1 (#5) of 5 (#1, 2, 3, 4, 5) residents reviewed as to being assessed with [REDACTED]. This resulted in actual harm for resident #5 who was not afforded the opportunity for resuscitation in accordance with his Advance Directive. The facility's census was 206 as documented on the Resident Census and Conditions of Residents form dated [DATE]. S2DON reported 161 residents in the facility with full code status. Findings: Review of resident #5's closed record revealed an Advance Directive Checklist dated [DATE] and signed by resident #5's Responsible Party documenting the Resident/Legal Representative had been given written material on their right to accept or refuse medical and/or surgical treatment and their right to formulate Advance Directives. Review of resident #5's Admission Agreement dated [DATE] and signed by resident #5's Responsible Party, revealed The Client/Patient Bill of Rights and Responsibilities listed: You are entitled to ...receive appropriate service without discrimination in accordance with physician orders. Further review revealed under the Acknowledgements and Consents, a section initialed by resident #5's Responsible Party and checked yes for Resuscitation: The policy of this Healthcare Facility is to initiate Cardiopulmonary Resuscitation (CPR) as a resuscitation procedure to restore breathing and/or heartbeat if I'm found to be in Cardiopulmonary arrest, except when my attending physician has documented a valid Do Not Resuscitate (DNR) order on my permanent record. Review of resident #5's [DATE] (Physician) Order Summary Report revealed an order dated [DATE] for code status: Full Code. During an interview on [DATE] at 9:40 a.m. S2Administrator stated S7Respiratory Therapist and S6LPN did not start CPR on resident #5 who was a full code status and should have received CPR until notified to stop by a physician. During an interview on [DATE] at 9:45 a.m. S2DON stated he was in the facility at the time of the incident with resident #5 on [DATE]. S2DON stated he immediately asked if CPR was started, if the physician and family were called. S2DON stated the investigation was started immediately why no CPR was administered to resident #5 that was a full code status and should have received CPR according to policy and the Responsible Party's request. During an interview on [DATE] at 1:00 p.m. S6LPN stated she was present on [DATE] and saw resident #5 before breakfast, and took his vital signs before resident #5 took his meds per PEG tube without problems. S6LPN stated resident #5 was awake and alert with no concerns noted. S6LPN stated between maybe 9:15 a.m. and 9:30 a.m., a trainee with S7Respiratory Therapist came down the hall and informed S6LPN resident #5 was gone. S6LPN stated she called a CNA to get the crash cart, and someone to call the downstairs front desk and S6LPN called S8LPN Unit Manager from the nurse station on the way to resident #5 ' s room. S6LPN stated she got to resident #5 ' s room and a CNA was behind S6LPN with the crash cart. S7Respiratory Therapist and a trainee were at the head of resident #5's bed. S6LPN stated S7Respiratory Therapist reported she heard no heart-rate and felt no pulse. S6LPN stated she observed resident #5 with the head of the bed elevated and his head was turned to the side. S6LPN stated she rolled the head of the bed down to begin CPR if needed, checked for a pulse and did not feel anything, and S7Respiratory Therapist said he is gone and no sense to do anything. S6LPN stated she did not start CPR and did not call for 911. S6LPN stated at that time, S8LPN Unit manager came in and asked S7Respiratory Therapist if she started CPR and S7Respiratory Therapist said I can if you want me to, but he is gone. S6LPN stated a book is on the crash cart with the code status of each resident, but was told the Code book was being updated and not on the crash cart. S6LPN stated she did not go to the medication cart to check the computer for code status of resident #5 or to the nurse station computer. S6LPN stated she did not know why she dropped the ball and did not perform CPR on resident #5, other than by what S7Respiratory Therapist had stated. S6LPN stated she was ready to do CPR on resident #5, but S7Respiratory Therapist swayed her plan. During an interview on [DATE] at 1:25 p.m. S7Respiratory Therapist stated she saw resident #5 about 9:35 a.m. on [DATE] for first rounds. S7Respiratory Therapist stated when she walked in resident #5's room with an orientee, resident #5's head of the bed was elevated, and he was slumped to the side, with a little blood running from his mouth. S7Respiratory Therapist stated she asked the orientee to run get the nurse. S7Respiratory Therapist stated she assessed resident #5 with no chest rise or fall, auscultated the lungs with no breath sounds, no radial or carotid pulse, and the pulse ox had no reading. S7Respiratory Therapist stated resident #5 ' s oxygen was intact to the [MEDICAL CONDITION]. S7Respiratory Therapist stated by that time, CNAs and nurses came to the room, but did not know resident #5's code status. S7Respiratory Therapist stated her assessment of no pulse and asked how long since someone was in the room, and was told resident #5 had eaten and was awake about 20 -30 minutes ago. S7Respiratory Therapist stated she rolled the head of the bed down, looked for a syringe if needed to inflate the [MEDICAL CONDITION] cuff to use the ambu bag, then the crash cart was in room, but no CPR was started. S7Respiratory Therapist stated she is trained to begin CPR if a resident is assessed with [REDACTED]. Review of the facility's Policy and Procedure Manual revealed the following Cardiopulmonary Resuscitation (CPR) policy: CPR will be instituted on all residents without a DNR or Advanced directives identified. CPR is used to restore or maintain breathing or pulse in emergency situations and to prevent brain damage. Cardio [MEDICAL CONDITION] resuscitation is initiated in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest to sustain or support a resident ' s cardiac and/or [MEDICAL CONDITION] function until advanced life support systems are available.

Based on record reviews, interviews, Facility Policy Manual and Nursing Standards of Practice, the facility failed to provide services that met professional standards of quality. The facility failed to ensure nursing staff initiate CPR for 1 (#5) of 5 (#1, 2, 3, 4, 5) residents reviewed as to being assessed with [REDACTED]. This resulted in actual harm for resident #5 who was not afforded the opportunity for resuscitation in accordance with his Advance Directive. The facility's census was 206 as documented on the Resident Census and Conditions of Residents form dated [DATE]. S2DON reported 161 residents in the facility were with full code status. Findings: Review of resident #5's Admission Agreement dated [DATE] and signed by resident #5's Responsible Party, revealed The Client/Patient Bill of Rights and Responsibilities listed: You are entitled to ...receive appropriate service without discrimination in accordance with physician orders. Further review revealed under the Acknowledgements and Consents, a section initialed by resident #5's Responsible Party and checked yes for Resuscitation: The policy of this Healthcare Facility is to initiate Cardiopulmonary Resuscitation (CPR) as a resuscitation procedure to restore breathing and/or heartbeat if I'm found to be in Cardiopulmonary arrest, except when my attending physician has documented a valid Do Not Resuscitate (DNR) order on my permanent record. Review of resident #5's [DATE] (Physician) Order Summary Report revealed an order dated [DATE] for code status: Full Code. During an interview on [DATE] at 9:40 a.m. S2Administrator stated S7Respiratory Therapist and S6LPN did not start CPR on resident #5 who was a full code status and should have received CPR until notified to stop by a physician. During an interview on [DATE] at 9:45 a.m. S2DON stated he was in the facility at the time of the incident with resident #5 on [DATE]. S2DON stated he immediately asked if CPR was started, if the physician and family were called. S2DON stated the investigation was started immediately why no CPR was administered to resident #5 that was a full code status and should have received CPR according to policy, nursing principles, and the Responsible Party's request. During an interview on [DATE] at 1:00 p.m. S6LPN stated she was present on [DATE] and saw resident #5 before breakfast, and took his vital signs before resident #5 took his meds per PEG tube without problems. S6LPN stated resident #5 was awake and alert with no concerns noted. S6LPN stated between maybe 9:15 a.m. and 9:30 a.m., a trainee with S7Respiratory Therapist came down the hall and informed S6LPN resident #5 was gone. S6LPN stated she called a CNA to get the crash cart, and someone to call the downstairs front desk and S6LPN called S8LPN Unit Manager from the nurse station on the way to resident #5 ' s room. S6LPN stated she got to resident #5 ' s room and a CNA was behind S6LPN with the crash cart. S7Respiratory Therapist and a trainee were at the head of resident #5's bed. S6LPN stated S7Respiratory Therapist reported she heard no heart-rate and felt no pulse. S6LPN stated she observed resident #5 with the head of the bed elevated and his head was turned to the side. S6LPN stated she rolled the head of the bed down to begin CPR if needed, checked for a pulse and did not feel anything, and S7Respiratory Therapist said he is gone and no sense to do anything. S6LPN stated she did not start CPR and did not call for 911. S6LPN stated at that time, S8LPN Unit manager came in and asked S7Respiratory Therapist if she started CPR and S7Respiratory Therapist said I can if you want me to, but he is gone. S6LPN stated a book is on the crash cart with the code status of each resident, but was told the Code book was being updated and not on the crash cart. S6LPN stated she did not go to the medication cart to check the computer for code status of resident #5 or to the nurse station computer. S6LPN stated she did not know why she dropped the ball and did not perform CPR on resident #5, other than by what S7Respiratory Therapist had stated. S6LPN stated she was ready to do CPR on resident #5, but S7Respiratory Therapist swayed her plan. During an interview on [DATE] at 1:25 p.m. S7Respiratory Therapist stated she saw resident #5 about 9:35 a.m. on [DATE] for first rounds. S7Respiratory Therapist stated when she walked in resident #5 ' s room with an orientee, resident #5 ' s head of the bed was elevated, and he was slumped to the side, with a little blood running from his mouth. S7Respiratory Therapist stated she asked the orientee to run get the nurse. S7Respiratory Therapist stated she assessed resident #5 with no chest rise or fall, auscultated the lungs with no breath sounds, no radial or carotid pulse, and the pulse ox had no reading. S7Respiratory Therapist stated resident #5 ' s oxygen was intact to the [MEDICAL CONDITION]. S7Respiratory Therapist stated by that time, CNAs and nurses came to the room, but did not know resident #5 ' s code status. S7Respiratory Therapist stated her assessment of no pulse and asked how long since someone was in the room, and was told resident #5 had eaten and was awake about 20 -30 minutes ago. S7Respiratory Therapist stated she rolled the head of the bed down, looked for a syringe if needed to inflate the [MEDICAL CONDITION] cuff to use the ambu bag, then the crash cart was in room, but no CPR was started. S7Respiratory Therapist stated she is trained to begin CPR if a resident is assessed with [REDACTED]. During an interview on [DATE] 1:39 p.m. S8LPN Unit Manager, stated she was in a care plan meeting downstairs when she received a phone call from S6LPN that resident #5 had passed. S8LPN Unit Manager stated she did not hear a code called over the intercom. S8LPN Unit Manager stated she immediately went upstairs to resident #5 ' s room where S7Respiratory Therapist, S6LPN, and other CNAs were present. S8LPN Unit Manager stated she assessed resident #5 was lying flat in bed with a small amount of blood noticed in the corner of his mouth, pulse ox on his finger with no reading, pupils fixed , gray color. S8LPN Unit Manager stated she went back to the nurse station to check resident#5 ' s code status in the computer and called the physician ' s office at the same time. S8LPN Unit Manager stated she saw resident #5 was a full code in the computer Physician order [REDACTED].#5 was a full code found with no pulse, no respirations, gray color, and blood from the mouth. S8LPN Unit Manager stated the physician related back to call the coroner. S8LPN Unit Manager stated the call system lights up by the door and at the nurse desk but you must go to the room to respond, there is no verbal communication or intercom from the nurse station to the room. S8LPN Unit Manager stated she did tell someone, can ' t remember who, to tell the staff in resident #5 ' s room resident #5 was a full code but she had spoken to the doctor and was to call the coroner now. S8LPN Unit Manager stated she went back to resident #5 ' s room and told everyone present she had talked with the doctor and the coroner ' s office. S8LPN Unit Manager stated she would do things differently for all staff to treat residents as a full code with CPR until the code status was determined. Review of the facility's Policy and Procedure Manual revealed the following Cardiopulmonary Resuscitation (CPR) policy: CPR will be instituted on all residents without a DNR or Advanced directives identified. CPR is used to restore or maintain breathing or pulse in emergency situations and to prevent brain damage. Cardio [MEDICAL CONDITION] resuscitation is initiated in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest to sustain or support a resident ' s cardiac and/or [MEDICAL CONDITION] function until advanced life support systems are available. Review of the Louisiana Administrative Code, Title 46, Professional and Occupational Standard, Part XLV11, Nurses: Practical Nurses and Registered Nurses (As amended through December, 2009) Subpart, I. Practical Nurse, under subchapter E. Curriculum Requirements revealed in part: 7. Principles and Practice of Nursing-presenting the application of concepts which will provide basic principles of nursing care and correlated experiences to develop competency in medical-surgical nursing, geriatric nursing, obstetrical nursing, pediatric nursing, and mental health. Clinical experience shall include, but not be limited to, the performance of basic and advanced nursing skills, general health and physical assessment, critical thinking and critical problem solving, medication administration, IV therapy, patient education, health screening, health promotion, health restoration and maintenance, supervision and management, safety and infection control, communication and documentation, and writing as member of the interdisciplinary health care team.

Based on record reviews, interviews, and the facility Policy Manual, the facility failed to provide the necessary care and services for the resident to maintain their highest practicable physical, mental, and psychosocial well being. The facility failed to ensure CPR (Cardio [MEDICAL CONDITION] Resuscitation) was provided by the nursing staff to 1 (#5) of 5(#1, 2, 3, 4, 5) residents reviewed who were assessed to have no pulse and no respirations and had a full code status Advance Directive. This resulted in actual harm for resident #5 who was not afforded the opportunity for resuscitation in accordance with his Advance Directive. The facility's census was 206 as documented on the Resident Census and Conditions of Residents form dated [DATE]. S2DON reported 161 residents in the facility were with full code status. Findings: Review of resident #5's closed record revealed an Advance Directive Checklist dated [DATE] and signed by resident #5's Responsible Party documenting the Resident/Legal Representative had been given written material on their right to accept or refuse medical and/or surgical treatment and their right to formulate Advance Directives. Review of resident #5's Admission Agreement dated [DATE] and signed by resident #5's Responsible Party, revealed The Client/Patient Bill of Rights and Responsibilities listed: You are entitled to ...receive appropriate service without discrimination in accordance with physician orders. Further review revealed under the Acknowledgements and Consents, a section initialed by resident #5's Responsible Party and checked yes for Resuscitation: The policy of this Healthcare Facility is to initiate Cardiopulmonary Resuscitation (CPR) as a resuscitation procedure to restore breathing and/or heartbeat if I'm found to be in Cardiopulmonary arrest, except when my attending physician has documented a valid Do Not Resuscitate (DNR) order on my permanent record. Review of resident #5's [DATE] (Physician) Order Summary Report revealed an order dated [DATE] for code status: Full Code. During an interview on [DATE] at 9:40 a.m. S2Administrator stated S7Respiratory Therapist and S6LPN did not start CPR on resident #5 who was a full code status and should have received CPR until notified to stop by a physician. During an interview on [DATE] at 9:45 a.m. S2DON stated he was in the facility at the time of the incident with resident #5 on [DATE]. S2DON stated he immediately asked if CPR was started, if the physician and family were called. S2DON stated the investigation was started immediately why no CPR was administered to resident #5 that was a full code status and should have received CPR according to policy and the Responsible Party's request. During an interview on [DATE] at 1:00 p.m. S6LPN stated she was present on [DATE] and saw resident #5 before breakfast, and took his vital signs before resident #5 took his meds per PEG tube without problems. S6LPN stated resident #5 was awake and alert with no concerns noted. S6LPN stated between maybe 9:15 a.m. and 9:30 a.m., a trainee with S7Respiratory Therapist came down the hall and informed S6LPN resident #5 was gone. S6LPN stated she called a CNA to get the crash cart, and someone to call the downstairs front desk and S6LPN called S8LPN Unit Manager from the nurse station on the way to resident #5 ' s room. S6LPN stated she got to resident #5 ' s room and a CNA was behind S6LPN with the crash cart. S7Respiratory Therapist and a trainee were at the head of resident #5's bed. S6LPN stated S7Respiratory Therapist reported she heard no heart-rate and felt no pulse. S6LPN stated she observed resident #5 with the head of the bed elevated and his head was turned to the side. S6LPN stated she rolled the head of the bed down to begin CPR if needed, checked for a pulse and did not feel anything, and S7Respiratory Therapist said he is gone and no sense to do anything. S6LPN stated she did not start CPR and did not call for 911. S6LPN stated at that time, S8LPN Unit manager came in and asked S7Respiratory Therapist if she started CPR and S7Respiratory Therapist said I can if you want me to, but he is gone. S6LPN stated a book is on the crash cart with the code status of each resident, but was told the Code book was being updated and not on the crash cart. S6LPN stated she did not go to the medication cart to check the computer for code status of resident #5 or to the nurse station computer. S6LPN stated she did not know why she dropped the ball and did not perform CPR on resident #5, other than by what S7Respiratory Therapist had stated. S6LPN stated she was ready to do CPR on resident #5, but S7Respiratory Therapist swayed her plan. During an interview on [DATE] at 1:25 p.m. S7Respiratory Therapist stated she saw resident #5 about 9:35 a.m. on [DATE] for first rounds. S7Respiratory Therapist stated when she walked in resident #5 ' s room with an orientee, resident #5 ' s head of the bed was elevated, and he was slumped to the side, with a little blood running from his mouth. S7Respiratory Therapist stated she asked the orientee to run get the nurse. S7Respiratory Therapist stated she assessed resident #5 with no chest rise or fall, auscultated the lungs with no breath sounds, no radial or carotid pulse, and the pulse ox had no reading. S7Respiratory Therapist stated resident #5 ' s oxygen was intact to the [MEDICAL CONDITION]. S7Respiratory Therapist stated by that time, CNAs and nurses came to the room, but did not know resident #5 ' s code status. S7Respiratory Therapist stated her assessment of no pulse and asked how long since someone was in the room, and was told resident #5 had eaten and was awake about 20 -30 minutes ago. S7Respiratory Therapist stated she rolled the head of the bed down, looked for a syringe if needed to inflate the [MEDICAL CONDITION] cuff to use the ambu bag, then the crash cart was in room, but no CPR was started. S7Respiratory Therapist stated she is trained to begin CPR if a resident is assessed with [REDACTED]. During an interview on [DATE] 1:39 p.m. S8LPN Unit Manager, stated she was in a care plan meeting downstairs when she received a phone call from S6LPN that resident #5 had passed. S8LPN Unit Manager stated she did not hear a code called over the intercom. S8LPN Unit Manager stated she immediately went upstairs to resident #5 ' s room where S7Respiratory Therapist, S6LPN, and other CNAs were present. S8LPN Unit Manager stated she assessed resident #5 was lying flat in bed with a small amount of blood noticed in the corner of his mouth, pulse ox on his finger with no reading, pupils fixed , gray color. S8LPN Unit Manager stated she went back to the nurse station to check resident#5 ' s code status in the computer and called the physician ' s office at the same time. S8LPN Unit Manager stated she saw resident #5 was a full code in the computer Physician order [REDACTED].#5 was a full code found with no pulse, no respirations, gray color, and blood from the mouth. S8LPN Unit Manager stated the physician related back to call the coroner. S8LPN Unit Manager stated the call system lights up by the door and at the nurse desk but you must go to the room to respond, there is no verbal communication or intercom from the nurse station to the room. S8LPN Unit Manager stated she did tell someone, can ' t remember who, to tell the staff in resident #5 ' s room resident #5 was a full code but she had spoken to the doctor and was to call the coroner now. S8LPN Unit Manager stated she went back to resident #5 ' s room and told everyone present she had talked with the doctor and the coroner ' s office. S8LPN Unit Manager stated she would do things differently for all staff to treat residents as a full code with CPR until the code status was determined. Review of the facility's Policy and Procedure Manual revealed the following Cardiopulmonary Resuscitation (CPR) policy: CPR will be instituted on all residents without a DNR or Advanced directives identified. CPR is used to restore or maintain breathing or pulse in emergency situations and to prevent brain damage. Cardio [MEDICAL CONDITION] resuscitation is initiated in cases of recognized cardiac and/or [MEDICAL CONDITION] arrest to sustain or support a resident ' s cardiac and/or [MEDICAL CONDITION] function until advanced life support systems are available.