Every finding on record at Kings Daughters Community Health & Rehab

Based on staff interviews, resident interviews and record reviews, the facility failed to protect residents from neglect. The facility failed to ensure licensed nursing services were available on the [NAME] Wing nursing unit from approximately 7:47 p.m. on 1/31/26 until 7:00 a.m. on 2/1/26. During this period, 39 residents were without access to licensed nursing assessment, medication administration, monitoring, physician notification, and nursing intervention. As a result, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) experienced untreated pain, delayed or missed medications, anxiety, insomnia, and psychosocial distress. This deficient practice constituted neglect and resulted in Immediate Jeopardy. Following validation of corrective actions, the Immediate Jeopardy was removed and the deficiency remained cited at Level 2, Pattern noncompliance. The findings included:The facility neglected residents by failing to ensure the availability of licensed nursing services for approximately 12 hours on the [NAME] Wing nursing unit. No licensed nurse was available to administer medications, conduct resident assessments, monitor changes in condition, communicate with practitioners, receive physician orders, or respond to resident emergencies. Residents experienced missed medications, untreated pain, sleep disturbances, anxiety, and emotional distress resulting in psychosocial harm On 5/12/26 at 2:30 pm, an interview was conducted with licensed practical nurse #2 (LPN2). During the interview LPN2 was questioned about the incident that happened on 1/31/26. She stated that she did leave early on the 31st. LPN2 stated that she should not have left the medication cart without giving a report to a relief nurse or counting off the narcotics with someone. She stated that she told a nurse she passed in the hallway as she was leaving the facility that she wrote down report on the report sheet and counted against herself [a process of counting narcotic medications at the change of each shift/staff change to ensure an accurate accounting of narcotic medications on hand]. She asked the other nurse if there were any discrepancies with the narcotic count to give her a call. LPN2 stated she should not have left the keys in the narcotic book on top of the medication cart. LPN2 stated she was talked to by the DON and received a correction action.On 5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. The interview was conducted in reference to an incident that happened on 1/31/26 on the west wing nursing unit. LPN3 stated the nurse that was supposed to relieve LPN2 called out at the last minute, so there was no relief nurse that took report, counted the narcotics, took the medication cart keys, or assumed the responsibility to oversee the care of residents on the unit. LPN3 stated she didn't feel comfortable taking the medication cart when LPN2 did not give her report or count the narcotics with her prior to leaving the facility. LPN3 stated that no nurse came into the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. On 5/13/26 at 9:40 am, an interview was conducted with the DON. She said, neglect- it's intentionally not doing something that needs to be done considered neglecting a role as a nurse failure to provide any kind of care, medications, treatments, fluids, and notifying MD [physician] of changes. The DON said, I spoke with [name redacted] R6, and I told the resident [R6] I didn't think it was right for her to leave. The DON said, there were two sides to that story that happened on 1/31/26. I have what is right here in front of me and then I have what the resident [R6] says and told the resident [R6] I will look into it. On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because they had no nurse on the unit and it was snowing. R8 said that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. Anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with Resident #7 (R7). R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am here to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us, and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasm, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was supposed to receive at bedtime were Melatonin for insomnia, Trazodone for sleep, Flecainide for atrial fibrillation, Oxycontin ER 12 hours for pain, and Buspar for anxiety.R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was supposed to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.The facility's failure to maintain licensed nursing coverage deprived residents of necessary care and services required to avoid physical harm, pain, mental anguish, and emotional distress. The deficient practice was not limited to staffing concerns; it resulted in the absence of nursing assessment, medication administration, clinical monitoring, and emergency response capabilities for all 39 residents residing on the [NAME] Wing nursing unit. Residents were exposed to the likelihood of serious injury, serious harm, serious impairment, or death. For approximately 12 hours, residents had no access to licensed nursing services needed to identify and respond to changes in condition, administer medications, obtain physician intervention, or implement emergency measures. Actual resident harm occurred, as evidenced by resident reports of untreated pain and missed medications.On 5/13/26 at 2:53 p.m., after consultation with state agency supervisory staff, Immediate Jeopardy was identified related to neglect as a result of the facility's failure to provide licensed nursing services on the [NAME] Wing nursing unit from 1/31/26 through 2/1/26. The deficient practice affected all 39 residents residing on the unit and resulted in actual resident harm as well as the likelihood of serious injury, serious harm, serious impairment, or death. On 5/13/26 at 8:50 pm, the facility submitted a removal plan that read as follows: F6001. Immediately upon notification of the Immediate Jeopardy, the Administrator and Director of Nursing verified that every nursing unit is staffed with licensed nurses.2. Staffing schedules for previous week were reviewed to confirm adequate coverage. The IDT [interdisciplinary team] reviewed all medication administration records for the previous 48 hours. Any identified missed medications were immediately addressed, with physician and family notifications completed as indicated.Investigation performed for all potential residents and FRI submitted. All residents were assessed for any psychosocial concerns. Nurse suspended pending investigation, report made to DHP [department of health professions].3. All staff will receive education prior to their next scheduled shift on Abuse and Neglect. Licensed nurses will be education on emergency staffing plan4.DON/ED will review daily staffing patterns to ensure licensed nurse coverage through the weekend. Results will be reported to QAPI for review and adjustments made as needed.Date: 5/14/2026 Time: 3pmOn 5/14/26 at 3:00 pm, the survey team completed the following to verify the removal of the immediacy:1. Reviewed the medication administration records (MAR) that were reviewed 2. Reviewed the corrective action on missed medications from the MAR reviews3. Reviewed the FRI's submitted and the investigations completed4. Reviewed the nurse investigation, suspension and verified reporting to DHP 5. Reviewed the staffing patterns for the previous week 6. Interviewed staff for education regarding abuse and neglect and the emergency staffing plan.The IJ was determined to have been removed as of 3:00 pm on 5/14/26, at which time the scope and severity was lowered to level two pattern. On 5/13/26 a review of facility documentation was conducted. The facility document titled, Abuse, Neglect and Exploitation, and read in part, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or requirements others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.On 5/13/26 at 8:50 pm, a meeting was called with the Administrator, Director of Nursing, and Regional Director of Clinical Services. They were informed of the above concerns. The RDCS reported that the staff member that the allegation of neglect was reported on was LPN2 and she was suspended on 5/13/26 pending investigation.No additional information was provided prior to exit conference.

Based on staff interviews, resident interviews, and facility documentation reviews, the facility staff failed to ensure sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident affecting 39 residents on the [NAME] Wing. Specifically, the facility failed to ensure licensed nurse coverage on the west wing, resulting in one of the three nursing units operating without a licensed nurse available to administer medications or provide nursing oversight for approximately 12 hours. This deficient practice resulted in the identification of immediate jeopardy (IJ), and subsequent substandard care. Following the removal of the IJ, the scope and severity was lowered to a level 3 widespread noncompliance. The findings included: The facility failed to provide sufficient licensed nursing staff to meet resident needs when the [NAME] Wing nursing unit operated without licensed nurse coverage from approximately 7:47pm on 1/31/26 until 7:00am on 2/1/26. During this 12-hour period, residents lacked access to licensed nursing assessment, medication administration and nursing intervention in response to changes of condition or emergencies. On 1/31/26 a licensed practical nurse (LPN2), who was the unit manager left the [NAME] Wing nursing unit, clocked out at 7:47 pm, and left the facility without another nurse being present to provide for resident needs. There was no oncoming nurse coverage. LPN2 did not give a verbal report to a nurse, did not count her narcotics with a nurse, and left the medication cart keys in the narcotic logbook on the medication cart. Another nurse did not arrive at the west wing unit to take care of the residents until the following day, 2/1/26 at 7 AM. On 5/12/26 at 4:46 pm, an interview was conducted with the director of nursing, DON. She stated that on 1/31/26 she was contacted by a licensed practical nurse, LPN3. She stated that LPN3 informed her that LPN2 had left the facility and placed the medication cart keys inside the narcotic logbook on top of the medication cart. The DON stated while she was speaking with LPN3 on the telephone, another call came through from a nurse employed at the facility who stated she was going to come into the facility and assume responsibility for the unit medication cart for the night shift on 1/31/26. The DON stated she was not contacted again and did not speak with any additional facility staff regarding the situation until the following morning. The DON acknowledged she later became aware that no nurse had come into the facility that night. On 5/12/26 at 2:30 pm, an interview was conducted with LPN2, unit manager of west wing nursing unit. She said, I shouldn't have left the med cart without giving report and counting narcotics. I did get talked to by the DON about that and she did a corrective action on me about that. I know it wasn't later than 7:00 pm when I left, I needed to work my schedule shift. I left the facility, left the medication cart keys in the narcotic book on top of medication cart, and I know leaving the keys in book was wrong. When leaving the unit, in the hallway I told a nurse that I wrote a report down and left it the nursing station and told her if she had any questions, call me. I counted narcotics against myself. On 5/12/26 at 4:30 pm, a telephone interview was conducted with LPN3. LPN3 stated the scheduled nurse called out at the last minute, and no one ever assumed responsibility for the medication cart keys. LPN3 stated she contacted both the director of nursing, (DON) and the administrator to notify them of the situation occurring at the facility and to obtain guidance. LPN3 was working the unit as an aide, to have sufficient staffing to care for the residents and was doing solely aide duties. LPN3 stated that the DON returned the call and instructed her to take the medication cart keys. LPN3 stated she informed the DON that she did not feel comfortable taking the keys because no resident report had been given and no narcotic count was completed. LPN3 stated the DON reported she was already in bed and that it was not safe for her to come into the facility. According to LPN3, the DON stated she would not be coming into the facility. LPN3 further stated the DON did not call back to follow up regarding nursing coverage for the unit and no licensed nurse came into the facility that night to assume responsibility for the oversight and nursing care of the residents on the unit, medication cart keys or provide medication administration coverage. LPN3 stated the administrator was also contacted; however, he never responded to the voicemail messages or text messages left regarding the situation. On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because they had no nurse on the unit and it was snowing. R8 said that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. Anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with Resident #7 (R7). R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am here to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasm, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was supposed to receive at bedtime were Melatonin for insomnia, Trazodone for sleep, Flecainide for atrial fibrillation, Oxycontin ER 12 hours for pain, and Buspar for anxiety.R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was supposed to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.On 5/15/26 at 2:25 pm, an interview was conducted with LPN 4. She stated that she was the oncoming nurse on 2/1/26. She stated that there were no nurses to get reports from, count narcotics with and the medication cart keys were in the narcotic logbook on top of the medication cart. She said, this was the night of 1/31/26 and staff that were here told me the unit manager had left the evening before, and residents had not been medicated all night I called the DON [name redacted] and she came in and we counted the cards. I work [NAME] B Hall I cannot remember anyone on that hall but the [NAME] A Hall didn't get meds and were calling their families. She stated staffing and callouts was an issue and said, we just get burnt out as nurses. On 5/14/26 a review of facility documentation was conducted. The facility policy titled, During an emergency, staff currently on duty will be required to stay on duty until they are relieved by other staff. Staff may not leave during an emergency to attend to personal needs.The facility document title, Job Description-Executive Director I, read in part, The local standards, guidelines, and regulations direct the day-to-day functions of the facility in accordance with current federal, state, and that govern nursing facilities to ensure that the highest degree of quality care can be provided to ideas our residents and concepts at all that times provide leadership to all facility staff in meeting the goal of providing quality resident care. This evaluated in part based upon the performance duties of the job. You may be asked by the supervisors or managers to perform other duties. You will be employment, and either you or the employer of the tasks listed in this job description at any time. This job description is not a contract for may terminate employment at any time, for any reason. It was signed by the administrator on 3/5/2026.The facility document titled, Job description Director of Clinical Services I, read in part, Purpose of Your Job Position As the company Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, co-workers. visitors, and all others; as well as demonstrating in all interactions. The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. Responsible for planning, organizing, and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner. Assistant Director of Clinical Services, Clinical Nurses, and Nurse Techs. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility. either you or the employer may terminate employment at any time, any reason. It was signed by the DON on 11/19/2025LPN2 leaving the facility without an oncoming nurse left the [NAME] Wing nursing unit without nursing supervision, without someone to give medications, complete treatments, assess and monitor residents, identify changes in condition, communicate with the medical doctor/providers, receive new orders, or respond in the event of an emergency. As a result of the facility's failure to provide licensed nurse coverage, resident interviews confirmed negative outcomes, including untreated pain, delayed medication administration, anxiety and psychosocial harm. Resident #8 reported not receiving prescribed bedtime medication and stated. Anytime you have no nurse it upsets you. Staff interviews further confirmed residents did not receive medications during the overnight period and were contacting family members about lack of nursing staff. The facility needs to take immediate action to ensure the facility has adequate nurse staffing to meet the needs of residents. The likelihood of a serious injury, serious harm, serious impairment, or death is likely without a nurse to respond to resident changes. On 5/13/26 at 2:53 pm, after consulting with the state agency supervision, immediate jeopardy (IJ) was identified regarding insufficient staffing, which started 1/31/26. A meeting was held with the Administrator, the Director of Nursing, and the Regional Director of Clinical Services. They were informed that immediate jeopardy had been identified and a copy of the IJ template was provided. During the reading of immediate jeopardy (IJ) the Administrator said, did they [residents] remember that they didn't get medicine, they couldn't sleep and nobody was there. January February, March, April, May, 5 months later? It was explained on the night of 1/31/26 there were no nurses on west wing to meet their needs, and it was snowing is how this night was recalled by the residents. The Regional Director of Clinical Service said, as to the harm if nothing happened, no one went to the hospital, and nothing drastic, so what is the harm? He was asked to allow the IJ template to be read completely to answer his questions. The second section of the template was read which included the details of the resident interviews and after that the RDCS stated his question was answered. On 5/13/26 at 20:50 pm, the facility submitted a removal plan that read as follows: F725: 1. Immediately upon notification of the Immediate Jeopardy, the Administrator and Director of Nursing verified that every nursing unit had a licensed nurse.2. The facility implemented an emergency staffing protocol requiring that if scheduled relief fails to arrive: Initiate emergency staffing [NAME]. Off-going nurse must remain on duty.b. The Director of Nursing to be notified immediatelyc. On-call leadership staff or PRN staff to provide coverage until relief arrives3. All licensed nurses will be educated on emergency staffing plan.4. The DON/ED will review daily staffing patterns to ensure adequate coverage. Any identified gaps in coverage will be identified and corrected.QAPI meeting held with IDT review.Date: 5/14/2026 Time: 3pm On 5/14/26 at 3:00 pm, the survey team completed the following:1. Reviewed the emergency staffing protocol2. Reviewed the on-call leadership schedule3. Reviewed the staffing patterns throughout the weekend4. Interviewed staff for education regarding the emergency staffing plan. After verification of the plan of immediate jeopardy removal and consultation with state agency supervisory staff, the immediate jeopardy was removed on 5/14/26 at 3 PM at which time the facility administration was notified. Following the removal of immediate jeopardy status, this deficiency was cited at level three widespread.No additional information was provided prior to the exit conference.

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews the facility staff failed to 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. This deficient practice resulted in harm for three residents, Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8) out of a survey sample of nine residents. The findings included:The facility staff failed to have a licensed nurse on the west wing for approximately 12 hours to assess, monitor and to administer pain medications to the residents for pain management, resulting in untreated pain for Resident #6 (R6), Resident #7 (R7), and Resident #8 (R8), which was harm. 5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. LPN3 stated that no nurse came in to the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. LPN3 stated that LPN2 apparently passed the medications on the west wing unit A hall but didn't pass any medication on the b hall. She stated that some of the residents on the b hall were complaining and went to the east unit to see if the nurse on that unit could give them medications and she told them she didn't have keys to their medication cart and she gave the residents grievance forms to fill out with their concerns. On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because we had no nurse on the unit and it was snowing. She stated that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasms, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was suppose to receive at bedtime was Melatonin for insomnia, Trazodone for sleep, Flecainde for atrial fibrillation, Oxycontin ER 12 hour for pain, and Buspar for anxiety R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was suppose to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.On 5/13/26, a facility documentation was reviewed. The facility policy titled, Medication Administration, read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify medication to be administered. Observe resident consumption of medication. 19. Wash hands using facility protocol and product. 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 21. If medication is a controlled substance, sign narcotic book. 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.The facility document titled, Pain Management, read in part, 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. 3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident). 8. a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences. b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. C. If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. d. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion. On 5/13/26 at 8:50 pm, a meeting was called with the administrator, director of nursing, and the regional director of clinical services. They were informed of the above concerns. No additional information was provided prior to exit conference.

Based on observations, clinical record reviews, staff interviews, resident interview, and facility documentation the facility staff failed to ensure adequate interventions were implemented and followed to prevent the development and or worsening of pressure ulcers for one resident, resident #2 (R2) out of a survey sample of nine residents This failure resulted in harm as R2 developed in house acquired pressure ulcers. The findings include: The facility failed to provide preventative skin interventions for R2 who was at moderate risk for pressure ulcer development, which resulted in the resident developing an in-house acquired pressure ulcer, which constituted harm. On 5/12/26, a clinical record review was conducted. During the review, the Braden Scale for Predicting Pressure Sore Risk, dated 10/3/2025, which was R2's admission date was reviewed. R2's score was 13 which is category of moderate risk for developing pressure ulcers. A skilled nursing note dated 10/4/25 had R2's skin was warm and dry with no skin impairments noted. A progress note dated 12/4/25, by the medical provider under assessment and plan read in part . patient has a suspected deep tissue injury on her heel. Stating under general note read in part . patient has a small wound to the right heel, with protective dressings applied to both heels and legs. A skin/wound note dated 12/8/25 noted an unstageable wound on right heel, measuring 2.5x2x0. A skin assessment dated [DATE], was reviewed. The skin assessment read in part, .left heel pressure injury wound acquired in house, right heel pressure injury wound acquired in house, buttocks moisture associated skin damage wound acquired in house. A progress note dated 12/19/25 by the medical doctor (MD), read in part .patient reports soreness in both heels. The nursing aide have noted that the wounds appear to be worsening. The assessment portion of the note read in part, . Examination of the left heel reveals signs of infection, including erythema, warmth, and drainage, consistent with cellulitis with ulceration in the center. Examination of the right heel also shows signs of infection, similar to the left heel, indicating cellulitis. Under general plan note reads in part .patient, age [AGE], has infected bilateral heel wounds and appears stable otherwise. Please keep feet clean and elevated as needed. A review of physician orders was conducted. On 10/5/25, there was an order for pressure reducing mattress and pressure reducing cushion to wheelchair. The pressure relieving/reducing device on bed was implemented on the care plan dated 1/12/26. A review of R2's treatment record was conducted. During the review, the pressure reducing mattress and wheelchair cushion was not implemented on the treatment record for the month of October 2025 or November 2025. The Wound Evaluation and Management Summary, written by the wound physician dated 12/8/25 was reviewed. During the review, the summary read in part, .Optimizing Moist Wound Healing, Off-loading, close monitoring, education and counseling, debridement as needed. The wound physician's recommendations for off-loading were not implemented on the care plan or treatment administration record. On 5/13/26 at 2:00 pm, an observation of wound care was conducted. The wound nurse, which was a license practical nurse (LPN8) performed wound care to R2's stage three sacral wound which was pink in color and had moderate bleeding. LPN8 stated R2 was on a blood thinner, and she was going to apply pressure dressing until the bleeding stopped. Then LPN8 performed wound care to R2's stage four left heel pressure ulcer and the wound bed had slough tissue noted. All R2's wounds were in house acquired. During the observation it was observed that R2's heels were not off loaded prior to wound care. On 5/14/26 at 4:30 pm, a staff interview was conducted with registered nurse (RN), which was the Minimum Data Set (MDS) coordinator. RN3 stated that facility follows policies and procedures for the prevention and treatment of skin breakdown. RN3 stated pressure reducing mattresses or cushions for wheelchairs are used for ones not so mobile, it helps for bony prominences. RN3 stated that baseline care plans are started when a resident arrives. She stated care plans are updated for anything new such as, falls, weight loss, new diagnosis, psychiatric medications and anything we put in place. RN3 stated that the care plan was for how care is to be given. She stated that care plans are personalized to each resident. RN3 stated that if a doctor recommends it, then it was specific for that resident. She stated, that if off-loading was entered by the medical doctor, it is in the care plan. On 5/15/26 at 9:15 am, an interview was conducted with R2. R2 has a diagnosis of cognitive impairment and a BMI (brief interview for mental status) score of nine. R2 was able to answer questions during the interview. R2 stated that she receives, good care, things change so much. Sometimes it's good and sometimes it's bad. R2 said, I do get turned to my left side in the evening but I'm on my back most of the time. I have a bad hip on the right side. During the interview, it was observed that R2's feet were not off loaded, and she was lying on her back. A license practical nurse (LPN1) came into the room to check R2's feet and put pillow under her legs, so her heels were not touching the mattress. R2 told LPN1 she was hurting and LPN1 stated that she was going to get her pain medication. LPN1 stated, maybe it will feel better now that we are floating heels and getting them off the bed. On 5/15/25, a facility documentation review was conducted. The facility policy titled Pressure Injury and Management, which reads in part .4a after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. 4b Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 4c Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to redistribute pressure (such as repositioning, protecting, and /or offloading heels, etc) i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; 4e the goals and preferences of the resident and/or authorized representative will be included in the plan of care. 4f Interventions will be documented in the care plan and communicated to all relevant staff. On 5/15/26 at 10:06 am, conducted an interview with Director of Nursing (DON) and Regional Director of Clinical Services (RDCS). The DON stated, I feel our skin and wound care was not robust in the past, that it is better now, more robust. RDCS stated that in March 2026, staff completed an eight-week prevention program. They became more focused and now more robust in trying to prevent skin break down. RDCS provided copies of the eight-week prevention program. On 5/15/26 an end-of-day meeting was held with Administrator, DON and Regional Director of Clinical Services and they were made aware of the above concerns. No additional information was provided prior to the exit conference.

Based on staff interviews, resident interviews, and facility documentation the facility staff failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident which resulted in harm to several residents, who had untreated pain, residing on one unit out of three units. The findings includedThe facility administration failed to ensure a licensed nurse was present on an entire unit for approximately a 12-hour period to administer scheduled medications, assess for changes in condition, communicate with the doctor, receive new orders, initiate life-saving measures in the event of an emergency, and provide any skilled nursing care such as enteral feedings, intravenous medications and fluid management, dialysis port monitoring, etc. This failure to have a nurse available on the unit had the potential to result in harm to all residents on the unit. On 5/12/26 at 4:46 pm, an interview was conducted with the director of nursing, DON. She stated that on 1/31/26 she was contacted by a licensed practical nurse, LPN3. She stated that LPN3 informed her that LPN2 had left the facility and placed the medication cart keys inside the narcotic logbook on top of the medication cart. The DON stated while she was speaking with LPN3 on the telephone, another call came through from a nurse employed at the facility who stated she was going to come into the facility and assume responsibility for the unit medication cart for the night shift on 1/31/26. The DON stated she was not contacted again and did not speak with any additional facility staff regarding the situation until the following morning. The DON acknowledged she later became aware that no nurse had come into the facility that night. The DON stated that the following morning she came into the facility, completed the narcotic count with the oncoming nurse, and had LPN2 come into the facility to sign out the narcotic logbook for the medications administered on 1/31/26. The DON further stated she completed corrective action/counseling with LPN2 on the Monday following the incident. On 5/12/26 at 2:30 pm, an interview was conducted with LPN2, who was the unit manager of west wing nursing unit. She said, I shouldn't have left the med cart without giving report and counting narcotics. I did get talked to by the DON about that and she did a corrective action on me about that. I know it wasn't later than 7:00 pm when I left, I needed to work my scheduled shift. I left the facility, left the medication cart keys in the narcotic book on top of medication cart, and I know leaving the keys in book was wrong. When leaving the unit, in the hallway I told a nurse that I wrote a report down and left it [the report] at the nursing station and asked her if she had any questions to call me. I counted narcotics against myself. On 5/12/26 at 4:30 pm, a telephone interview was conducted with LPN3. LPN3 stated the scheduled nurse called out at the last minute, and no one ever assumed responsibility for the medication cart, keys, or unit. LPN3 stated she contacted both the director of nursing, (DON) and the administrator to notify them of the situation occurring at the facility and to obtain guidance. LPN3 stated that the DON returned the call and instructed her to take the medication cart keys. LPN3 stated she informed the DON that she did not feel comfortable taking the keys because no narcotic count had been given. LPN3 stated the DON reported she was already in bed and that it was not safe for her to come into the facility. According to LPN3, the DON stated she would not be coming into the facility. LPN3 further stated the DON did not call back to follow up regarding nursing coverage for the unit and no licensed nurse came into the facility that night to assume responsibility for the medication cart keys or provide medication administration coverage. LPN3 stated the administrator was also contacted; however, he never responded to the voicemail messages or text messages left regarding the situation. On 5/13/26 at 2:53 pm, during the reading of immediate jeopardy (IJ) template regarding the incident, the administrator said, did they [residents] remember that they didn't get medicine, they couldn't sleep and nobody was there. January February, March, April, May, five months later? The surveyor explained on the night of 1/31/26 there was no nurse on west wing to meet their needs, and it was snowing was how that night was recalled by the residents. The Regional Director of Clinical Services (RDCS) said, as to the harm if nothing happened, no one went to the hospital, and nothing drastic, so what is the harm? He was asked to allow the IJ template to be read completely to answer his questions. The second section of the template was read and after that the RDCS stated his question was answered. On 5/15/26 at 2:25 pm, an interview was conducted with LPN 4. She stated that she was the oncoming nurse on 2/1/26. She stated that there were no nurses to get reports from, count narcotics with and the medication cart keys were in the narcotic logbook on top of the medication cart. She said, this was the night of 1/31/26 and staff that were here told me the unit manager had left the evening before, and residents had not been medicated all night I called the DON [name redacted] and she came in and we counted the cards. I work [NAME] B Hall I cannot remember anyone on that Hall but the west a Hall didn't get meds and were calling their families. She stated staffing and callouts were issues and said, we just get burnt out as nurses.On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because we had no nurse on the unit and it was snowing. She stated that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She said, I did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/14/26 a review of facility documentation was conducted. The facility policy titled, During an emergency, staff currently on duty will be required to stay on duty until they are relieved by other staff. Staff may not leave during an emergency to attend to personal needs.The facility document title, Job Description-Executive Director I, read in part, Purpose of Your Job, is responsible but for management of the facility in a manner which exemplifies the company's standard of not limited to creating an environment in which employees demonstrate the Company's core values primary towards purpose one another of the and Executive everyone Director they come is to into contact with, and business practices are conducted with those same core values. The local standards, guidelines, and regulations direct the day-to-day functions of the facility in accordance with current federal, state, and that govern nursing facilities to ensure that the highest degree of quality care can be provided to ideas our residents and concepts at all those times. continually You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new improve systems and processes to achieve superior results. Job Functions assigned Executive duties. Director Responsible I, you for are delegated the administrative authority, responsibility, and accountability necessary for carrying out your day-to-day clinical and administrative activities of the facility, including profit and loss responsibility and ensures Office Coordinator, compliance with Director all state and federal regulations. It was signed by the administrator on 3/5/2026.The facility document titled, Job Description Director of clinical services I, read in part, Purpose of Your Job Position As the company Director of Clinical Services, you are entrusted with the responsibility of caring for our residents, families, co-workers. visitors, and all others; as well as demonstrating in all interactions, The company's core values. The primary purpose of your job position is to plan, organize, develop and direct the overall operation of our Nursing Service Department in accordance with current federal, state, and local standards, guidelines, and regulations that govern our facility, and as may be directed by the Executive Director to ensure that the highest degree of quality care is maintained at all times. You are entrusted to provide innovative, responsible healthcare with the creation and implementation of new ideas and concepts that continually improve systems and processes to achieve superior results. Job Functions As Director of Clinical Services I, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. Responsible for planning, organizing and directing the functions for the nursing department. You will assume the primary role in ensuring the delivery of high quality, efficient nursing care. Supervises Nurse Practitioner. Assistant Director of Clinical Services, Clinical Nurses, and Nurse Techs. In the absence of the Executive Director, you are charged with carrying out the resident care policies established by this facility. This job description does not list all the duties of the job. You may be asked by the supervisors or managers to perform other duties. You will be evaluated in part based upon your performance of the tasks listed in this job description at anytime. This job description is not a contract for employment, and either you or the employer may terminate employment at any time, any reason. It was signed by the DON on 11/19/2025.On 5/15/26 at 12:30 pm, an exit conference was being conducted and during the exit conference the administrator was smacking his hand on the table and saying several times that he would fight this that he would bust hell wide open before this went on his administrative license. The administrator again stated he would fight it because he was not here in Virginia when it occurred and said again, I will fight bust hell wide open because I was not going to take a hit to my administrators license, when I was not even in the state of Virginia. Then he stated to the regional director of clinical services and the DON and said, as y'all will lose a good administrator because I'm not renewing my license in the state of Virginia.No additional information was provided prior to the end of the exit conference.

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews, the facility staff failed to ensure quality nursing care was provided to meet resident needs on one of three nursing units. Specifically, the facility failed to ensure licensed nurse coverage on the west wing nursing unit, resulting in no licensed nurse being available to administer medications, assess residents, respond to change in condition, provide treatments, or ensure resident safety. This deficient practice resulted in harm to residents #6, 7, and 8. The findings included:The facility staff failed to follow accepted standards of nursing practice by failing to ensure a licensed nurse was present on the unit, residents missed medications, lack of assessment for changes in condition, delayed response to emergencies, uncontrolled pain, medication errors, and lack of appropriate clinical oversight. This failure resulted in harm to Resident #6, 7, and 8. On 5/12/26 at 2:30 pm, an interview was conducted with LPN2, unit manager of west wing nursing unit. She said, I shouldn't have left the med cart without giving report and counting narcotics. I did get talked to by the DON about that and she did a corrective action on me about that. I know it wasn't later than 7:00 pm when I left I needed to work my schedule shift. I left the facility, left the medication cart keys in the narcotic book on top of medication cart, and I know leaving the keys in book was wrong. When leaving the unit, in the hallway I told a nurse that I wrote a report down and left it the nursing station and told her if she had any questions call me. I counted narcotics against myself. 5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. The interview was conducted in reference for a incident that happened on 1/31/26 on the west wing nursing unit. During the interview , LPN3 stated that she never observed LPN2 enter any resident rooms. LPN3 stated she was asked to come in and work as an aide that evening. LPN3 stated that she agreed to working as an aide but she would not take a medication cart that evening. LPN3 stated she only signed up for aide duties.LPN3 stated the nurse that was suppose to relieve LPN2 called out at the last minute, so there was no relief nurse that took report, counted the narcotics or took the medication cart keys. LPN3 stated she didn't feel comfortable taking the medication cart when LPN2 did not give her report or count the narcotics with her prior to leaving the facility. LPN3 stated she called the director of nursing (DON), and left a message. LPN3 stated the DON called back and commented she was ready for bed and not safe to come in the building, and told me to take the keys to the medication cart. LPN3 stated she refused to take the medication cart because it was unsafe for me to do so because I had no report, and didn't count the narcotics with LPN2 prior to her leaving the facility. LPN3 said, if I would have taken the keys to the medication cart it would be my responsibility. LPN3 stated that no nurse came in to the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. LPN3 stated that she called the administrator several times and LPN3 said, and as of this day he has not returned my calls. LPN3 stated that LPN2 apparently passed the medications on the west wing unit A hall but didn't pass any medication on the b hall. She stated that some of the residents on the b hall were complaining and went to the east unit to see if the nurse on that unit could give them medications and she told them she didn't have keys to their medication cart and she gave the residents grievance forms to fill out with their concerns.LPN3 stated that when the nurse came in on dayshift, LPN4 she called the DON and told her she did not feel safe taking the keys and someone needed to come in to count with her. LPN3 also stated that LPN 2 was suppose to call her and let her know who received medications and who did not get their medications and she never called that evening to let her know. On 5/12/26 at 8:55 pm, a second telephone interview was conducted with LPN3. LPN3 stated that on the west wing unit A hall there were several resident that complained about not receiving their medications and called their families. LPN3 gave the names of Resident #6, Resident #7 and Resident #8. She also stated that Resident #9 filled out a grievance form about her pain medicated cream that was not applied. On 5/13/26 at 8:45 am, an interview was conducted with LPN5. Neglect was discussed during the interview. LPN5 stated that neglect in her role is not answering call bells timely, not providing basic needs as a nurse, not getting a proper medication to a resident when needed, and treatments not being completed as ordered. On 5/13/26 at 9:10 am, an interview was conducted with LPN7 and she said, neglect in my role would be not getting their meds on time not giving pain meds if requested not doing treatments and not answering their questions when they ask.On 5/13/26 at 9:40 am, an interview was conducted with the DON. She said, neglect- it's intentionally not doing something that needs to be done considered neglecting a role as a nurse failure to provide any kind of care, medications, treatments, fluids, and notifying MD [physician] of changes.On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because we had no nurse on the unit and it was snowing. She stated that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasms, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was suppose to receive at bedtime was Melatonin for insomnia, Trazodone for sleep, Flecainide for atrial fibrillation, Oxycontin ER 12 hour for pain, and Buspar for anxiety R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was suppose to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.On 5/13/26, a facility documentation was reviewed. The facility policy titled, Medication Administration, read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify medication to be administered. Observe resident consumption of medication. 19. Wash hands using facility protocol and product. 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 21. If medication is a controlled substance, sign narcotic book. 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.The facility document titled, Pain Management, read in part, 2. Facility staff will observe for nonverbal indicators which may indicate the presence of pain. 3. Facility staff will be aware of verbal descriptors a resident may use to report or describe their pain. Based on professional standards of practice, an assessment or evaluation of pain by the appropriate members of the interdisciplinary team (e.g., nurses, practitioner, pharmacists, and anyone else with direct contact with the resident). 8. a. Facility staff will reassess resident's pain management at established intervals for effectiveness and/or adverse consequences. b. If re-assessment findings indicate pain is not adequately controlled, the pain management regimen and plan of care will be revised as indicated. C. If pain has resolved or there is no longer an indication for pain medication, the interdisciplinary team will work to discontinue or taper (as needed to prevent withdrawal symptoms) analgesics. d. If a resident reports or there are signs of increased pain, the facility should evaluate whether there is a time or day pattern to ensure that the problem is not due to drug diversion. According to accepted standards of nursing practice outlined in, Lippincott's Nursing Procedure Sixth Edition, page 44, read in part, A nursing care plan serves as a database for planning assignments, giving change-of-shift reports, conferring with the doctor or other members of the health care team, planning patient discharge, and documenting patient care. In addition, the care plan can be used as a management tool to determine staffing needs and assignments. On 5/13/26 at 8:50 pm, a meeting was called with the administrator, director of nursing, and regional director of clinical services. They were informed of the above concerns. The RDCS reported that the staff member that the allegation of neglect was reported on, LPN4 was suspended on 5/13/26 pending investigation.No additional information was provided prior to exit conference.

Based on observation, staff interviews, and facility documentation the facility staff failed to maintain an infection prevention and control program designed to provide residents with a safe, sanitary and comfortable environment for one of ten residents (Resident #10). The findings included:The facility staff failed to follow infection prevention and control practices when staff wore gloves in the hallway and Resident #10's foley catheter drainage bag was lying on the floor with an over bed table sitting on top of the foley bag.On 5/11/26 at 12:00 pm, during the initial tour of the nursing units of the facility it was observed on the east wing nursing unit several staff members wearing gloves in the hallway and Resident #10's foley catheter drainage bag on the floor with a over-bed table sitting on top of the foley bag. The foley bag was observed to be excessively full.On 5/11/26 at 12:08 pm, a certified nursing assistant, CNA (CNA1) was interviewed. CNA1 observed the foley drainage bag on the floor lying under the over bed table. CNA1 said, urine bags should be on the bed frame hanging, this bag needs to be emptied, it's about to burst.On 5/12/26 at 5:30 pm, an end of day meeting was held with the director of nursing, and the regional director of clinical services. They were made aware of the above concerns. On 5/13/26 at 10:00 am, the director of nursing and regional director of clinical services presented a Quality Assurance and Performance Improvement (QAPI) Meeting concerning infection control. A review of the QAPI meeting was conducted. The QAPI minutes read in part, .witnessed staff carrying linen unbagged to soiled utility, gloves in hallway, analysis rushing not doing what they are suppose to do education. On 5/13/26 at 6:00 pm, and end of day meeting was held with the director of nursing and the regional director of clinical services. The above concerns were discussed. They asked if the QAPI meeting minutes were reviewed and they were informed the QAPI minutes provided was reviewed.On 5/14/26 at 5:10 pm, an interview was conducted with CNA3. She stated she knew gloves were not suppose to be worn in the hallways. She said, you are suppose to take them off before you leave the residents room and clean your hands that they are not supposed to be worn out in the common areas.On 5/14/26 at 5:20 pm, an interview was conducted with CNA2 about wearing gloves in the hallway. She stated that gloves should not be worn in the hallways.On 5/14/26, a facility document was reviewed. During the facility documentation review, the facility policy titled, Standard Precautions Infection control, read in part, .All staff are to assume that all residents are potentially infected or colonized with an organism that could be transmitted during the course of providing resident care services. Therefore, all staff shall adhere to Standard Precautions to prevent the spread of infection to residents, staff and visitors Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. This includes hand hygiene, selection and use of PPE (e.g., gloves, gowns, facemasks, respirators, eye protection), respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment.On 5/14/26 at 5:00 pm, and end of day meeting was held with the director of nursing and the regional director of clinical services. The above concerns were discussed. No additional information was provided prior to exit.

Based on clinical record review, staff interviews, and facility documentation review the facility staff failed to notify the physician when ordered laboratory tests were not obtained as prescribed for one resident, Resident #102(R102) out of a survey sample of eight residents. The findings included:The facility staff failed to notify the physician in a timely manner that ordered laboratory tests were not obtained for Resident #102. On 6/29/26, a clinical record review was conducted. Review of the clinical record revealed that on 6/25/26, laboratory tests, including a magnesium level, CBC (complete blood count), and CMP (comprehensive metabolic panel), were ordered but were not obtained. The laboratory tests were subsequently reordered for 6/26/26, 6/27/26, 6/28-6/29/26, and again for 6/30/26. Progress note documentation dated 6/26/26 indicated that the laboratory tests were not obtained on 6/25/26 and that the order was updated to populate on the night shift. A progress note dated 6/27/26 documented that the laboratory technician attempted to obtain the blood specimens twice without success and planned to redraw them on 6/29/26. Despite the repeated failure to obtain the ordered laboratory tests, the physician was not notified until 6/29 at approximately 4:00 p.m. Following notification, the physician issued a new order for the laboratory tests to be obtained on 6/30/26. A progress note dated 6/30 documented that the laboratory tests had not been obtained on the previously ordered dates and that the physician had been notified, resulting in the order to obtain the laboratory tests on 6/30/26. On 6/29/26 at approximately 5:10 pm, a was held with the Regional of Clinical Services, Administrator, and Director of Nursing. They were informed of the above concerns and to provide any information they may have with clarifying these issues. On 6/30/26 at 11:35 am, an interview was conducted with the Director of Nursing (DON). The DON stated the reason for the missed laboratory test (labs) was the nursing staff had entered the orders incorrectly. She stated labs was obtained during the night between one to five am. She stated that on 6/27/26 two blood draws were attempted and unable to obtain. The DON stated the laboratory technician was supposed to try again on 6/29/26. The DON stated that the physician was notified about the labs not being obtained on 6/29/26 and ordered the labs for 6/30/26 and they were obtained today. She stated the mistakes came due to the way the lab orders were put in the system and night shift was supposed to check the labs. She stated that the physician was to be notified for missed labs and when unable to obtain the lab work.On 6/30/26 at 12:45 pm, an interview was conducted with a licensed practical nurse, the unit manager of East Wing, LPN2. During the interview, LPN2 stated the we obtained the lab order from the physician, we enter in the point click care system, we put it on night shift at four in the morning, and the night shift nurse prepares the lab requisition for the lab technician. If a lab was missed or unable to obtained the physician should be notified and then follow the providers instructions.On 6/30/26, a review of the facility documentation was conducted. The facility policy titled, Notification of Changes, read in part, The purpose of this policy is to ensure the facility promptly informs the resident, consults the resident's physician; and notifies, consistent with his or her authority, the resident's representative when there is a change requiring notification.No additional information was provided prior to exit conference.

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation reviews the facility staff failed to follow the facility's abuse, neglect, and exploitation policy after allegation of neglect were reported, resulting in residents not being adequately protected form potential ongoing harm. The findings included:The facility staff failed to implement their abuse policy after an allegation of neglect was reported.5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. The interview was conducted in reference for a incident that happened on 1/31/26 on the west wing nursing unit. During the interview , LPN3 stated that she never observed LPN2 enter any resident rooms. LPN3 stated she was asked to come in and work as an aide that evening. LPN3 stated that she agreed to working as an aide but she would not take a medication cart that evening. LPN3 stated she only signed up for aide duties.LPN3 stated the nurse that was suppose to relieve LPN2 called out at the last minute, so there was no relief nurse that took report, counted the narcotics or took the medication cart keys. LPN3 stated she didn't feel comfortable taking the medication cart when LPN2 did not give her report or count the narcotics with her prior to leaving the facility. LPN3 stated she called the director of nursing (DON), and left a message. LPN3 stated the DON called back and commented she was ready for bed and not safe to come in the building, and told me to take the keys to the medication cart. LPN3 stated she refused to take the medication cart because it was unsafe for me to do so because I had no report, and didn't count the narcotics with LPN2 prior to her leaving the facility. LPN3 said, if I would have taken the keys to the medication cart it would be my responsibility. LPN3 stated that no nurse came in to the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. LPN3 stated that she called the administrator several times and LPN3 said, and as of this day he has not returned my calls. LPN3 stated that LPN2 apparently passed the medications on the west wing unit A hall but didn't pass any medication on the b hall. She stated that some of the residents on the b hall were complaining and went to the east unit to see if the nurse on that unit could give them medications and she told them she didn't have keys to their medication cart and she gave the residents grievance forms to fill out with their concerns.LPN3 stated that when the nurse came in on dayshift, LPN4 she called the DON and told her she did not feel safe taking the keys and someone needed to come in to count with her. LPN3 also stated that LPN 2 was suppose to call her and let her know who received medications and who did not get their medications and she never called that evening to let her know. On 5/12/26 at 8:55 pm, a second telephone interview was conducted with LPN3. LPN3 stated that on the west wing unit A hall there were several resident that complained about not receiving their medications and called their families. LPN3 gave the names of Resident #6, Resident #7 and Resident #8. She also stated that Resident #9 filled out a grievance form about her pain medicated cream that was not applied. On 5/13/26 at 8:45 am, an interview was conducted with LPN5. Neglect was discussed during the interview. LPN5 stated that neglect in her role is not answering call bells timely, not providing basic needs as a nurse, not getting a proper medication to a resident when needed, and treatments not being completed as ordered. On 5/13/26 at 9:10 am, an interview was conducted with LPN7 and she said, neglect in my role would be not getting their meds on time not giving pain meds if requested not doing treatments and not answering their questions when they ask.On 5/13/26 at 9:40 am, an interview was conducted with the DON. She said, neglect- it's intentionally not doing something that needs to be done considered neglecting a role as a nurse failure to provide any kind of care, medications, treatments, fluids, and notifying MD [physician] of changes.On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because we had no nurse on the unit and it was snowing. She stated that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasms, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was suppose to receive at bedtime was Melatonin for insomnia, Trazodone for sleep, Flecainde for atrial fibrillation, Oxycontin ER 12 hour for pain, and Buspar for anxiety R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was suppose to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.On 5/13/26 a review of facility documentation was conducted. The facility document titled, Abuse, Neglect and Exploitation, and read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or requirements others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.On 5/13/26 at 2:53 a meeting was called with the administrator, director of nursing, and regional director of clinical services. They were informed of the above concerns.No additional information was provided prior to exit conference.

Based on staff interviews, resident interviews, and facility documentation reviews the facility staff failed to follow their abuse policy and report an allegation of neglect. The findings included:The facility staff failed to report an allegation of neglect.5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. The interview was conducted in reference for a incident that happened on 1/31/26 on the west wing nursing unit. LPN3 stated the nurse that was suppose to relieve LPN2 called out at the last minute, so there was no relief nurse that took report, counted the narcotics or took the medication cart keys. LPN3 stated she didn't feel comfortable taking the medication cart when LPN2 did not give her report or count the narcotics with her prior to leaving the facility. LPN3 stated that no nurse came in to the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. On 5/13/26 at 8:45 am, an interview was conducted with LPN5. Neglect was discussed during the interview. LPN5 stated that neglect in her role is not answering call bells timely, not providing basic needs as a nurse, not getting a proper medication to a resident when needed, and treatments not being completed as ordered.On 5/13/26 at 9:10 am, an interview was conducted with LPN7 and she said, neglect in my role would be not getting their meds on time not giving pain meds if requested not doing treatments and not answering their questions when they ask.On 5/13/26 at 9:40 am, an interview was conducted with the DON. She said, neglect- it's intentionally not doing something that needs to be done considered neglecting a role as a nurse failure to provide any kind of care, medications, treatments, fluids, and notifying MD [physician] of changes. She said, I did not do a formal investigation and went by just what was on the grievance form.On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. During the interview she stated she had requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She stated she did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasms, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was suppose to receive at bedtime was Melatonin for insomnia, Trazodone for sleep, Flecainde for atrial fibrillation, Oxycontin ER 12 hour for pain, and Buspar for anxiety R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was suppose to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication.On 5/13/26 a review of facility documentation was conducted. The facility document titled, Abuse, Neglect and Exploitation, and read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or requirements others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.On 5/13/26 at 2:53 a meeting was called with the administrator, director of nursing, and regional director of clinical services. They were informed of the above concerns.No additional information was provided prior to exit conference.

Based on staff interviews, resident interviews, and facility documentation the facility staff failed to investigate an allegation of neglect that was reported, resulting in residents not being adequately protected from potential ongoing harm. The findings included:The facility staff failed to investigate an allegation of neglect that occurred at the facility.On 5/12/26 at 2:30 pm, an interview was conducted with LPN2. During the interview LPN2 was questioned about the incident that happened on 1/31/26. She stated this was the first weekend she had worked at the facility. She stated she was hired as the unit manager of the west wing. She stated that she did leave early on the 31st. LPN2 stated that she should not have left the medication cart without giving a report to a relief nurse or counting off the narcotics with someone. She stated that she told a nurse as she was leaving the facility that she wrote down report on the report sheet and counted against herself. She told the nurse if any discrepancies with the narcotic count to give her a call. LPN2 stated she should not have left the keys in the narcotic book on top of the medication cart. LPN2 stated she was talked to by the DON and received a correction action.5/12/26 at 4:30 pm, a telephone interview was conducted with licensed practical nurse, LPN3. The interview was conducted in reference for a incident that happened on 1/31/26 on the west wing nursing unit. LPN3 stated the nurse that was suppose to relieve LPN2 called out at the last minute, so there was no relief nurse that took report, counted the narcotics or took the medication cart keys. LPN3 stated she didn't feel comfortable taking the medication cart when LPN2 did not give her report or count the narcotics with her prior to leaving the facility. LPN3 stated that no nurse came in to the facility that night and there was no nurse on west wing nursing unit medication cart until the nurse from first shift came in the following morning at 7:00 a.m. On 5/13/26 at 9:40 am, an interview was conducted with the DON. She said, neglect- it's intentionally not doing something that needs to be done considered neglecting a role as a nurse failure to provide any kind of care, medications, treatments, fluids, and notifying MD [physician] of changes. She said, I did not do a formal investigation and went by just what was on the grievance form. She said she spoke with a resident and she told the resident she didn't think it was right for her to leave. The DON said, there was two sides to that story that happened on 1/31/26. I have what is right here in front of me and then I have what the resident says and told the resident I will look into it. On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. During the interview she stated she had requested pain medication several times during the night and there was no nurse to give her pain medication. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 a review of facility documentation was conducted. The facility document titled, Abuse, Neglect and Exploitation, and read in part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Alleged Violation is a situation or occurrence that is observed or reported by staff, resident, relative, visitor or requirements others but has not yet been investigated and, if verified, could be indication of noncompliance with the Federal related to mistreatment, exploitation, neglect, or abuse, including injuries of unknown source, and misappropriation of resident property. Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.On 5/13/26 at 8:50 pm, a meeting was called with the administrator, director of nursing, and regional director of clinical services. They were informed of the above concerns. The RDCS reported that the staff member that the allegation of neglect was reported on, LPN2 was suspended on 5/13/26 pending investigation.No additional information was provided prior to exit conference.

Based on clinical record review, staff interviews, and facility documentation review, the facility staff failed to complete required post-fall assessments and neurological checks following an unwitnessed fall for one resident, Resident #102 out of a survey sample of eight residents. The findings included:The facility staff failed to complete post-fall assessments and neurological checks after an unwitnessed fall. On 6/29/26, a clinical record review was conducted. A progress note dated 6/28/26 at 2:14 pm was written by a licensed practical nurse, LPN3 and read, Resident called call bell at 1300 from bathroom. This writer answered. Observed resi [resident] laying across toilet. Stated stood up and fell. Noted scratch to left arm about 5 inch long. Cleaned with wound cleaner and applied dressing. Educated resi [resident] to use call bell . All r/p [responsible party] made aware. No c/o [complaint] pain at this time. A progress note was reviewed that was written by the Director of Nursing dated 6/29/26 at 10:07 am, and read, IDT [interdisciplinary team] met to review recent incident. Therapy provided education regarding energy conservation techniques. On 6/29/26 at approximately 5:10 pm, a was held with the Regional of Clinical Services, Administrator, and Director of Nursing. They were informed of the above concerns and to provide any information they may have with clarifying these issues. On 6/30/26 at 11:50 am, an interview was conducted with the Director of Nursing (DON). The DON said, I put a note in after the fall. The DON stated she put the note in where IDT met and discussed the incident. The DON then looked in R102's medical record and read an incident report that was in the medical record. The Regional Director of Clinical Services was present during the interview and he inquired about where the neurological (neuro) checks were to provide. The DON said, I will run up and get the incident report off the printer and see if the neuro checks are on the unit for [name redacted] R102's fall on the 28th [6/28/26]. On 6/30/26 at 12:35 pm, an interview was conducted with a registered nurse, RN1. RN1 stated with the fall protocol we check vitals, make sure the resident are safe and if they had been able to get up themselves, we do not have to assist with that part. RN1 stated that we let the provider know and follow providers instructions. RN1 stated that an unwitnessed fall that we do neuro checks because we do not know it they hit their head or not. He stated that post-fall assessments are completed for three days after the fall. He stated that neuro checks was completed on paper and in the point click care electronical system. RN1 stated that in point click care (PPC) electronical system it is more to chart about the neuro checks.On 6/30/26 at 12:45 pm, an interview was conducted with a licensed practical nurse, LPN2. LPN2 stated that if a resident has an unwitnessed fall we assess the resident, take care of any bleeding, obtain vitals, notify the physician and follow the physician instructions. She stated that an order for neuro checks would be obtained and neuro checks would start right after the fall. She stated post-fall assessments continue for three days and charted on every shift. LPN2 stated that neuro checks were completed on paper and the paper had how often to complete the neuro checks and when the checks was completed. On 6/30/26 at 12:55 pm, the DON provided the incident report for R102. She also provided a neuro check sheet that was dated 6/29/26. She stated that all the neuro checks was on the paper except for the one at 9:00 pm, that one was in PCC. The DON stated that neuro checks begin at the time of the fall and continue for 19 hours.On 6/30/26, On 6/30/26, a review of the facility documentation was conducted. The facility policy titled, Fall Prevention Program, read in part, each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.On 6/30/26 at 2:02 pm, an exit conference was conducted with the Administrator, Director of Nursing, and Regional Director of Clinical Services. After the conference the DON and RDCS talked about the fall and the neuro checks. The DON was made aware the date on the neuro checks was dated 6/29/26 and R102's fall happened on 6/28/26. The DON said, Oh I thought she fell on the 29th yesterday. The DON stated she would like to check one more thing. The RDCS stated maybe the wrong date was placed on the form and asked to see the date on the incident form that was provided and it was 6/28/26 at 1300. The DON came back an was unable to provide any additional information.

Based on clinical record reviews, staff interviews and facility documentation review, the facility staff failed to review and revise the comprehensive person-centered care plan for two residents, Resident #1 (R1) and Resident #2(R2), out of a survey sample of nine residents.The findings included #1. The facility staff failed to implement wound interventions and precautions for R1 to the care plan. On 5/13/26, a clinical record review was conducted. During the review a physician order was reviewed. R1 was admitted on [DATE]. An order for a pressure-reducing mattress was noted on 12/9/24 and a pressure-reducing cushion to wheelchair was noted on 12/9/24. On 5/13/26, a clinical record review was conducted. A review was conducted on R1's care plan. Staff failed to implement the pressure reducing mattress and pressure reducing cushion to wheelchair on the care plan. On 5/14/26, a clinical review of R1's Braden Scale was conducted. R1's score was a 16 on admission which according to Braden Scale for Predicting Pressure Sore, put resident at risk for skin injury. On 5/14/26 @ 4:30pm, a staff interview was conducted with registered nurse (RN), which was the Minimum Data Set (MDS) coordinator. RN3 stated that facility follows policies and procedures for the prevention and treatment of skin breakdown. RN3 stated pressure reducing mattresses or cushions for wheelchairs are used for ones not so mobile, it helps for bony prominences. RN3 stated that the care plan was for individualized care. RN3 stated that if a doctor recommends it, then it is specific for that resident. She stated that if off-loading is entered by medical doctor, it was supposed to be on the care plan. #2. The facility staff failed to implement wound interventions and precautions for R2 to the care plan. On 5/11/26, a clinical record review was conducted. R2 was admitted on [DATE]. During the review, R2's care plan was reviewed. There were no interventions put in place for pressure prevention to prevent skin injury upon admission. On 5/13/26, a clinical review of order summary was conducted. On 10/5/25, there was an order for pressure reducing mattress and pressure reducing cushions to wheelchairs. Pressure relieving/reducing device on bed was implemented on the care plan on 1/12/26; however, it was ordered on 10/5/25. On 5/13/26, a clinical record review of R2's treatment record was conducted. During review there was no pressure reducing mattress or wheelchair cushions for October 2025 or November 2025 implemented on the treatment administration record; however, it was ordered on 10/5/25. On 5/13/26, a clinical record review was conducted. The Braden Scale for Predicting Pressure Sore Risk, dated 10/3/2025, was reviewed. R2's score was 13 which is category of moderate risk. On 5/15/25 a clinical review was conducted on Wound Evaluation and Management Summary, VOHRA wound physicians, dated 12/8/2025. During review it was noted for right heel approach as read in part,.Optimizing Moist Wound Healing, Off-loading, close monitoring, education and counseling, debridement as needed. Off-loading was not added to the care plan or treatment plan. On 5/14/26 @ 4:30pm, a staff interview was conducted with registered nurse (RN), which was the Minimum Data Set (MDS) coordinator. RN3 nurse stated that facility follows policies and procedures for the prevention and treatment of skin breakdown. RN3 stated pressure reducing mattresses or cushions for wheelchairs are used for ones not so mobile, it helps for bony prominences. She stated that care plans was individualized to each resident. RN3 stated that if a doctor recommends it, then it was specific for that resident. She stated that if off-loading was entered by medical doctor, it was supposed to be in the care plan. On 5/15/25, a facility documentation review was conducted. The facility policy titled Pressure Injury and Management, which reads in part .4a after completing a thorough assessment/evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries with appropriate interventions. 4b Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment (e.g., moisture management, impaired mobility, nutritional deficit, staging, wound characteristics). 4c Evidence-based interventions for prevention will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to redistribute pressure (such as repositioning, protecting, and /or offloading heels, etc) i. Redistribute pressure (such as repositioning, protecting and /or offloading heels, etc); ii. Minimize exposure to moisture and keep skin clean, especially of fecal contamination; iii. Provide appropriate, pressure-redistributing, support surfaces; 4e The goals and preferences of the resident and/or authorized representative will be included in the plan of care. 4f Interventions will be documented in the care plan and communicated to all relevant staff. On 5/15/26 an end-of-day meeting was held with Administrator, DON (Director of Nursing) and Regional Director of Clinical Services and made aware of above concerns. No additional information was provided prior to exit conference.

Based on staff interviews, clinical record reviews, and facility documentation reviews the facility staff failed to ensure that professional standards of quality care were met for one resident, Resident #5 out of a survey sample of nine residents. The findings included:The facility staff failed to ensure that a registered nurse (RN) pronounced the resident's death in accordance with professional standard and facility policy. In addition, there was no physician order or documented authorization to release the resident's body to the funeral home. On [DATE] at 3:45 pm, an interview was conducted with a licensed practical nurse, LPN6, the unit manager on east wing. She said, when a patient becomes unresponsive assess the the scene attempt to get then to respond-obtain vitals, checking pulse, check code status, if a DNR [do not resuscitate] no pulse no blood pressure then do nothing call my DON because I am a LPN and need RN to pronounce. Initiate CPR [cardiopulmonary resuscitation] if a full code. LPN6 then stated that both nurses should document and there should be an order to release the body to the funeral home.On [DATE] at 4:00 pm, an interview was conducted with LPN1. She said, if a resident is unresponsive find out code status DNR, RN has to pronounce if a full code start CPR and call 911. If the RN pronounced they should chart it and should have an order to release body. The RN notifies the responsible person and physician. She stated that she thought there was a policy for release of body, release of body form and an physician order. LPN1 went and checked with the director of nursing (DON). When she came back she said, there was no policy just the advance directive lesson on there yearly in-services we take.On [DATE] at 5:00 pm, an interview was conducted with the DON. She stated that a RN has to pronounce death in the facility. If there was no RN int the building the charge nurse would call myself or another RN to come in the facility to pronounce. She said, that the resident would be assessed and if no vital signs we call the death at that time. She stated that the RN that pronounced the death should chart the assessment and time of death. The DON stated the RN should notify the physician and obtain an order for the release of body. The DON stated that any nurse can get the order to release the body and an order should be in the residents clinical record. On [DATE], a clinical record review was conducted. There was a progress note dated [DATE] at 4:34 pm, that read, this nurse went to administer medication. Upon entering pt [patient] room pt [patient] had no signs of life. On call number went straight to VM [voicemail], [name redacted] the DON was then notified, which I was informed that [name redacted] RN3 was on call. RN4 returned my phone call, she will be making her way in the building to pronounce. The physicians orders were reviewed and there was no order to release R5's body to the funeral. There was a progress note dated [DATE] at 11:06 pm, written by LPN3 that read in part, [name redacted] funeral home notified at 0730. There was no progress note written when R5's body was released to the funeral home and no progress note written by R4 about pronouncing, notifying physician or an order to release R5's body to the funeral home. There was not progress note that the physician was notified of R5's death by any nurse. On [DATE] at 9:00 am, a policy for code status and pronouncing of death in the facility was requested. The DON provided a policy titled, Residents Rights Regarding Treatment and Advance Directives. The DON stated that this was the only policy that she could provide. She said, we don't have a policy on pronouncing of death we just go by what the state rules are.According to accepted standards of nursing practice outlined in, Lippincott's Nursing Procedure Sixth Edition, page 38-40, read in part, Performing physical assessment calls for four basic techniques: inspection, palpation, percussion, and auscultation. Performing these techniques correctly helps elicit valuable information about the patient's condition. Document your assessment findings and the technique used to elicit those findings. Indicate who you notified of any abnormal findings and the time of the notificationXXX[DATE] 3:36 pm, a telephone call was placed to the RN4 that was suppose to come to the facility to pronounce and she did not answer or return the phone call. On [DATE] an end of day meeting was conducted with the DON and the regional of clinical services (RDCS). They were informed of the above concerns.On [DATE] at 6:30 pm, the RDCS and DON stated they had been trying to reach RN4 and was unable to reach her by phone and had called several times.On [DATE] at 10:10 am, the DON, and the RDCS came to the conference room and presented a QAPI minutes for infection control and the nurses notes from the night of R5's death and a death certificate. The RDCS said RN's name should be on the death certificate that pronounced R5. There was no RN's name on the death certificate and both of them reviewed it again. The DON left the room to look for something else and the RDCS stated that he didn't know what she was looking for, but that's all we have to present.On [DATE] at 11:00 pm, a meeting was held with the administrator, the RDCS and DON to inform them of the above concerns.No additional information was provided prior to exit conference.

Based on facility documentation review, and staff interview the facility staff failed to ensure complete nurse staffing information was available for review. The findings included:The facility staff failed to provide the staff postings for the last two weeks of January that was requested for review.On 5/11/26 at 2:00 pm, a request was made for the staff posting for the month of January 2026; however, while reviewing the staff postings there were several days that was not provided. A second request was made for the staffing post for for the last week of January 2026 which would have been the days of the 24th through the 31st. I was provided with the assignment sheets on the units for the 25th and 31st of January and then the as worked schedule for the 25th, 29th, 30th and the 31st of January. Then a 3rd request was made for the staff posting and the social worker director, other staff #3, (OS3) provided the 25th, 29th - 31st of January copies of the staff information that is submitted for the payroll based journal report. On 5/12/26 at 3.45 pm, an interviewed was conducted with OS3 that had provided the payroll based journal reports. She was asked if they had the daily staff postings that was suppose to be posted daily where the visitors and residents knew what staff was suppose to be in the facility. She said, oh yes we have the one that are for nursing staff daily and it is posted at the time clock daily with corrections on it if a call off but these are the ones we submit for staffing and I will bring you the others. OS3 then provided the daily staffing reports for 1/25, 1/29, 1/30, 1/31 and May 11th through 15th 2026.On 5/13/26, the staff daily postings were reviewed. During the review, the staff daily posting that was provided did not have LPN2 listed on the posting as being at the facility on 1/31/26; however, she was the charge nurse on the west wing unit. The staff nursing posting for 1/31/26 was not an accurate posting of the staff that was working in the facility that day.On 5/13/26, an end of day meeting was conducted with the director of nursing, and the regional director of clinical services and they were informed of the above concerns. No additional information was provided prior to exit conference.

Based on staff interviews, resident interviews, clinical record reviews, and facility documentation review the facility staff failed to ensure residents were provided pharmaceutical services that included administration of medications to meet the needs of each resident. The findings included:The facility staff failed to have a licensed nurse on the medication cart to administer medications for approximately 12 hours on 1/31/26.On 5/12/26 at 4:30 pm, an interview was conducted with a licensed practical nurse, LPN3. During the interview, LPN3 stated that LPN2 apparently passed the medications on the west wing unit A hall but didn't pass any medication on the b hall. She stated that some of the residents on the b hall were complaining and went to the east wing unit to see if the nurse on that unit could give them medications and she told them she didn't have keys to their medication cart and she gave the residents grievance forms to fill out with their concerns. LPN3 also stated that LPN 2 was suppose to call her and let her know who received medications and who did not get their medications and she never called that evening to let her know. On 5/13/26 at 11:00 am, an interview was conducted with Resident #8 (R8). During the interview, R8 stated that she remembered that night because we had no nurse on the unit and it was snowing. She stated that Tramadol helps keep my legs from hurting. R8 said, I asked when it was so late when I was going to get my medicine and someone said no nurse was here to give the medicine at bedtime. anytime you have no nurse it upsets you.On 5/13/26 at 11:15 am, an interview was conducted with R7. R7 was interviewed in reference to the incident that occurred on 1/31/26 on the west wing nursing unit. R7 stated that it was no nurse on the unit that night. R7 stated she requested pain medication several times during the night and there was no nurse to give her pain medication. R7 stated that she could not go back to sleep that night due to her pain. She said, I did not like not having a nurse. R7 said, scary with no nurse when you have things that I have and that is why I am her to be taken care of.On 5/13/26 at 11:30 am, an interview was conducted with R6. R6 stated that she was wide awake all night waiting on her medications. She stated 12 hours was a long time to go without any of my medications. R6 said, the nurse just took off and left us and it pissed me off seeing her back in here the next morning. R6 stated every resident on the unit was upset about not having a nurse all night.On 5/13/26 at 9:40 am, an interview was conducted with the director of nursing (DON). She said she spoke with a resident about no nurse being on the unit and stated I don't think it was right ; however, there are two sides to that story that happened on 1/31/26, she said, I have what is right here in front of me [medication administration record and narcotic control log book] and what you [resident] say, I will look into it. She stated that she came in the next morning and on Sunday morning she counted with the nurse, compared the narcotic medication cards with the MAR and stated that the count was correct. She stated that there were no discrepancies with the narcotic count and she was not aware of any missed medications that evening. She stated that she had LPN2 come in and sign off the narcotic log book for the medications that was given by LPN2 on 1/31/26. The DON stated that she did not do a formal investigation and was only going by the grievance that was submitted.On 5/13/26 at 12:00 pm, a clinical record review was conducted. A review of R6's medication administration record (MAR) was completed during the review. R6's MAR had not been signed off by a nurse for medications on the evening of 1/31/26 at bedtime. R6 was not given Melatonin for insomnia, Tizanidine for spasms, Tylenol for pain and Gabapentin for painR7's clinical record was reviewed. R7's MAR had no nurse signature on bedtime medications for 1/31/26. The medications R7 was suppose to receive at bedtime was Melatonin for insomnia, Trazodone for sleep, Flecainide for atrial fibrillation, Oxycontin ER 12 hour for pain, and Buspar for anxiety R8's medication administration record was reviewed. There was no signature on R8's MAR for the evening on 1/31/26 at bedtime. R8 was suppose to get Metoprolol scheduled and she also gets Tramadol nightly, but it is as needed medication and was unable to request the Tramadol because there was no nurse to administer the as needed medications.On 5/13/26, a facility documentation was reviewed. The facility policy titled, Medication Administration, read in part, Medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Review MAR to identify medication to be administered. Observe resident consumption of medication. 19. Wash hands using facility protocol and product. 20. Sign MAR after administered. For those medications requiring vital signs, record vital signs onto the MAR. 21. If medication is a controlled substance, sign narcotic book. 22. Report and document any adverse side effects or refusals. 23. Correct any discrepancies and report to nurse manager.On 5/13/26 at 2:53 pm, the regional director of clinical services, RDCS. He stated, after IJ [immediate jeopardy] was called, said, that we know that we had done wrong. We did it and accepted and moved on; however, my concern was between the harm versus staffing, and we had already started working on notifying the physician, looking at the MARS and clinical records of the resident's and looking at staffing, and we need to concentrate on not having this issue. It was staffing issues back then and it was bad.On 5/14/26 at 6:30 pm, we had an end of day meeting with the administrator, DON, and the RDCS. Above concerns were discussed. Explained we would be back tomorrow for the removal of IJ and requested the items that was needed.No additional information was provided prior to exit conference.

Based on observation, resident interviews, staff interviews, and facility documentation the facility staff failed to ensure resident furnishings and equipment were maintained in good repair and safe condition for one resident, Resident #7 (R7) out of a survey sample of nine residents. The findings included:The facility staff failed to ensure that the resident's furniture was safe and functional.On 5/13/26 at 11:15 am, an observation was made of R7 in her room holding the facing of a dresser drawer after the drawer had fallen apart. The resident's belongings were observed lying on the floor. While the surveyor was present in the room the maintenance assistant entered to repair the wrong piece of furniture and had to be redirected to the broken dresser drawer. The maintenance assistant picked up the broken wood, stated someone would be in to sweep the floor, and reported the drawer would be fixed. R7 reported that the dresser drawer facing had struck her knee when the drawer fell apart, and the concern was reported to nursing staff.On 5/13/26 at 11:15 am, an interview was conducted with R7. She stated that she had asked several times for the dresser to be replaced because two to three drawer facings would come off when the drawers were opened and the dresser was broken.On 5/14/26 at 6:30 pm, an end of day meeting was held to discuss the concerns above. The regional of clinical services stated a new dresser was placed in the room yesterday. He said, the resident came to me, asked was I from the state. I told her no, but I could help her so he went into the room. She showed me the dresser and they put in a new one.On 5/14/26 at 7:16 pm, an interview was conducted with the maintenance director. He stated that R7 had asked him several times for another dresser; however, he assumed she wanted an additional dresser and told her there was not enough room in the room for two dressers. The maintenance director stated he never checked the dresser and was unaware it was broken until the previous day, at which time repairs were initiated. On 5/14/26, a review of the facility documentation was conducted. The facility policy titled, Safe and Homelike Environment, read in part, .In environment, accordance with residents' rights, the facility will provide a safe, clean, comfortable and homelike includes allowing the resident to use his or her personal belongings to the extent possible. This facility, both ensuring inside that the resident can receive care and services safely and that the physical layout of the and outside, maximizes resident independence and does not pose a safety risk. Environment to) the residents' refers to any environment in the facility that is frequented by residents, including (but not and activity areas. rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas A extent homelike possible, environment is one that de-emphasizes the institutional character of the setting, to the and allows the resident to use those personal belongings that support a homelike environment. environment. A determination of homelike should include the resident's opinion of the living.No additional information was provided prior to exit conference.On 5/15/26 at 12:30 pm, during the exit conference the administrator stated he did not understand why the concern was being cited because the dresser was repaired quickly after being identified; however, the dresser had not been maintained in safe and functional condition prior to the surveyor's observation.

Based staff interview and facility document review, the facility staff failed to provide services of a registered nurse (RN) for at least 8 consecutive hours per day on three of seventeen days in December 2025 (12/7/25, 12/13/25 and 12/14/25).The findings include:On 12/17/25 at 10:25 a.m., the facility's as-worked nursing schedule for December 2025 was reviewed. The as-worked schedule documented no RN work hours on 12/7/25, 12/13/25 or 12/14/25.On 12/17/25 at 10:30 a.m., the scheduler (other staff #6) was interviewed about the days listed in December 2025 without RN coverage. The scheduler stated that no RNs worked on 12/7/25, 12/13/25 or 12/14/25 as she had no RN available to work. The scheduler stated the DON was on-call but that no RN actually worked on those dates.On 12/17/25 at 10:50 a.m., the director of nursing (DON) was interviewed about no RN coverage on the dates listed above. The DON stated the RN that typically worked weekends was out of medical leave on those dates and not available to work. The DON stated she had an abundance of licensed practical nurses but that she needed more RNs. This finding was reviewed with the administrator and director of nursing on 12/17/25 at 12:20 p.m. with no further information presented prior to the end of the survey.

Based on staff interview and clinical record review, the facility staff failed to follow physician orders for medication administration for four of eleven residents in the survey sample (Residents #1, #4, #7 and #8).The findings include: 1. Registered nurse (RN) #1 administered the medication methadone 5 mg (milligrams) to Resident #4 when the physician's order required a 2.5 mg dose.Resident #4 was admitted to the facility with diagnoses that included osteoarthritis, hypertension, chronic kidney disease, liver cirrhosis, mood disorder, atrial fibrillation, chronic pain and congestive heart failure. The minimum data set (MDS) dated [DATE] assessed Resident #4 with moderately impaired cognitive skills.Review of Resident #5's clinical record revealed a physician's order dated 6/28/24 for methadone 5 mg (milligrams) at each bedtime for treatment of chronic pain. This order was discontinued on 5/9/25 with a physician's order entered for methadone 5.0 mg, with instructions to give 1/2 tab (2.5 mg) at each bedtime for chronic pain. Resident 4's clinical record documented a nursing note dated 5/10/25 stating, .This writer was notified that the resident was given Methadone 5mg instead of scheduled 2.5mg at 2100 [5/9/25 at 9:00 p.m.] .On call provider notified after assessment was completed by assigned charge nurse. VS [vital signs] obtained .PERRLA [pupils equal, round, reactive to light and accommodations], A&O [alert and oriented] .at baseline. No s/s [signs/symptoms] of acute distress. Order given to reassess VS prior to end of shift and notify provider of any changes . The clinical record documented resident assessment following the error, no changes in condition noted and the provider ordered no further actions needed.On 12/16/25 at 12:55 p.m., the director of nursing (DON) was interviewed about Resident #4's methadone dose error. The DON stated she was not employed at the facility when this error occurred. The DON stated from reviewing the incident, the dose error occurred on the date the dosage order was changed. The DON stated dose change was entered on the medication administration record correctly but that the nurse must have pulled the wrong supply card when administering the medication. RN #1 that administered the incorrect dose of methadone to Resident #4 on 5/9/25 was not available for interview as she no longer worked at the facility. 2. LPN #5 administered the intravenous antibiotic (ertapenem sodium) at the wrong time to Resident #8.Resident #8 was admitted to the facility with diagnoses that included osteomyelitis, sepsis, pressure ulcers, anemia, hydrocephalus, metabolic encephalopathy, dysphagia, diabetes, long-term antibiotic use and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed Resident #8 with short and long-term memory problems and severely impaired cognitive skills.Resident #8's closed clinical record documented a physician's order dated 5/28/25 for ertapenem sodium 1 gram administered intravenously (IV) every 24 hours for treatment of osteomyelitis. Resident #8's medication administration record documented the ertapenem administration was scheduled each day at 6:00 a.m.Resident #8's clinical record documented a nursing note dated 6/4/25 stating the resident was administered the IV ertapenem at the incorrect time with notification made to the on-call provider. The on-call provider note dated 6/4/25 documented Resident #8 was receiving two IV antibiotics (ertapenem and daptomycin) for treatment of osteomyelitis. The note documented the licensed practical nurse (LPN #5) reported that he went to administer the daptomycin and administered the ertapenem instead. The note documented the ertapenem was scheduled at 6:00 a.m. and was given six hours early, on 6/4/25 at 12:15 a.m. Resident #8's clinical record documented vital signs and assessment of the resident resting peacefully in bed. The on-call provider ordered adjustment of the antibiotic administration times but no new care orders in response to the error.LPN #5, that administered the ertapenem to Resident #8 at the wrong time, was not available for interview as he no longer worked at the facility.On 12/16/25 at 12:55 p.m., the director of nursing (DON) was interviewed about the ertapenem medication error. The DON stated she was not employed in the facility when the error occurred. The DON stated the nurse apparently pulled the incorrect antibiotic and administered it at the wrong time.On 12/16/25 at 1:15 p.m., the medical director (other staff #7) was interviewed about the ertapenem error. The medical director stated she did not consider the timing error significant. 3. LPN #5 administered Resident #7 another resident's medications.Resident #7 was admitted to the facility with diagnoses that included liver cirrhosis, pancytopenia, insomnia, congestive heart failure, morbid obesity, respiratory failure, major depressive disorder, anxiety, dementia and cognitive communication deficit. The minimum data set (MDS) dated [DATE] assessed Resident #7 with moderately impaired cognitive skills.Resident #7's closed clinical record documented a nursing note dated 7/5/25 stating, During evening med [medication] pass resident received the wrong medications. The NP [nurse practitioner] was contacted and notified of the situation .Resident in no acute distress. Remain A&3 [alert and oriented x 3] at baseline. All parties notified. The NP ordered monitoring with vital signs every 2 hours x 4, every 4 hours x 4, every 6 hours x 4. A nursing note dated 7/7/25 documented it was reported at shift change that Resident #7 received another resident's medications over the weekend including cancer medication and that vital signs were monitored every four hours and were stable. The nursing notes nor the error incident report identified the medication administered in error. The clinical record documented monitoring of the resident following the error with no changes in condition noted. The NP assessed Resident #7 on 7/7/25 and listed the resident in usual state of health and feeling quite well today with no outcomes from the medication error mentioned. Resident #7 was seen by a psychiatry provider on 7/7/25 with no mention of the medication error.The licensed practical nurse (LPN #5) that administered the medication in error on 7/5/25, the physician/provider and director of nursing caring for Resident #7 at the time of the error were not available for interview as they no longer worked at the facility.On 12/16/25 at 12:55 p.m., the current director of nursing (DON) was interviewed about the medication error on 7/5/25 with Resident #7. The DON stated she was not employed with the facility at the time of this error. The DON reviewed the incident report and staff education done around the time of the error. The DON stated she did not find anything else documented about the error other than what was in nursing notes, the incident report and the NP note. The DON stated the nurse, NP and DON at the time of the error no longer worked at the facility. 4. LPN #8 administered the medication Percocet 10-325 mg (milligrams) to Resident #1 instead of prescribed oxycodone 2.5 mg for pain management.Resident #1 was admitted to the facility with diagnoses that included Alzheimer's disease, cerebrovascular disease, major depressive disorder, anxiety, atrial fibrillation, chronic pain, mood disorder and dysphagia. The minimum data set (MDS) dated [DATE] assessed Resident #1 with short and long-term memory problems and severely impaired cognitive skills.Resident #1's clinical record documented a physician's order dated 7/17/25 for oxycodone 2.5 mg every 8 hours as needed for moderate to severe pain. Resident #1 had no physician's order for Percocet.Resident #1's clinical record documented a notification to the on-call provider on 10/1/25 stating the resident was administered a dose of Percocet 10-325 mg instead of the prescribed oxycodone 2.5 mg. Nursing documented the medication was in response to pain rated 7 (on scale of 0 = no pain and 10 = worst pain). The on-call nurse practitioner (NP) note documented the Percocet 10-325 mg was given at 5:40 p.m. Vital signs were assessed at the time of the error with the resident at baseline. The NP instructed nurses to notify of any changes in condition. Nursing notes documented no changes in condition following the error.The medication error incident report dated 10/1/25 documented the Percocet 5-325 mg was administered when the nurse pulled the incorrect medication supply card for Resident #1. The incident report documented prompt notification to the on-call provider and family and listed that the error was made by a new nurse.LPN #8, that administered the Percocet to Resident #1 in error, was not available for interview as she no longer worked at the facility.On 12/16/25 at 12:55 p.m., the director of nursing (DON) was interviewed about the Percocet error with Resident #1. The DON stated the nurse pulled another resident's card with Percocet instead of Resident #1's card with oxycodone.The facility's policy titled Staff-Administered Medication Procedure (eff.11/30/14) documented, .Medication administration includes the following activities . identification of the correct resident . and listed that the medication labels should be compared to the order on the medication administration record to ensure accuracy.These findings were reviewed with the administrator and director of nursing on 12/16/25 at 2:30 p.m. with no further information presented prior to the end of the survey.

Based on observation, staff interview and clinical record review, the facility staff failed to follow professional standards of care during medication administration for one of eleven residents (Resident #11).The findings include:A medication pass observation was conducted on 12/16/25 at 8:25 a.m. with licensed practical nurse (LPN #2) administering medications to Resident #11. Among medications administered to Resident #11 was one inhalation of Breo Ellipta (fluticasone furoate-vilanterol) aerosol powder 100-125 micrograms/actuation (mcg/act). After Resident #11 inhaled the medication from the device, LPN #2 administered the other prescribed oral medications. LPN #2 provided prompt or request for Resident #11 to rinse the mouth after inhaling the Breo Ellipta medication.Resident #11's clinical record documented a physician's order dated 7/10/25 for Breo Ellipta inhalation aerosol powder with breath activated device, 100-25 mcg/act with instructions to inhale one puff daily for treatment of COPD (chronic obstructive pulmonary disease).On 12/16/25 at 10:20 a.m., accompanied by LPN #2, Resident #11's Breo Ellipta medication was inspected at the medication cart. The Breo Ellipta pharmacy label and the manufacturer's labelling included instructions for the patient to rinse the mouth after each use. LPN #2 was interviewed at this time about not prompting Resident #11 to rinse and spit after the Breo Ellipta. LPN #2 stated, I didn't ask her to rinse. LPN #2 stated Resident #11 did not cooperate with rinsing the mouth. LPN #2 stated, [Resident #11] doesn't do it [rinse mouth].The Breo Ellipta manufacturer's patient use instructions documented on page 7, .Breo Ellipta contains fluticasone furoate .Localized infections of the mouth and pharynx with Candida albicans have occurred in patients treated with orally inhaled drug products containing fluticasone furoate .Advise the patient to rinse his/her mouth with water without swallowing following administration of Breo Ellipta to help reduce the risk of oropharyngeal candidiasis . (1) This finding was reviewed with the administrator and director of nursing on 12/16/25 at 2:30 p.m. with no further information provided prior to the end of the survey.(1) Breo Ellipta Instructions for Use. Revised May 2023. GlaxoSmithKline, [NAME], NC. 12/18/25. https://www.mybreo.com.

Based on staff interview, resident interview, and facility documentation review, the facility staff failed to prevent further potential abuse, neglect, or mistreatment, while investigations were in progress, and the facility staff lacked the knowledge of the need to protect the resident if abuse is reported and/or witnessed. The facility conducted inadequate investigations and removed protective measures that were implemented following the allegation prior to a conclusion being reached regarding the abuse allegations, which had the potential to expose residents on 3 of 3 nursing units to abuse. Immediate Jeopardy and substandard quality of care were identified. The findings included: The facility staff failed to have credible evidence of thorough investigations being conducted, and that measures were being taken to protect residents during the investigation process, permitting the alleged perpetrators to return to work prior to the conclusion of the investigation being determined. On 3/19/24 - 3/21/24, a review of a sample of abuse allegations investigated by the facility was conducted. This review revealed 5 occurrences where the facility staff failed to protect residents from their alleged perpetrator, while an investigation was being conducted. 1. On 4/7/23, the facility's Director of Nursing reported an allegation of abuse that was made by a resident's family member, who reported an allegation of abuse involving CNA #3. CNA #3 was scheduled off 4/8/23-4/10/23, and returned to their next scheduled shift on 4/11/23, providing direct care to the assigned residents. The facility documentation revealed that the investigation into the allegation of abuse involving CNA #3 was not completed until 4/14/23. 2. On 4/13/23, Resident #32 reported an allegation of abuse and neglect involving CNA #2. CNA #2 was not scheduled to work 4/14/23 but did return to work on 4/15/23. The facility documentation revealed that the investigation into the allegation of abuse and neglect was not completed until April 20, 2023, which was five days after CNA #2 had been permitted to return to work. The investigation also revealed that 4 residents who were potentially exposed to abuse were never interviewed and of the interviews conducted, 4 residents verbalized concerns with how staff treated them or expressed being afraid of staff. No evidence was presented to indicate the additional concerns were investigated. 3. On 8/25/23, Resident #23 (R23) reported an allegation of verbal abuse involving CNA #1. CNA #1 was scheduled off 8/26/23 and 8/27/23. According to CNA #1's timecard, CNA#1 returned to duty on 8/28/23, and worked 12-hour shifts on 8/28/23, 8/29/23, and 8/30/23. The facility documentation revealed that the investigation was not completed until 9/1/23. Therefore, CNA #1 was permitted to return to duty and provided direct resident care while under investigation for an allegation of abuse. The facility documentation revealed that the resident interviews failed to include 4 residents who were potentially exposed to abuse and that 5 additional residents verbalized responses that warranted further abuse investigation. No evidence was found or presented that further investigations were conducted into these residents' concerns, but the facility concluded that the initial allegation of abuse against CNA #1 was unsubstantiated. 4. On 10/18/23, a resident reported an allegation of abuse involving CNA #10. The resident alleged that CNA #10 Violated him and Tried to rip his clothes off. It was noted that CNA #10 worked their entire shift on 10/18/23. CNA #10 was scheduled off 10/19-10/22 and returned to work on 10/23/23. The investigation involving the allegation of abuse involving CNA #10 was not completed until 10/26/23, at which time CNA #10 had already been permitted to providing direct resident care. During the resident interviews conducted as part of the investigation, five additional residents expressed concerns with regards to being asked, Has any staff member mistreated you since you have been a resident here? There was no evidence of any additional questioning or investigation into those residents' responses. 5. On 12/9/23, Resident #22 (R22) reported an allegation of abuse involving CNA #1. CNA #1 was suspended from their shift on 12/9/23 and 12/10/23. According to CNA #1's timecard, they were permitted to return to work on 12/11/23 and provided direct resident care. The facility documentation revealed that the investigation was not completed until 12/18/23. During the investigation, the facility conducted resident interviews, but noted five residents as not being available or asleep and were not interviewed. During the resident interviews, four residents responded yes to the questions asked, which were: Has any staff member mistreated you since you have been a resident here? Has any staff member hit you or threatened you since you have been a resident here? Are you fearful of any staff member while residing here? There was no evidence of any additional investigations being conducted to address the residents' responses that potentially indicated abuse. 6. On 9/4/23, Resident #1 (R1) was witnessed by a facility staff member, being physically abused by another resident. The initial facility synopsis noted, 15-minute checks initiated. The final synopsis noted, Both residents were placed on 15-minute checks for 72 hours. However, no evidence of R1 having 15-minute checks was found among the documentation. On 3/20/24, when asked to provide the missing documentation, the director of nursing reported that she had no further evidence to provide. On 3/19/24, during a resident interview, Resident #9 (R9) reported to the surveyor that she witnessed CNA #9 be verbally abusive to a resident across the hall. The surveyor immediately reported this allegation to the administrator. The facility initiated an investigation and suspended CNA #9. On 3/21/24, the survey team observed CNA #9 actively working and providing direct resident care. An interview was conducted with the Director of Nursing (DON). When asked to provide an update on the status of the investigation involving CNA #9 that the survey team had made them aware of on 3/19/24, the DON stated that she was still working on the investigation, and that it was not finalized yet. When asked again if the investigation had been completed, the DON stated that the investigation was not complete. When questioned why CNA #9 was back at work, if the investigation was not completed, the DON stated that she had conducted interviews with residents and staff, had discussed the findings with the Administrator, and called CNA #9 back to work. The interviews the DON had conducted were presented for review and it was noted that one nurse had expressed concern about CNA #9. When questioned about the findings, the DON revealed that during the investigation, one of the nurses reported that CNA #9 .is half a$$ed, unfriendly, and sassy at times and I have to stay on her all the time. No further investigation was conducted regarding the nurse's statement. On 3/19/24 through 3/20/24, staff interviews were conducted with 8 staff members across various departments, with only one staff person verbalizing that they would take measures to protect the resident or intervene if abuse was witnessed. On 3/20/24 approximately 2:30p, the Director of Nursing stated that staff are trained on the abuse policy upon hire, during monthly town hall meetings, and during the investigation of abuse allegations. When asked if staff are educated to intervene and take measures to protect the residents, the DON said, No. When asked what action the staff are expected to take with allegations of abuse, the DON stated that the staff is to call her or the administrator. When asked about instances when she or the administrator are not present, such as evenings or weekends, the DON stated that they haven't really had that happen, but the staff would call them. On 3/21/24, the facility's policy titled, Abuse, Neglect, Exploitation & Misappropriation, was reviewed. The policy read in part, . 6. Protection. Any suspect(s), who is an employee or contract service provider, once he/she has (have) been identified, will be suspended pending the investigation. The resident will be evaluated for any signs of injury, including a physical exam and/or psychosocial assessment, as appropriate. Increased supervision of the alleged victim and residents. Room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. Protection from retaliation Immediate Jeopardy was identified, and the facility Administrator and Director of Nursing were made aware of the Immediate Jeopardy on 3/21/24 at 2:45 p.m. On 3/22/24 at 11:34 a.m., the facility submitted a plan for removal of immediacy, that was accepted by the state survey agency. The facility's plan read as follows: 1. The investigation for Res #9 will be reviewed by RVPO (regional vice president of operations) & RDCS (regional director of clinical services) to ensure adequate investigation and implementation of protective measures. CNA #9, ED [executive director] & DON [director of nursing] were suspended pending the investigation. 2. Residents who reside in the facility had the potential to be affected. Current residents with a BIMS (brief interview for Mental Status) of 9 or greater will be interviewed to ensure that they had not been abused or neglected. The questions that they were asked were the following: Describe any instances where staff: made you feel afraid or humiliated/degraded, said mean things to you, hurt you (hit, slapped, shoved, handled you roughly), made you feel uncomfortable (touched you inappropriately), have you seen or heard of any residents being treated in any of these ways, did you tell anyone about what happened (e.g., staff, family, or other residents), what was their response? Any further allegations will be thoroughly investigated. Employee involved will be suspended pending investigation and will not return until investigation is completed. Current residents with a BIMS of 8 or less will be assessed by a licensed nurse via skin sweeps for suspicious injuries. 3. The facility staff across all departments will be reeducated on abuse & neglect to include: Employees must take steps to intervene to safeguard resident then, immediately report to DON/ED (Acting DON & PIC [person in charge]), employees suspended for allegation of abuse/neglect will not be allowed to return while investigation is ongoing. Current staff has been educated. On coming staff will not be allowed to work until the education has been completed. 4. An ad hoc QAPI met to review Facility Policy and Procedure for Abuse and reviewed the policy without any changes or revisions. 5. Compliance March 22, 2024, at 1400. On 3/22/24 at 2:05 p.m., the survey team requested that facility Administration provide the credible evidence. On 3/22/24 at 2:15 p.m.-3:30 p.m., the survey team conducted staff interviews with facility staff across all departments, to verify their knowledge of the need to protect the resident in the event abuse is witnessed or reported. There was an overwhelming number of staff that reported in the event they witnessed abuse; they would report to the Administrator. The facility staff were not able to verbalize that they would intervene to stop the abuse and take measures to protect the resident. On 3/22/24 at 3:30 p.m., the survey team called the OLC (Office of Licensure and Certification) LTC (long-term care) supervisor to review the above noted interviews with facility staff. On 3/22/24 at 3:50 p.m., the facility staff provided a 3-ring binder to the survey team, which was said to contain the credible evidence of the staff education, resident interviews, and skin checks. On 3/22/24 at 4 p.m., the facility's acting administrator was made aware that the survey team had been unable to abate the IJ based on staff interviews and would return on Monday, 3/25/24, to attempt verification again. On 3/25/24 at approximately 10:30 a.m., the survey team began conducting staff interviews again. It was noted that 2 facility staff reported they would report to their supervisor if they witnessed a resident being abused. When asked if they would intervene, both staff stated they would not. The facility acting administrator was made aware of this and given the employees names. On 3/25/24, in the late morning, the acting administrator provided evidence of the 2 employees being re-educated once again and made aware that they were to immediately intervene to protect the resident if abuse is witnessed. On 3/25/24 at approximately 11 a.m., the facility's credible evidence of resident interviews and skin checks were compared to the current resident census. The survey team identified 17 Residents that had not been interviewed, nor that had a skin check conducted. The surveyor had the acting administrator review the binder and she confirmed that the 17 residents' information was not included. On 3/25/24 at approximately 4:15 p.m., the facility staff provided the resident interviews and/or skin checks for the residents who had not previously been assessed and/or interviewed. On 3/25/24 at 4:45 p.m., the facility's acting administrator was advised the survey team had verified all the credible evidence and abated the IJ for F610. On 4/2/24, the RDCS (Regional Director of Clinical Services) reported that interviewing all interviewable residents had resulted in 26 additional allegations of abuse/neglect/mistreatment being investigated, all of which were unsubstantiated. No additional information was provided. Subsequently, the remaining noncompliance was cited at Level 4, Widespread.

Based on observation, resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to implement interventions to ensure that 4 residents (Resident #14, Resident #13, Resident #3, and Resident #12), in a survey sample of 48 residents, maintained an acceptable parameter of nutritional status and as a result, all 4 experienced insidious, severe weight loss that was unplanned resulting in immediate jeopardy being identified. The findings included: On 3/19/24 at approximately 12:05 p.m., an interview was conducted with the Registered Dietician (RD), who was in the dining room. The RD reported that he comes weekly and is at the facility for 8 hours. The RD said, It's not much weight loss in this building, we have one resident losing weight, but they refuse to eat and take supplements. 1. For resident #14 (R14), who lost 46.6 pounds since May 2023, the facility staff failed to identify and take measures to address the weight loss, which constituted harm. On 3/19/24, at approximately 11:30 a.m., observations were conducted of the kitchen to include the meal service/tray line. It was observed that no alternate meal was prepared. Staff interviews conducted with the dietary manager confirmed that only one serving of the alternate had been prepared. On 3/19/24, the lunch meal service was observed in the dining room. R14 was observed to not eat any of her meal and stated that she didn't like what was served. The facility staff did not offer any alternate options and R14 left the dining room having ate nothing. On 3/20/24, R14 was again observed to refuse her lunch meal and reported to the surveyor that she had lost 50 lbs., which R14 related to the inability to eat the food because of lack of flavor and it being cold. On 3/20/24, a clinical record review was conducted. According to the MDS (minimum data set - an assessment tool), dated 3/6/24, R14 was not on a planned weight reduction. R14 was also noted on this same assessment to have a BIMS (brief interview for mental status) score of 15 out of 15, which indicated the resident was cognitively intact. Review of R14's meal intakes noted that it was documented R14 had consumed 76-100% of the meal that had been refused at lunch on 3/19/24. It was documented that R14 ate 26-50% of the lunch meal on 3/20/24. Observations on 3/19/24-3/20/24 revealed that the facility staff did not record the resident's meal consumptions anywhere and didn't immediately document meal consumption upon retrieval of the meal trays. On 3/19/24-3/20/24, interviews were conducted with CNA #5, CNA #6, and CNA #7, all who reported they document meal consumptions by memory, stating that they remember what each person ate when they pick up the meal trays and then record it later. Review of R14's weights noted that on 9/8/23, R14 triggered for a 24-pound weight loss, which was a 7.6 % weight loss in 3 months. Then on 12/3/23, R14 triggered for a 11 % weight loss of 34.6 lbs. in 6 months. As of 3/5/24, R#14 had lost a total of 46.6 lbs. since 5/31/23. There was no evidence that indicated that R14 was on a physician-ordered weight reduction program. There was no evidence that the registered dietician (RD) or physician had been made aware of the significant weight loss. A nutritional review was completed 12/9/23, by a dietary technician, who noted a weight loss trend by indicating the most recent 3 months weights as 279, 292, 297 [December, November, and October weights in pounds]. The Care Plan changes noted Will consult Rd [registered dietician] for follow up as needed. According to R14's nutritional care plan, it had not been reviewed since 9/13/23. There were no interventions implemented to address R14's nutritional deficits and/or to indicate the weight loss was a desired loss. There was an additional care plan entry that read, [R14's name redacted] will order food at times knowing she doesn't have funds to pay for it. Interventions for this care plan read, Resident education on making sure funds are available prior to order take order [sic] and if funds aren't available, she will not order take out. According to R14's physician's order, R14 was on a therapeutic diet, which included no added salt. Observations revealed that on 3/25/24, the physician ordered therapeutic diet was not being followed/provided by the facility, as salt packages were noted on the meal tray. 2. For Resident #13 (R13), who had a significant weight loss, the facility staff failed to implement interventions to prevent insidious weight loss, which constitutes harm. On 3/21/24, a clinical record review revealed that R13 had a significant weight loss. Physician orders dated 1/30/24 indicated that R13 was on a therapeutic which included, 2 g [gram] sodium diet, for edema. On 3/21/24 and again on 3/22/24, the survey team made observations that the physician ordered sodium restriction was not being followed as the resident had salt packages on the meal tray. Nutritional Risk Factors identified for R13 included congested heart failure, arteriosclerotic heart disease, morbid obesity, and chronic kidney disease, noting that R13 had been admitted with 3+ edema to arms and legs. Care plan review noted the following goal: Maintain weight without significant change. On 10/18/23, R13 triggered for a 5.2% weight loss of 13 lbs. On 11/3/23, R13 triggered for an 8% weight loss of 20 lbs. within 2 months. On 12/18/23, R13 had triggered for 7.9% weight loss of 19.6 lbs., in 3 months. On 1/12/24, R13 had been identified with a 25 lb. weight loss, 10% loss in 4 months. On 2/28/24, the physician noted a 20 lb. weight loss and asked that the weight be rechecked. Another weight was not obtained until 3/3/24, but there was no evidence was found that the weight results had been communicated to the physician. According to the nutritional assessments, R13 was seen by the RD (registered dietician) on 10/24/23, and not again 2/7/24. According to the nutritional assessment conducted on 10/24/23, R13 .may not be meeting energy needs on days where PO intake is less than 100%, for which the RD recommend adding supplement Med Pass 30 ml BID [twice a day]. This order was implemented, but was discontinued on 11/24/23, with no reason identified. R13 was seen by the attending physician on 11/24/23, but the doctor didn't address weight loss or the use of a nutritional supplement, nor provide any orders to stop the supplement. No further interventions were implemented until 2/8/24, when Prostat was ordered as a supplement to promote wound healing. On 3/21/24, an interview with the RD was conducted. The RD attributed R13's weight loss to the Lasix (started on 1/30/24. This physician's order for the Lasix read as follows: Furosemide oral tablet 40 mg tablet by mouth one time a day for edema. However, the weight loss had been ongoing since 10/18/23, which was prior to the start of the Furosemide. On the afternoon of 3/21/24, the Assistant Director of Nursing confirmed that the ordered dose of Lasix would not have resulted in such an ongoing loss of weight. According to R13's nutrition care plan, no revisions had been made since 10/31/23, other than a change to the target goal date. This care plan did not indicate that R13 was on a physician ordered weight reduction plan, but it inaccurately noted that the supplement Med Pass was still being provided, when it had been discontinued on 11/24/23. 3. For Resident #3 (R3), who experienced significant and ongoing weight loss, the facility staff failed to implement interventions to maintain adequate nutrition and prevent insidious weight loss, which constitutes harm. On 3/21/24, a clinical record review was conducted of R3's chart, which included weights, care plan, physician orders, physician progress notes, and nutritional notes. According to R3's weight records, R3 was not weighed in December 2023. When a weight was obtained on 1/3/24, it noted a significant weight loss of 10%, 11 lbs. in 5 months. R3 continued to experience on-going weight loss. On 2/17/24, R3 weighed 94.2 lbs., which was a 12.2 lb. weight loss, 11.5% loss in 6 months. On 3/18/24, R3's current weight was 91.6 lbs., which was a 13.2 lb. loss, 12.6% loss in 6 months. On 2/13/24, R3 was seen by the RD (registered dietician) and a recommendation was made for dietary supplement of house shakes three times daily. However, as of 3/20/24, the recommendation had not been carried out. R3's physician orders included an order for weekly weight every day shift every Sat, which was ordered 1/27/24. Following this order, Resident #3 had only had 3 weights documented, which were on 2/17/24, 3/16/24, and a re-weight obtained on 3/18/24. According to a clinical record review, R3 was last seen by the physician on 1/29/24, for which documentation made no mention of the weight loss. When R3's questioned about this, the facility administration provided the surveyor with a physician note dated 3/18/24, which was not available within the clinical record. Within that note the physician noted that continual and gradual weight loss since admission .is unavoidable . However, there was no evidence of any clinical testing to determine if it was unavoidable as the additional nutritional supplements recommended by the registered dietician had not been attempted. R3's clinical record documented the last time labs were drawn was on 5/23/23. On 3/20/24, an interview was conducted with the RD. The RD stated he was not aware that the 2/13/24 dietary recommendation for the dietary supplements had not been carried out. On 3/21/24, the RD reported to the survey team that the order for house shakes were started. Review of R3's care plan revealed that the nutritional care plan had been implemented 2/6/22, with a revision on 8/17/23, and noted that R3 was at risk for wt. changes and altered nutrition status RT [related to] self-care deficit . feeding assistance. According to R3's care plan, the interventions had not been revised since 11/02/23 and did not address actual weight loss. Last revised on 1/10/24, the goal read as Maintain adequate nutritional status as evidenced by no significant weight change through review date, which was noted as 5/1/24. Specific interventions included, monitor/record/report to MD PRN [as needed] s/sx [signs/symptoms] of . significant weight loss: 3lbs in 1 week, 10% in 6 months. 4. For R12, who experienced a significant weight loss, the facility staff delayed in implementing interventions and failed to ensure a therapeutic diet was provided, which constituted harm. According to the clinical record, R12's weight on 6/2/23, noted a 7 lb. weight loss in 3 weeks. On 6/20/23, the RD recommended weekly weights to establish a baseline. No weights were documented for the months of July and August. The next weight was obtained 9/13/23 and noted a 19.9% weight loss of 31 lbs. Following this identification, R12 was ordered large portions with meals, which was still an active order. Observations by the survey team on 3/19/24, 3/20/24, 3/21/24, and 3/22/24 revealed R12 was not receiving large portions, as ordered by the physician. According to a social services progress note dated 1/4/24, the social worker (SW) met with R12 regarding him not wanting to eat and take medications. This note documented that R12 verbalized a desire to have a ham and cheese sandwich with lunch. This preference was not noted on his meal ticket and on 3/20/24-3/22/24, and 3/25/24, R12 was not provided a ham and cheese sandwich at lunch, which was observed by the survey team. Review of the facility policy and procedure titled, Weekly Weight Meeting (Quality Assurance), it read in part, A weekly weight meeting will be conducted to review resident weights . No documentation was found to evidence that these meetings were occurring. The survey team conducted a review of the facility policy titled, Weighing the Resident. The policy read in part, Residents will be weighed unless ordered otherwise by the physician: admission/re-admission x 3 days, weekly x 4 weeks, monthly thereafter, as needed . When there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed and a licensed nurse to validate. Record weight and alert nurse to any significant change. Nurse to notify the physician of any significant weight change, consult with the director of dietary services and/or dietitian, notify the interdisciplinary team in order to update the plan of care. On 3/25/24, Immediate Jeopardy (IJ) was identified based upon the above findings, and confirmed by the state agency, of which the facility's acting administrator and corporate staff were notified of IJ at 4:20 p.m. On 3/26/24 at 11 a.m., the facility submitted IJ removal plan was approved by the survey team, in collaboration with the state agency. The removal plan read as follows: 1. R14 was weighed by the licensed nurse on 3-25-24 with a documented weight of 275.0 pounds. R13 was weighed on 3-25-24 by the licensed nurse with a documented weight of 198.2 pounds. R3 was weighted by the licensed nurse on 3-25-24 with a documented weight of 92 pounds. R12 was weighed on 3-25-24 by the licensed nurse with a documented weight of 92.6 pounds. The MD reviewed R14, R14, R3, & R12 on 3-25-24 to ensure the residents are clinically stable and are not experiencing an acute change in condition requiring transfer to a higher level of care. The MD reviewed the diets for R14, R13, R3 & R12 to ensure appropriate orders are in place to meet their nutritional needs. The MD ordered labs on R14, R13, R3 & R12 for insight into nutritional status and to ensure clinical stability. The Registered Dietician (RD) reviewed R14, R13, R3 & R12 for nutritional needs and preferences and provided recommendations for therapeutic diets and supplement recommendations for R14, R13, R3 & R12 for new orders which were implemented, as per the md orders. Residents R14, R13, R3, & R12 were screened by Occupational Therapy (OT) and Speech Therapy (ST) for services required to [NAME] the residents' needs. The Licensed Nurse notified the family of weight loss and new orders given by the MD with documentation in the medical record for R14, R13, R3, & R12. The MDs nurse completed a significant changes assessment on R14, R13, R3, & R12, and updated the care plans for R14, R13, R3, & R12 with the therapeutic diets and interventions, as per the MD orders given and dietary preferences. The Nurse Manager completed education with the Responsible Party (RP) for R14, R13, R3, & R12 to explain the risk versus benefits of the therapeutic diets as ordered per the MD. QAPI Was held with the DCS, Medical Director, Infection Preventionist Nurse and at least one additional member from the IDT and a line staff employee to discuss the center's status of immediate jeopardy and the action plan being implemented to ensure the safety and care of the residents at the center. 2. Current residents were weighed on 3-25-24 to obtain baseline weights. Current weights were then reviewed by the dietician to determine any significant weight loss. Based on findings, RD recommendations were obtained for residents to ensure therapeutic diets are in place to meet residents' nutritional needs per residents' preference. MD was then notified of RD recommendations and for new orders to accommodate residents' needs. New orders were then carried out by the licensed nurse and RP was notified of weight loss and new orders accordingly. OT and ST screened current residents to ensure needs. Current residents were observed by the Licensed Nurse Manager and Registered Dietician to be serviced physician ordered therapeutic diets as ordered to include correct consistency, dietary restrictions, and correct portion sizes. Current residents have the option to request and receive an alternate meal if they do not like the first meal offering being served. 3. The center Registered Dietician was educated by the Regional Dietician on ensuring residents are reviewed for nutritional status no less than quarterly and with a significant change in condition to ensure prescribed diets are in place to meet nutritional needs. The Dietary Staff were educated on preparing meal trays as per the prescribed MD diet orders for the center residents. The Dietary Staff were additionally educated on temperature, portion, appearance, and variety to meal portion sizes, serving the proper meal and consistency per the diet order, and preparing meals as per the recipe. The Director of Nursing (DON) was educated by the Regional Nurse on the policy and procedure for maintaining a weight program to include weighing residents upon admission and re-admission, and then weekly x 4 weeks and then at least monthly and more frequently, as per MD orders. Additionally, the DON is to review the weights with the previous months weights to determine the percentage of weight loss or gain to include 5% in a month, 7.5% in 3 months or 10% in 6 months. The MDS nurse was educated by the Regional Nurse to ensure residents care plans are updated with interventions to ensure optimal health. Licensed Nurses were educated by the Nurse Manager on obtaining weights for center residents on admission and re-admission and for 4 weeks thereafter and then at least monthly and with significant changes. Licensed nurses were also educated on notification to the RD, MD and RP for significant weight loss or gain. Nursing staff were educated on checking meals before serving to ensure when they are serving meals that they [sic] are the correct consistency, dietary restrictions, and correct portion sizes. Additionally, the Nursing staff have been educated on accurately recording and then documenting in the system the residents' meal percentages. The IDT team was educated on grievance and grievance resolution to include ongoing concerns, and the responsibility resident council complaints through the Quality Assurance and Performance Improvement process. Completion date and time: 03-26-24 at 11:59 p.m. On 3/27/24, the survey team started verifying that the facility had implemented their IJ removal plan. Facility documentation reviews were conducted, clinical record reviews, and meal observations, which also included resident and staff interviews. Multiple errors were observed with regards to the resident meals and being served in accordance with their prescribed therapeutic diets and portion sizes. The errors observed were not identified by the nursing staff serving the trays to residents and the residents were served trays with incorrect portion sizes with regards to residents who had orders for large and double portions. Several residents who were ordered additional supplements and fortified foods did not receive them. One resident had requested an alternate meal prior to the meal/tray line service, the kitchen was notified of such, but did not provide the alternate as requested. The survey team conducted a review of other clinical records that revealed 3 additional residents who had experienced significant weight loss, for which there had been no assessment by the registered dietician or physician. No interventions had been implemented and the care plans had not been revised. On 3/27/24 at 3 p.m., the facility administration was made aware that the survey team had been unable to abate the IJ, given these findings. The facility administration verbalized that they would be ready for the survey team to attempt verification again on 3/27/24 at 4:45 p.m. On 3/28/24 at 8 a.m., the survey team returned to the facility and again started verifying that the IJ removal plan had been implemented. Clinical records were again reviewed, and it was noted that the 3 additional residents identified on 3/27/24, with significant weight loss, had still not been addressed by the registered dietician and/or physician, nor had any interventions been implemented. On 3/28/24, the survey team again notified the facility administration that they were unable to abate the IJ. The facility submitted a revised IJ removal plan which indicated a completion date of Monday, April 2, 2024, at 11:59 p.m. On 4/2/24 at 5:13 p.m., an interview was conducted with the registered dietician (RD). The RD was asked about his involvement in interdisciplinary team meetings to discuss residents who are experiencing weight loss. The RD stated that this past weekend, following the identification of immediate jeopardy, was the first facility meeting of such nature that he had attended. On 4/2/24 at 5:45 p.m., an interview was conducted with the Regional Director of Clinical Services (RDCS). The RDCS stated that it has always been an expectation of the company that weekly interdisciplinary weight meetings be held. The RDCS further confirmed that this had not been occurring at this facility and that she had no record of any past meetings. Working through implementation of the removal plan, the facility staff obtained and reviewed weights on all the residents, reporting that an additional 25 residents were identified as having experienced weight loss. The facility also reported that eighteen of the 25 had new orders implemented for nutritional interventions to address the identified weight loss. On 4/2/24, the survey team verified implementation of the removal plan through observations, staff interviews, clinical record review, and facility documentation review, subsequently IJ was removed at 6:10 p.m. No additional information was provided. Based on the seriousness of the noncompliance, this deficiency was cited at Level 4, Pattern.

Based on observation, resident interview, staff interviews, clinical record review, and facility documentation review, the facility staff failed to have sufficient nursing staff to meet the resident care needs on 2 of 3 nursing units, which affected many residents and resulted in psychological harm for one resident (Resident #44). The findings included: 1. For Resident #44 (R44), the facility staff failed to provide incontinence care for an extended period of time due to insufficient staffing, which resulted in psychological harm for the resident. R44 was admitted to the facility on [DATE]. Diagnoses for R44 included but were not limited to multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, history of falling, and abnormal posture. R44's Minimum Data Set (MDS - an assessment tool), with an Assessment Reference Date of 3/19/2024, coded R44 with a BIMS of 13 out of 15, which indicated R44 was cognitively intact for daily decision making. On the afternoon of 4/16/24, it was observed and confirmed through staff interviews, that only one CNA (idenitified as CNA6) was assigned to care for all of the residents on the East unit, where Resident #44 resided, from 2 p.m., until 7 p.m On 4/16/24 at 1:10 p.m., a phone interview was conducted with a certified nursing assistant (CNA18) who worked on East Unit. CNA18 stated, [R44's name redacted] had been left saturated and it smelled like ammonia and the brief was brown and the resident said to me she felt like she was an animal and like she wasn't human. [R44's name redacted] said she had asked to be changed several times and was ignored by staff. On 4/16/24 at 3:00 p.m. an interview was conducted with R44. During the interview R44 became tearful several times while talking about the incident during the interview with the surveyor. R44 verbalized that sometimes the staff will not get me up out of bed. R44 verbalized that last Wednesday (4/10/24), the aide wouldn't get her up and R44 stated, [CNA #6's name redacted] said I am by myself, and so it's not fair. I got really upset about wanting to get up and move around, but notbeing aqllowed to. R44 stated, I was left soaking wet last Thursday, and I mean I was soaking wet, and did number two on myself. It was [CNA #6's name redacted] and another guy. They knew about it and in the end a nurse came and helped [staff name redacted] finally to clean me up. R44 stated, It made me feel like I didn't matter. R44 stated, I told the nurse I didn't feel like I was a human, and you don't see animals treated like that! R44 again verbalized that the feeling of not being human has been present since the day of the incident. R44 verbalized, this is not right, and it is unhealthy to be left in this condition. R44 stated, I am almost scared to touch the call button, because they don't come, make excuses of why they cannot help, and leave and don't come back . it makes you angry and feel less than a person. R44 stated, It is so unhealthy and makes me feel ugly on the inside and makes me think something is wrong with me. I try to be nice to everyone but I have feelings and I don't understand it but it still effects me and makes me want to leave here. What am I paying for? To be treated like a dog, inhuman . and to be a female, it's pretty unhealthy. R44 verbalized that when not attended to and left wet that R44 will not leave the room. R44 verbalized loving to come to bingo but has missed the activity because of being left wet and smelling, which is upsetting. R44 verbalized the feeling of being picked on by staff and singled out, because of having to use a Hoyer lift for transfers and the need for two people to do the transfer. R44 stated, They all get together and talk about the situation and it really makes me feel like I am less human. I wasn't able to leave the room, it makes me feel horrible, like a dog. It feels horrible and made me lose trust. It still affects me now but there's nothing I can do about it. I can't walk and will fall on the floor but it still makes me feel degraded. R44 verbalized it takes longer to get staff to help with care due to the Hoyer lift and other residents seem to get the help quicker for their needs, but R44 verbalized having to wait hours for help. R44 stated, The feeling on the inside is not good, it makes me feel sad, I feel sad ever since that incident. I am a alien and didn't know it. I cry every day when I think about the incident and wonder how I will be treated today. It makes me angry on the inside, it's like I am sitting around waiting for another incident. On 4/16/24 at 3:50 p.m., an interview was conducted with CNA #6 (CNA6) and was asked about the incident involving R44. CNA6 stated, I said that we are short staffed and see if I can find help. CNA6 verbalized the end of the shift is at 7:00 p.m. and the incident must have happened after the shift ended. CNA6 verbalized if R44 needed care it would have been provided before the end of shift or made sure to report it off to oncoming shift to take care of the issue. CNA6 stated, [R44's name redacted] does express concerns about different things. [R44's name redacted] has been different, since that incident, towards me and also her attitude. On 4/16/24 a review of the facility documentation was reviewed. A witness statement written by CNA18 dated 4/11/24 was reviewed. In the witness statement CNA18 had written and read in part, .[R44's name redacted] when we got to her, she was crying saying she wasn't changed since 4 am the night before she stated he left her and she doesn't feel human for being left in the predicament she was in. On 4/16/24 a review of the facility documentation was reviewed. A witness statement written by CNA #17 (CNA17) dated 4/11/24 was reviewed. In the witness statement CNA17 had written and read in part, .[R44's name redacted] was fussing about not being changed, me and [CNA18's name redacted] went into her room to help her and she starts crying saying she's been left in bed all day by [CNA6's name redacted] and hasn't been changed since 4 am the previous day. she was soaked from head to toe. On 4/17/24 at 8:32 a.m., an interview was conducted with the administrator. The administrator reported she was investigating two facility staff members, CNA17 and CNA18. During the investigation being conducted by the facility, CNA17 and CNA18 were asked to write statements and in the statement it was noted that R44 had made a complaint of the lack of care and feeling like not being human. The administrator verbalized that the human resource manager was helping with conducting the investigation. The administrator verbalized that no investigation involving R44 had been conducted. The administrator verbalized that I read the witness statements and the administrator stated, I read the statement incorrectly from 4/11/24 and should have investigated the allegation made with [R44's name redacted]. I will go and talk with the resident now. On 4/17/24 at 9:07 a.m., an interview was conducted with the social worker director. The social worker director stated, I am not aware of anything about [R44's name redacted]. No one has shared with me anything about [R44's name redacted] being tearful or upset and if I would have known, I would have talked with [R44's name redacted]. On 4/17/24 at 10:33 a.m., an interview was conducted with the activity director. The activities director verbalized that R44 liked to come to bingo, parties, and musicals. The activities director verbalized that R44 likes food and social gathering activities. The activities director stated, [R44's name redacted] likes to get up every day and the staff didn't get [R44's name redacted] up that day and [R44] had been tearful. [R44's name redacted] feels like if she doesn't get up, she loses independence. On 4/17/24, a review of the clinical record was conducted and R44's care plan was reviewed. R44's care plan documented that R44 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease process. R44's care plan indicated that assistance with all of the activities of daily living (ADL) is required from facility staff. R44's care plan documented that R44 was incontinent of bowel and bladder, and that staff were to check every two hours and assist with toileting as needed. On 4/17/24, a review of the clinical record was conducted and R44's ADL record was reviewed. R44 was incontinent of bowel and bladder daily and required total assistance with elimination. On 4/17/24, a review of the clinical record was conducted, including R44's group activity participation. It was noted that in February, R44 attended 11 group activities. For the month of April, R44 had only attended 3 activities to date. On 4/17/24, a review of the clinical record was conducted and R44's social service progress notes were reviewed, with the most recent note dated 3/17/24, but there was no reference to R44's expressed concerns. On 4/17/24 at 10:20 a.m., a meeting with the administrator and DON was conducted, during which the surveyor expressed concerns regarding R44. Administrator verbalized based on CNA statements, R44 should have been assessed by the social worker but was not. The administrator went on to say that she had talked with R44 today and that R44 said everything was fine, call bell was being answered, and did not have any concerns at this time. The administrator verbalized the questions were how breakfast was, how is your day going, and if R44 needed anything or had any concerns this morning. The administrator was asked if any questions were asked to the resident about the incident on 4/11/24 and the administrator stated, No. The clinical chief of operations verbalized they would be more on point with their questions and will go back to re-interview R44 about the incident. No additional information was provided prior to the exit conference. 2. The facility staff failed to answer call bells in a timely manner due to insufficent staffing on the East unit. On 4/15/24 at 11:11 a.m. an interview was conducted with CNA2. CNA2 verbalized I was the only aide on the unit from 7:00 a.m. until 11:30 a.m., so management had the transport driver come to the unit to help answer the call bells until another aide came to the unit. On 4/15/24 at 11:40 a.m. an interview was conducted with a resident on East unit and the resident verbalized waiting an hour sometimes to get the call bell answered. The resident verbalized if it is the change of shift or report time then it is a longer wait. The resident verbalized things were rough and not enough aides or nurses to take care of the residents on the unit because so many have quit. On 4/15/24 at 11:50 a.m. an interview was conducted with the social worker assistant. The social worker assistant verbalized that staffing is not great and the facility is very short staff. The social worker assistant verbalized the outcome to insufficent staffing is the residents were having to wait longer for their care. On 4/15/24 at 1:23 p.m. an interview was conducted with Resident #15 (R15). R15 verbalized I had a fall on Saturday evening in my bathroom and my roommate pushed the call bell for me to get assistance. R15 verbalized that it took 30 minutes for the staff to answer the call bell after the roommate had called for help. On 4/15/24 at 3:40 p.m. an interview was conducted with the administrator concerning insufficent staffing on the units. The administrator verbalized that the faciliy had enough staff for all shifts and all units, but was having 10-12 call outs daily. On 4/15/24 an observation was made of 6 call bell lights that were on at 3:54 p.m. The east unit had one aide, one nurse and one nurse that was split between the East and [NAME] units. Observed a nurse that was standing at the medicene cart between 3 of the call bell light that were on and the nurse did not answer any of the call bells until after ringing for 30 minutes and only responded to the resident that was recieving medication. At 4:33 p.m. 4 call bell lights remain on and have not been answered. On resident was sitting in the doorway and 5 staff members walked by the room and did not respond to the call bell light that was ringing. The surveyor left the east unit at 5:05 p.m. and the 4 call bell lights remained on and had been on for 1 hour and 10 minutes. On 4/15/24 at 4:45 p.m. an interview was conducted with Resident #48 (R48). R48 verbalized that the call bell light had been on since 3:30 p.m. R48 stated, I go to the bathroom and have to wait there an hour. R48 verbalized there were days that only one aide was on the unit to assist 50 residents. R48 verbalized that short staffing was the reason for residents not getting showers, call bell lights not being answered for long periods of time and the meals were being served late. On 4/16/24 at 8:20 a.m. an interview was conducted with CNA #14 (CNA14). CNA14 verbalized that last Thursday I was the only aide on the unit until 11:30 a.m. with one nurse. CNA14 verbalized that being short staffed, we cannot meet everyone's needs. CNA14 stated, rounds are to be done every 2 hours but most days that doesn't happen because of short staffing. I am here for 12 hour shifts and on a good day 4 rounds maybe, but most of the time it is 2-3 rounds. Lack of rounding is due to not enough staff onb the floor. Mostly bed baths are given and showers don't happen it is bed baths. On 4/16/24 at 8:40 a.m. an interview was conducted with a resident on the East unit. The resident verbalized that no staff had not been in this morning to check on me. The staff here has been short and everytime I used my call bell light, the staff will come in and turn it off and say they had something going on somewhere else and never come back to help. On 4/16/24 at 9:35 a.m. an interview was conducted with a registered nurse, (RN2). RN2 stated, not enough staff. Last Thursday, all the staff here couldn't answer the bells. Staff should round every 2 hours but some residents might not even get rounded on. I feel the residents are not safe and are lacking care. I was here last Thursday and the only staff for the building was 3 nurses and 2 aides, for the entire building. On 4/16/24 at 10:15 a.m. a meeting was conducted with the administrator and the regional director of clinical services to discuss the above concerns of insufficent staffing and staffing not responding to the call bell lights for long periods of time. No other information was provided prior to exit conference. 28106 3. Staff failed to provide scheduled showers due to staffing concerns for Resident #41 (R41). The Findings Include: R41's The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/28/2024 and documented R41 was assessed with a cognitive score of 15 indicating cognitively intact. Section GG, Functional Status indicated R41 needed set up assistance for showers/bathing. During the interview with R41 conducted on 4/15/24 at 11:30 AM, R41 verbalized that the staff had not given her a shower in about three weeks and felt unclean. On 4/15/24 R41's bathing record was reviewed for a time period of 30 days and documented R41 last received a shower on 3/28/24. Check marks under the column Partial were placed on 4/7/24 and 4/14/24. Review of progress notes and care plan did not indicated R41 had refused or refuses showers. Review of the nursing unit shower schedule indicated R41 was scheduled to receive showers on Tuesday and Friday weekly. On 4/15/24 at 4:30 PM certified nursing assistant (CNA #6) was interviewed regarding resident showers. CNA #6 explained sometimes he is the only one working the unit and showers don't always get done and are usually done on another day when there are more staff. CNA #6 went onto say that morning care is being provided such as brushing teeth, combing hair and performing partial bed baths. On 4/16/24 at 8:30 AM CNA #13 (person who had documented partial on R41's shower record) was interviewed. CNA #13 verbalized showers are sometimes not performed due to staffing and just depends on the staff if the showers get completed. When asked about documenting Partial on R41's shower record, CNA #13 verbalized that R41 received daily hygiene or partial bed bath, but a shower was not performed. On 4/16/24 at 8:40 AM CNA #14, also working the unit where R41 resides was interviewed. CNA #14 verbalized showers are not being provided all the time due to staffing and when this happens bed baths are given. On 4/16/24 at 10:15 AM the above information was presented to the administrator and DON. No other information was provided prior to exit conference on 4/17/24. 4. Staff failed to provide scheduled showers due to staffing concerns for Resident #20 (R20). The Findings Include: R20's The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 3/28/2024 and documented R20 was assessed with a cognitive score of 15 indicating cognitively intact. Section GG, Functional Status indicated R20 needed set up assistance for showers/bathing. On 4/15/24 at 4:20 AM, R20 was interviewed regarding getting shower after overhearing a conversation with another resident residing in the same room concerning showers. R20 verbalized that the staff had not given her a shower in a few weeks and felt it was due to not having enough staff. On 4/15/24 R20's bathing record was reviewed for a time period of 30 days and documented R41 last received a shower on 3/19/24. Documentation also showed a bed bath was given on 4/2/24 and partial bath was performed on 4/9/24 and 4/12/24. Review of progress notes and care plan did not indicated R20 had refused or refuses showers. Review of the nursing unit shower schedule indicated R20 was scheduled to receive showers on Tuesday and Friday weekly. On 4/15/24 at 4:30 PM certified nursing assistant (CNA #6) was interviewed regarding resident showers. CNA #6 explained sometimes he is the only one working the unit and showers don't always get done and are usually done on another day when there are more staff. CNA #6 went onto say that morning care is being provided such as brushing teeth, combing hair and performing partial bed baths. On 4/16/24 at 8:30 AM CNA #13 (person who had documented partial on R20's shower record) was interviewed. CNA #13 verbalized showers are sometimes not performed due to staffing and just depends on the staff if the showers get completed. When asked about documenting Partial on R20's shower record, CNA #13 verbalized that R20 received daily hygiene or partial bed bath, but a shower was not performed. On 4/16/24 at 8:40 AM CNA #14, also working the unit where R20 resides was interviewed. CNA #14 verbalized showers are not being provided all the time due to staffing and when this happens bed baths are given. On 4/16/24 at 10:15 AM the above information was presented to the administrator and DON. No other information was provided prior to exit conference on 4/17/24. 41449 5. The facility staff failed to have sufficient nurse staffing to provide for resident care needs and respond to call bells. On 3/19/24 at 3:56 p.m., during an interview with Resident #9 (R9), the resident reported, Response time with the call bell isn't good. Sometimes I have to wait 40-45 minutes more than I should. I sat on the toilet for an hour for a roll of toilet paper yesterday and they didn't bring it until today. On 3/20/24 at 2:16 p.m., an interview was conducted with LPN #3. LPN #3 said, I think we try to do the best we can with the staff we have, we all try to answer call bells. On 3/21/24 at 8:50 a.m., the surveyor observed on the east unit that 3 call bells were engaged. At 9:20 a.m., CNA #7, entered Resident #7's room to respond to the call bell and told the resident, I am the only aide here, this is as good as it gets. On 3/21/24 at 9:32 a.m., an interview was conducted with LPN #7 who stated, I realized at 7:30 a.m., that we only had one aide and I told [Director of Nursing's name redacted], and she texted [supply clerk's name redacted] and she came to help. We don't just have one aide. On 3/21/24 at approximately 9:50 a.m., an interview was conducted with LPN #8. LPN #8 said she had just been made aware that they only had one nursing assistant on the unit and was not aware. LPN #8 went on to say, This is an ongoing problem. On 3/21/24 at approximately 9:55 a.m., an interview was conducted with the supply clerk. The supply clerk reported that she had only been employed at the facility a couple of weeks and when she arrived to work around 8 a.m., had been told to come to help on the floor since she is also a CNA [certified nursing assistant]. Review of the staffing records revealed that three nursing assistants scheduled for the unit had called off for their assigned shift and no alternate staff had been arranged, until LPN #7 notified the director of nursing. On 3/22/24, only one CNA was scheduled for the east unit to care for the 48 residents on the unit. The schedule indicated that 10 total CNAs were required for the shift to cover all three units and only 4.1 were scheduled for the 12-hour shift. For the 7pm.-7am shift, there was only 1 CNA scheduled from p.m. until 5 a.m. for one unit. Review of staffing records revealed that frequently there were only 2 CNA's working on a unit, where over 40 residents resided and required on-going care. On 3/26/24 at 11:20 a.m., an interview was conducted with Resident #37 (R37). R37 reported that he refuses a lot of care needs, such as medications, bed baths, meals, etc. because I just don't bother them to come in because of the lack of staff. If they had enough staff and people that could use the Hoyer lift I would. Over the weekend it was so bad they didn't have no aides here and had to bring in aides from [town/locality redacted- referring to bringing staff from other facilities]. Basically I am here til I die, I prefer not to bother the staff. I only get changed twice daily 2:30 p.m., and 2:30 a.m., some of it is convenience for me and some is due to lack of staff There are times I ring my bell and it may be an hour for a response. R37 went on to say that he refuses care because he thinks if the staff don't come in to provide care, meals, or medications to him it will allow them more time to care for other residents. Observation of the resident council minutes and grievance log revealed a preponderance of concerns related to the call bell response times. On 3/28/24, during an end of day meeting, the facility corporate staff and acting administrator were made aware of concerns surrounding staffing. The corporate staff stated that they were unaware of the staffing challenges within the facility because according to reports and data submitted it appeared they had sufficient staff and were not aware of any problems. 6. For Resident #39 (R39), the facility failed to have sufficient staff to provide baths, which resulted in R39 refusing to go to dialysis due to having not received a bath to clean the resident following episodes of bowel incontinence. On 4/15/24 at approximately 11 a.m., the survey team was notified the facility had closed the eclipse/skilled care unit on 4/11/24, due to staffing challenges and for renovations of the unit. On 4/15/24 at 11:16 a.m., an interview was conducted with R39. R39 reported that he did not go to dialysis today because I was pooping and couldn't get my bath. R39 reported he is to get a complete bed bath before going to dialysis on Monday, Wednesday, and Fridays. R39 said, last night they had 2 people here until 3 a.m., then only 1 person and [CNA #16's name redacted] said a bed bath wasn't part of her job. I wanted an hour and 45 minutes before I got changed, there is only 1 person on the floor now, they are overworking the ones here. Everybody is just walking out of this place. I think its 52 people on the unit for 1 aide to care for. On 4/15/24 at 11:20 a.m., an interview was conducted with the nurse assigned to R39, LPN #5. LPN #5 was asked about R39 not going to dialysis. LPN #5 said, He said he didn't get a bed bath last night, I wasn't here. LPN #5 reported that normal staffing for the unit would be 2 nurses and 4 aides and currently they have 2 CNA's. LPN #5 confirmed that when they arrived, the overnight shift only had 1 nurse and 1 CNA on the unit. When asked if it is reasonable to think 1 CNA could give showers and/or baths, LPN #5 said no. During a clinical record review conducted on 4/16/24, it was confirmed that R39's documentation with regards to a bed bath being given was blank. According to the shower assignment sheet, it noted that R39 is to receive a complete bed bath every Sunday, Tuesday, and Thursday on the 7 p.m., to 7 a.m. shift. On 4/15/24 at approximately 11:30 a.m., an interview was conducted with CNA #15. When asked about staffing, CNA #15 reported, It was bad, we had people here working long hours, one nurse worked from 3 a.m., until 9 p.m., it's horrible. Today I've been running between both units because there was only 1 aide on the other side and it is very dangerous, they had someone come in at 11 a.m On 4/15/24 at 4:20 p.m., an interview was conducted with CNA #19. CNA #19 was the only CNA working the west unit at that time and had a CNA student who had come in to help her. She said, In my 12 hours shift it is all I can do for a second round of incontinence care and feed meals. There isn't time for baths and showers, it breaks my heart because they deserve better. On 4/15/24 at 4:25 p.m., an interview was conducted with the physician's assistant (PA) who was on-site. When asked about the staffing and notified that there was one nurse and one CNA on the unit, the PA said, I understand 1 nurse and 1 CNA can't provide care for that many residents. On 4/15/24 at approximately 4:30 p.m., an interview was conducted with the admissions staff. When asked about census, they reported that the facility currently had 97 residents and had the capacity for 99 across the two units upstairs (east and west) that were open. When asked if they were accepting new admissions, they reported they are only taking back residents who are hospitalized that were previously at the facility. When asked when this happened, they reported they were notified of this on 4/11/24, by the administrator. On 4/15/24 at 4:40 p.m., an interview was conducted with the facility administrator with regards to staffing. When asked about agency staffing, the administrator said, If [corporation name redacted] would do agency staffing that would be great. We are pulling from other building, and I have regional staff coming in. I had 11 interviews scheduled last Friday but none of them showed up, the word is out in the community and people are scared for their license. We are looking to move 10 residents to [name of a sister facility redacted]. When asked when that was supposed to happen, the administrator said, well I was supposed to have a call about it today. I just sent a wage proposal to corporate to try to get wages competitive. I was able to offer some vacant shift bonuses. I am sitting here crying because I don't have anyone to take care of my people. If I had a license I would be up there helping too. On 4/16/24 at 8:31 a.m., another interview was conducted with CNA #15. When asked about showers, CNA #15 said, when we only have 1 or 2 CNA's we can't get them into the shower, we can only do bed baths and it's not fair to them, they are supposed to have 2 showers a week. On 4/16/24 at 10:15 a.m., an interview was conducted again with the administrator and director of nursing, who was also the regional director of clinical services (RDCS). When asked about staffing and how they plan to move forward to ensure residents are receiving the care they need and if agency staffing had been considered. The RDCS said, Agency staffing, that's not the answer. You identified people aren't getting baths, we received 27-28 citations when you were here before, and we have done staff education and asked for their input. They talked a lot about having a shower aide. We are pulling staff from other centers, and we are recruiting and hiring. When the survey team acknowledged that the facility administration is trying to recruit staff and pull staffing from sister facilities, but asked again, recruitment and hiring takes time, what is the plan for the current situation to ensure resident needs are met. The Administrator and RDCS had no further comment. On 4/16/24 at 3:18 p.m., an interview was conducted with LPN #5. When questioning the shower/bath schedule and lack of documentation of baths being given for Resident #39. LPN #5 stated, There was only 1 CNA Sunday night, it's not reasonable to think they could give baths. No additional information was provided. 7. The facility staff failed to have sufficient nurse staffing to provide medications to residents timely on 2 of 2 nursing units open. On 4/15/24, at approximately 11 a.m., the survey team was made aware that on 4/11/24, the facility had closed on of their nursing units. Interviews with facility staff reported the closure was due to staffing. The Administrator confirmed that technically the unit was closed for renovations, but it was also to help with staffing. On 4/15/24, during resident interviews conducted throughout the day numerous residents, which included but were not limited to R39, R46, and R11 reported concerns with the timing of medication administration and reported medications being late or having to wait long periods of times (over an hour). On 4/15/24-4/16/24, during staff interviews conducted with various staff which included but were not limited to, LPN #5, LPN #10, and RN #2. Comments were made of numerous occasions where there was only one nurse was available for the unit which had over 45 residents and they weren't able to attend to and administer medications timely. On 4/15/24-4/16/24, a sample of residents were selected for review of medication administration. The following was noted: Resident #39 had reported that his medications are late at times. Review of the clinical record to include medication administration record, medication audit report and progress notes revealed that on 4/13/24, medications scheduled to be administered at 9 a.m., were not given until 10:58 a.m., and 11:07 a.m. For the medication Sevelamer, which was scheduled three times daily, the 9 am dose was given at 11:07 a.m., and the 1 p.m., dose was given at 12:07 p.m., which was only an hour after the first administration given that day. For Resident #21 (R21), several medications were not given timely. According to the physician orders, R21 was to receive Eliquis, which is an anticoagulant/blood thinner, twice daily and Buspirone, which is an antidepressant, three times a day. On 4/10/24, R21's dose of Eliquis scheduled to be given at 9 am was given at 1 p.m. Then the second dose of Eliquis, scheduled to be administered at 5 p.m., was given at 4:42, which was only 3 hours and 42 minutes after the previous administration. On the same day, 4/10/24, R21's 9 am dose of Buspirone was given at 1 p.m., and the 1 p.m., dose was given at 1:01 p.m. Therefore, both doses were administered at the same time. For Resident #36 (R36), a physician order was noted to state, Change Libre 2 sensor [a device to check blood glucose levels] q [every] 14 days, one time a day every 2 weeks on Wed for DM [diabetes mellitus]. According to the medication administration record (MAR), the Libre 2 device was scheduled to be changed on 4/10/24 at 9 am. The MAR noted it was not changed and had a code 9, which according to the legend said [TRUNCATED]

Based on clinical record review, resident interview, facility documentation review, and facility documentation review, the facility failed to protect the resident's right to be free from abuse and neglect from staff, for two residents (Resident #1 & Resident #44) in a survey sample of 48 residents, which resulted in harm for both residents. The findings included: 1. The facility staff physically abused R1 and neglected to leave the resident with a means to call for assistance by taking the call bell away from the resident, which constituted harm. Resident #1 (R1) had diagnoses that included congestive heart failure, coronary heart disease, adult failure to thrive, and generalized muscle weakness. The most current minimum data set (MDS - assessment tool) was a quarterly assessment, dated 9/29/23, which assessed R1 with moderate cognitive impairment. Review of R1's closed clinical record, the MDS dated [DATE] documented R1 required extensive assistance transferring from bed to wheelchair. R1's care plan initiated 1/23/23 documented R1 had an activity of daily living (ADL) self-care performance deficit due to weakness and limited mobility which required assistance with transfers as needed. The care plan also documented R1 was at risk for falls due to weakness, repeated falls, and unsteadiness on feet. The care plan also documented interventions to assist with transfers as needed and be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed. Review of facility documentation revealed that R1 reported to facility staff on 5/28/23, that certified nursing assistant #11 (CNA #11) had been rough with him and requested that he not take care of him anymore. According to the facility investigation documents, R1 had rang the call bell to use the bathroom, during the nightshift on 5/28/23, CNA #11 came in and cleared the bell but did not take him. R1 rang the call bell again and reported that CNA #11 came back and seemed angry that he was ringing again. Per the report R1 stated that CNA #11 picked him up and threw him in his wheelchair like a rag doll and took him to the bathroom. During the facility's investigation, it was determined that R1's roommate witnessed the incident. Per the facility's final investigative report CNA #11 was suspended pending investigation, terminated on 6/1/23 when the investigation was completed, and the abuse and neglect allegations were substantiated. The facility then reported CNA #11's actions to the board of nursing. On 3/20/24 at 4:35 PM, an interview was conducted with the Director of Nursing (DON). The DON was asked about the protocol with regards to residents reporting abuse/neglect. The DON stated that residents are not to be abused by anyone and when a report is made, they suspend the employee, get them to write a statement as to the allegation, and they initiate an investigation. On 3/21/24 at 8:50 AM, resident #8 (R8), the resident council president was interviewed. R8 was asked how she would feel if staff handled her roughly and placed the call bell out of reach. R8's response was normal, this is the most disorganized place, so many odd things go on here, it's an everyday experience. On 3/21/24 at 9:28 AM, resident #24 (R24) was interviewed. R24 stated sometimes they put the call light behind the pillow, and I can't find it and it makes me feel bad. On 3/27/24 at 9:06 AM, resident #11 (R11) was interviewed. R11 stated that one time she rang the call light, it took so long for staff to answer that she didn't think they were ever going to come, I was upset. When questioned how she would feel if staff came in and turned off the call light without providing assistance, R11 stated she would feel mad. R11 stated that if staff handled her roughly, she would not feel safe and would tell someone. The facility policy for Abuse, Neglect, Exploitation and Misappropriation effective date 11/30/14 was reviewed. Per the policy it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. Per the policy abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, punishment with resulting physical harm, pain, or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. The facility policy defines neglect as the failure of the center, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy listed examples of neglect as intentional lack of attention to physical needs including, but not limited to, toileting and bathing, and failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program, On 3/26/24 at 1:00 PM, during the end of the day meeting with the facility chief operating officer, chief clinical director, and regional director of clinical services (acting administrator) were made aware of the above concerns. No further information was provided. 2. For Resident #44 (R44) the facility staff failed to provide incontinence care for an entire 24 hour period, which resulted in neglect and subsequent psychological harm for the resident. R44 was admitted to the facility on [DATE]. Diagnoses for R44 included but were not limited to multiple sclerosis, muscle weakness, history of falling, and abnormal posture. R44's OSA (optional state assessment) Minimum Data Set (MDS - an assessment protocol), with an Assessment Reference Date of 3/19/2024, coded R44 with a BIMS of 13 out of 15, which indicated R44 was cognitively intact. On the afternoon of 4/16/24, it was observed and confirmed through staff interviews, that only one CNA, identified as CNA6, was assigned to care for all the residents on the East unit, where Resident #44 resided from 2 p.m. until 7 p.m. On 4/16/24 at 1:10 p.m., a phone interview was conducted with a certified nursing assistant (CNA #18, CNA18). CNA18 stated, [R44's name redacted] had been left saturated and it smelled like ammonia and the brief was brown and the resident said to me she felt like she was an animal and like she wasn't human. [R44's name redacted] said that she asked to be changed several times and was ignored by staff. On 4/16/24 at 3:00 p.m., an interview was conducted with R44. During the interview, R44 became tearful several times, while talking about the incident. R44 stated, I was left soaking wet last Thursday, and I mean I was soaking wet and did number two on myself and it was [CNA #6's name redacted] and another guy and they knew about it and in the end a nurse came and helped finally to clean me up. R44 stated, It made me feel like I didn't matter. R44 stated, I told the nurse I didn't feel like I was a human, and you don't see animals like that. R44 verbalized the feeling of not being human has been present since the day of the incident. R44 verbalized, this is not right, and it is unhealthy to be left in this condition. R44 stated, I am almost scared to touch the call button, because they don't come, excuses of why they cannot help and leave and don't come back, makes you angry and feel less than a person. R44 stated, it is so unhealthy and makes me feel ugly on the inside and makes me think something is wrong with me and I try to be nice to everyone but I have feelings and I don't understand it but still affects me and makes me want to leave here, what am I paying for to be treated like a dog, unhuman and to be a female it's pretty unhealthy. R44 verbalized that if unattended and left wet that R44 will not leave the room. R44 verbalized loving to come to bingo but has missed the activity because of being left wet, smelling, and upset. R44 verbalized feeling sad ever since that incident. R44 stated, I feel like I am an alien and didn't know it. I cry every day when I think about the incident and wonder how I will be treated today. It makes me angry on the inside, it's like I am sitting around waiting for another incident. On 4/16/24 at 3:50 p.m., an interview was conducted with CNA #6 (CNA6) and was asked about the incident involving R44. CNA6 stated, I say we are short staffed and see if I can find help. CNA6 verbalized the end of the shift is at 7:00 p.m. and the incident must have happened after the shift ended. CNA6 verbalized if R44 needed care it would have been provided before the end of shift or made sure to report it off to oncoming shift to take care of the issue. CNA6 stated, [R44's name redacted] does express concerns about things, [R44's name redacted] has been different since that incident towards me and her attitude. On 4/16/24, a review of the facility documentation was reviewed. A witness statement written by CNA18 and dated 4/11/24 was reviewed. This witness statement read in part, . [R44's name redacted] when we got to her, she was crying saying she wasn't changed since 4 am the night before she stated he left her, and she doesn't feel human for being left in the predicament she was in. On 4/16/24, a review of the facility documentation was conducted. A witness statement written by CNA #17 (CNA17) and dated 4/11/24 was reviewed. This witness statement read in part, .[R44's name redacted] was fussing about not being changed, me and [CNA18's name redacted] went into her room to help her and she starts crying saying she's been left in bed all day by [CNA6's name redacted] and hasn't been changed since 4 am the previous day she was soaked from head to toe. On 4/17/24 at 8:32 a.m., an interview was conducted with the administrator. The administrator reported that she was investigating two facility staff members, CNA17 and CNA18. During the investigation being conducted by the facility, CNA17 and CNA18 were asked to write statements and in the statement, it was noted that R44 made a complaint of the lack of care and feeling like she was not a human. The administrator verbalized that the human resource manager was helping with conducting the staff investigation. The administrator verbalized that no investigation involving R44 had been conducted. The administrator verbalized that he read the witness statements but stated, I read the statement incorrectly from 4/11/24 and I should have investigated the allegation made with [R44 name redacted]. I will go and talk with the resident now. On 4/17/24 a review of the clinical record was conducted and R44's care plan was reviewed. R44's care plan documented that R44 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease processes. R44's care plan also documented that assistance with all the activities of daily living (ADL's) is required from facility staff and that R44 was incontinent of bowel and bladder, for which staff were to check every two hours and assist with toileting as needed. On 4/17/24, a review of the clinical record was conducted and R44's ADL record was reviewed. The documentation reflected that R44 was incontinent of bowel and bladder daily and required total assistance. The facility policy for Abuse, Neglect, Exploitation and Misappropriation effective date 11/30/14 was reviewed. Per the policy it is inherent in the nature and dignity of each resident at the center that he/she be afforded basic human rights, including the right to be free from abuse, neglect, mistreatment, exploitation and/or misappropriation of property. The facility policy defines neglect as the failure of the center, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. The policy listed examples of neglect as intentional lack of attention to physical needs including, but not limited to, toileting and bathing, and failure or refusal to provide a service for the purpose of punishing or disciplining a resident, unless withholding of a service is being used as part of a documented integrated behavioral management program, On 4/17/24 at 10:20 a.m., a meeting with the administrator and DON was conducted, during which these concerns regarding R44 were expressed. The administrator verbalized that based on the CNA statements, R44 should have been assessed by the social worker but was not. The administrator went on to say she had talked with the resident today and that R44 had said everything was fine, the call bell was being answered, and that R44 did not have any concerns at this time. When questioned further, the administrator verbalized that the questions asked were 'how breakfast was', 'how is your day going', and if R44 needed anything or had any concerns this morning. The administrator was asked if any questions were asked to the resident about the incident on 4/11/24 and the administrator stated, No. The clinical chief of operations then verbalized that they would be more on point with the interview questions, and would go back to re-interview R44 about the incident. No additional information was provided prior to the exit conference.

Based on observation, staff interviews, resident interviews, clinical record review and facility documentation review it was determined that the facility staff failed to identify pressure wounds until they were an advanced stage for two residents (Resident #4, R4 and Resident #17, R17) in a survey sample of four residents reviewed for pressure wounds. This constitutes harm for both residents. The findings included: 1. For R4, the facility staff failed to identify a pressure ulcer until it was an advanced stage, with necrotic tissue that required surgical debridement at the time of discovery, which was harm. R4 was admitted to the facility on [DATE]. Diagnoses for R4 included but were not limited to cerebral infarction, unspecified, dysphagia, epilepsy, hyperlipidemia, and muscle weakness. R4's Quarterly Minimum Data Set (an assessment protocol, MDS) with an assessment reference date (ARD) of 10/30/23 coded R4 with a BIMS of three which indicates severe cognitive impairment. In addition, the MDS coded R4 requiring total dependence on staff, for Activities of Daily Living care and noted that R4 had a stage III wound that was not present on admission/readmission. R4 was non-verbal and therefore was unable to be interviewed with regards to the wound. On 3/26/24 a clinical record review was conducted. R4's skin assessment titled, [Company name redacted] weekly skin integrity review, was reviewed and identified that on 10/18/23 R4's skin was intact with only bruising to eyes and forehead with a hematoma to right side. On 10/25/23 and 11/08/23 the weekly skin integrity review showed redness to sacrum and skin was intact. On 11/15/23 the skin integrity review showed skin intact, and no impairments noted. R4's patient visit records from, Integrated Wound Healing, LLC (IWH), was reviewed and the note from 10/25/23 identified a stage III to left buttock pressure injury. The wound documentation read in part, . excisional debridement was completed with removal of devitalized necrotic tissue. On 11/8/23 IWH patient visit record reads in part, .stage III left buttock now re-identified on sacrum unstageable pressure injury. Performed excisional debridement of sacrum wound with removal of devitalized necrotic tissue. On 11/15/23 IWH patient visit record reads in part, .sacrum unstageable pressure injury has 90% thin adherent slough in three small circular areas, conservative sharp debridement was performed. Removal of devitalized necrotic tissue and there was scant bleeding. 2. For Resident #17 (R17), the facility staff failed to implement preventative interventions to prevent the development of and failed to identify a pressure ulcer until it was an advanced stage and required surgical debridement, which was harm. R17 was admitted to the facility on [DATE]. Diagnoses for R17 included but are not limited to Type 2 diabetes mellitus, mild protein malnutrition, muscle weakness, hypertension, and history of falls. R17's Quarterly MDS with an ARD 12/25/23 coded R17 with a BIMS of 13, which indicated no cognitive impairment. In addition, the MDS coded R17 requiring moderate assistance, for Activities of Daily Living care. On 3/26/24 a clinical record review was conducted. R17's care plan included a focus area for impairment to skin integrity, which was initiated 4/18/23, with a revision 2/27/24. The interventions did not include any measures to reduce pressure from oxygen tubing. R17's skin assessment titled, [Company name redacted] weekly skin integrity review, was reviewed and identified that on 2/3/24 R17 had scattered bruising to bilateral upper extremities and skin was intact. On 2/10/24 the weekly skin integrity identified that R17 had no skin impairment and skin is intact. On 2/16/24 the weekly skin integrity identified that R17 has no skin impairment and skin is intact. The skin integrity review did not identify the Stage III to left top of ear until on 2/23/24. On 3/26/24 a clinical record review was conducted. R17's patient visit record from, Integrated Wound Healing, LLC, was reviewed and identified on 2/14/24 a stage III pressure injury to left ear due to medical device. The IWH wound note read in part, .please make sure patient has foam protectors on oxygen tubing when wearing oxygen to help prevent future wounds. Conservative sharp debridement was performed. Removal of devitalized necrotic tissue, with scant bleeding. On 3/26/24 at 8:15 a.m. an observation was made of R17. R17 was sitting on the side of the bed without oxygen tubing on and had no wound dressing on the left ear wound. The left ear wound was observed and was a small open area with red tissue noted. No foam protectors were observed on R17's oxygen tubing to alleviate pressure to the ear. On 3/26/24 at 8:15 a.m. an interview was conducted with R17. R17 verbalized that the wound dressing will come off and R17 notifies the nurse and then sometime during the day the nurse will come in and apply another wound dressing. R17 pulled down the left ear down to show the surveyor the wound. R17 verbalized that the wound was tender at times. R17 verbalized removing the oxygen and putting it back on, several times during the day. R17 was not aware of any oxygen foam covers that should be on oxygen tubing. On 3/27/24 at 9:16 a.m. an interview was conducted with a certified nursing assistant, CNA #2 (CNA2). CNA2 verbalized that skin impairments checks are completed on the residents on their shower day. If a skin impairment is noted, it is reported to the nurse and documented on the facility document titled, skin monitoring, comprehensive CNA shower review. On 3/27/24 at 9:22 a.m. an interview was conducted with a licensed practical nurse, LPN#5 (LPN5). LPN5 verbalized that the CNA will fill out a bath sheet if they see a skin impairment and the nurse has to review and sign the bath sheet. The bath sheets are turned into the director of nursing and the unit manager daily for review. On 3/27/24 at 9:32 an observation was made of R17 with a gauze folded under the oxygen tubing to protect the left ear wound. On 3/27/24 at 9:38 a.m. an interview was conducted with the assistant director of nursing (ADON). The ADON verbalized that if a CNA finds a skin impairment, the aide should notify the nurse in charge. The ADON verbalized that the nurse should do a complete skin assessment, and get the wound nurse involved and notify the physician and responsible party. The ADON stated, I don't know how it is done here, I personally would implement a treatment within my scope of practice and the treatment is based on the type of area and I am not sure because I have only been here 9 days. The ADON verbalized the nurses should document what they see on the skin, with every skin assessment. On 3/27/24 a review of facility document was conducted. A policy titled, Skin and wound, reads in part, .nurse to complete skin evaluation weekly and prior to transfer/discharge and document in the medical record. CNA to complete skin observations and report to Nurse. Document presence of skin impairment/new skin impairments when observed and weekly until resolved. Nurse to report changes in skin integrity to the physician. On 3/26/24 at 12:11 p.m. The Chief Clinical Director verbalized I notice that wounds were being reviewed and presented a facility document titled, Plan for wounds at [facility name redacted], beginning week of 3/26/24. The document reads in part .current residents were reassessed by Licensed Nurse using a Braden scale to determine those at risk for skin breakdown. Regional director of clinical will conduct train the trainer education with the director of nursing and nurse managers to ensure skin is assessed daily, supplements are given as ordered, skin impairments are reported to the nurse and nurses notify the physician. The facility had failed to self-identify the deficient practice prior to the survey and therefore past non-compliance was not achieved. On 3/27/26, an end of the day meeting was conducted with the regional director of clinical services and other corporate staff, during which they were informed of the above concerns. No more information was provided.

Based on resident interview, staff interviews, clinical record review and facility documentation review, the facility staff failed to provide incontinence care for one resident (Resident #44), in a survey sample of 48 residents, resulting in psychosocial harm. The findings included: For Resident #44 (R44) the facility staff failed to provide incontinence care for an entire 24 hour time period from 4/11/24 through 4/12/24, resulting in psychosocial harm. R44 was admitted to the facility on [DATE]. Diagnoses for R44 included but were not limited to multiple sclerosis, chronic obstructive pulmonary disease, muscle weakness, history of falling and abnormal posture. R44 OSA (optional state assessment) Minimum Data Set (MDS, an assessment protocol) with an Assessment Reference Date of 3/19/2024 coded R44 with a BIMS of 13, which indicated the resident was cognitively intact. On 4/16/24 at 1:10 p.m. a phone interview was conducted with a certified nursing assistant (CNA #18, CNA18). CNA18 stated, [R44's name redacted] had been left saturated and it smelled like ammonia and the brief was brown and the resident said to me she felt like she was an animal and like she wasn't human. [R44's name redacted] said she asked to be changed several times and was ignored by staff. On 4/16/24 at 3:00 p.m. an interview was conducted with R44. During the interview R44 became tearful several times while talking about the incident that occurred on 4/11/24. R44 reported that no incontinence care was provided from 4 a.m., on 4/11/24, until 4 a.m., on 4/12/24. During the interview, R44 stated, I was left soaking wet last Thursday, and I mean I was soaking wet and did number two on myself and it was [CNA #6's name redacted] and another guy and they knew about it and in the end a nurse came and helped finally to clean me up. R44 stated, It made me feel like I didn't matter. R44 stated, I told the nurse I didn't feel like I was a human, and you don't see animals like that. R44 verbalized the feeling of not being human has been present since the day of the incident, 4/11/24. R44 verbalized, this is not right, and it is unhealthy to be left in this condition. R44 stated, I am almost scared to touch the call button, because they don't come, excuses of why they cannot help and leave and don't come back, makes you angry and feel less than a person. R44 stated, it is so unhealthy and makes me feel ugly on the inside and makes me think something is wrong with me and I try to be nice to everyone but I have feelings and I don't understand it but still affects me and makes me want to leave here, what am I paying for to be treated like a dog, unhuman and to be a female it's pretty unhealthy. R44 verbalized that if unattended and left wet that R44 will not leave the room. R44 verbalized loving to come to bingo but has missed the activity because of being left wet, smelling, and upset. R44 verbalized feeling sad ever since that incident. R44 stated, I feel like I am an alien and didn't know it. I cry every day when I think about the incident and wonder how I will be treated today. It makes me angry on the inside, it's like I am sitting around waiting for another incident. On 4/16/24 at 3:50 p.m. an interview was conducted with CNA #6 (CNA6) and was asked about the incident involving R44. CNA6 stated, he tells the residents, I say we are short staffed and see if I can find help. CNA6 verbalized the end of the shift is at 7:00 p.m. and the incident must have happened after the shift ended. CNA6 verbalized if R44 needed care it would have been provided before the end of shift or made sure to report it off to oncoming shift to take care of the issue. CNA6 stated, [R44's name redacted] does express concerns about things, [R44's name redacted] has been different since that incident towards me and her attitude. On 4/16/24 a review of the facility documentation was reviewed. A witness statement written by CNA18 dated 4/11/24 was reviewed. In the witness statement CNA18 had written and read in part, . [R44's name redacted] when we got to her, she was crying saying she wasn't changed since 4 am the night before she stated he left her, and she doesn't feel human for being left in the predicament she was in. On 4/16/24 a review of the facility documentation was reviewed. A witness statement written by CNA #17 (CNA17) dated 4/11/24 was reviewed. In the witness statement CNA17 had written and read in part, .[R44's name redacted] was fussing about not being changed, me and [CNA18's name redacted] went into her room to help her and she starts crying saying she's been left in bed all day by [CNA6's name redacted] and hasn't been changed since 4 am the previous day she was soaked from head to toe. On 4/17/24 at 8:32 a.m. an interview was conducted with the administrator. The administrator reported she was investigating two facility staff members, CNA17 and CNA18. During the investigation being conducted by the facility, CNA17 and CNA18 were asked to write statements and in the statement, it was noted that R44 made a complaint of the lack of care and feeling like she was not a human. The administrator verbalized that the human resource manager was helping with conducting the investigation. The administrator verbalized that no investigation involving R44 had been conducted. The administrator verbalized that I read the witness statements and the administrator stated, I read the statement incorrectly from 4/11/24 and I should have investigated the allegation made with [R44 name redacted]. I will go and talk with the resident now. On 4/17/24 a review of the clinical record was conducted and R44's care plan was reviewed. R44's care plan had R44 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to disease process. R44's care plan had that assistance with all the activities of daily living (ADL) is required from facility staff. R44's care plan had that R44 was incontinent of bowel and bladder and staff were to check every two hours and assist with toileting as needed. On 4/17/24 a review of the clinical record was conducted and R44's ADL record was reviewed. R44 was incontinent of bowel and bladder daily and required total assistance. The ADL record for 4/11/24, was blank and not signed off as incontinence care having been provided. On 4/17/24 at 10:20 a.m. a meeting with the administrator and DON was conducted and the surveyor expressed the concerns regarding R44. Administrator verbalized based on CNA statements R44 should have been assessed by the social worker but was not. The administrator went on to say she had talked with the resident today and administrator verbalized that R44 said everything was fine, call bell was being answered and did not have any concerns at this time. The administrator verbalized the questions were how breakfast was, how is your day going and if R44 needed anything or had any concerns this morning. The administrator was asked if any questions were asked to the resident about the incident on 4/11/24 and the administrator stated, No. The clinical chief of operations verbalized they would be more on point with our questions and will go back to re-interview the resident about the incident. No additional information was provided prior to the exit conference.

Based on observation, staff interview, clinical record review, and facility document review, the facility staff failed to attempt appropriate alternatives prior to the use of side/bed rails, failed to assess residents for risk of entrapment prior to use, failed to review the risks/benefits of side/bed rails with the resident and/or resident representative and failed to obtain informed consent prior to use, failed to have a system in place to ensure residents beds were appropriate for the resident's size and weight, and failed to have a system in place for assessment and ongoing monitoring/supervision of side/bed rails in use. One resident (Resident #1) in the survey sample was identified as having his legs entrapped in the side/bed rails. Five additional residents (Resident #46, #89, #18, #80, and #97) were identified at risk for falls, had bed alarms due to attempts to get out of bed, and had side/bed rails in use. These six residents did not have attempted alternatives prior to the use of side/bed rails, proper assessment, consent, or ongoing monitoring/supervision of the side/bed rails. The facility census was 107 at the time of the survey. Forty-eight (48) residents had side/bed rails in use without assessments. The facility had not implemented the policy and procedure developed by the company, nor had they implemented new assessments and consent forms developed by the company in response to the (YEAR) regulation, thus identifying a system wide failure. Immediate Jeopardy (IJ) and SQC (substandard quality of care) was identified in the area of Quality of Care on 06/20/2019 at 5:02 p.m. The plan of removal for the immediacy was accepted by the survey team on 06/20/2019 at 9:40 p.m. The IJ was abated on 06/24/2019 at 3:42 p.m. with the Scope and Severity lowered to Level II, Widespread. Findings were: 1. Resident #1 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Diffuse TBI ([MEDICAL CONDITION]) with loss of consciousness greater than 24 hours without return to pre-existing conscious level, repeated falls, [MEDICAL CONDITION] and [MEDICAL CONDITION] following cerebral infarction affecting right dominant side, mixed receptive-expressive language disorder, cardiac arrhythmia, [MEDICAL CONDITIONS], spinal stenosis, and hypertension. A quarterly MDS with an ARD of 06/07/2019 (completed after his entanglement in the side rails), assessed Resident #1 as severely impaired in his cognitive function with a score of 01. The previous MDS was a annual assessment with an ARD of 03/08/2019, and assessed Resident #1 as moderately impaired in his cognitive status with a score of 09. A review of the electronic clinical record was done on 06/18/2019 at approximately 3:00 p.m Observed in the nurse's note section was the following entry: 06/07/2019 03:11 (3;11 a.m.) Res (resident) personal alarm noted sounding @ (at) 0215 this morning, staff immediately attending to the sound and entered res room. Res noted on the right side of bed at the nightstand, res was on left hand side with arm behind body and head on the fall mat. Res noted (with) bilateral legs in railing of bed, Assessment was performed on res, limitedly due to positioning of res at the time, res stated no pain at all. Multiple staff were attending, staff assisted res back to bed, assessment was completed thoroughly at that time and one noted marking on the back of reddened area, laterally, less than a half inch long . On 06/19/2019 at approximately 9:00 a.m., Resident #1 was observed sitting in his wheelchair next to his bed. A tab alarm was in place on his chair. He was wearing a self-releasing seatbelt. Resident #1 was able to remove the alarming seatbelt on request but he did not communicate verbally. There were no side/bed rails on his bed. An alarm box for a bed alarm was observed on his bed. The clinical record was reviewed on 06/19/2019 and included the following: SBAR (Situation; Background; Appearance; Review and Notify) forms were on the clinical record for the following falls: 12/11/2018: Resident found sitting next to bed facing wall, side rails still up on bed-no injuries noted .; 12/14/2018: Patient observed trying to roll himself out of bed .unable to reach in time to prevent patient from falling, pad alarm sounding .; 4/11/2019: Res found on floor on fall matt (sic) beside bed .; 05/14/2019: Res fell from bed @0155 (1:55 a.m.), landed on L (left) should which has had previous fx (fracture) with dislocation. Res screaming in pain, abrasion noted to L shoulder .sent to ER for eval; 06/07/2019: Staff assisted res when alarm was sounding res noted on floor @0215 .1/2 inch reddened abrasion to L lateral side . On 06/20/2019 at approximately 8:20 a.m., the clinical record was reviewed for bed rail evaluations, consents, and the attempt of alternates prior to using the side/bed rails. A quarterly data collection tool dated 03/08/2019 included: SIDE RAIL EVALUATION. The first area of yes/no questions were in regard to RESIDENT STATUS .Is the resident non-ambulatory? YES; Is the resident comatose, semi-comatose, obtunded, or has fluctuation in levels of consciousness? NO; Does the resident have alteration in safety awareness due to cognitive decline? NO; Does the resident have a history of falls? YES: Has the resident demonstrated poor bed mobility or difficulty moving to a sitting position on the side of the bed? YES; Does the resident have difficulty with balance or poor trunk control? YES; Does the resident have difficulty with postural hypertension? NO; Is the resident on any medications, which would require safety precautions? NO; Is the resident currently using the side rail for positioning or support? YES; Has the resident expressed a desire to have side rails raised while in bed for their own safety and/or comfort? YES; Has the resident requested that side rails not be released while sleeping? YES; Is the resident visually challenged? NO. The next area was INTERVENTIONS. The following interventions were checked: Periodic assisted toileting for resident at night; Verbal reminders to use the call light .RECOMMENDATIONS: Bilateral Quarter Rails .Side rails are indicated and serve as an enabler to promote independence .COMMENTS/RECOMMENDATIONS: Resident requires bilateral quarter side rails to provide bed mobility. There was no documentation in the clinical record regarding the attempt to use alternative measures prior to the use of side/bed rails, nor was there an informed consent for the use of the side/bed rails. On 06/07/2019, after Resident #1's fall from the bed and entanglement in the side/bed rails, an additional side/bed rail evaluation was completed. Under the area RESIDENT STATUS the questions were answered the same as the (MONTH) evaluation with the exception of the following: Does the resident have alteration in safety awareness due to cognitive decline? YES; Has the resident requested that side rails not be released while sleeping? NO. Under RECOMMENDATIONS the following was checked: Side rails do not appear to be indicated at this time. COMMENTS/RECOMMENDATIONS: Resident was using bilateral half rails to help position self when in bed however not indicated @ this time due to poor safety and cognition. On 06/20/2019 at approximately 9:00 a.m.,, the DON (director of nursing) was interviewed regarding side/bed rails in the facility. She stated that there was a tool in her office when she came to the facility and she had given it to the maintenance director. She was asked for the investigation regarding Resident #1's fall from his bed on 06/07/2019. A witness statement from 06/07/2019 was presented and contained the following: Res alarm sounded and myself/CNA (certified nursing assistant) (Name) noted res on fall mat on (R) (right) side of bed in front of nightstand. Res appeared in a position of majority of upper body weighted on res (L) side and (L) arm behind body-res noted with bilat legs in railing. Res upper body was fully over railing, at hips body was noted partially on mattress and bilat legs at area of railing. (L) (left) was noted under railing/mat and (R) leg overhead railing to mattress. CNA (Names) and this nurse present at time of transfer due to positioning, bed was slowly moved over for assessment, res stated, 'no' r/t (related to) pain, ROM (range of motion) wnl (within normal limits); transferred res to bed for further assessment. (L) lateral abrasion noted- (symbol for no) other noted injuries. At approximately, 10:30 a.m., on 06/20/2019 the maintenance director came to the conference room. He stated, I haven't measured the beds .(Name of former DON) developed this tool. He was holding a wooden rod with a flat round disc on the top an another on the bottom. He stated, This measures the sides of the mattresses, the head board and the footboard. (Name of former DON) did measurements on all the beds last year before you came to survey .I don't know where those measurements are and I haven't measured them since .I can look at a bed and see if there are gaps without measuring it. On 06/20/2019 at approximately 10:50 a.m. LPN (licensed practical nurse) #3 was called regarding her witness statement and was asked if she could explain what had happened. She stated, Yes, I was working and there were two CNAs working with me. The CNAs were in other resident rooms. We heard the bed alarm sounding and all went to the room. (Resident name) whole upper body was resting on the fall mat that was on the side of the bed where the air conditioner is .His left leg knee was touching the fall mat, part of his calf on his left leg was under the side rail, his right leg was over the rail. All of his weight was on his upper body on his left side .It looked like if you were doing a cartwheel and your first leg went down and the other leg was trying to come over .that's where he stopped, in the middle of the cartwheel .he couldn't go over any further because he got caught. LPN #3 was asked where the side rails were located on the bed. She stated, They were in the middle of the bed .his whole calf wasn't under the bed, just part of it if all his pressure hadn't been on his upper body he would have been hurt .he's a frail man, very limited in communication .he just had a reddened area on his side when we assessed him. On 06/20/2019 at approximately 11:50 a.m., a meeting was held with the DON, the administrator and the maintenance director. Questions were asked regarding the bed frames and mattresses. The maintenance director stated, All mattresses are purchased from the same company that the bed frames come from .when we replace a mattress I call the company and tell them what I size I need and they send it .all our mattresses come from them, the concave mattresses, air mattresses .all of them .Some of our beds are from hospice and they bring in their beds and mattresses and install them. I can see if the mattress fits the bed, I don't need to measure it .(Name of former DON) measured all the beds a year ago .he made the tool I showed you .he and (name of another employee) went room to room and made sure the rails did not exceed the tool measurements. The DON stated, We are looking for those measurements now. The DON was asked when the side/bed rails were removed from Resident #1's bed. She stated, They were removed after the fall (06/07/2019). She was asked if any alternatives had been attempted with Resident #1 prior to the use of his side/bed rails. She stated, I can't answer that I wasn't here at the time. The administrative team was asked how it was ascertained if the beds were the right size based on a resident's size and weight. The DON stated, We get the height and weight at admission. They were asked what the guidelines were regarding height and weight of the beds in use. The maintenance director stated, All the mattresses are 80 inches long .the maximum weight on the bed frame is 500 pounds, I don't know what the mattress is. The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. At approximately 12:30 p.m. the survey team conducted a walk through of the facility to determine what residents had side/bed rails either in use or available for use. It was determined that every bed in the facility except two had side/bed rails in place and available for use by the residents. Multiple beds had side/bed rails in the upright position at the time of the walk through. Five additional residents with side/bed rails up, bed alarms in place, and a history of falls, were identified at that time. Review of the five residents identified indicated that no alternatives to side/bed rails had been attempted prior to their use, no measurements or assessments were present to prevent the risk of entrapment, there were no informed consents present for the use of side/bed rails, nor was there a system in place for ongoing monitoring and supervision of side/bed rails in use. The team supervisor and the State Agency were contacted with the concerns identified by the survey team. The office concurred and Immediate Jeopardy with subsequent Substandard Quality of Care identified. At 5:00 p.m., on 06/20/2019 the administrator and the DON were called to the conference room. They were informed at 5:02 p.m., that the survey team with concurrence from the State Agency had identified immediate jeopardy with subsequent substandard quality of care. A system wide failure was identified due to the facility's failure to attempt appropriate alternatives prior to the installation of side/bed rails, had failed to assess residents for the risk of entrapment, had failed to review the risks of side/bed rails with residents or their representatives and obtain an informed consent for their usage. They had also failed to have a system in place to ensure that resident beds were appropriate for the resident's size and weight and failed to have a system in place for assessment and ongoing monitoring/supervision of side/bed rails in use. The administrative team was informed that one resident (Resident #1) had been identified as having his legs entrapped in his side/bed rails and five additional residents had been identified as having bed alarms due to the risk of falls and having side/bed rails in use without proper assessment and monitoring. The DON was asked to verify how many residents in the facility were using the side/bed rails on their beds. She verified that of the 107 residents residing in the facility, 48 had side/bed rails in use. At approximately 7:00 p.m., the facility administrator presented a blank side/bed rail evaluation form. The revision date on the form was 04/18. This form had been revised to include the regulatory requirements set forth in the (YEAR) Federal Long Term Care regulations for bed/side rails. Also presented with the side rail evaluation was an INFORMED CONSENT FOR THE USE OF BED RAILS form that was dated 05/18 and contained information regarding the benefits and potential risks/negative outcomes associated with bed rail usage. The back of the consent contained the following: Assessed medical needs addressed by the use of bed rails, the type of rails recommended for the resident, and the actual consent stating that the resident or representative had been informed of the medical need for the bed rails as well as the risks versus benefits of the rails. There were two choices for the person signing the form, I DO voluntarily consent to the use of bed rails . or I DO NOT consent to the use of bed rails . The bottom of the consent had a line for signatures, additional comments and the following Physician order has been obtained, including medical symptom/condition. In addition to the two forms detailed above, a policy and procedure for Side Rail/Bed Rail was presented. The effective date of the policy was 04/19/2018 and contained the following: POLICY: The Center, will attempt alternative interventions, and document in the medical record, prior to the use of side rail/bed rail. Side Rail/Bed rail may include but not limited to: Side rails, bed rails, safety rails, grab bars and assist bars. Procedure: 1. Prior to installation of a side rail/bed rail complete the side rail/bed rail evaluation to evaluate the resident for risk of entrapment. 2. Review the risk and benefits with the resident and/or representative. 3. Obtain consent from the resident and/or resident representative. 4. Obtain physician order for [REDACTED]. 6. Re-evaluate the use of side rail/bed rail, quarterly, with a change in condition or as needed. 7. Follow the manufacturers' recommendations and specifications for installing and maintaining side rails/bed rails. After reviewing the documents above, the administrator was asked where the forms had come from. He stated, They came from the corporate office. The revision dates on the two forms were pointed out to the administrator. He was asked if the revision dates/effective dates (April (YEAR) and (MONTH) (YEAR)) indicated the forms were implemented by the corporate office and should have been put into use at the facility at that time. He stated, Yes. He was asked how the information was communicated to the facility. He stated, An email was sent to either the administrator or the DON (director of nursing). He was asked if he had received the email. He stated, I don't recall ever seeing it. He was asked if the former DON had received it should it have been communicated to him. He stated, Yes. The plan of removal was accepted on 06/20/2019 at 9:40 p.m. and contained the following information: 1. The corrective action for the alleged deficient practice will be accomplished by: * The 5 identified residents were observed, the resident or RP was interviewed to identify who requested the bed rail to be installed, and assessed for the risk of entrapment from bed rails. * The bed rails were removed for 4 residents identified on 6/20/19. * Bed rails will be removed from beds of current residents with no assessment in place, an alternative measure will be put in place to assess the effectiveness prior to installing a side rail by 6/23/19. * (Resident #18's Name) RP (responsible party) was educated on the risks/benefits of the side rails and verbalized understanding and signed consent on 6/20/19. * Current staff working have been in serviced on the side rail/bed rail policy and F770 (typo should be 700) 6/20/19. * Staff not working will be in serviced on the side rail/bed rail policy and F770 (typo) prior to working their next scheduled shift by 6/23/19. Any staff currently on leave will be educated upon return. * For the 5 identified residents their bed was measured to ensure appropriate size and dimensions on 6/20/19 *The facility Executive Director and Director of Nursing have been educated via telephone on 6/20/2019 at 5:30 pm by the Regional Director of Clinical Services on the policy and federal regulations for side rails. The interdisciplinary team will be educated on the same policy by the Regional Director of Business Development on 6/20/2019 by 6:05 pm. 2. Residents with the potential to be affected by alleged deficient practice: Quality review of all residents currently with side rails in-house will be evaluated by a licensed nurse by 6/23/19 and alternative measures will be put in place i.e. - bed bolsters, bed alarm, tab alarm, low bed. Physician orders to be obtained and care plan revised by 6/23/19. Residents identified as candidates for side rail usage, will have risk and benefits reviewed and consent signed per the policy. Maintenance to provide measurements for bed and side rail to ensure no potential risk for entrapment by 6/23/2019. 3. Systemic Changes: I. Facility staff currently in the facility will be educated on policy regarding bed rails/side rails to include assessment schedule as well as risk on 6-20-2019. All other clinic staff will be educated prior to working their next shift. Staff not working will be in serviced on the side rail/bed rail policy and F770 (typo) prior to working their next scheduled shift by 6/23/19. Any staff currently on leave will be educated upon return. II. Residents with side rails/bed rails will be assessed quarterly and with any change of condition. III. Quality Review of residents with side rails weekly X 4 to ensure that risk and benefits, measurements, consent signed then monthly X 6 months IV. The quarterly assurance committee will meet monthly to review the results of quality review and make changes as necessary. On 06/21/2019 at approximately 9:00 a.m., the SBARs for Resident #1's falls out of bed were reviewed. After review, the DON was asked if Resident #1's side rails had been in the up position at the time of the falls, as only the fall out of bed on 12/11/2018 included information regarding the side rails. She stated, I don't know, I wasn't here then. I have looked for witness statements and I can't find them for any of the falls out of bed except the one on 06/07/2019. She was asked when the bed rails were removed for Resident #1. She stated, We removed them right after that fall. A meeting was held with the DON, the corporate nurse consultant and the administrator on 06/21/2019 at approximately 11:30 a.m. While discussing side rails the corporate nurse consultant stated, We know we need to put a process in place, it is broken. On 06/24/2019 the survey team returned to the facility. The plan of removal was reviewed for evidence verifying the plan had been fully implemented and no residents in the facility were in jeopardy. Information reviewed included the bed/side rail evaluations for the 48 residents identified by the facility as having bed/side rails in use. Of those 48 residents, the facility determined by use of the bed/side rail evaluation, that bed/side rails were not indicated for 30 of those residents. The remaining 18 residents or their RPs (responsible party) refused the use of alternatives to bed/side rails. For those 18 residents, bed/side rail assessments were completed, consents were signed, physician orders were obtained and the care plans were updated. The facility bed/side rail policy was also updated to include the following: Addendum: On going (sic) monitoring will include: 1) Side rail/bed rail will be monitored by licensed nurse per physician order; 2) Side rails will be lowered as indicated to provide care. toileting, hydration, meals and positioning; 3) Re-evaluate the use of side rail/bed rail, on admission, quarterly, and with any change of condition as needed by a licensed nurse. If the side rail/bed rail is no longer indicated the licensed nurse will notify maintenance for removal of the bed rail/side rail; 4) Maintenance will conduct routine maintenance of beds and side rail/bed rail to ensure they meet safety standards and are not in need of repair upon resident admission, readmission, significant change and quarterly. Education of staff regarding the changes to the use of bed/side rails was evidenced by in-service records and staff interviews. The Immediate Jeopardy was abated at 06/24/2019 at 3:42 p.m. The Scope and Severity was lowered from a pattern of Immediacy to a Level II, widespread. No further information was obtained prior to the exit conference. 2. Resident #46 was originally admitted to the facility on [DATE] and was recently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. A significant change MDS (minimum data set) with an ARD (assessment reference date) of 05/04/2019, assessed Resident #46 as severely impaired in her cognitive status with a summary score of 00. On 06/18/19 at approximately 12:00 p.m., Resident #46 was observed in bed, asleep, a tab alarm was in place, a fall mat was on the right side of her bed between her bed and the wall, a wedge cushion was on her left side, and an air mattress overlay was in place on her bed. At approximately 12:30 p.m., Resident #46 was heard yelling in her room, I can't breath, I can't breath. Staff went to the room and Resident #46 was observed with the head of her bed up, a lunch tray was in the room, Resident #46 was attempting to sit up in the bed. Staff went to the room and assisted her. The electronic record was reviewed at approximately 3;15 p.m., on 06/18/2019. Included in the documentation was the following note: 05/18/2019 19:46 (7:46 p.m.) Patient's bed alarm sounding off, patient found in the floor, between her bed and wall. Appears that patient had thrown her legs over the side of the bed. And d/t (due to) contractures in her legs, caused her whole body to fall. Patient states that she was making cookies when asked what had happened .Patient assisted back into bed, alarm in place and on. Wedge under patient's right side. Bed in low position The clinical record was reviewed for bed/side rail assessments. Two quarterly data collection tools, one dated 03/12/2019 and the other dated 03/19/2019, were reviewed. There was a section on the tool, SIDE RAILS with a yes or no question, Is the resident using Side Rails? Both tools were checked Yes and the type entered was Bil (bilateral) quarterly. Further instructions on the form were: If yes, complete additional Side Rails Evaluation. Side rails include bed rails, grab bars, assist rails. There were no Side Rails Evaluation observed in the clinical record. The care plan was reviewed. There was no mention of bed/side rails on the care plan. There were no physician orders, consent, or attempts at alternatives to bed/side rails documented in the clinical record. At approximately, 11:50 a.m., on 06/20/2019 the maintenance director was interviewed about measuring beds to ensure they were the proper size for a resident's height and weight with the use of bed/side rails. He stated that he had not measured the beds but that mattresses were ordered from the same company that the bed frames came from to ensure proper fit. He was asked about the air mattress overlay used by Resident #46. He stated, She is hospice, they bring in their own beds and mattresses and install them .that air overlay is over the LAL mattress (low air loss) . I can see if the mattress fits the bed, I don't need to measure it . The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. A system wide failure regarding side rails was identified by the survey team and Immediate Jeopardy was called at 5:02 p.m., on 06/20/2019. Resident #46 was included in the immediacy due to her lack of assessment for the use of her bed/side rails, her history of falls, and the use of a bed alarm to alert staff when she was trying to get out of bed. During the plan of removal the facility staff identified 48 residents with bed/side rails in use in the facility. Resident #46 was one of those residents. After a side rail evaluation was completed on 06/20/2019, it was determined by the facility staff that side rails were not indicated for Resident #46. On 06/24/2019 a walk through of the facility was conducted by the survey team. There were no bed/side rails on Resident #46's bed. During a meeting with facility staff on 06/24/2019 at approximately 4:30 p.m., the DON was asked if the bed/side rails had been up at the time of Resident #46's fall from her bed. She stated that she had been unable to find a witness statement regarding the fall and was unable to determine by the SBAR if the bed/side rails had been in the up position or not. No further information was obtained prior to the exit conference on 06/24/2019. 3. Resident #89 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: [MEDICAL CONDITION], weight loss, Chronic diastolic heart failure, anxiety, history of TIA ([MEDICAL CONDITION]), history of falls, and abnormal posture. A quarterly MDS (minimum data set) with an ARD (assessment reference date) of 05/29/2019, assessed Resident #89 as severely impaired in her cognitive status with a summary score of 03. On 06/18/2019 at approximately 12:00 p.m., Resident #89 was observed lying in her bed. A tab alarm was observed on her bed, and bilateral bed/side rails were in use. The clinical record was reviewed on 06/19/2019. The note dated 06/18/2019 written by the interdisciplinary team documented that Resident #89 continued to need her bed alarm. (A copy of the note was requested but was not received.) The care plan was reviewed. A focus areas, At Risk for Falls r/t (related to) poor safety awareness .frequent falls was observed. Interventions included but were not limited to: Resident has Velcro self release seatbelt for safety; Tab alarm in Bed-check function & placement Q (every) shift . Another focus area: .ADL self-care included the following intervention: Bed Mobility: The resident requires assistance from staff with bed mobility. There was no mention of side rails on the care plan. There were no physician orders, consent or attempts at alternatives prior to the implementation of bed/side rails documented in the clinical record. On 06/20/2019 at approximately 11:50 a.m., a meeting was held with the DON, the administrator and the maintenance director. The DON was asked why bed alarms were used in the facility. She stated, To alert staff when they are trying to get out of bed and they can try to get to them before they fall. A system wide failure regarding bed/side rails was identified by the survey team and Immediate Jeopardy was called at 5:02 p.m., on 06/20/2019. Resident #89 was included in the immediacy due to her lack of assessment for the use of her bed/side rails, her history of falls, and the use of a bed alarm to alert staff when she was trying to get out of bed. During a meeting with the DON (director of nursing), the corporate nurse consultant and the administrator on 06/21/2019 at approximately 11:30 a.m. The DON was asked why Resident #89 had bed/side rails. She stated,I don't know why she had them, she's not using them for bed mobility. During the plan of removal the facility staff identified 48 residents with bed/side rails in use in the facility. Resident #89 was one of those residents. After a bed/side rail evaluation was completed on 06/20/2019, it was determined by the facility staff that bed/side rails were not indicated for Resident #89. On 06/24/2019 a walk through of the facility was conducted by the survey team. There were no bed/side rails on Resident #89's bed. A meeting was held with the facility administrator, DON and corporate nurse consultant on 06/24/2019 at approximately 4:40 p.m., the DON was asked why the IDT had elected to leave Resident #89's bed alarm on during their last meeting. She stated, They continued the bed alarm because she sits up in the bed. It is to alert them before she gets up. No further information was obtained prior to the exit conference on 06/24/2019. 4. Resident # 18 was admitted to the facility 12/19/15 with a readmission date of [DATE]. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a significant change assessment and had Resident # 18 with severe impairment in cognition with a total summary score of 00 out of 15. On 6/20/19 at approximately 4:45 p.m. Resident # 18 was observed in bed with bed/side rails up. A review of the clinical record revealed there was no assessment for the use of the bed/side rails, and also documented several falls for the resident. The current POS (physician order summary) dated 6/2019 included an order for [REDACTED].

Based on observation, staff interview, and clinical record review, the facility staff failed to maintain nutritional status for two of 23 residents, Resident #4 and Resident #20. 1. Resident #4 suffered a significant weight loss of 14.9% (26.8 pounds) from July 2, 2014 until October 1, 2014 (A three month time period) resulting in harm to the resident. An annual review signed and dated by the RD (registered dietitian) on 09/19/2014 documented that Resident #4's had no weights recorded for August or September and had a history of [REDACTED]. Resident #4's weight was recorded on 09/03/2014 as 156.7 on the vital signs and weight record. The weight was obtained sixteen days prior to the assessment. 2. Facility staff failed to implement measures to address Resident # 20 ' s weight loss of 11.4 pounds (7.16% in 30 days), 19.4 pounds (11.8% in six months), and 16.7 pounds (10.15 % in six months). Findings were: 1. Resident #4 was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 03/03/2015. Resident #4 was assessed as having a cognitive summary score of "00", indicating severe impairment with her cognitive status. The clinical record was reviewed beginning on 03/17/2015 at approximately 3:00 p.m. The vital signs and weight record were observed. According to the documentation Resident #4 weighed 179 pounds on 07/02/2014. She refused to be weighed on the one attempt made in August. Further weights recorded were: 09/03/2014, 156.7 pounds; 10/1/2014, 152.2, and on 11/26/2014, 151.8. The dietary section of the clinical record was reviewed. An "Annual Nutrition Evaluation" was observed. The front of the evaluation was completed by the dietary manager and dated 09/15/2014. The height and weight section of the front of the page was completed, but the weight of 156.7 was crossed through, as if in error. The back of the evaluation was signed by the RD and included the following: "No CBW (current body weight) noted for Aug or Sept. Hx stable wts 177-180 (pound sign). Will monitor nutritional parameters routinely and alter interventions as indicated." Ongoing documentation from the RD was: 10/03/2014, "Oct wt(weight): 152.2 (pounds) down 14.97 % X (times) 3 months and down 14.11% X 6 months. Puree diet with Nectar liquids and MVI (multivitamin) with iron. Pt (patient) (with Stage II to coccyx reported by NS (nursing services). Recommend Prostat one oz (ounce) BID (twice a day) and Med Pass 60 cc (cubic centimeter) TID (three times a day). 9/24 Alb ([MEDICATION NAME]) 2.6-depleted. Following for response to change." 11/14/2014 "Pt with Stage II on sacrum, Puree with nectar liquids..10/10 DC Prostat and medpass per family request. High risk. Fortified foods initiated. 12/05/2014 CBW 151.8 (pounds) down 4.3% X 1 wk (week). Puree diet with nectar liquids. 10/10 Supplements DC (discontinue) per family request "G" (good) intake documented. Wts DC per family request. Declining. Following." 12/12/2014 "Pt with 2 Stage II pressure areas: sacrum and R (right) knee. Supplements DC per family request. Fortified foods ongoing. Declining status. Following." 01/15/2015 "Pt with 2 stage II areas reported. Sacrum and R lateral calf. Pureed diet with nectar liquids...no wt, no new labs. Supplements DC per family request. High risk. Following." 02/12/2015 "Pt with stage II pressure areas reported as above, ongoing. No supplements per family request. No wts. Declining and not expected to meet needs. PO (by mouth) as tolerated/desired. Following routinely." The physician order [REDACTED]."; and 10/10/2014 "D/C Prostat, (family preference), D/C Med Pass." No orders were observed in the clinical record for wts to be discontinued. The physician progress notes [REDACTED]. No documentation was present regarding Resident #4's weight loss or the decision to discontinue her supplements and weights. The care plan was then reviewed. Two different care plans were observed with the focus category "Nutrition/Hydration". The first was implemented 9/19/2014 with a target date of 12/19/2014. Information included: "Focus: The resident has potential for imbalanced nutrition. Etiologies: Disease process - [MEDICAL CONDITION], Swallowing problems, chewing problems, cognitive loss, obesity. As evidenced by: Nothing was entered in this area. Goals: The resident will not develop complications related to obesity, including skin breakdown, ineffective breathing pattern, altered cardiac output, diabetes, impaired mobility through review date. Approaches and Interventions: Weight per protocol, Administer medications as ordered. Monitor & report for side effects and effectiveness, Obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, Provide and serve diet as ordered." The second nutrition/hydration care plan was implemented on 02/12/2015 with a target date of 05/12/2015. Information included: "Focus: CAA 12 -The resident has imbalanced nutrition, Etiologies: Disease process -pressure, Swallowing problem, chewing problem, cognitive loss. As evidenced by: Weight change hx, no c/o (complaints of) hunger or thirst. Goals: None listed. Approaches & Interventions: Provide supplements as ordered: D/C per family, Provide and serve diet as ordered." The Unit Manager was asked if the second care plan (the most recent) took precedence over the first since the resident went from potential for imbalance nutrition to actual imbalanced nutrition. He stated, "Yes." The most recent MDS with an ARD of 03/03/2015 coded Resident #4 as a 4/2, indicating total dependence on staff for feeding. This was not addressed on the care plans. On 03/18/2014 at approximately 10:20 a.m., Resident #4 was observed sitting in her bed at approximately a 75-80 degree angle. She had two sippy cups (cups with lids and a spout) beside her bed. Both cups were filled with water and she drank without difficulty. On 03/18/2015 at approximately 10:40 a.m., this surveyor observed RN (registered nurse) #4 perform dressing changes to both pressure areas described above. According to RN #1 both areas were staged as Stage II pressure areas but were healing. She stated, that Resident #4 was resistant to turning in spite of the facility efforts. At approximately 1:00 p.m. on 03/18/2015, Admin #3 was asked if an order could be located that discontinued Resident #4's weights. She returned to the conference room at approximately 2:00 p.m. and spoke with this surveyor. She stated, "I can't find an order for [REDACTED]. The RD was interviewed on 03/18/2015 at approximately 3:00 p.m.. According to the RD she recommended that Resident #4 receive prostat and medpass on 10/03/2014 and the supplements were discontinued per the family request. She stated that she had started Resident #4 on fortified foods beginning on 11/14/2014. The RD was asked why there was no order on the clinical record for fortified foods. She stated, "I was told we don't need an order for [REDACTED]." The RD was asked how that information was communicated to the kitchen. She stated, "I tell them verbally." The RD was asked what fortified foods entailed. She stated, "I don't know the exact policy but it is extra calories, extra protein, at least one food per meal..her [MEDICATION NAME] was also decreased, it was down to 2.6...I like to see it greater than 3.4" The corporate RD joined the interview. She was asked about the fortified foods. She stated, "We don't need an order for [REDACTED]. A copy of the current day's meal tickets were obtained from the kitchen by another member of the survey team. The tray tickets did not indicate that Resident #4 was receiving fortified foods. The RD was asked if the tickets would indicate that the resident was on fortified foods. She stated, "Yes." The tickets for 3/18/2015 were shown to the RD and she was asked if she saw any indication that the resident was on fortified foods. She stated, "No, but that is just a snapshot." The surveyor who got the tray cards from the dietary manager stated, "(Name of dietary manager) said that she has a list of residents on fortified foods and (Resident #4) is not on there." Further review of the clinical record indicated that Resident #4 had been on 60 cc of med pass three times per day since March 26, 2013. Review of the MARs (medication administration records) from June 2014 through October 2014 indicated the following: June 2014 100% consumption on 88 of 90 passes, with 2 passes being 75%; July 2014 of the 92 passes recorded (one pass was blank) Resident #4 consumed 100 % of her supplement 88 times, 75 % once and 50% three times; August 2014 86 of 91 passes recorded, 84 at 100% consumption and 2 at 50%; September 2014 84 of 90 passes documented, 82 passes at 100%. one pass at 75 % and one at 50% consumption; October 2014 27 of 30 opportunities recorded, 25 at 100%, and 2 passes recorded as 50% consumption. The RD's recommendation to add Med Pass 60 cc on 10/03/2014 was a duplication of an order already in place and not a new intervention to address Resident #4's significant weight loss. During an end of the day meeting on 03/18/2015 at approximately 4:45 p.m., the administrator and the DON (director of nursing) were made aware of this surveyors serious concerns regarding Resident #4's significant weight loss, the discontinuation of her supplements, the discontinuation of the weights, and the lack of implementation regarding the RD's recommendation of adding a fortified diet. Admin #4 stated, "(Name of doctor) spoke with the family and had a conversation with the son regarding the supplements and the weights...the doctor is willing to talk with you." A time was set up to speak with the attending physician on 03/19/2015. On 03/19/2015 at approximately 8:30 a.m., this surveyor spoke via telephone with Resident #4's attending physician. He stated that Resident #4 had been a patient of his for many years. She was originally admitted to the facility with a PEG tube which was eventually removed as her PO intake improved. He stated that the had suspected that her stroke would progress quicker than it did, but over the past 6-9 months she had declined, was moving less and not eating as well. He continued that the resident was aphasic (an impairment of language) and seemed to be able to best communicate with her son. He stated, that he relied on the son to communicate to him information regarding the resident... happy, sad, comfortable, etc. He continued that he was "generally aware of Resident #4's weight loss." This surveyor then voiced the survey teams concerns regarding Resident #4's weight loss of 26.8 pounds (14.9%) from July 2 - October 1, 2014. He stated, "I must admit, I don't see much in the way of comments regarding her weight in my notes...I do share her care with the NP (nursing practitioner) and my partner." The physician was asked if he remembered speaking with the son regarding the discontinuation of Resident #4's weights and supplements. He stated, "Not specifically...I have 60-80 patients...I don't know if we had that exact conversation...we probably discussed it, but I didn't document anything about it or the weight loss." The physician was asked if he had been aware of the amount of weight the resident had lost. He stated, "There is nothing to defend here...sometimes when residents are in the facility for long periods of time the changes don't seem as dramatic as they do on paper...I don't recall knowing about this...26 pounds in that short amount of time is pretty dramatic." During an end of the day meeting on 03/19/2015 at approximately 2:00 p.m., the DON and the administrator the above information was shared. Again this surveyor voiced serious concerns regarding the weight loss of Resident #4, the lack of physician involvement regarding the weight loss, the lack of knowledge of the RD regarding the supplementation Resident #4 was receiving and the failure of the facility to implement fortified foods as recommended by the RD. No further information was obtained prior to the exit conference on 03/19/2015. 2. The facility staff failed to implement measures to address Resident # 20's weight losses of 11.4 pounds (7.16% in 30 days), 19.4 pounds (11.8% in six months), and 16.7 pounds 10.15% in six months). Resident # 20 in the survey sample, an [AGE] year-old female, was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to an Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 1/8/15, the resident was assessed under Section C (Cognitive Patterns) as being moderately cognitively impaired, with a Summary Score of 11 out of 15. Under Section K (Swallowing/Nutritional Status), at Item K0200 - Height and Weight, the resident's weight was listed as 148 pounds. At Item K0300 - Weight Loss, the resident was noted to have a weight loss of 5% or more in 30 days or 10% or more in six months that was not part of a physician prescribed weight loss regimen. On 2/5/15, Resident # 20's weight was 156.4 pounds. On 3/5/15, her weight was 145 pounds, a loss of 11.4 pounds (7.16% in 30 days). On 9/3/14, Resident # 20's weight was 164.4 pounds. On 3/5/15, the resident's weight was 145 pounds, a loss of 19.4 pounds (11.8% in six months). On 6/4/14, Resident # 20's weight was 164.4 pounds. On 12/8/14, her weight was 147.7 pounds, a loss of 16.7 pounds (10.1 % in six months). During the period 6/4/14 through 3/18/15, the date of record review, the resident received a pureed, controlled carbohydrate no added salt diet. On 12/5/14, the Registered Dietician (RD) made the following recommendation, "Recommend Med Pass 90 cc (cubic centimeters) TID (three times a day)." There was no documentation in the resident's clinical record that the RD's recommendation was followed. At 9:10 a.m. on 3/19/15, the RD was interviewed regarding her recommendation for the addition of Med Pass as a dietary supplement. Asked about the recommendation process, the RD said that she, "...submits the recommendation on a form. I am not told if the recommendation is accepted or not." At the request of the surveyor, the RD reviewed Resident # 20's clinical record and confirmed that she was not receiving the recommended Med Pass. On 1/14/15, based on an Occupational Therapy recommendation, a utensil with a red foam handle, and individual bowls for feeding was ordered for the resident. Observation of the resident during breakfast on 3/19/15, found her using a spoon with a red foam handle. Her food items were in individual bowls. On 3/5/15, the resident received an order for [REDACTED]. There were no other documented interventions to address Resident # 20's weight loss. A review of the meal slip listing the resident's dietary requirements, obtained from the Certified Dietary Manager on 3/19/15, revealed her diet included the use of fortified foods. The use of fortified foods was not a part of Resident # 20's clinical record, including her care plan. At 2:10 p.m. on 3/19/15, during a meeting with the Administrator and Director of Nursing Services (DNS), the process for approval of a recommendation by the RD was discussed. "The RD does not have writing privileges," the DNS said. "The recommendation goes to nursing and is discussed with nursing and the MD whether or not to follow the recommendation." The DNS went on to say that the decision was made not to follow the RD's recommendation for Resident # 20.

Based on observation, resident interview, staff interview, clinical record review, and facility document review, the facility staff failed to ensure proper application of a wanderguard (A transmitter attached by a band that is placed on the wrist, ankle, or wheelchair that prevents a resident from leaving the facility unattended or without staff knowledge) for one of 23 residents in the survey sample (Resident # 6), which resulted in the resident sustaining a laceration requiring sutures. The facility staff failed to properly apply a wanderguard safety device to Resident #6's right ankle, as a result the resident sustained [REDACTED]. Findings include: Resident #6 was admitted to the facility originally on 03/11/13. [DIAGNOSES REDACTED]. The most recent MDS (minimum data set) was a quarterly review dated 12/19/14. This MDS assessed the resident as having short and long term memory impairment with severe impairment in daily decision making skills. The resident was also assessed as requiring total assistance from staff with at least two staff members for bed mobility, transfers, dressing and toileting. An annual MDS assessment, with CAAS (care area assessment summary) dated 3/8/14 was reviewed for comparison. In the CAAS section of this MDS, the resident triggered for, but not limited to: cognition, communication, urinary, falls, and pressure ulcers. On 03/17/15 at approximately 3:00 p.m., Resident # 6 was observed in bed laying supine (on the back), covered with eyes closed. The resident's bed had 2 (1/4) side rails that were in the up position and an alarm was attached to the side of the bed. The resident's high back w/c (wheelchair) was sitting next to the bed, a pommel cushion (a device designed to help prevent patients from sliding forward or out of wheelchairs) was in the seat of the w/c, with bilateral leg rests and a foot board attached. During clinical record review on 03/17/15, an 'Emergency Department Dictation' dated 11/7/14 was reviewed and documented: "...Date of Service: 11/07/14 Time seen by MD (Medical Doctor): 05:43 (5:43 a.m.) PRESENTS FROM (NAME OF FACILITY) WITH LAC (laceration) TO RLE (right lower extremity) SUSTAINED WHILE STAFF WERE MOVING PT (patient) FROM BED TO WHEELCHAIR...The injury occurred in the past hour or so...7 cm (centimeter) laceration to her right leg. This is on the medial aspect about halfway down her tibial surface...Laceration repair--the patient had a 7 cm laceration of the right leg which I repaired...a total of 7 simple interrupted sutures..." Nursing notes were then reviewed. A nursing note dated 11/07/14 and timed 5:25 a.m. documented: "...When 2 CNA's (certified nursing assistants) (CNA # 2 and # 3) were transferring (name of Resident # 6) from bed to w/c she (resident) yelled ouch and when they looked down they stated she had a large gash on her right lower leg which was bleeding very heavily, they then yelled for me to come in and I applied pressure getting the bleeding to stop. Dr. (name of physician) was notified and ordered her to be sent to ER. All RP's (responsible parties) notified...signature of LPN (Licensed Practical Nurse) # 7." The next nursing note entry was dated 11/07/14 (no time) documented: "Resident also stated 'It's okay honey, I know you didn't mean to' after CNA told her she was sorry...signature of LPN # 7." Resident # 6's CCP (comprehensive care plan) dated 09/18/14 through present, was then reviewed and documented: "...09/18/14...At risk for skin breakdown related to: fragile skin, decreased mobility, incontinent of bladder and bowel, acute conditions: Over next 90 days will have no breakdown, Nutritional status will improve: (no interventions were checked for this section of the resident's CCP)" A hand written entry on this section of the CCP documented, "...01/08/15 skin tear right arm will resolve without complication...provide exposure to allergens." The Elopement section of the MDS documented: "Elopement risk 09/18/14-At risk for complications or decline related to use of physical restraint because of: Aimlessly propels self in w/c, Unawareness of safety hazards, Dementia [DIAGNOSES REDACTED].-release restraint for exercise and repositioning...continued evaluation every week by restraint reduction committee..." On 03/18/15 at approximately 8:30 a.m., the Unit Manager RN (Registered Nurse) # 3 was asked for the investigation regarding laceration to Resident # 6's leg. At approximately 9:30 a.m., the investigation was presented and reviewed and documented: "Name of Resident # 6 11/07/14 4:45 a.m., fresh bleeding assist x (times) 2...2 CNA's were getting resident out of bed and when they looked down her leg was cut open...Reviewed and signed by RN # 6 (previous DON-director of nursing)..." RN # 6 (previous DON) documented on the back of this sheet: "Looked at resident, ST (skin tear) caused by wanderguard band improperly placed. Band replaced...signature of RN # 6 (previous DON)." At approximately 10:40 a.m., RN # 3 (unit manager) and the RN # 1 (current DON) were asked if this was the complete investigation for Resident # 6. RN # 3 stated, "Yes, that's all." RN # 3 then looked at RN # 1 and RN # 1 voiced, that they (staff) would find out if there was anymore to the investigation. RN # 1 further voiced that it may be part of the facility's QA (quality assurance). RN # 1 and RN # 3 were both made aware that if there is additional investigative information regarding this incident, it needs to be presented and reviewed by the survey team. RN # 1 stated, "I'll have to check with (Name of Corporate Consultant) AS (administrative staff) # 4." At approximately 2:30 p.m., the DON (RN # 1) and AS (administrative staff) # 3 were interviewed regarding the above. The DON voiced that LPN # 7 was still an employee at the facility, but the two CNA's were no longer employed. The DON and AS # 3 were asked about the resident's CCP and was specifically asked, which interventions on the CCP applied to Resident # 6. AS # 3 voiced that the items should be checked if they apply to that resident. AS # 3 stated, "If it isn't checked it doesn't apply to the resident." The DON and AS # 3 were showed the resident's CCP that had few interventions checked/marked and were asked again, are they supposed to be checked. Both staff members voiced, 'yes, if they apply.' AS # 3 and the DON were asked at this time for any additional information, documentation or clarification regarding this incident. Any policy/procedure information was also requested at this time regarding significant injuries. At 3:30 p.m. a policy titled, "Accident and Incident Investigation" was presented and reviewed and documented: "...Certain accidents and incidents...will be investigated to determine root cause and provide opportunity to decrease future occurrences of the event...1. Any happening that is not consistent with routine operations of the facility or care of a resident will warrant the completion of an incident report. 2. Specified incidents will also warrant completion and investigation of the event. 3. The following events warrant the completion of designated investigative forms...c. Skin Tears-using the skin tear root cause investigation...4. The executive director and director of clinical services (DON) are to be notified immediately...6. The executive director, director of clinical services (DON) , or their designee, must begin a documented investigation of the cause of the injury. 7. The investigation will include interviews with the resident, all staff involved (directly or indirectly)...which may have had contact with the resident and may help with the investigation. Obtain statements...Results of the investigation will be reviewed by the director of clinical services (DON) to ensure completed and thorough. 10. If there is no reasonable cause to believe or suspect that an injury has been a result of abuse, or that neglect occurred: a. The investigation must be thoroughly documented using the investigative report form to show there is no cause to believe that abuse or neglect by staff caused the injury. b. The facility must use it Performance improvement process for problem identification and corrective action when necessary..." At 4:45 p.m., the administrator and DON were asked in a meeting with the survey team, if they had any information regarding the above. The administrator voiced that he was the administrator at the time of the incident and he recalled the incident, but could not provide specific details. The administrator voiced it was while staff were getting the resident up, but voiced that he couldn't recall if the wanderguard band got caught on something or not. The administrator was asked if this incident was reported to him. The administrator voiced, yes and again provided few details. Both, the administrator and DON were asked at that time if any type of action had been completed regarding this incident to prevent the possibility of a future event. Both staff members nodded their head in a 'no' side to side manner. On 03/19/15 at 8:30 a.m., LPN # 7 was contacted via telephone for an interview regarding Resident # 6. LPN # 7 voiced that she was very familiar with Resident # 6 and remembered the date and incident in question. LPN # 7 voiced that she heard the resident yell from the room and she went down to see what had happened. LPN # 7 verbalized that CNA # 2 and # 3 were transferring Resident # 6 from the bed to the w/c and at first they (staff) had no idea how it happened; LPN # 7 voiced that they looked all around and couldn't figure it out, because there was no blood on the bed or the w/c. The LPN voiced that after assessing the resident and doing initial first aid, she then immediately called the physician and the physician instructed her to send the resident out for evaluation and treatment. LPN # 7 stated, "...the wound was pretty deep and you could see inside tissue (inside of the wound)." The LPN voiced that she was told by told the wound could have used more sutures, but her skin wouldn't hold them. LPN # 7 was asked who told her that and the LPN could not recall that information. The LPN again voiced, that after the resident was taken care of first, she (LPN #7) called the physician and then she (LPN #7) filled out the investigation sheet and had both CNA's ( # 2 and # 3) complete their statements, LPN # 7 stated, "I wrote a witness statement, also." LPN # 7 voiced that she then turned it all in together, the completed investigation (all documents) to the DON at the time, which was RN # 6. LPN # 7 stated, "The injury came from the wanderguard, the flap should have been on the inside, but was on the outside, it was a little loose and it (wanderguard) was replaced." The LPN was asked how did she know or find out that information. LPN # 7 voiced that the next day when she came in for work the current DON, who was acting as the ADON (assistant director of nursing) at the time told her, that is what they (staff) had determined. The LPN was asked if she spoke with the DON (RN # 6) regarding the incident. LPN # 7 stated, "No" and went on to say that she and the DON really didn't have a conversation about it, but voiced that the DON told her (LPN # 7) that she should come to day shift that she would learn a lot more and told her (LPN #7) that she could have used steri-strips on Resident # 6. LPN # 7 voiced that she saw the wound and it was deep and that she called the Dr. and he said to go ahead and send her out. LPN # 7 was asked what she could specifically remember about that morning and was asked if the lights were on and what was the resident wearing. The LPN voiced that the lights were on in the room, the resident's wanderguard was on her right leg and the resident was wearing Capri pants that morning and further voiced that a good part of the resident's legs were exposed. LPN # 7 also voiced that she (Resident # 6) had her booties on, also when this happened. At 2:00 p.m., the administrator, DON, and AS # 3 were interviewed with the survey team. The staff were asked again if there was any additional information/documentation regarding Resident # 6's significant injury. The administrator voiced, 'no, there may have been, but we can't find anything else.' The administrator was asked if he was or was suppose to be a part of the investigative process, when something like this happens, specifically in regards to Resident # 6. The administrator voiced that he was informed and that the nurse's usually handle most of it and he could not say that it was not a complete investigation The administrator stated, "I would believe the investigation to be accurate, unfortunately we can't produce (any additional information). The administrative staff were asked again, if any action had been taken to possibly prevent this from reoccurring. The DON (RN # 1) stated, "Yes we did check everyone with wanderguards." The DON (RN #1) was asked what the result was of that check. The DON stated, "I wasn't part of that, I can't say." The DON was asked who checked all of the resident's with wanderguards and when was it done. The DON again stated, "...I can't say..." The DON was then asked, how did he know that the wanderguards had even been checked, if he wasn't part of it and he did not know who performed the checks or when the checks occurred. The DON did not respond. A review of the wanderguard instruction manual named, " Wandering Management Transmitters User Guide " documented, " ...It is important for your facility to implement and enforce the following warnings ...Disregarding the information and instructions in this document is considered abnormal use and may result in injury or system failure ...Installation and configuration-It is the responsibility of the facility to follow the installation instructions carefully, as outlined ...WARNING STRANGULATIONS AND TRIPPING HAZARD- ...Cables and cords must be routed in a way to prevent tripping hazards ...WARNING USER TRAINING-Only users who have received adequate training on the use of the system, as outlined in this manual, should use the system. It is the responsibility of the facility to ensure all users have been trained ...The Adult transmitter is a small device placed on the ankle or wrist of a resident ...Banding the transmitters ...To fasten an Adult Transmitter: 1. Insert the band through the slot on one side of the transmitter, from the bottom to top. 2. Pull the band over the top of the transmitter and insert it through the slot on the other side of the transmitter, from the top to bottom. 3. Holding the transmitter in place, wrap the band around the wrist or the ankle of the resident. NOTE: To monitor a resident in a wheelchair, attach the transmitter to the seat or the back of the chair as the metal on the chair can interfere with the transmitter ' s signal. 4. Adjust the band so the transmitter is in a comfortable position or the resident ' s wrist or ankle; the band should be tight enough to prevent the transmitter from slipping off, and loose enough to prevent discomfort or possible edema. 5. Align the holes in the band with the snaps on the wide collar of the band. 6. Fold the flap of the wide collar of the band and squeeze the snaps together. 7. Use safety scissors to cut off the excess banding material ...Banding ...Features: One-time use, tamper resistant, latex free Material: Flexible PVC plastic ... " No further information or documentation was provided prior to the exit conference on 03/19/15 at 3:30 p.m., to evidence that the laceration incurred by Resident # 6's wanderguard was an unavoidable occurrence.

Based on observation, resident interview, family interview, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, the facility staff failed to follow infection control practices for one of two residents, Resident #1. Resident #1 was admitted to the facility with a Right Internal Jugular tunneled line. The facility failed to ensure the ports of the central line were capped to prevent infection, they did not assess the line, they did not obtain orders for the care and management of the line, and the staff was not knowledgeable regarding the type of line they were caring for. Resident #1 was on contact isolation and the facility staff did not ensure that staff donned PPE (personal protective equipment) prior to entering the room. This resulted in the identification of immediate jeopardy on 5/1/14 at 3:30 p.m. Findings were: Resident #1 was admitted to the facility on [DATE] with the following diagnoses, but not limited to: Crohn's disease with multiple fistulas, ileostomy, short gut syndrome, systolic heart failure, and VRE ([MEDICATION NAME]-resistant [MEDICATION NAME]). No MDS (minimum data set) was available for Resident #1 due to her recent admission. Information included on her Admission/Readmission Data Collection form, dated 04/23/2014, included information on cognition. According to the assessment Resident #1 was described as "Alert, oriented to person, place, time, short/long term memory OK and independent in daily decision making skills." Initial tour of the facility was conducted on 05/01/2014 beginning at approximately 11:45 a.m. Resident #1's room was located on the second floor of the facility. The door to her room was closed and the call light over the door was on. Observed on the door frame was a sign, "See nurse before entering room." This surveyor asked a staff member in the hall if Resident #1 was on isolation. She stated, "I don't know...I don't work up here...I will get you a nurse." LPN (licensed practical nurse) #1 was coming down the hall. She was asked if Resident #1 was on isolation. She stated, "Yes, I am going in there now." This surveyor donned a gown and gloves, knocked on Resident #1's door and entered the room. Introductions were made and this surveyor told Resident #1 that a complaint had been received regarding the care of her ileostomy and her central line and that this surveyor was there to investigate the allegations. Resident #1 stated, "Yes, they don't have any caps for my central line." An IV (intravenous) pump was observed on a pole beside the bed. An empty IV bag was hanging on the pole and IV tubing was threaded from the bag through the pump and attached to one of two ports observed protruding from the sleeve of Resident #1's hospital gown. The pump was not on and no fluids were running at that time. The other port was capped with an orange cap. Resident #1 continued. (Name of hospital) was suppose to call and tell them what I needed, I don't know where that got lost...I didn't have any pouches for my ileostomy over the weekend and it was leaking...they covered it with a towel until a friend of mine could go to my apartment and get some bags." At that time LPN #1 knocked on the door and entered the room. She addressed Resident #1 and stated, "I am going to disconnect you now." LPN #1 had on an isolation gown and nonsterile gloves. She disconnected the IV tubing from the central line port and flushed the port with a syringe containing normal saline. She then flushed the port with a syringe containing 5 cc of [MEDICATION NAME]. LPN #1 did not hold the open port in her hand between flushes but allowed it to rest on Resident #1's shoulder. She did not change gloves or wash her hands prior to the flushes or during the flushes. Resident #1 stated, "Do you have the caps yet?" LPN #1 stated, "No, I don't think we do." At that time a knock was heard at the door. LPN #1 went to the door, opened it with her gloved hand, and a staff member outside the door was heard to say, "Here are the caps." LPN #1 returned to the bedside and stated, "We haven't had caps for her PICC (peripherally inserted central catheter) line ports...I just got these, but they look like the ones I tried to use the other day that didn't fit." LPN #1 opened one of the caps and attempted to connect it to the port. She stated, "It's too small." She then stated to Resident #1, "These don't fit...I am going to cover this with an alcohol prep pad and go get some tape to secure it." LPN #1 then opened a new alcohol prep pad. She placed the alcohol prep pad over the open port and then slid the port into the wrapper the alcohol prep pad had been in. LPN #1 continued to wear the same gloves and did not wash her hands after opening the door or before opening the caps for the port. LPN #1 then laid the port back on Resident #1's chest, removed her gloves and went to the bathroom to wash her hands. When LPN #1 left the bedside the alcohol prep pad slid from the port and the open port was exposed. Resident #1 picked the port up in her bare hand and stated, "I am going to hold this until she gets back...I had an infected port-a-cath one time and I am pretty particular with this line...I don't want to get another infection." LPN #1 was asked if the physician was aware that there were no caps for the ports. She stated, "No, (name of doctor) doesn't know...he will be in today and I will tell him then." This surveyor then left the room at approximately 12:20 p.m. to continue the initial tour of the facility. At approximately 12:30 p.m., LPN #1 came down the hallway to speak with this surveyor. She stated, "They found some caps for her port and they fit." LPN #1 and this surveyor went into one of the resident living areas to talk. LPN #1 stated, "I've been working on this for three days...I don't know why she didn't have any caps for her ports...I called (Name of pharmacy) and they sent me the wrong thing...I tried these and they work...I am going to work on getting her more." LPN #1 was asked where the ports she had just gotten came from. She stated, "(Name of nurse) got them...they had them downstairs...I called down there and told them what I needed and they had some I could use." LPN #1 was asked if central supply was downstairs and if that was where the caps had come from. She stated, "No, we called the (name of nursing unit downstairs), they had them..I don't know where they got them, from the pharmacy maybe." At approximately 12:40 p.m. RN #4 was interviewed. RN #4 was the charge nurse on the unit which provided the caps for the ports. She stated, "We had them down there for another resident who has a PICC line." At approximately 12:45 p.m. the unit manager, RN (registered nurse) #3 was interviewed regarding Resident #1. RN #3 was asked what type of line Resident #1 had. She stated, "It is a PICC line." RN #3 was asked if she knew that one of the ports did not have a cap on it. She stated, "Yes, I knew that...she didn't have a cap on it when she came from the hospital." RN #3 was asked if she was working when Resident #1 was admitted . She stated, "No,I wasn't here when she came in but I am 95% sure that there was no cap on that port." RN #3 was asked what had been done about the missing cap. She stated, "Well, we improvised like nurses do." RN #3 was asked if the physician had been notified that the port was not capped. She stated, "No, I don't think so." RN #3 was asked about Resident #1's isolation. She stated, "Yes, she is on contact isolation for VRE in her stool." RN #3 was asked if CNAs (certified nursing assistants) changed colostomy bags at the facility. She stated, "No, they empty bags but they do not change them...that is a nursing job." RN #3 was told that according to Resident #1 an "aide" had changed her ileostomy bag over the weekend and the bag had leaked. RN #3 was asked if she was aware that had happened. She stated, "No, I wasn't here over the weekend, I didn't know about that." RN #3 was asked if there were any concerns regarding infection since Resident #1 had an open port and a leaking ileostomy. She stated, "Well if I had known about that I could have helped them get supplies...I don't know why she didn't have anything up here but we could have gotten her something...the girl in charge of supplies is off today so I really don't know what was available then." A copy of Resident #1's care plan was requested and obtained. The initial care plan contained the following: "Goal: per protocol peripheral IV fluids." At approximately 1:10 p.m., the DON (director of nursing) met with this surveyor. The DON was interviewed regarding Resident #1. The DON was asked about the type of line for Resident #1. She stated, "I believe it is a PICC line in her chest." The DON was asked if she was aware that one of the ports was not capped. She stated, "No, I was not aware of that." Copies of policies regarding care of PICC lines were requested. The initial care plan obtained from Resident #1's unit was shown to the DON. The goal regarding the peripheral IV fluids was discussed. The DON was asked what the entry meant. She stated, "That would make you think the fluids are going through her arm...they aren't they are using the PICC line." At approximately 1:30 p.m. this surveyor notified the complainant, Resident #1's mother, that this surveyor was in the facility to investigate the complaint allegations. She stated, "I don't know what is going on there...she hasn't had any caps on her central line all weekend...I just don't think covering it with an alcohol pad is good enough..." The clinical record was reviewed at that time. Nursing documentation throughout the clinical record referred to the line in Resident #1's chest as a PICC line. The POS (physician order [REDACTED]. Flush 5 cc NS Q (every) shift [MEDICATION NAME] 5 cc Q shift." There were no orders regarding dressing changes to the insertion site or changing the caps on the ports. An order on the chart dated 04/29/2014 read: "PICC Line dressings (4) Luerloc caps for PICC Line." Also observed in the clinical record was a discharge summary from a local hospital dated 04/23/2014. Information on the discharge summary included Resident #1's past medical history, including but not limited to: "September 2013: admitted to Gen Med for [DIAGNOSES REDACTED] (thought secondary to malnutrition form Crohn's), increased ileostomy output and hypoxic episode...discharged to (name of unit) for wound care and TPN (total [MEDICATION NAME] nutrition) for high output ostomy management, RIJ (right internal jugular) tunneled line placed 09/23/2013 for long term TPN." At approximately 2:10 p.m., a policy on Central Line Flush and Cap Change was obtained. According to the policy: "1. A cap change will be accomplished: With a dressing change; Once a week when a catheter is not in use. 2. Obtain a physician's orders [REDACTED]. 4. Provide privacy...5. Assemble the following: alcohol swabs; flush equipment; luer lock injection cap; sterile gloves. 6. Wash hands and follow standard precautions. 7. Put on sterile gloves. 8. Clamp central line...9. Open sterile injection cap and remove old injection cap; 10. Cleanse the luer lock threads with an alcohol swab; 11. Attach sterile injection cap and twist to secure; 12. Wipe the injection cap with an alcohol swab and attach normal saline solution to the injection cap; 13. Open the clamp, aspirate air bubbles in the cap in normal saline syringe by gently pulling back on the plunger. Tap the syringe to allow air bubbles to rise to the top; 14. Flush catheter with 5 cc normal saline. Wipe with alcohol swab. 15. Repeat #14 with [MEDICATION NAME] flush protocol...Clamp the line..." At approximately 2:20 p.m., this surveyor and the DON went to speak with LPN #1. LPN #1 was asked what type of gloves she was wearing when she flushed Resident #1's line. She stated, "Nonsterile." LPN #1 was asked if she had aspirated air bubbles prior to injecting the saline or the [MEDICATION NAME]. She stated, "No." LPN #1 was asked if additional caps for Resident #1's ports had been obtained. She stated, "No, that's who I was just on the phone with...I know what we need I am just having a hard time getting them." The Co-medial director, who was also the attending physician for Resident #1 was on the unit and was asked if he could speak with this surveyor. He was asked what type of line Resident #1 had. He stated, "It is a central line." He was asked if he was aware that one of the ports had not been capped. He stated, "No, I was not aware of that." He was asked what he thought about the line being uncapped. He stated, "Either we provide the care needed or we send them somewhere that can provide the care...they can go to the emergency room if needed." The physician accompanied this surveyor to the conference room to review Resident #1's clinical record. The section regarding the RIJ tunneled line was shown to the physician. He stated, "I am not familiar with the term tunneled but what she has is a central line." The physician was asked if the terms central line and PICC line were interchangeable or the the same thing. He stated, "No. A PICC line is peripheral, it is in a smaller vessel...what she has is a central line going into a bigger vessel." He was asked what the implications were for an uncapped port. He stated, "A central line port should not be without a cap." He was asked if wrapping the open port with an alcohol prep pad and securing it was sufficient coverage. He stated, "No, not for a central line...I trust the nurse's I depend on the nurse's to let me know when something is going on...they usually do, but it looks like that didn't happen this time..a central line that is not capped would give rise to infection...that hasn't happened but if we don't have what a resident needs we need to send them somewhere that does." The physician was asked about orders for the care and treatment of [REDACTED]. He stated, "The orders come from the hospital initially...the nurse's copy them over and then run them by us (the doctors)...we add what we think is needed...again we depend on the nurse's to let us know if they don't have orders for things like the central line, and they usually do. It just didn't happen this time." Lippincott Manual of Nursing Practice 10th Edition on pages 92 and 93 states, "A tunneled catheter is inserted into a central vein (usually the [MEDICATION NAME], then the superior vena cava) and subcutaneously tunneled to an exit site approximately 4 inches (10 cm) from the insertion site...A Dacron cuff is located approximately ? to 1 inch (2 to 3 cm) from the exit site, providing a barrier against microorganisms...Examples of the tunneled catheters in current use are Hickman, Broviac, and Groshong." (1) After consulting supervisors at the state agency it was determined Resident #1 was at immediate risk of serious injury. At 3:25 p.m. this surveyor met with the DON and the administrator regarding the Resident #1's central line. They were informed of this surveyors concerns regarding the care being provided to the line, the lack of assessment regarding the line, the lack of physician notification regarding the lack of a proper cap to close the line, the lack of supplies in the facility to care for/cap the line, and the decreased knowledge of the staff for what type of line they were caring for. The facility staff was notified of Immediate Jeopardy (IJ) status (scope/severity of isolated, level 4) on 5/1/14 at 3:30 p.m. At 3:45 p.m., this surveyor went to the unit where the caps for the ports had been obtained. LPN #2 was interviewed. She stated, "We have a resident down here who has a PICC line in his left arm...we had some ports for him down here." LPN #2 was asked where the ports came from. She stated, "They come from the pharmacy, but if something happens and the pharmacy doesn't send them we have them in the stat box." LPN #2 was asked if the caps were in the stat box because of the resident on the unit who had a PICC line. She stated, "No, we keep them in there all the time." At approximately 4:00 p.m. this surveyor went back to Resident #1's room. The door was closed. After donning a gown and gloves this surveyor knocked and the door and was granted admittance into the room. CNA #1 was at the bedside and was emptying Resident #1's ostomy bag into a bedpan. CNA #1 was wearing gloves but did not have on an isolation gown. Resident #1 was assisting CNA #1 with the ostomy bag. When the ostomy care was completed, CNA #1 went to the bathroom, removed her gloves and then left the room. CNA #1 did not offer Resident #1 a cloth to wash her hands after assisting with the colostomy care. Resident #1 stated, "They found caps for my port." She then showed this surveyor the two ports. Both were capped. The dressing over the central line insertion site was observed. There was no date on the dressing to indicate when it had been changed. Resident #1 was asked when the dressing was changed. She stated, "I think they have done it once since I got here...I don't remember when...I'm just glad they have the caps now." Resident #1 was asked if the port was capped when she came from the hospital. She stated, "Oh yes, they had caps here...I think they were left over from the last time I was here, but they used them all and I haven't had any since the end of last week....I kept asking them when they would get them but they just got them a little while ago." Resident #1 was asked if the central line was the same line that was inserted in September 2013. She stated, "Yes, I was on TPN and lipids up until I fell at home...they are trying to see if I can do without it." Resident #1 then stated, "My therapist came in here to do my therapy this afternoon. She said I am on isolation and I can't leave the room...I didn't know I was on isolation...the therapy was easier in here but I would rather go to the therapy department." CNA #1 was interviewed at approximately 4:15 p.m. She was asked if she was aware that Resident #1 was on isolation. She stated, "Yes, I know...I just don't feel good today...I wasn't going to do anything but take her vitals and then she wanted me to dump her bag." CNA #1 was asked if she knew why Resident #1 was on isolation. She stated, "I think maybe[DIAGNOSES REDACTED] or VRE." CNA #1 was asked if she knew what she was suppose to wear in the room with Resident #1. She stated, "I should have had on a gown and gloves...I am sorry, I just don't feel good and I didn't do it...I am sorry." The facility policy. "Preventing Spread of [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE): Wear clean non sterile gloves when entering the room of a VRE infected or colonized resident...Clean non sterile gowns shall be worn when entering the room of a VRE infected or colonized resident due to the environmental significance of the organism...Note: A resident with VRE should be allowed to ambulate and participate in social and therapeutic activities as long as moist body substances (urine, feces...) are contained..." At approximately 4:40 p.m., this surveyor informed the DON and the administrator of the above information. On 05/01/2014 at approximately 6:10 p.m., the administrator, the DON and other members of the facility corporate team presented this surveyor with the facility's plan for removal of the immediate jeopardy. The form was titled: "Plan of Action Plan: Central line monitoring 5/01/2014" and contained the following information: Problem: Central line with no documentation, care plan not updated to reflect present (sic) of central line, no assessment documentation of central line, no MD orders and nurse's not knowledgeable on the care of a central line. Step I-Evaluation of System and immediate response: Caps applied to resident's central line. Updated MD orders to reflect residents care need regarding the central line. Care plan updated to reflect the present (sic) of the central line. Nurses on duty were educated on center's policy for the care of a central line. How to identify other residents: Assessment of other residents with central lines for care planning of central line, physician orders, and assessments. What measures were put in place to prevent reoccurrence: Licensed nurses in the center will be educated prior to their next scheduled shift on the center's policy on the care of a central line. In addition, education will also include assessments, MD orders and updating of care plans. How to Monitor to ensure the problem does not reoccurrence (sic): Director of Nursing Services/designee will monitor central lines daily to ensure staff is following MD orders. QA: The results will be reported to the monthly quality committee for review and discussion to ensure substantial compliance. Once the QA Committee determines the problem no longer exits (sic), then review will be completed on a random basis. In addition to the Plan of Action other items were presented including: a manifest from the facility's pharmacy verifying delivery of dressing change kits for the central line site, as well as luer tip caps to be used in the ports of the central line. Also presented were inservice sheets containing staff signatures of the staff on duty at the facility verifying inservice training on: Care plans, Infection Control and Isolation, Central Lines/PICC lines, and Central Line Care. The facility team also stated that any licensed staff not in the facility at the time the inservices were presented would be educated prior to their next scheduled shift. Resident #2 was added to the survey sample due to his similar [DIAGNOSES REDACTED]. After observation, clinical record review and staff interview no problems were identified with his care. After review of the facility's plan for the removal of IJ it was determined that the plan was appropriate and IJ was lifted at 6:20 p.m. The scope and severity of IJ was lowered to a scope and severity level of II, pattern. Additional inservice verification was presented to this surveyor at approximately 9:15 a.m., on 05/02/2014. The DON stated, "We also inserviced the therapy department...the therapist that was working with (name of Resident#1) is new to us and is from (name of another stated)...we have inserviced to be sure the therapists know that residents can come out of the room and go to therapy when they are on isolation." No further information was obtained prior to the exit conference on 05/02/2014. (1) Nettina, Sandra M. Lippincott Manual of Nursing Practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2014. *State Operation Manual Appendix P - Survey Protocol for Long Term Care revised 4/24/09 defines Level 4 as "immediate jeopardy, a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility." Level 2 is defined as, "noncompliance that results in no more than minimal physical, mental and/or psychosocial discomfort to the resident and/or has the potential (not yet realized) to compromise the resident's ability to maintain and/or reach his/her highest practicable physical, mental and/or psychosocial well-being as defined by an accurate and comprehensive resident assessment, plan of care, and provision of services." This is a complaint deficiency.

Based on observation, resident interview, staff interview, facility document review, and clinical record review, the facility staff failed to provide necessary care and services to attain or maintain the highest practicable well being for six of 24 residents in the survey sample, Residents #10, #1, #3, #5, #8 and #9. 1. The facility failed to effectively manage pain for Resident #10. 2. Resident #1 did not receive a fracture shoe as ordered by the physician. 3. Resident #3 did not receive insulin as ordered by the physician. 4. Resident #5 did not receive [MEDICATION NAME] as ordered by the physician. 5. Resident #8 did not receive [MEDICATION NAME] as ordered by the physician. 6. Resident #9 did not receive [MEDICATION NAME] as ordered by the physician. The findings include: 1. The facility staff failed to effectively manage pain for Resident #10 consistent with the plan of care. Resident #10's physician ordered [MEDICATION NAME] was unavailable for administration resulting in a decline in mood and physical functioning. [MEDICATION NAME] is defined in Lippincott's Nursing 2008 Drug Handbook on page 1328 as combination [MEDICATION NAME] used to treat pain. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 11/23/10 assessed the resident had no short or long term memory loss and needed no assistance with decision making. On 12/1/10 at 9:00 a.m., Resident #10 was interviewed. The resident stated that his "pain meds were out for about 4 days last week. Tylenol was not helpful. Once the pain medication was in I was able to do more. I cried every 4 hours." The clinical record was reviewed and revealed a physician's telephone order dated 11/16/10 to receive 1 [MEDICATION NAME] 5/325 milligrams (mg) every 6 hours as needed for pain. The physician's order sheet (POS) also included an order for [REDACTED]. The skilled nursing progress notes included a section for pain assessment. On 11/21/10 at 5:49 p.m., the back of the form documented that Resident #10 "requested and rec'd (received) Tylenol for pain with minimal + (positive) effect but did not request other pain meds at this time." At 7:30 p.m., Resident #10 "c/o (complained of) increased pain to LLE (Left lower extremity). States that pain medicine not enough." (Physician's name written here) notified and new order given." Resident #10's pain was assessed at 5 out of 10 during this time frame. A physician's telephone order dated 11/21/10 documented "DC (discontinue) Tylenol; [MEDICATION NAME] 5/500 milligrams (mg) 2 tabs PO (by mouth) q (every) 4 hrs (hours) prn (when needed) (for) pain." A skilled nursing progress note dated 11/22/10 at 2:00 p.m. documented the "Pt (patient) said his Left leg was hurting that PT (physical therapy) during therapy over the weekend pushed his leg back to far during exercise and immediately started to hurt. I informed the unit manager and she contacted therapy and talked to (name of therapy department employee they spoke with written here). (Therapy employee name written here) stated that Pt would have some soreness as his therapy is moving along." On the front of the progress note the resident's pain was documented as 6 out of 10 during the night shift and 5 out of 10 for both day and evening shifts. Further review of the skilled nursing progress notes revealed the following: 11/23/10 pain assessed as 7 out of 10 for the night, day and evening shifts. Resident #10 received pain medication at 12:30 a.m., 1:50 p.m. and 8:00 p.m. 11/23/10 at 2:55 a.m. "requested cold compress be put on Left knee and that was done." 11/24/10 no pain assessment documented. At 9:00 p.m. that the resident "cont (continues) on s/c (skilled care) for wound care of Left femur Fx (fracture) and Left arm Fx, pain mgm (management), PT, OT (occupational therapy)...given pain meds at 4:00 p.m. and 8:00 p.m. no pain meds left." 11/25/10 pain assessed as 2 out of 10 for the night shift, and 0 out of 10 for both the day and evening shifts. At 2:00 a.m. - That the resident "c/o mild pain. Resident has no [MEDICATION NAME]. Pharmacy notified. (Name of on-call physician written here) notified. New orders for Tylenol 500mg 2 PO q 4 hours until [MEDICATION NAME] is reordered. This was explained to resident and he is OK with it. Tylenol given at 11:30 p.m. and resident is sleeping." At 10:00 p.m. - "pain meds still has not arrived." 11/26/10 pain assessed as 0 out of 10 for the night shift, 3 out of 10 for the day shift and 4 out of 10 for the evening shift. At 2:00 a.m. - "Res. (Resident) still has no [MEDICATION NAME] available, even after pharmacy has been notified and has been using his Tylenol prn to get him through." At 3:00 p.m. - "c/o discomfort, Tylenol given. Effective." At 9:00 p.m. - "still no [MEDICATION NAME] available, talked to Dr on call (name of doctor written here) he faxed script to pharmacy." 11/27/10 pain assessed as 5 out of 10 for the night shift and 7 out of 10 for the evening shift. There was no pain assessment for the day shift. The back of the notes included the following: ? 4:00 a.m. - "Resident c/o (complained of) pain in Left leg medicated with 500 mg Tylenol 2 PO per order. That is the only pain med resident has. The other pain med has not come from the pharmacy and explained to resident." ? 5:00 a.m. - "Resident awake in bed eyes closed." ? 6:00 a.m. - "Resident awake and wanted some more pain med and said Tylenol did not help. Instructed it was too early for anymore Tylenol and that was all he had." ? 3:00 p.m. - "PRN Tylenol given per order. [MEDICATION NAME] not in from pharmacy until 1:00 p.m. Tylenol did seem to alleviate resident's pain after 2nd dose given, 1st dose was ineffective." ? 10:30 p.m. - "Medicated with [MEDICATION NAME] 2 tabs at 9:00 p.m. per res request." The PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ? 11/25/10 at 4:50 a.m. - Tylenol 500 mg 2 tabs - eff. (effective) ? 11/25/10 at 7:40 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/26/10 at 6:00 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/27/10 at 4:00 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/27/10 at 8:30 a.m. - Tylenol 500 mg 2 tabs - (-) not effective ? 11/27/10 at 1:00 p.m. - Tylenol 500 mg 2 tabs - (-) not effective ? 11/27/10 at 9:00 p.m. - [MEDICATION NAME] 5/500 mg tabs (no result documented) Resident #10's active care plan identified Resident #10 as being at risk for pain with the following interventions: ? "Pain assessment on admission, quarterly and daily." ? "Complete pain flow sheet." ? "Review flow sheet." ? "Determine factors to pain." ? "Medication as ordered." ? "Notify MD with new onsets of pain and when medications or interventions are not effective." ? "Attempt non-pharmacological interventions" 1. Encourage rest 2. Reposition 3. Warm/Cold compress 4. Massage 5. Room temp (temperature) change 6. Smooth linens 7. Relaxation techniques 8. Reminiscing 9. Diversions 10. Offer nutrition 11. Activities 12. Music Therapy 13. Bath/Shower ? "Therapy screen as needed and ordered." ? "Exercise as desired." ? "Medicate prior to procedures/activities." ? "Monitor for non-verbal s/s (signs or symptoms) pain (i.e. grimacing; crying; bracing; rubbing area; etc.)." According to the documentation above, Tylenol was not effective on 11/27/10 from 6:00 a.m. through 3:00 p.m. The physician was not notified in accordance with the care plan nor were any other interventions put into place to manage Resident #10's pain. An additional problem of nutritional needs and being at risk for weight loss was added to the care plan on 11/23/10. The problem section included "Complains of pain when he chews his food." There was no documentation regarding pain while chewing food. On 12/1/10 at 5:15 p.m., the administrator, director of clinical services, assistant director of clinical services and vice president of clinical services were advised of the findings during a meeting with the survey team. During this meeting, this surveyor asked for a copy of the facility's policy regarding unavailable medications. On 12/2/10 at 8:25 a.m., the vice president of clinical services was interviewed about Resident #10's order for Tylenol when [MEDICATION NAME] was unavailable from the pharmacy. The vice president of clinical services stated that Resident #10's "pain was addressed - Tylenol extra strength was ordered by the physician to substitute for the [MEDICATION NAME] until it came in from the pharmacy. The resident went to therapy during this time on the 26th and documentation shows that the Tylenol was effective." When this surveyor asked if the facility has any pain modalities set up for residents in the short term skilled care services for therapy, the vice president of clinical services replied "there are no pain modalities at facility, Resident #10 was care planned for pain." Then the vice president stated that the "[MEDICATION NAME] came in on the 27th at 1:00 p.m." On 12/2/10 at 9:15 a.m., licensed practical nurse (LPN) #1 was interviewed regarding medications being unavailable. LPN #1 stated that the facility staff are to "circle initials on the MAR, document in clinical record that the medication is unavailable and to call the pharmacy to verify first if the medication has been sent." LPN #1 stated that the "medications are supposed to be ordered a couple of days before they run out." On 12/2/10 at 11:10 a.m., the vice president of clinical services was asked for the policy regarding unavailable medications. The policy was provided to this surveyor. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services was asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that meant the medication was not administered. The facility's policy "Medication ordering and receiving from pharmacy provider" was provided to this surveyor. This policy, under procedure 2 states to "a) reorder medication (three to four) days in advance of need to assure an adequate supply is on hand." There was no procedure in this policy regarding what facility staff needs to do when medications are unavailable for administration. 2. Resident #1 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The minimum data set ((MDS) dated [DATE] assessed Resident #1 as having no memory problems and independent cognitive skills for daily decision-making. Resident #1's clinical record revealed a physician's order dated 11/22/10 for a "Fracture shoe to L (left) foot." On 11/30/10 at 3:50 p.m. an interview was conducted with Resident #1 in the privacy of Resident #1's room. Resident #1 was observed to have gauze wrapped around the left foot and without a fracture shoe in place. Resident #1 verbalized that the facility was supposed to be getting a fracture shoe to allow more mobility getting around his room. Resident #1 conveyed disappointment over the inconvenience of not being able to do for himself because of not having any protection to the left foot and the time it has taken to order the fracture shoe. On 12/1/10 at 9:45 a.m. LPN #2 (license practical nurse) was interviewed concerning Resident #1's fracture shoe. LPN #2 verbalized that she is responsible for ordering supplies for all residents. When asked by the surveyor about Resident #1's fracture shoe, LPN #2 verbalized the order was on her desk, but the shoe had not been ordered due to being off from work over the recent holiday. LPN #2 went on to say that she would order it today. The above finding was brought to the attention of the director of nursing and the administrator during an end of day facility staff/survey meeting on 12/1/10. No other information was presented prior to exit conference on 12/2/10. 3. Resident #3 did not have insulin administered as ordered by the physician. Insulin was held in response to low blood sugar readings without any physician's order or physician ordered parameters. Resident #3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The minimum data set (MDS ) dated 9/30/10 assessed Resident #3 as having short and long-term memory problems and severely impaired cognitive skills for daily decision-making. Resident #3's clinical record documented a physician's order for [MEDICATION NAME]to be administered three times per day for management of diabetes. The order stated for 3 units of insulin to be administered before breakfast, 4 units before lunch and 5 units before dinner. Resident #3's medication administration records (MAR) documented the resident was not administered insulin before breakfast on 8/14/10, 8/20/10, 9/25/10, 9/30/10, 10/27/10, 10/30/10 and 10/31/10. Insulin was not administered before lunch on 10/30/10. Notes on the MAR indicated [REDACTED]. There was no physician's order for the insulin to be held or any standing orders providing parameters for holding insulin. On 12/1/10 at 9:15 a.m. the licensed practical nurse unit manager (LPN #3) was interviewed about Resident #3's low blood sugars and the held insulin. After reviewing the record, LPN #3 stated, "They (nurses) should be calling the doctor. They should not be making that decision (to hold insulin). They should be calling the physician." On 12/1/10 at 2:15 p.m. LPN #3 stated she called the physician today and advised him about the low blood sugar readings and the held insulin. LPN #3 stated the physician was not aware of the low blood sugars or that the scheduled insulin was not administered. The administrator, director of nursing and vice president of clinical services were made aware of these findings on 12/1/10 at 4:45 p.m. 4. Resident #5 was not administered the pain medication [MEDICATION NAME] as ordered by the physician. Resident #5 was admitted to the facility on [DATE] with a re-admission on 5/5/10. [DIAGNOSES REDACTED]. The minimum data set (MDS) assessed Resident #5 as having no memory problems and modified independent cognitive skills for daily decision-making (some difficulty in new situations only). Resident #5's clinical record included a physician's order for [MEDICATION NAME] 10 mg (milligrams) to be administered each day at 6:00 a.m. and 12:00 p.m. for pain management. Resident #5's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The clinical record including nursing notes and MAR indicated [REDACTED]. 12/1/10 at 10:35 a.m. the registered nurse unit manager (RN #1) was interviewed about why Resident #5 missed doses of [MEDICATION NAME]. After reviewing the record, RN #1 stated, "There's nothing here (in nursing notes) or on back of the MAR. I'll have to check with the DON (director of nursing)." On 12/3/10 at 11:30 a.m. the vice president of clinical services stated RN #1 had investigated further about Resident #5's missed [MEDICATION NAME]. A copy of the investigation dated 12/1/10 stated, "[MEDICATION NAME] not given on 11/14, 11/15 or 11/22 at 6 a.m. by ...the nurse on duty. (Nurse) states she honestly does not remember, but (Resident #5) might have been asleep." On 12/1/10 at 4:45 p.m. and on 12/2/10 at 2:15 p.m. the administrator, DON and vice president of clinical services were made aware of these findings. 5. The facility staff failed to follow physician's orders for the administration of the medication, [MEDICATION NAME], for Resident #8. [MEDICATION NAME] is defined in Lippincott's Nursing 2008 Drug Handbook on page 1174 as an opthalmic used to treat pressure in the eye due to [MEDICAL CONDITION]. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 9/9/10 coded the resident as having no short or long term memory loss and needing no assistance with decision making. The clinical record was reviewed. The 11/1/10 to 12/31/10 physician's order sheet (POS) included an order for [REDACTED]. Resident #8's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the MAR indicated [REDACTED]. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services were made aware of the findings during a meeting with the survey team. During this time this surveyor asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that that meant that the medication was not administered. 6. The facility staff failed to follow physician's orders for the administration of the medication, [MEDICATION NAME], for Resident #9. [MEDICATION NAME] is defined in Lippincott's Nursing 2008 Drug Handbook on page 488 as a medication used to treat anxiety. Resident #9 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 11/2/10 showed that the resident has no short or long term memory loss and needs moderate help with decision making. The clinical record was reviewed. The 10/1/10 to 11/30/10 physician's order sheet (POS) included the order for the medication [MEDICATION NAME], 0.5 milligram (mg) as a half tablet to be administered to the resident at 8:00 a.m. and 4:00 p.m. The 11/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials circled and no other documentation on the front of the MAR. The 4:00 p.m. doses on 11/5/10, 11/12/10 and 11/23/10 through11/25/10 documented the nurse's initials circled with no other documentation on the front of the MAR. The back of the MAR indicated [REDACTED]. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services were made aware of the findings during a meeting with the survey team. During this time this surveyor asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that that meant that the medication was not administered.

Based on observation, clinical record review, resident interview, family interview, and staff interview, the facility staff failed to effectively assess and manage pain for 1 of 13 residents in the survey sample, Resident #112. The findings include: Resident #112 was admitted to the facility on [DATE] with, but not limited to the following Diagnoses: [REDACTED]. There was no Minimum Data Set (MDS) for comparison as the resident was a new admit. Hepatic [MEDICAL CONDITION] - "[MEDICAL CONDITION] disease of the liver causing an impairment in the detoxification of drugs, alcohol etc..." (Anderson, Anderson, Glanze, 1998, p. 344). Lumbar Laminectomy - "...surgical removal of the bony arches of the lumbar vertebrae; done to relieve pressure off the spinal cord" (Anderson, Anderson, Glanze, 1998, p. 914). [MEDICATION NAME] - "Management of severe pain; detoxification and maintenance treatment of [REDACTED]. Tylenol / [MEDICATION NAME] - "treatment of [REDACTED]. "Hepatic Impairment: Use with caution. Limited, low-dose therapy is usually well tolerated in hepatic disease/ [MEDICAL CONDITION]. However, cases of hepatotoxicity at daily [MEDICATION NAME] dosages < 4 g (grams)/ day have been reported. Avoid chronic use in hepatic impairment" (Turkowski, Lance, & Bonfiglio, 2006, p.32). [MEDICATION NAME] - "Management of moderate to severe pain..." (Turkowski, Lance, & Bonfiglio, 2006, p.927). "Opioid agonist therapy is an accepted medical treatment for [REDACTED]. [MEDICATION NAME] maintenance treatment (MMT), the most common form of opioid agonist therapy, is approved by all major medical and professional organizations concerned with addiction treatment...Undertreatment of [REDACTED]., 2000, p. 412). On 1/18/11 at approximately 2:53 p.m. Resident #112 was observed lying in bed with his eyes closed. This surveyor knocked on the resident's door and awaited entrance into the resident's room. Resident #112 stated he did not want any visitors because, "I don't feel good today." On 1/18/11 at approximately 3:00 p.m., Resident #112's clinical record was reviewed to include the following documentation: ? A History and Physical dated 1/10/11 which included: "Chief complaint: Legs weak and swollen. History of Present Illness: The patient is a [AGE] year old white male with [MEDICAL CONDITION], narcotic-dependent pai[DIAGNOSES REDACTED], multifactorial [MEDICAL CONDITION] of the combination of new onset [MEDICAL CONDITION], weakness, and [MEDICAL CONDITION], admission was requested. Past Medical History...2. chronic back pain for which he is now narcotic dependent on [MEDICATION NAME]. 3. status [REDACTED]. ? A hospital "Transfer Medication Orders" sheet which listed the medications the resident received at the hospital, included the medication, "[MEDICATION NAME] 5 milligrams by mouth every 6 hours as needed for pain." The medication was discontinued prior to the resident's discharge to the nursing facility and an as needed order for "Tylenol 650 milligrams by mouth three time a day for pain / fever" was added to the list of discharge medications. Skilled nurse's notes were reviewed to include the following: ? "1/13/11 0350 (3:50 a.m.) Restless at the beginning of shift. Stated his back was hurting and he wanted something for pain. Tylenol was ordered and was offered to resident but he refused. Stated he could not take Tylenol because of his [MEDICAL CONDITION] of the liver. I explained to (Resident named) that the doctor had reviewed his meds (medicines) this afternoon and that the Tylenol was a low dose and only three times a day. The doctor felt this would be OK. Resident still refused to take the Tylenol..." ? "1/13/11 1400 (2:00 p.m.) ...He (Resident #112) complained of hip pain and received is [MEDICATION NAME] as scheduled...(sic)." ? "1/14/11 0304 (3:04 a.m.)...Has slept most of the night until this time. Is now complaining to this writer that (physician named) was in to talk with him on 1-13-11 and that they had discussed his pain medication and (physician named) felt the Tylenol would help his pain. Resident named said, "That damn doctor took 1/3rd of my medicines away." He (Resident #112) mumbled more curse words told me to forget it and get out of his room..." ? "1/14/11 1400 (2:00 p.m.)...He (Resident #112) enjoys going to PT (physical therapy) and walking with them..." A "Nurse's Assessment for Pain" dated 1/13/11 evidenced the resident was assessed for pain, using the pain scale of 0-10. He was assessed as a 4 (hurts little more) on the 11 p.m.-7 a.m. shift and a 6 (hurts even more) on the 7 a.m.-3 p.m. shift. An "Admission Care Plan (CP)" dated 1/12/11 included pain with the following goals: "Resident will be as comfortable as possible" by implementing the following: ? Monitor pain ? Non-drug interventions ? Administer pain medications as ordered ? Eliminate or reduce causative factors On 1/18/11 at approximately 3:30 p.m., Resident #112 was observed lying in bed watching television; his right arm over was resting over top his forehead and his brows were slightly furrowed. Resident #112 agreed to an interview with this surveyor at this time. Resident #112 was asked about his pain. He stated, "I hurt all the time." When asked if he was hurting at the time of the interview, he stated, "Yes" and that his medications were taken away when he was admitted to the facility. Resident #112 then stated the staff wanted to give him Tylenol but because of his [DIAGNOSES REDACTED]." Resident #112 proceeded to state that he takes [MEDICATION NAME] three times a day and that the medication "only helped a little" in controlling the pain, "I have been hurting since I got here." He further stated he was taking [MEDICATION NAME] while in the hospital and when he "came to the nursing home the medicine stopped." Resident #112 stated that he did not know why the medicine was stopped but "I wish someone would tell me because I am in pain." On 1/18/11 at approximately 3:35 p.m., registered nurse and unit manager (RN #3) was interviewed regarding the nurse's notes dated 1/13 and 1/14/11 and the resident's refusal to take Tylenol and continued complaint of pain. RN #3 stated she reviewed the resident's [DIAGNOSES REDACTED]. RN #3 stated the 11-7 nurse did not report to her that the resident refused to take the Tylenol. RN #3 was asked if the resident's CP for pain management was effective, RN #3 stated, "Not if he is in pain." RN #3 further stated that the resident's doctor was in the facility and he, the physician, could explain why Tylenol was chosen. On 1/18/11 at approximately 3:52 a.m., the resident's physician (MD) was interviewed regarding Resident #112's complaint of pain and refusal to take Tylenol. The MD stated that he assessed the resident once on admission and ordered Tylenol for breakthrough pain. The MD stated he (Resident #112) was already on [MEDICATION NAME] and he did not recall the resident complaining of pain. The MD further stated that he saw the resident on 1/13/11 and explained to the resident that when he was discharged from the hospital they (the hospital staff) felt that the medicines were adequate. The MD stated, "This is the first time I'm hearing that there is a problem with pain management. I would have given him [MEDICATION NAME] or whatever he wanted." When asked if he (the MD) assessed the resident to see if the Tylenol was effectively managing his pain, the MD stated, "I don't recall. I can't answer without looking at the chart." On 1/18/11 at approximately 3:55 p.m., during the interview with the resident's MD, the vice president of clinical services stated that an initial assessment was done on admission and the resident did not complain of pain, "we did not know he was in pain. He's (Resident #112) an abuser and he is seeking pain medicines." On 1/18/11 at approximately 4:08 p.m., Resident #112 was observed lying in bed visiting with his mother. The resident's MD was in the room talking to Resident #112 and his mother. This surveyor overheard the MD telling Resident #112 that he was going to "initiate a consult for pain management, reorder his [MEDICATION NAME] and not delay his pain management any longer." At the above date and time, Resident #112's mother stated to this surveyor, "Thanks for getting him (Resident #112) something for pain. I hate to see him in pain when I come to visit." Resident #112 stated, "Thanks for getting the ball rolling." On 1/18/11 at approximately 4:09 p.m., a physician's telephone order was reviewed in the clinical record: "1/18/11 N.O. (new order) Consult (clinic named) for pain control." A physician's prescription was reviewed to include: "1/18/11 [MEDICATION NAME] 5 milligrams one by mouth every 4 hours as needed." On 1/18/11 at approximately 4:10 p.m., the resident's MD stated, "Thanks for bringing this to my attention. I had nine admissions on that day; normally I would have picked up on something like that." On 1/18/11 at approximately 4:15 p.m. a "Daily Record of Treatment" for PT (physical therapy) was reviewed in the clinical record to include the following: ? "1/13/11 ...PT eval (evaluation) done per MD (doctor / physician) orders...POC (plan of care) established. Gait c (with) RW (rolling walker) -20 min (minimal) A (assist), patient tends to put foot flat during initial contact, VC (verbal cues) to improve heel strike, step and stride length. Transfer training min (minimal) A (assist), reach out activities outside BOS (base of support) to increase dynamic stand balance, decrease risk of falls." ? " 1/14/11 ...Seated B (bilateral) LE (lower extremity) there (therapeutic) ex (exercises) c (with) 2# on R (right) and 0# on L (left) 3x15 reps (repetitions) and green TB (theraband) all joints and all planes to increase upper LE (lower extremity) strength for increase safety and I (independent) gait and transfers. Pt (patient) c/o (complain of) L (left) eye pain and feeling like his eye was going to pop out, took BP (blood pressure) and 144/77. Reported BP and sx's (symptoms) to nurse. Pt (patient) did not make any more complaint ..." ? 1/15/11 ...Seated B (bilateral) LE (lower extremity) there (therapeutic) ex (exercises) c (with) 2# on R (right) and 0# on L and green TB (theraband) (left) 3x15 reps (repetitions) all joints and all planes to improve strength for gait and transfers. Transfer training for sit to stand and SPT (stand pivot transfers) c (with) SBA (stand by assist) / CGA (contact guard assist) for safety. Gait training 1 x 175' c (with) FWW (front wheel walker) and VCs (verbal cues) to stay within FWW ..." ? "1/16/11 ..Pt (patient) complain of (R) right knee pain 8/10 (8 meaning hurts whole lot)...pt refused to walk and refused exercises." ? "1/17/11 Supervisory Notes/Comments/Barriers ...He is progressing towards all functional goals however no STG (short term goals) were met this week. He c/o (complain of) B (bilateral) LE (lower extremity) pain daily that limits his standing tolerance and overall activity endurance. Pt (patient) noted that his pain meds "only help a little" to reduce his overall discomfort. He has not yet reached max functional potential..." On 1/19/11 at approximately 8:00 a.m., Resident #112 was observed sitting up in bed, smiling as he ate his breakfast. He was interviewed at this time and asked how he was feeling. Resident #112 stated, "I got pain medication last night. I feel so much better, I still hurt a little but not as much as before." Resident #112 thanked this surveyor. On 1/19/11 at approximately 8:30 a.m., the physical therapy manager (PTA) was interviewed regarding the documentation dated 1/16/11 and 1/17/11. In regards to the PT note dated 1/16/11, the PTA stated that the therapist reported the resident's pain to nursing but there was no documentation and he was not sure what was done to address the resident's pain. The PTA stated that the physical therapist who saw the resident was a "prn therapist" and he would call him to see what happened on 1/16/11. When asked about the PT note dated 1/17/11, the PTA stated the note did not mean that the resident was not able to reach his max potential but that the resident "had not reached his max potential as of yet and we will continue to keep him on case load." When asked if the delay was due to the pain, the PTA stated, "I see what you mean. I don't know." On 1/19/11 at approximately 9:35 a.m., the nurse practitioner (NP) from the pain clinic was observed in Resident #112's room. This surveyor overheard the NP informing Resident #112 that she was going to increase his [MEDICATION NAME] and [MEDICATION NAME]; the NP then stated, "We are going to work together to control the pain so you can participate in therapy and other activities." On 1/19/11 at approximately 9:40 a.m., Resident #112 was interviewed and asked if pain was preventing him from participating in therapy and activities, Resident #112 stated, "Yes, weakness and pain but mostly the pain." On 1/19/11 at approximately 10:00 a.m., A "Pain Assessment Tool" dated 1/18/11 was reviewed in the resident's clinical record. The resident was interviewed by RN #3 and the following information was documented on the assessment tool: ? Location: both calfs (sp.), bilateral feet, and lower back. ? Pain scale: 5-6 (hurts even more). ? Intensity: Present 5 and one half. ? Quality: Ache, throb ? Onset duration, variations, rhythms: "always have pain, but pain medicine helps control it." ? Manner of expressing pain: Verbalize. ? What relieves the pain: "[MEDICATION NAME] helps but [MEDICATION NAME] helps more." ? What causes or increases the pain: Activity ? Sleep disruption: Yes. ? Physical activity reduction: Yes ? Other comments: "[MEDICATION NAME] helps my breakthrough pain." 1/18/11 1815 (6:15 p.m.) offered [MEDICATION NAME] 5 milligrams by mouth. Resident states, "I want to take it with my other bedtime medications..." A pain assessment note dated 1/19/11 was reviewed to include the following: "1/19/11 0630 (6:30 a.m.) Pain interview with Resident, he explained he has had constant stabbing pain over the past five days; however went on to explain he always has pain...He explained, "I have severe pain, but that's no different for me, sometimes at home I'd take an extra [MEDICATION NAME] pill when I thought I needed it...He explained his pain does keep him up and stops him from doing activities and he went on to explain he has been sleeping. Explained to resident a consult was written by his MD to bring extra help in for his pain control...(sic)." On 1/19/11 at approximately 10:15 a.m., a consultation note dated 1/19/11 by the NP was reviewed in the clinical record to include the following: "Pt (patient) seen for pain management...Today pain assessment indicates need to increase prn (as needed / necessary) in short-term. Will follow up tomorrow." A prescription dated 1/19/11 by the NP included the following order: "[MEDICATION NAME] 5 milligrams tablets two tablets by mouth q (every) 6 hours prn (as needed / necessary)." On 1/19/11 at approximately 10:45 a.m., the regional director, director of clinical services and the director of nursing (DON) were made aware of the above findings, the regional director stated, "He's a drug addict and I feel he's manipulating a lot of people to get what he wants. He gets his [MEDICATION NAME] and he's happy. His history clearly states he's addicted." The regional director of nursing responded in regards to Resident #112's pain, "He is not telling the doctor he's telling the nurses." The regional director of clinical services was interviewed and asked if it was the responsibility of the nurses or the residents to report concerns to the MD. The regional director of clinical services did not comment at this time. According to Simeca et al. (2000), "The [MEDICATION NAME]-maintained patient experiences as much pain in association with illness, injury, and surgery as do other individuals. [MEDICATION NAME] used chronically for maintenance does not treat acute or chronic pain. Therefore, the [MEDICATION NAME] patient needs adequate [MEDICATION NAME] medications. [MEDICATION NAME]-maintained patients who have pain often require relatively large doses of opioids at relatively short intervals to control their pain..." (p.421). "In the context of a medical problem such as pain, simple labeling of aberrant behaviors as abusive "drug seeking" is inappropriate. Without careful assessment...behaviors can be misinterpreted" (p. 413). On 1/19/11 at approximately 1:22 p.m., the regional director stated to this surveyor during a meeting with the survey team, "The PTA called the therapist who saw the resident on the 16th (1/16/11). The therapist did write for the pain scale 8/10, he did not tell the nurses." On 1/19/11 at approximately 2:12 p.m., licensed practical nurse (LPN) #1 was interviewed regarding the documentation in the nurse's notes dated 1/13/11 and 1/14/11 and if the MD was made aware of the resident's concerns regarding the Tylenol. LPN #1 stated that the Tylenol was ordered by the resident's doctor and because it was a "low dose" it was ok for the resident to take the medicine. LPN #1 stated that because the resident did not take the Tylenol offered to him "he was not in pain." LPN #1 was asked if the resident was assessed for pain LPN #1 stated, "Yes he was assessed for pain" and "he did not appear to be in pain." LPN #1 then stated that per her "nursing skills and assessment" she "would have called the doctor if she felt the resident was in pain." LPN #1 was made aware that according to her documentation in the nurse's notes dated 1/13/11 and 1/14/11, the resident verbalized that he was in pain. LPN #1 stated, "You were not here, I was and based on my nursing judgement and skills I felt like he was not in pain. LPN #1 was asked if the resident's complaint of pain and concern regarding the Tylenol was reported to the oncoming nurse's (7 a.m.-3 p.m. or first shift), LPN #1 stated, "Yes I reported that the resident refused to take the Tylenol and explained the reason; the day shift nurse's report to the doctor according to their judgement." On 1/19/11 at 2:20 p.m., LPN #1 was asked how they assess residents about their pain level and if they used the 1-10 pain scale assessment. LPN #1 stated "I ask residents most of the time where their pain is on the scale," otherwise "write the number down I feel the resident is by my nursing assessment." According to Potter and Perry (2005), "The extent to which nurses make assumptions about clients and pain seriously limits their ability to offer pain relief. Unfortunately, all people are influenced by biases based on their culture, education, and experiences. Too often, nurses allow misconception about pain to affect their willingness to intervene, many nurses even avoid acknowledging a clients pain because of their own fear and denial. Nurses may not believe a client report of pain if they do not "look" like they are in pain. Nurses are entitled to their personal belief; however, they must accept the client's report of pain and act according to professional guidelines standards physicians' statements policy and procedures and evidenced based research findings..." (p. 1235). Anderson, K. (Ed.), Anderson, L. (Ed.), Glanze, W. (Ed.) (1998). Mosby's Medical, Nursing and Allied Health Dictionary. Mountain Home: Publishers Editorial Services. Turkoski, B., Lance, B., & Bonfiglio, M. (2006). Drug Information Handbook for Nursing. Hudson: Lexi-Comp. Scimeca, M., Savage, S., Portenoy, R., & Lowinson, J. (2000). treatment of [REDACTED]. The Mount Sinai Journal of Medicine. 67 (5 & 6), 412-422. Potter P., & Perry A. (2004). Fundamentals of Nursing. St Louis: Mosby.

Based on staff interview, resident interview, clinical record review and facility document review, the facility staff failed to ensure physician ordered medications were available for administration for 3 of 24 Residents. (Residents #8, #10 and #20) The findings include: 1. The facility staff failed to ensure the physician ordered medication Percocet was available for administration for Resident #10. Percocet is defined in Lippincott's Nursing 2008 Drug Handbook on page 1328 as combination analgesic used to treat pain. Resident #10 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 11/23/10 assessed the resident had no short or long term memory loss and needed no assistance with decision making. On 12/1/10 at 9:00 a.m., Resident #10 was interviewed. The resident stated that his "pain meds were out for about 4 days last week. Tylenol was not helpful. Once the pain medication was in I was able to do more. I cried every 4 hours." The clinical record was reviewed and revealed a physician's telephone order dated 11/16/10 to receive 1 Percocet 5/325 milligrams (mg) every 6 hours as needed for pain. The physician's orders [REDACTED]. The skilled nursing progress notes included a section for pain assessment. On 11/21/10 at 5:49 p.m., the back of the form documented that Resident #10 "requested and rec'd (received) Tylenol for pain with minimal + (positive) effect but did not request other pain meds at this time." At 7:30 p.m., Resident #10 "c/o (complained of) increased pain to LLE (Left lower extremity). States that pain medicine not enough." (Physician's name written here) notified and new order given." Resident #10's pain was assessed at 5 out of 10 during this time frame. A physician's telephone order dated 11/21/10 documented "DC (discontinue) Tylenol; Percocet 5/500 milligrams (mg) 2 tabs PO (by mouth) q (every) 4 hrs (hours) prn (when needed) (for) pain." A skilled nursing progress note dated 11/22/10 at 2:00 p.m. documented the "Pt (patient) said his Left leg was hurting that PT (physical therapy) during therapy over the weekend pushed his leg back to far during exercise and immediately started to hurt. I informed the unit manager and she contacted therapy and talked to (name of therapy department employee they spoke with written here). (Therapy employee name written here) stated that Pt would have some soreness as his therapy is moving along." On the front of the progress note the resident's pain was documented as 6 out of 10 during the night shift and 5 out of 10 for both day and evening shifts. Further review of the skilled nursing progress notes revealed the following: 11/23/10 pain assessed as 7 out of 10 for the night, day and evening shifts. Resident #10 received pain medication at 12:30 a.m., 1:50 p.m. and 8:00 p.m. 11/23/10 at 2:55 a.m. "requested cold compress be put on Left knee and that was done." 11/24/10 no pain assessment documented. At 9:00 p.m. that the resident "cont (continues) on s/c (skilled care) for wound care of Left femur Fx (fracture) and Left arm Fx, pain mgm (management), PT, OT (occupational therapy)...given pain meds at 4:00 p.m. and 8:00 p.m. no pain meds left." 11/25/10 pain assessed as 2 out of 10 for the night shift, and 0 out of 10 for both the day and evening shifts. At 2:00 a.m. - That the resident "c/o mild pain. Resident has no Percocet. Pharmacy notified. (Name of on-call physician written here) notified. New orders for Tylenol 500mg 2 PO q 4 hours until Percocet is reordered. This was explained to resident and he is OK with it. Tylenol given at 11:30 p.m. and resident is sleeping." At 10:00 p.m. - "pain meds still has not arrived." 11/26/10 pain assessed as 0 out of 10 for the night shift, 3 out of 10 for the day shift and 4 out of 10 for the evening shift. At 2:00 a.m. - "Res. (Resident) still has no Percocet available, even after pharmacy has been notified and has been using his Tylenol prn to get him through." At 3:00 p.m. - "c/o discomfort, Tylenol given. Effective." At 9:00 p.m. - "still no Percocet available, talked to Dr on call (name of doctor written here) he faxed script to pharmacy." 11/27/10 pain assessed as 5 out of 10 for the night shift and 7 out of 10 for the evening shift. There was no pain assessment for the day shift. The back of the notes included the following: ? 4:00 a.m. - "Resident c/o (complained of) pain in Left leg medicated with 500 mg Tylenol 2 PO per order. That is the only pain med resident has. The other pain med has not come from the pharmacy and explained to resident." ? 5:00 a.m. - "Resident awake in bed eyes closed." ? 6:00 a.m. - "Resident awake and wanted some more pain med and said Tylenol did not help. Instructed it was too early for anymore Tylenol and that was all he had." ? 3:00 p.m. - "PRN Tylenol given per order. Percocet not in from pharmacy until 1:00 p.m. Tylenol did seem to alleviate resident's pain after 2nd dose given, 1st dose was ineffective." ? 10:30 p.m. - "Medicated with Percocet 2 tabs at 9:00 p.m. per res request." The PRN Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] ? 11/25/10 at 4:50 a.m. - Tylenol 500 mg 2 tabs - eff. (effective) ? 11/25/10 at 7:40 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/26/10 at 6:00 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/27/10 at 4:00 a.m. - Tylenol 500 mg 2 tabs - eff. ? 11/27/10 at 8:30 a.m. - Tylenol 500 mg 2 tabs - (-) not effective ? 11/27/10 at 1:00 p.m. - Tylenol 500 mg 2 tabs - (-) not effective ? 11/27/10 at 9:00 p.m. - Percocet 5/500 mg tabs (no result documented) Resident #10's active care plan identified Resident #10 as being at risk for pain with the following interventions: ? "Pain assessment on admission, quarterly and daily." ? "Complete pain flow sheet." ? "Review flow sheet." ? "Determine factors to pain." ? "Medication as ordered." ? "Notify MD with new onsets of pain and when medications or interventions are not effective." ? "Attempt non-pharmacological interventions" 1. Encourage rest 2. Reposition 3. Warm/Cold compress 4. Massage 5. Room temp (temperature) change 6. Smooth linens 7. Relaxation techniques 8. Reminiscing 9. Diversions 10. Offer nutrition 11. Activities 12. Music Therapy 13. Bath/Shower ? "Therapy screen as needed and ordered." ? "Exercise as desired." ? "Medicate prior to procedures/activities." ? "Monitor for non-verbal s/s (signs or symptoms) pain (i.e. grimacing; crying; bracing; rubbing area; etc.)." According to the documentation above, Tylenol was not effective on 11/27/10 from 6:00 a.m. through 3:00 p.m. The physician was not notified in accordance with the care plan nor were any other interventions put into place to manage Resident #10's pain. An additional problem of nutritional needs and being at risk for weight loss was added to the care plan on 11/23/10. The problem section included "Complains of pain when he chews his food." There was no documentation regarding pain while chewing food. On 12/1/10 at 5:15 p.m., the administrator, director of clinical services, assistant director of clinical services and vice president of clinical services were advised of the findings during a meeting with the survey team. During this meeting, this surveyor asked for a copy of the facility's policy regarding unavailable medications. On 12/2/10 at 8:25 a.m., the vice president of clinical services was interviewed about Resident #10's order for Tylenol when Percocet was unavailable from the pharmacy. The vice president of clinical services stated that Resident #10's "pain was addressed - Tylenol extra strength was ordered by the physician to substitute for the Percocet until it came in from the pharmacy. The resident went to therapy during this time on the 26th and documentation shows that the Tylenol was effective." When this surveyor asked if the facility has any pain modalities set up for residents in the short term skilled care services for therapy, the vice president of clinical services replied "there are no pain modalities at facility, Resident #10 was care planned for pain." Then the vice president stated that the "Percocet came in on the 27th at 1:00 p.m." On 12/2/10 at 9:15 a.m., licensed practical nurse (LPN) #1 was interviewed regarding medications being unavailable. LPN #1 stated that the facility staff are to "circle initials on the MAR, document in clinical record that the medication is unavailable and to call the pharmacy to verify first if the medication has been sent." LPN #1 stated that the "medications are supposed to be ordered a couple of days before they run out." On 12/2/10 at 11:10 a.m., the vice president of clinical services was asked for the policy regarding unavailable medications. The policy was provided to this surveyor. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services was asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that meant the medication was not administered. The facility's policy "Medication ordering and receiving from pharmacy provider" was provided to this surveyor. This policy, under procedure 2 states to "a) reorder medication (three to four) days in advance of need to assure an adequate supply is on hand." There was no procedure in this policy regarding what facility staff needs to do when medications are unavailable for administration. 2. The facility staff failed to ensure the physician ordered medication Timolol was available for administration for Resident #8. Timolol is defined in Lippincott's Nursing 2008 Drug Handbook on page 1174 as an ophthalmic used to treat pressure in the eye due to glaucoma. Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 9/9/10 showed the resident as having no short or long term memory loss and needing no assistance with decision making. The clinical record was reviewed. The 11/1/10 to 12/31/10 physician's orders [REDACTED].#8 twice daily at 8:00 a.m. and 4:00 p.m. The 10/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]'s initials circled. The back of the MAR indicated pharmacy notified n/a (not available)." On 12/1/10 at 5:15 p.m., the administrator, director of clinical services, assistant director of clinical services and vice president of clinical services were advised of the findings during a meeting with the survey team. During this meeting, this surveyor asked for a copy of the facility's policy regarding unavailable medications. On 12/2/10 at 9:15 a.m., licensed practical nurse (LPN) #1 was interviewed regarding medications being unavailable. LPN #1 stated that the facility staff are to "circle initials on the MAR, document in clinical record that the medication is unavailable and to call the pharmacy to verify first if the medication has been sent." LPN #1 stated the "medications are supposed to be ordered a couple of days before they run out." On 12/2/10 at 11:10 a.m., the vice president of clinical services was asked for the policy regarding unavailable medications. The policy was provided to this surveyor. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services was asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that meant the medication was not administered. The facility's policy "Medication ordering and receiving from pharmacy provider" was provided to this surveyor. Under procedure 2 states to "a) reorder medication (three to four) days in advance of need to assure an adequate supply is on hand." There was no procedure in this policy regarding what facility staff needs to do when medications are unavailable for administration. 3. The facility staff failed to ensure the physician ordered medications Restoril and Zofran were available for administration for Resident #20. Restoril is defined in Nurse's Pocket Drug Guide 2009 as a class IV sedative/hypnotic/benzodiazepine which is used for insomnia, anxiety, depression and panic attacks. Zofran is defined in Lippincott's Nursing 2008 Drug Handbook on page 711 as an antiemetic used to treat nausea and vomiting. Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The current minimum data set (MDS) with an assessment reference date (ARD) of 11/12/10 showed the resident as having no short or long term memory loss and needing minimal assistance with decision making. The clinical record was reviewed. The current physician's orders [REDACTED]. Zofran was ordered to be administered at 4 milligrams (mg) every 4 hours while awake at 8:00 a.m., 12:00 p.m., 4:00 p.m., 8:00 p.m., 12:00 a.m., and 4:00 a.m. Restoril was ordered to be administered at 15mg before bedtime at 8:00 p.m. The 11/10 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. The back of the MAR indicated [REDACTED] ? 11/7/10 - "Restoril not avail (available) pharm (pharmacy) states need script spoke to (physician's name written here) stated he would send script." ? 11/8/10 - "Restoril not avail spoke to pharm no script spoke with (physician's name written here) stated his nurse sent script." ? 11/9/10 - "Restoril not avail - called pharmacy - they are sending." ? 11/10/10 - "Restoril not avail spoke to (physician's name written here) at beginning of shift d/t (due to) ongoing problem." The 12/10 MAR indicated [REDACTED] ? 12/1/10 at 12:00 a.m., "Zofran 4mg was not available. Pharmacy was contacted as to when to expect Zofran. Pharm (pharmacy) stated on next pharmacy run." ? 12/2/10 at 8:00 a.m., "Zofran 4mg was not available. Pharmacy was contacted again and stated Zofran was coming during early pharmacy run." On 12/1/10 at 5:15 p.m., the administrator, director of clinical services, assistant director of clinical services and vice president of clinical services were asked by this surveyor for a copy of the facility's policy regarding unavailable medications. On 12/2/10 at 9:15 a.m., this surveyor saw Resident #20 and asked how they were feeling? The resident replied that they "could not keep anything down." Physical therapy and a certified nurse's assistant were in the room with the resident at the time. The resident had a full plate from breakfast on the tray table next to their bed. On 12/2/10 at 9:15 a.m., licensed practical nurse (LPN) #1 was interviewed regarding medications being unavailable. LPN #1 stated that the facility staff are to "circle initials on the MAR, document in clinical record that the medication is unavailable and to call the pharmacy to verify first if the medication has been sent." LPN #1 stated that the "medications are supposed to be ordered a couple of days before they run out." LPN #1 stated that they "called the pharmacy yesterday and today and the medication should have come yesterday." On 12/2/10 at 11:10 a.m., the vice president of clinical services was asked for the policy regarding unavailable medications. The policy was provided to this surveyor. On 12/2/10 at 2:15 p.m., the administrator, director of clinical services and vice president of clinical services were made aware of the findings during a meeting with the survey team. During this time this surveyor asked what it means when the nurse's initials are circled on the MAR indicated [REDACTED]. The administrator stated that meant the medication was not administered. The facility's policy "Medication ordering and receiving from pharmacy provider" was provided to this surveyor. Under procedure 2 states to "a) reorder medication (three to four) days in advance of need to assure an adequate supply is on hand." There was no procedure in this policy regarding what facility staff needs to do when medications are unavailable for administration.