Every finding on record at Lakeview Rehabilitation and Healthcare Center

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 2 of 2 medication cart observed for medication storage and for medication labeling. The facility failed to ensure insulin was dated when opened on the medication/nurse cart for the East Hall. The facility failed to ensure that insulin was labeled with a resident name the medication/nurse cart for the [NAME] Hall. These failures could place residents at risk for not receiving drugs and biologicals as needed, not receiving the right medication, medications being used passed their effective or expiration date, and a drug diversion.Findings included: 1. During an observation on [DATE] at 9:01 am, the medication/nurse cart on the East Hall A Lantus Solostar Pen (pre-filled long-acting insulin pen used to treat and manage diabetes) was not dated with the opened date. During an interview on [DATE] at 9:05 a.m., LVN A said she did not know why the insulin was not dated. LVN A said insulin should be dated with the date it was open because it was only good for 28 days after opening. 2. During an observation on [DATE] at 9:07 a.m., the medication/nurse cart on the [NAME] Hall had a Tresiba FlexTouch pen (pre-filled long-acting insulin pen used to treat and manage diabetes) without a resident name or opened date. During an interview on [DATE] at 9:08 a.m., LVN B said the Tresiba (insulin pen) was probably out of the emergency kit. LVN B said insulin from the emergency kit should be labeled with the name of the resident it was for and dated with an open date, so the wrong person did not get the wrong medication and because insulin pens are only good for 28 days after opening. During an interview on [DATE] at 1:32 p.m., the DON said she expected insulin pens that were labeled by the pharmacy with a resident's name on it to be dated when it was opened. The DON said if the nurses pulled an insulin pen out of the emergency kit, she expected the insulin pen to be labeled with the resident's name and date of birth who it was pulled for from the emergency kit and dated with the date it was opened. The DON said insulin was only good for 28 days after being opened. The DON said the importance of ensuring insulin was dated when it was opened was to ensure a resident was not given expired or ineffective medication. The DON said the importance of ensuring each insulin pen was labeled with the correct resident name was to ensure the right person was receiving the right medication. Record review of the facility's Medication Administration policy last revised [DATE] indicated, Medications are administered in a safe and timely manner, and as prescribed.Insulin pens containing multiple doses of insulin are for single-resident use only. Changing the needle does not make it safe to use insulin pens for more than one resident. Insulin pens are clearly labeled with the resident's name or other identifying information. Prior to administering insulin with an insulin pen, the nurse verifies what the correct pen is used for that resident.

Based on observation, interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 5 of 9 residents (Resident #7, Resident #13, Resident #25, Resident #34, and Resident #45) reviewed for abuse. 1. The facility failed to implement their policy when they did not complete incident reports after a resident-to-resident incident between Resident #34, Resident #13, and Resident #25 on 05/01/2025, and on 07/19/2025 for Resident #7. 2. The facility failed to implement their policy when they did not complete incident report after injury of unknown origin for Resident #45 on 07/31/25 and failed to document the training related to this incident. These failures could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of complete documentation of the incidents.Findings included: Record review of the facility's policy titled, Abuse Prohibition Policy, revised 06/02/2025 indicated, This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse. Physical abuse includes hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment. Verbal abuse is defined as the use of, oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Examples of verbal/mental abuse include, but are not limited to, cursing, yelling, saying things to frighten a resident. Resident to Resident Incidents: The following guidelines will be implemented when resident to resident incidences occur: 4. An incident report will be completed for the perpetrator and the victim. Reporting/ Response.2. The Abuse Coordinator will report . injuries of unknown origin will be reported withing 24 hours of the allegations. Investigation reporting i. and indicate any corrective actions taken. 1. Record review of Resident #34's face sheet dated 02/09/2026 indicated he was an [AGE] year-old male initially admitted to the facility on [DATE] with diagnoses which included cerebral infarction (stroke), spastic hemiplegia affecting right dominant side (muscle stiffness and weakness on the right side of the body), and intermittent explosive disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). Record review of Resident #34's Quarterly MDS assessment dated [DATE] indicated he was sometimes understood by others and sometimes he understood others. The MDS assessment indicated Resident #34 had a BIMS score of 6, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #34 did not have behaviors. The MDS assessment indicated Resident #34 required substantial/maximal assistance with personal hygiene, toileting hygiene, and partial/moderate assistance with showering bathing and setup or clean-up assistance for eating. Record review of Resident #34's care plan with a target date of 03/30/2026 indicated he had the potential to be physically aggressive. Resident #34's care plan indicated to analyze times of day, places, circumstances, triggers, and what de-escalated his behavior and to document it, to assess and anticipate his needs, to monitor/document/report as needed any signs and symptoms of him posing danger to himself and others. Record review of the Provider Investigation Report dated 05/05/2025 indicated, an incident date of 05/01/2025. The investigation summary indicated, Resident #34 was at a table in the front lobby with Resident #13 and Resident #25. Resident #13 and Resident #25 expressed their worries, real or imagined, at length to anyone they saw. Resident #34 was upset, and started telling them to shut up, but they did not respond positively to the negative attitude. Resident #34 started telling them that he was going to kill them if they did not shut up. Record review of a witness statement indicated LVN A was the nurse when the incident occurred. Record review of the Provider Investigation Report dated 07/22/2025 indicated, an incident date of 07/19/2025. The investigation summary indicated, Resident #34 was at a table in the front lobby with Resident #7, they started arguing. Resident #34 told Resident #7 to shut up and then grabbed her right wrist as she reached her hand out towards him and squeezed it. A volunteer of the facility intervened, and they were separated. The nurse assessed Resident #7 for any injury none were found and there were no complaints of pain. Record review of a witness statement indicated RN B was the nurse when the incident occurred. Record review of the Incidents Report with date range of 02/09/2025-02/09/2026 did not indicate an incident dated 05/01/2025 for Resident #34. An incident of physical aggression initiated was indicated on the Incidents Report for Resident #34 on 07/19/2025. Record review of Resident #34's electronic medical record on 02/10/2026 did not indicate documentation of the incidents on 05/01/2025 and 07/19/2025. 2. Record review of Resident #13's face sheet dated 02/09/2026 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included senile degeneration of the brain (deterioration of the brain which leads to cognitive decline, memory impairment, and changes in behavior and personality) and cerebral palsy (a group of neurological disorders that appear in infancy or early childhood and permanently affect body movement and muscle coordination). Record review of Resident #13's Comprehensive MDS assessment dated [DATE] indicated she was sometimes understood by others and sometimes she understood others. The MDS assessment indicated Resident #13's BIMS score was a 0, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #13 did not have behaviors. The MDS assessment indicated Resident #13 was dependent on staff for toileting, personal hygiene, and bathing, and required setup or clean-up assistance for eating. Record review of Resident #13's care plan with a target date of 04/11/2026 indicated she required total assistance from staff for meeting emotional, intellectual, physical, and social needs related to cognitive deficits. Record review of the Incidents Report with date range of 02/09/2025-02/09/2026 did not indicate an incident dated 05/01/2025 for Resident #13. Record review of Resident #13's electronic medical record on 02/10/2026 did not indicate documentation of the incident on 05/01/2025. 3. Record review of Resident #25's face sheet dated 02/09/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (weakness and paralysis of the left side after a stroke) and dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life). Record review of Resident #25's Quarterly MDS assessment dated [DATE] indicated she was sometimes understood by others and sometimes she understood others. The MDS assessment indicated Resident #25's BIMS score was a 0, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #25 did not have behaviors. The MDS assessment indicated Resident #25 required substantial/maximal assistance with personal and toileting hygiene, bathing, and setup or clean-up assistance for eating. Record review of Resident #25's care plan with a target date of 04/06/2026 indicated she had a potential to be verbally aggressive related to dementia. The care plan indicated to analyze key times, places, circumstances, triggers and de-escalate behaviors and to intervene before agitation escalated. Record review of the Incidents Report with date range of 02/09/2025-02/09/2026 did not indicate an incident dated 05/01/2025 for Resident #25. Record review of Resident #25's electronic medical record on 02/10/2026 did not indicate documentation of the incident on 05/01/2025. 4. Record review of Resident #7's face sheet dated 02/09/2026 indicated she was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included vascular dementia (loss of memory, language, problem solving and other thinking abilities that were severe enough to interfere with daily life) and essential primary hypertension (high blood pressure). Record review of Resident #7's Quarterly MDS assessment dated [DATE] indicated she was sometimes understood by others and sometimes she understood others. The MDS assessment indicated Resident #7's BIMS score was a 0, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #7 did not have behaviors. The MDS assessment indicated Resident #7 was dependent on staff for all ADLs. Record review of Resident #7's care plan with a target date of 05/11/2026 indicated she had the potential to be physically aggressive to other residents related to cognitive impairment. Resident #7's interventions included to assess and anticipate her needs, monitor seating positions when she was out of bed, and to intervene before agitation escalated, and engage her calmly in a conversation. Record review of the Incidents Report with date range of 02/09/2025-02/09/2026 did not indicate an incident dated 07/19/2025 for Resident #7. Record review of Resident #7's electronic medical record on 02/10/2026 did not indicate documentation of the incident on 07/19/2025. During an attempted phone interview on 02/10/2026 at 10:21 AM, RN B did not answer the phone. During an interview on 02/10/2026 at 10:28 AM, LVN A said if she was the nurse on 05/01/2025, the incident with Resident #34, Resident #13, and Resident #25, was not reported to her. LVN A said she did not remember anything being reported to her. LVN A said when there was a resident-to-resident altercation it should be documented in the progress notes, and an incident report should be completed. LVN A said documentation was important for everyone to know what happened. LVN A said it was important for an incident report to be completed so there was proper follow-up on the incident and the residents involved in the incident. During an interview on 02/10/2026 at 1:36 PM, the DON said when an incident happened, such as a resident-to-resident altercation, the nurses were responsible for completing an incident report, and within the incident report the nurses were able to document a progress note to ensure it was documented in the resident's electronic medical record. The DON said she was responsible for monitoring the nurses to ensure the documentation and incident reports were completed and the ADON provided her assistance with monitoring the nurses. The DON said every morning they looked at the incidents to ensure all incidents were documented properly and an incident report was completed. The DON said she did not know why the incidents on 05/01/2025 and 07/19/2025 were not documented in Resident #34's, Resident #7's, Resident #13's, and Resident #25's electronic medical records. The DON said she did not know why an incident report was not completed for Resident #34 on 05/01/2025. The DON said it was not necessary to complete an incident report for Resident #13 and Resident #25 for the incident with Resident #34 on 05/01/2025. The DON said it was not necessary to complete an incident report for Resident #7 for the incident with Resident #34 on 07/19/2025. The DON said an incident report was only necessary for the perpetrator. The DON said it was important for incidents to be properly documented and incident reports to be completed to ensure they had completed everything, so they knew what was going on with the residents, and for trending the incidents. During an interview on 02/10/2026 at 2:00 PM, the ADON said when there was a resident-to-resident altercation an incident report should be completed for all the residents involved. The ADON said the DON and Administrator reviewed the incidents to ensure they were properly documented, and incident reports were completed. The ADON said she did not know why the incident reports and documentation for the incidents on 05/01/2025 and 07/19/2025 was not completed. The ADON said it was important to complete incident documentation and incident reports to ensure there was proper follow-up, to keep the residents safe, to prevent other accidents/incidents, and to catch trends. During an interview on 02/10/2026 at 2:10 PM, the Administrator said his expectations were if something happened an incident report should be completed, and it should be documented. The Administrator said when an incident occurred, all residents involved should have an incident report completed. The Administrator said the DON was responsible for ensuring incidents were documented an incident report was completed. The Administrator said the incident report let them know if something happened, and without it they would not be able to properly adjust the residents plan of care. The Administrator said the incident reports prevented future issues. The Administrator said documentation should be completed so they would be able to identify the care they needed to provide and address any care practice issues. 5. Record review of a face sheet dated 02/11/2026 indicated Resident #45 was [AGE] years old, admitted to facility on 07/11/2023. Her diagnoses included severe obesity, diabetes (high blood sugar), muscle weakness, major depressive disorder recurrent psychotic symptoms (severe reoccurring depressive episodes accompanied by delusions or hallucinations), hypertension (condition in which the blood against the artery walls is too high), and anxiety disorder. Record review of Resident #45's care plan with revision dated 08/22/2025 indicated Resident #45 was high risk for falls related to her cognitive impairment and was dependent on transfers. She had fall on 07/20/2025. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #45 was usually able to make herself understood and usually understand others. She had a BIMS of 03 (severely impaired cognitively). She exhibited no behaviors over the 7 days look back period. She was dependent on staff for most ADLS. She had a fall during the observation period. Record review of a quarterly MDS assessment dated [DATE] indicated Resident #45 was usually able to make herself understood and usually understands others. She had a BIMS of 11 (moderately impaired cognitively). She exhibited no behaviors over the 7 days look back period. She was dependent on staff for most ADLS. She had no falls during the observation period. Record review of the Incidents Report with date range of 07/30/2025 to 08/02/2025 did not indicate an incident dated 07/31/2025 for Resident #45. Record review of the provider investigation report dated 07/31/2025 for Resident #45 indicated she had a bruise on her chest and said the staff had dropped the left bar but did not know which CNAs were getting her up. The provider investigation form indicated the staff would be trained in reporting injuries of unknown origin. During an observation and interview on 02/9/2026 at 8:00 a.m., Resident #45 was in her bed and was watching TV. She said she had tried to stand up a while back and said she had forgotten she could not walk. She said she slid out of the bed, and she said she must had gotten bruised on her chest then but was unsure of the date the fall happened. She denied the staff had hurt her. During an interview on 02/11/2026 at 11:45 a.m., the Administrator said he expected an incident report to be completed for Resident #45. He said the nurse on duty that day does not work here anymore. He said she was terminated but not related to this issue. He said he could not find the documentation for the training that was completed on 7/31/25. He said he had given the training forms to the staff. He said he did not remember if they turned in the training forms with their signatures. During an interview on 02/11/2026 at 12:00 p.m., the DON said the incident report dated 07/20/2025 should have been updated or a new incident report made and that was not done as she pointed to the electronic record for Resident #45. She said the only training was done prior to this incident by her and she was not aware the PIR indicated more training was needed.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to seal, label and date a clear plastic bag of frozen chicken wings in freezer #1, and an opened box of egg rolls in Freezer #2. 2. The facility failed to label and date a clear plastic bag of frozen chicken parts in Freezer #1, and a bag of frozen cauliflower in Freezer #2. 3. The facility failed to label and date a clear plastic bag of sliced cheese and an open container of chicken base in Refrigerator #1. 4. The facility failed to keep a container identified as thickener sealed in dry storage room. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.Findings Included: During initial observation and interview on 02/09/2026 at 08:15 a.m. to 9:00 a.m., revealed freezer #1, freezer #2, refrigerator #1 and dry storage room in the kitchen contained the following: Freezer #1:*an open, unlabeled (missing the name of the food item, the open date, the expiration or use by date) clear plastic bag of frozen chicken wings that were not properly labeled, sealed and exposed to the elements. [NAME] D said the plastic bag contained chicken wings.*an unlabeled (missing the name of the food item, the open date, the expiration or use by date), clear plastic bag of frozen chicken parts that were not properly labeled with opened date or identifying the item. [NAME] D said the plastic bag contained chicken parts. Freezer #2*a sealed bag of unlabeled (missing the name of the food item, the open date, the expiration or use by date) bag of cauliflower. [NAME] D said the plastic bag contained cauliflower and the original bag was damaged during unpackaging last week, so he repackaged it.*an open box unsealed (missing the open date, the expiration or use by date) original cardboard box containing a clear plastic bag of frozen egg rolls that was not properly sealed and exposed to the elements. [NAME] D said the bag contained frozen egg rolls. Refrigerator # 1*a sealed bag of unlabeled (missing the name of the food item, the open date, the expiration or use by date) clear bag of sliced cheese. The Dietary Manager said the bag contained sliced cheese.*an open unlabeled (missing the open date, the expiration or use by date) container of chicken base. The Dietary Manager indicated the chicken base had been opened and partially used. Dry Storage Room*an open/unsealed/exposed container labeled Thickener. [NAME] D said the container had Thickener in it and closed and sealed the container. During an interview on 02/09/2026 at 8:45 a.m., [NAME] D said he did not know who left the bags of chicken wings and chicken parts unlabeled in the freezer #1 and all foods in the freezer should be labeled with content and date opened. He said that the original cauliflower bag was damaged during delivery and he repackaged the cauliflower and should have labeled and dated the new package when he repackaged it. He said all open boxes or bags of frozen foods being stored should be sealed or they could get freezer burn. He said once the packaging was opened or if food was repackaged it should be labeled with the content, opened date and/or expired or used by date. He said he had been trained to ensure that after opening a food item, it should be labeled with the open date and stored in a sealed container. He said in the dried food storage room all containers should be labeled and resealed after use to prevent air exposure or contamination. During an interview on 02/09/2026 at 10:40 a.m., the Dietary Manager said that he was not aware that frozen items in freezers #1 and #2 and foods and cooking base in refrigerator #1 were not sealed, labeled, and dated appropriately. He said that food packaging should have been resealed and labeled with name of the food item, the open date, the expiration or use by date) once opened. He said moving forward his expectations were all products in the kitchen be stored correctly. He said packages of food and dry storage containers should be sealed so not to expose food to the elements. The Dietary Manager said it was the responsibility of all the dietary staff to ensure products were labeled and stored correctly. He said he did spot checks periodically in kitchen to be sure everything was working in kitchen and completed a walk-through checking for sanitary conditions. He said not storing and preparing food appropriately could cause contamination and/or freezer burn affecting the freshness and quality of resident's food. During an interview on 02/11/2026 at 11:00 a.m., the Administrator said he was the direct supervisor of the Dietary Manager, and he expected kitchen staff to follow policies on food storage and preparation including all open items to be closed/sealed, labeled/dated when open and discarded when expired. He said not storing and preparing food appropriately could cause freezer burns, affecting the freshness and quality of residents' food. Review of a facility policy, revised June 25, 2025, Refrigerator and Freezer indicated Policy Statement: This facility will ensure safe refrigerator and freezer maintenance, temperatures, and sanitation, and will observe food expiration guidelines. Policy interpretations and implementation: .7. All food shall be appropriately dated to ensure proper rotation by expiration dates. Received dates (dates of delivery) will be marked on cases and on individual items removed from the cases for storage. Used by dates will be completed with expiration dates on all prepared foods in refrigerators. Expiration dates on unopened food will be observed and quotation used by quotation dates indicated once the food is opened. 8. Supervisors will be responsible for insuring food items in pantry, refrigerators, and freezers are not expired or passed parish dates. Review of a facility policy, revised June 25, 2025, Dry Storage indicated 4. If the food is taken out of the original container (what the manufacturer placed the product in) it must be labeled and dated. 9. If the item is open, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. Review of the FDA Food Code 2022 https://www.fda.gov/food/retail-food-protection/fda-food-code accessed 01/21/2026 indicated: .3-305.11 Food Storage. Food shall be protected from contamination by storing the food: (1) In a clean, dry location;(2) Where it is not exposed to slash, dust or other contamination . 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers .(B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement .Time/temperature control for safety refrigerated foods must be consumed, sold or discarded by the expiration date.

Based on observation, interview and record review the facility failed to ensure residents assessments accurately reflected the resident's status for 2 of 14 residents (Residents #17 and #41) reviewed for accuracy of assessments. 1. The facility failed to accurately complete the MDS assessment to indicate Resident #17's tobacco use. 2. The facility failed to accurately complete the MDS assessment to indicate Resident #41's PASARR positive. These failures could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being. Findings include: 1. Record review of Resident #17's face sheet, dated 02/09/2026, indicated an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted [DATE]. Resident #17 had a diagnosis which included chronic obstructive pulmonary disease (group of lung diseases that block airflow and make it difficult to breathe). Record review of Resident #17's admission MDS assessment, dated 09/22/2025, indicated Resident #17 was not marked for current tobacco use during the assessment period. The assessment indicated Resident #17 had a BIMS score of 15, which indicated intact cognition with a diagnosis of chronic obstructive pulmonary disease. Record review of Resident #17's care plan, with a target date of 04/21/2026, indicated Resident #17 was at risk of injury due to smoking preference with interventions that included evaluating her smoking safety ability and provided appropriate interventions as indicated. Record review of an Admit or Readmit Evaluation, dated 09/15/2025 indicated a smoking screening of Resident #17 currently smoked cigarettes and required monitoring during smoking episodes. Record review of Progress notes dated 09/18/2025 indicated Resident #17 went out to smoke before returning to bed. During an observation and interview on 02/09/2026 at 9:30 a.m., indicated Resident #17 was sitting in her wheelchair she said she smoked daily, the staff kept her smoking supplies and monitored her during smoking times. Resident #17 said she was aware of the smoking times. During an observation on 02/10/2026 at 9:43 a.m., Resident #17 was observed smoking, a staff member was observed lighting the cigarette and provided smoking supplies and monitored the resident during the smoking episode. During an interview on 02/10/2026 at 1:45 p.m., LVN A said she was providing care for Resident #17 today and she smoked cigarettes daily. LVN A said the staff kept Resident #17's smoking supplies, lit her cigarettes and monitored her during smoking episodes. She said the MDS Nurse was responsible for all MDSs in the facility. During an interview and record review on 02/10/2026 at 8:19 a.m., the MDS Nurse said she was responsible for all MDSs completed in the facility and her back up that double checked random MDSs was the Regional Case Mix. She said she was educated on completion of MDSs. The MDS Nurse said Resident #17 was a smoker but did not smoke on admission to the facility. On review of Resident #17's nurses note the MDS Nurse said Resident #17 did smoke during the look back period of the MDS and she would modify Resident #17's admission MDS. She said she overlooked the tobacco use on Resident #17's MDS. The MDS Nurse said the resident risk of an MDS not marked for tobacco use and the resident smoked was just an inaccurate MDS. During an interview on 02/11/2026 at 8:05 a.m., the DON said the MDS Nurse was responsible for all MDSs in the facility and was educated on completion of the MDSs. She said she was the backup that double checked random MDSs. She said Resident #17 smoked daily. The DON said she and the MDS Nurse both missed Resident #17's MDS not marked for smoking. The DON said the risk of an MDS not marked for tobacco use when the resident smoked was a resident may not be reevaluated for smoking and her smoking concerns may not be addressed. She said the MDS did not accurately describe the resident. The DON said her expectation was all MDSs completed accurately. During an Interview on 02/11/2026 at 8:19 a.m., the Administrator said the MDS Nurse was responsible for all MDSs in the facility and was educated on completion of MDSs. He said the DON and Regional Case Mix were the backup to double check MDSs for accuracy. The Administrator said Resident #17 was the only resident in the facility that smoked and all staff were aware she smoked. He said smoking was overlooked on Resident #17's MDS. The Administrator said the resident risk of a resident that smoked is not documented on their MDS was an inaccuracy of the MDS. He said his expectation was all MDSs be accurate, complete and individualized to each resident. 2. Record review of Resident #41's face sheet, dated 02/10/2026, indicated a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #41 had a diagnosis which included mild intellectual disabilities (a condition that affects a person's ability to learn and function at an expected level) and frontal lobe and executive function deficit (impairments in cognitive processes controlled by the front part of brain, affecting skills such as planning, organization, and impulse control). Record review of Resident #41's annual MDS assessment, dated 01/07/2026, indicated Resident #41 was not marked 1. Yes, for resident currently considered by the state level II PASARR process to have serious mental illness and/or intellectual disability or a related condition and Level II Preadmission Screening and Resident Review (PASARR) conditions and conditions related to ID/DD status were incomplete. The assessment indicated Resident #41 had a BIMS score of 15, which indicated intact cognition with a diagnosis of mild intellectual disabilities. Record review of Resident #41's care plan, with a target date of 04/09/2026, indicated Resident #41 was identified as having PASARR positive status related to ID with diagnosis of Intellectual Disability and required specialized services of habilitation coordination and independent skills training. Record review of a LIDDA Individual profile and habilitation service plan indicated Resident #41 was receiving PASARR services. She had habilitation service plan beginning 08/14/2025 with an end date of 08/13/2026 and individual profile indicating begin date 08/14/2025 with end date of 08/13/2026. During an observation and interview on 02/11/2026 at 9:30 a.m., indicated Resident #41 was sitting up in her bed she said she received habilitation and independent services through PASARR and a representative from LIDDA visited with her routinely. During an interview and record review on 02/11/2026 at 9:35 a.m., the MDS Nurse said Resident #41 was PASRR positive and received habilitation and individualized specialized services. On review of Resident #41's Individual and Habilitation Service Plans the MDS Nurse said Resident #41 was PASRR positive and was receiving habilitation and specialized services and her annual MDS should have reflected that in section A. She said she overlooked the PASRR positive on Resident #41's MDS. The MDS Nurse said after surveyor intervention she found that Resident #41's annual MDS did not indicate she was PASRR positive and she modified the annual MDS for accuracy. During an interview on 02/11/2026 at 10:55 a.m., the DON said she and the Regional Case Mix were the backup that double checked random MDSs. She said Resident #41 was PASARR positive and the MDS should have indicated that for accuracy. The DON said Resident #41's annual MDS was modified after the surveyors intervened. The DON said the annual MDS should have indicated Resident #41 was PASARR positive if not she may not have received available services. The DON said her expectation was all MDSs to be completed accurately initially and modified if inaccuracy identified. During an Interview on 02/11/2026 at 11:10 a.m., The Administrator said Resident #41 was PASARR positive and received services. He said PASARR was overlooked on Resident #41's annual MDS. The Administrator said the resident risk of a resident that are PASARR positive not documented on their MDS was an inaccuracy of the MDS. During an interview on 02/11/2026 at 10:45 a.m., the Regional Case Mix said the MDS Nurse was responsible for all MDSs in the facility and was educated on the completion of MDSs. She said nursing and SW were responsible for certain sections of the MDS, but the MDS Nurse was responsible for the smoking section. She said she was the back up and checked skilled MDS (MDSs that captured skills including therapy or medical services requiring professional staff) but not all MDS. She also checked any MDSs the MDS Nurse had a concern with. The Regional Case Mix said she did not check Resident #17's Annual MDS that was not marked for tobacco use. She said the tobacco use on Resident #17's MDS was overlooked and the MDS could be corrected. The Regional Case Mix said the resident risk of an MDS not marked for tobacco use when the resident smoked was that it could affect resident care. She said all smokers must have someone in attendance during smoking episodes. She said that Resident #41 MDS should have indicated she was PASRR positive and receiving rehabilitation and individualized services for her ID. She said the MDS should be accurate to reflect PASRR positive and services they are receiving so that resident care is not affected. Record review of the facility's policy titled, MDS CODING POLICY, reviewed 06/02 /2025, indicated . facilities utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. Record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2023, indicated . A1500: Preadmission Screening and Resident Review (PASRR) Code 1, yes: if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD or related condition, and continue to A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. A1510: Level II Preadmission Screening and Resident Review (PASRR) Conditions Item Rationale To document conditions associated with intellectual or developmental disabilities. Steps for Assessment 1. If resident is [AGE] years of age or older on the ARD, complete only if A0310A = 01 (admission assessment). 2. If resident is [AGE] years of age or younger on the ARD, complete if A0310A = 01, 03, 04, or 05 (admission assessment, Annual assessment, SCSA, Significant Correction to Prior Comprehensive Assessment) . Coding Instructions Check all conditions related to ID/DD status that were present before age [AGE]. When age of onset is not specified, assume that the condition meets this criterion AND is likely to continue indefinitely. Code A: if Down syndrome is present. Code B: if autism is present. Code C: if epilepsy is present. Code D: if other organic conditions related to ID/DD is present. Code E: if an ID/DD condition is present but the resident does not have any of the specific conditions listed. Code Z: if ID/DD condition is not present.J1300: Current Tobacco Use coding . Steps for Assessment 1. Ask the resident if they used tobacco in any form during the 7-day look-back period. 2. If the resident states that they used tobacco in some form during the 7-day look-back period, code 1. Yes. Coding Instructions, Code, no: if there are no indications that the resident used any form of tobacco. Code 1, yes: if the resident or any other source indicates that the resident used tobacco in some form during the look-back period

Based on interview, and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 14 residents (Resident #3) reviewed for comprehensive care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3's EBP (enhance barrier precautions) due to G-tube (gastric-tube for feeding and medications). This failure could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.Findings included: Record review of Resident #3's face sheet dated 02/10/2026 reflected the resident was an 81 -year-old male admitted to the facility on [DATE] with an original admission date of 07/24/2024. Resident #3 had diagnoses including dysphagia (difficulty swallowing), and gastrostomy tube (G-tube) - (a device inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication). Record review of Resident #3's Annual MDS assessment, dated 01/08/2026, reflected that he scored a 09 on his BIMS which reflected moderately cognitively impaired. Resident #3 had a G-tube for nutrition, hydration, and medications. Record review of Resident #3 most recent Care Plan reflected Resident #3 did not have EBP precautions developed on his care plan or interventions.Record review of Resident #3 Physician's Order Summary dated 01/05/2026 reflected clean G-tube site with NS (normal saline), pat dry and cover with dressing daily. There was no EBP precaution order. During an interview on 02/10/2026 at 3:10 p.m., the DON said the MDS nurse was responsible for developing care plan for Resident #3. The DON said that EBP should have been included in the care plan and did not know why it was not completed. She stated that EBP should have been care-planned for Resident #3, and she said it had been overlooked. During an interview on 02/11/2026 at 11:50 a.m., the MDS nurse said that the DON and herself were responsible for developing the care plans. She said the DON was ultimately responsible for signing off on all care plans for accuracy and completion. Review of a facility policy dated 06/202/2025 titled Care Plans, Comprehensive Person-Centered indicated the following: . 8. The comprehensive, person-centered care plan will.b) Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; .g) Incorporate identified problem areas; h) Incorporate risk factors associated with identified problems; and o) Reflect currently recognized standards of practice for problem areas and conditions.

Based on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 27 residents (Resident #29) observed for medication storage. 1. The facility failed to ensure Resident #29 did not have a refresh plus eye drop ampule sitting on top of a covered bowl of cereal on top of his dresser. These failures could place residents at risk for not receiving drugs and biologicals as needed and injury.Findings include: Record review of Resident #29's face sheet dated 02/10/26 indicated he was a [AGE] year-old male who re-admitted to the facility on [DATE] with the diagnoses which included dry eye syndrome and need for assistance with personal care. Record review of Resident #29's quarterly MDS assessment dated [DATE] indicate he was usually able to understand others and he could usually make himself understood. The MDS also indicated he had a BIMS score of 3 which meant he had severely impaired cognition. Record review of Resident # 29's care plan revised on 10/15/25 indicated he had impaired visual function related to use of eyeglasses and dry eye syndrome with interventions in place for nurse to administer refresh plus as ordered. Record review of Resident #29's order summary report dated as of 02/10/26 indicated he had an order for:1.Refresh Plus Ophthalmic Solution (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes at bedtime related to dry eye syndrome of bilateral lacrimal glands with a start date of 12/29/25 and no end date. 2.Refresh Plus Ophthalmic Solution (Carboxymethylcellulose Sodium) Instill 1 drop in both eyes in the morning related to dry eye syndrome of bilateral lacrimal glands with a start date of 12/29/25 and no end date. During an observation and interview on 02/09/26 at 11:15 AM Resident #29 was sitting on the side of his bed. Resident #29 had a Refresh eye drop ampule on his dresser, on top of his covered bowl of cereal. Resident #29 said he guessed the girl left the medication for his eyes for him to take but it was closed so it had not been used and he said he usually did not do it (administer the eye drops) but maybe the nurse was coming back. During an observation on 02/09/26 at 12:43 PM the refresh eye drops were not on Resident #29's dresser. During an interview on 02/10/26 at 1:47 PM LVN C said she did not know where Resident #29 got the refresh plus eye drops. She said it was scheduled early in the morning and LVN C was responsible for administering it to him. LVN C said she removed the refresh eye drop ampule from Resident #29's room. She said the failure placed a risk for other residents getting the medication and ingesting it or using it and having adverse side effects. During an interview on 02/10/26 at 10:41 AM LVN A said she did not know how Resident #29 got the refresh eye drops. LVN A said he did the eye drops himself and then said she saw Resident #29 take the eye drops and LVN A threw the used ampule away. LVN A said she always makes sure to give the refresh eye drops to Resident #29 and removed the empty ampule after use. LVN A said she was responsible for ensuring the eye drops were administered and the failure placed a risk for Resident #29 or other residents to get a hold of the medications when they were not supposed to and ingest or misuse. During an interview on 02/10/26 at 2:21 PM The DON said the charge nurse may have set the refresh eye drop down and forgot to administer it. The DON said all medications should be locked on the medication carts and not at any resident's bedside. The DON said she expected the nurses to give all medications while they were in the room and remove all used and unused medications. The DON said the failure placed risks for residents taking more medications than they should or other residents getting a hold of the medication and misusing it. During an interview on 02/10/26 at 2:52 PM The Administrator said his expectation was for the medications to be on a locked medication cart and not left in any resident's room. The Administrator said the failure placed a risk for residents to use medications for other purposes and demented residents drinking medications, using the medications inappropriately, and missing doses. Record review of the facility policy Storage of Medications, reviewed 06/24/25 indicated: Policy StatementThe facility stores all drugs and biologicals in a safe, secure, and orderly manner. Policy interpretation and Implementation:Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.3.The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.12. Only persons authorized to prepare and administer medications have access to locked medications.

Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 10 residents (Residents #3 and #31) observed for Infection Control. 1. The facility failed to implement EBP for Resident #3 during a G-tube medication administration on 02/10/2026. 2. The facility failed to implement EBP for Resident #31 during a wound care dressing change on 02/10/2026. These failures could place residents and staff at risk for cross-contamination and development of infections.Findings Included:1. Record review of Resident #3's face sheet dated 02/10/2026 reflected the resident was an 81 -year-old male admitted to the facility on [DATE] with an original admission date of 07/24/2024. Resident #3 had a diagnosis of gastrostomy tube (G-tube) - (a device inserted through the abdominal wall directly into the stomach to provide long-term nutrition, hydration, and medication). Record review of Resident #3's Annual MDS assessment, dated 01/08/2026, reflected that he scored a 09 on his BIMS which reflected moderately cognitively impaired. Resident #3 had a G-tube for nutrition, hydration, and medications. Record review of Resident #3 most recent Care Plan, last revised 01/15/26, failed to reflect Resident #3 had EBP precautions in place. Record review of Resident #3 Physician's Order Summary dated 01/05/2026 reflected clean G-tube site with NS (normal saline), pat dry and cover with dressing daily. There was no physician order indicating Resident #3 should be on EBP precautions. During an observation on 02/10/2026 at 1:30 p.m., outside Resident #3's room there was no EBP signage. There was EBP signage and 3-drawer PPE cart located across the hallway which was indicated for another resident. During a medication administration observation on 02/10/2026 at 1:30 p.m., LVN A prepared medication for Resident #3 to be administered via the G-tube. LVN A donned gloves, raised Resident #3's shirt, held the G-tube while checking for patency and assessed placement. She then administered the medication and water flushes. LVN A did not wear a gown during the medication administration via G-tube/direct contact with Resident #3. During an interview on 02/10/2026 at 1:45 p.m., LVN A said that she failed to follow the EBP because she forgot to wear a gown during Resident #3's G-tube medication administration. She said she had been trained on EBP and should have applied the gown prior to entering the room to perform the medication administration to Resident #3 but she forgot. She said that not wearing a gown during the G-tube medication administration could spread infection or cause cross contamination. During an interview on 02/10/2026 at 3:10 p.m., the DON said she had placed EBP signage on Resident #3's door and that it must have fallen off. She said her expectations were for nursing staff to follow EBP protocols and to wear gown and gloves when administering medications via G-tube. 2. Record review of admission Record dated 02/11/2026, indicated Resident #31 was [AGE] years old male with diagnosis of non-pressure chronic ulcer of abdomen (ulcer or break in skin that fails to heal as it should and typically more chronic in nature. Record review of Resident #31's quarterly MDS assessment dated [DATE] indicated he had a BIMS score of 15 indicating that he was intact cognitively. He made himself understood and understood others. He required ointment/medications application and nonsurgical dressings for ulcer treatment. He required maximum assistance for self-care and mobility tasks. Record review of Resident #31's care plan, revision dated 01/27/2026, indicated Resident #31 required wound care to RUQ of abdomen and right flank and enhance barrier precautions. Interventions included wound care as prescribed by physicians and enhanced barrier precautions used during high-contact resident care activities as applicable such as wound care (any skin opening requiring a dressing). Record review of physician's orders for Resident #31 dated 02/09/2026 indicated wound care to right outer thigh cleanse with normal saline, pat dry, apply hydrofera blue (antibacterial) foam to wound bed, cover with foam dressing every 3 days and as needed if dressing soiled or dislodged and wound care to RUQ cleanse with normal saline or wound cleanser, allow to air dry, clean 10 cm border of peri wound with chlorohexidine swab, allow to dry, apply saline moisten mesalt (sodium chloride impregnated) dressing, cover with foam dressing daily and as needed if dressing soiled or dislodged. No physician order indicating Resident #31 should be on EBP because of his open wounds. During an interview on 02/09/2026 at 10:56 a.m., Resident #31 said he has a wound or fistula to his RUQ of abdomen due to his enlarged hernia and wound to his right thigh. He said facility staff performed his wound care daily and he visits a wound care physician weekly for oversight of his wounds. He said the facility staff wore gowns and gloves during his wound care. During an observation on 02/10/2026 at 10:55 a.m., indicated outside Resident #31's room was an EBP signage. There was a 3-drawer PPE cart located at entrance to Resident #31's room. During an observation on 02/10/2026 at 11:00 a.m., indicated LVN A provided wound care and a dressing change. LVN A did not wear a gown during the dressing change/direct contact with Resident #31. During an interview on 02/10/2026 at 11:40 a.m., LVN A said that she failed to follow the EBP because she forgot to wear a gown during Resident #31's wound care and dressing change to his right thigh and abdominal wound. She said she had been trained on EBP and should have applied a gown prior to entering the room to perform wound care and dressing change to Resident #31's wounds but she forgot. She said that not wearing a gown during the wound care and dressing change could spread infection or cause cross contamination. During an interview on 02/11/2026 at 10:40 a.m., the DON said she has provided staff with training regarding infection control and enhance barrier precautions. She said her expectations were for staff and visitors to perform hand hygiene upon entering and when leaving a resident's room, and when hands were soiled. She said EBP should be followed by staff with direct care provided to residents with open wounds, tube feedings, IV's, foley catheters, and tracheostomies. The DON said her expectations are for all staff to be mindful of the residents' status and utilize EBP as required. The DON said the risk of failing to perform EBP could lead to spread of infection to other residents or even staff. During an interview on 02/11/2026 at 11:30 a.m., the Administrator said his expectations were that all staff adhere to the EBP when providing high contact care for residents with wounds, tube feedings, IV's, tracheostomies and indwelling devices. He said all residents requiring EBP should have orders, signage on the doors and care plans indicating the required precautions. He said not following EBP as required could cause spread of infection or cross contamination. Review of a facility policy, reviewed, June 30, 2025, Enhanced Barrier Precautions indicated Enhanced Barrier Precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug resistant organisms that employ targeted gown and glove use during high contact resident care activities. EBP are used in conjunction with standard precautions as expand the use of PPE to donning of gown and glove during high contact resident care activities that provide opportunities for transfer of MDRO's to staff's hands and clothing. A single set PPE cannot be used for more than one patient. EBP are indicated for residents with any of the following: colonization with a CDC targeted MDRO when contact precautions do not otherwise apply or wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a MDRO. Wounds generally include chronic wounds. Indwelling medical device examples include central lines, urinary catheters feeding tubes and tracheostomies. Donning PPE for residents on EBP based on activity provided/ assistance while in resident room: Resident activity of performing wound care does require enhance barrier precautions including donning gloves and gown. Resident activity of administering medications enterally does require enhanced barrier precautions including donning gloves and gown.

Based on observation, interview, and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 15 (Resident #19) residents reviewed for notification of change. The facility failed to ensure Resident #19's physician was notified of his increased pain following a wound debridement (removal of dead or unhealthy tissue from the wound to promote the healing process) by the Wound Care NP on 11/12/2024. This failure could place residents at risk for experiencing unnecessary pain, not receiving necessary treatments and medications, and a decreased quality of life. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #19 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4 (sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, ligaments, and bone in the lower back, buttocks area) and pain. Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated he was understood by others and was able to understand others. The MDS assessment indicated Resident #19 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #19 was dependent for showering/bathing, toileting hygiene, and required supervision or touching assistance for personal hygiene. The MDS assessment indicated Resident #19 received pain medications as needed. The MDS assessment did not indicate Resident #19 received non-medication intervention for pain. The MDS assessment indicated Resident #19 experienced pain occasionally, it occasionally affected his sleep, and it rarely or not at all interfered with his therapy and day-to-day activities. Record review of Resident #19's care plan with a target date of 01/21/2025 indicated he had acute/chronic pain related to low backpain, gout (pain, swelling of the joints), and rhabdomyolysis (muscle injury or breakdown). Interventions included to administer allopurinol, Tylenol, oxycodone as per orders to give half an hour before treatments or care, anticipate the residents need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Resident #19's care plan indicated he had a stage 4 pressure injury/ulcer to left buttock related to obesity, immobility, and refusal of care. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, and to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Record review of Resident #19's Order Summary Report dated 11/19/2024 indicated: Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for severe pain may use oxycodone 5 mg 2 tablets to equal 10 mg with a start date of 03/19/2024. Tylenol give 1000 mg by mouth every 8 hours as needed for pain with a start date of 03/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 with a start date of 09/29/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound (around the wound) with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD (gauze dressing used to reduce the growth of bacteria), cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/12/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD, cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/13/2024. Hydrocodone-Acetaminophen 5-325 mg give 2 tablets by mouth every 24 hours as needed for pain related to pressure ulcer of sacral region, stage 4 give prior to wound care treatments with a start date of 11/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 2 tablets by mouth every day shift related to pain give daily prior to wound care with at start date of 11/19/2024. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/10/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2 cm, width 1.4 cm, depth 2.5 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/12/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2.9 cm, width 1.4 cm, depth 2.3 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's progress notes dated 11/12/2024-11/19/2024 did not indicate Resident #19's wound was debrided by the Wound Care NP, and they did not indicate Resident #19 had increased pain. Record review of Resident #19's November 2024 MAR indicated. is this resident in pain? 0 indicated no pain, 1-3 indicated mild pain, 4-6 indicated moderate pain, 7-10 indicated severe pain. 11/12/2024: day shift, evening shift, and night shift indicated 0 (no pain). 11/13/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/14/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/15/2024: day shift 1 (mild pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/16/2024: day shift 4 (moderate pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/17/2024: day shift 0 (no pain), evening shift 3 (mild pain), night shift 0 (no pain). 11/18/2024: day shift 5 (moderate pain), evening shift 0 (no pain), night shift 0 (no pain). Record review of Resident #19's November 2024 MAR indicated, Norco 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 order date 09/29/2024: Administered 11/13/2024 for pain level of 5, 10:08 AM and was effective. Administered 11/14/2024 for pain level of 4, 8:56 AM and was effective. Administered 11/15/2024 for pain level of 4, 7:30 AM and was effective. Administered 11/15/2024 for pain level of 4, 5:47 PM and was effective. Administered 11/17/2024 for pain level of 9, 9:32 AM and was effective. Administered 11/18/2024 for pain level of 5, 9:01 AM and was effective. Record review of Resident #19's November 2024 MAR indicated; Tylenol Oral Tablet (Acetaminophen) give 1000 mg by mouth every 8 hours as needed for pain order date 03/19/2024: Administered 11/17/2024 for pain level of 8, 5:05 AM and was effective. Administered 11/18/2024 for pain level of 8, 4:59 AM and was effective. Administered 11/18/2024 for pain level of 3, 10:15 AM and was effective. Record review of Resident #19's November 2024 TAR indicated: Apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri wound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 10/30/2024, discontinued date 11/12/2024. The TAR indicated this was completed daily from 11/1/2024-11/11/2024. Lidocaine External Cream 5 % Apply to L buttocks topically every day shift for pain control & apply prior to wound care and leave for 2 minutes order date 06/15/2024 discontinued date 11/11/2024. The TAR indicated this was completed daily from 11/1/2024-11/10/2024. Wound #1 to left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and periwound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 11/12/2024. The TAR indicated this was completed daily from 11/13/2024-11/18/2024. During an interview on 11/18/2024 at 11:32 AM, Resident #19 said the wound care doctor had debrided his wound last week (11/12/2024), and he had been having increased pain during wound ever since. Resident #19 said the pain was while the wound care was being performed. Resident #19 said the pain did not affect his daily activities, eating, or sleep. Resident #19 said he had been asking the nurses to up his pain medication because every nerve ending is on fire. Resident #19 said they had been offloading the wound to help the pain. Resident #19 said he used to be an RN, so he was not big on narcotics (he tried not to use a lot of narcotic medications). Resident #19 said when he could he used Tylenol extra strength which usually took his pain away, but when they did the wound care, he wanted the narcotics because he did not want to hurt. Surveyor asked Resident #19 if observation of wound care could be done. Resident #19 said surveyor was going to get to listen to him holler and curse because the wound care was painful. Resident #19 said today's (11/18/2024) wound care had been completed, but surveyor could observe the wound care tomorrow (11/19/2024) since it was completed daily. Resident #19 said he could not refuse to have the wound care performed because his insurance required him to be compliant with the doctor's orders. During an observation of wound care with the Wound Care NP and LVN B on 11/19/2024 starting at 10:04 AM, Resident #19 was in bed. The Wound Care NP removed Resident #19's dressing and Resident #19 hollered out due to the pain. The Wound Care NP asked if Resident #19 wanted him to stop. Resident #19 said no to continue. The Wound Care NP continued, removed the old dressing, and measured the wound. The Wound Care NP did not apply any spray or creams to Resident #19. The Wound Care NP left, and LVN B started the wound treatment. LVN B started cleaning the wound and Resident #19 hollered out and said he had been in pain ever since the wound was debrided. LVN B asked Resident #19 if he wanted her to stop and he said no. LVN B continued and applied collagen, and Resident #19 continued to holler and said, it feels like somebody's taken a blow torch to my ass, careful please it's very sensitive. LVN B stopped and asked Resident #19, Can you take it?. Resident #19 said don't stop keep going. LVN B continued to pack the wound and Resident #19 again said feels like a torch to my butt. LVN B continued and finished the wound care. During an interview on 11/19/2024 at 10:57 AM, LVN B said Resident #19 received two hydrocodone 5-325 mg tablets prior to his wound care treatment today (11/19/2024). LVN B said Resident #19 started seeing the wound care NP last Tuesday (11/12/2024), and the wound care NP debrided Resident #19's wound on 11/12/2024. LVN B said ever since it was debrided Resident #19 had been hollering and screaming more with the wound care. LVN B said she had not contacted the doctor until yesterday afternoon (11/18/2024) and received an order for 2 hydrocodone tablets before wound care treatments. LVN B said Resident #19 was receiving oxycodone, but it was changed to hydrocodone because his insurance would not cover the oxycodone. LVN B said the order for oxycodone should have been discontinued from Resident #19's orders. LVN B said they used lidocaine prior to performing the wound care to help the pain, but when the wound care NP did his wound visits he used lidocaine spray, so she did not apply the lidocaine to Resident #19's wound prior to wound care today (11/19/2024). LVN B said she did not notice the wound care NP did not spray Resident #19 with lidocaine. LVN B said since Resident #19 had been hollering with pain she should have contacted the doctor to have his pain during wound care addressed when she noticed he had increased pain. LVN B said Resident #19 had been complaining of having a burning type of pain and said it was a burning sensation. LVN B said the lidocaine gel helped with the burning sensation, but Resident #19 was still complaining of pain. LVN B said Resident #19's pain tolerance was not very good, and he had a low pain tolerance. LVN B said pain was what the resident said it was. LVN B said she had not reported to the doctor that Resident #19 was having a burning type of pain. LVN B said Resident #19's pain was better today (11/19/2024), but he was still hurting therefore the medication was not effective. LVN B said she would contact the doctor to let him know the medication was not effective during wound care. LVN B said it was important for pain to be adequately addressed because they did not want to hurt Resident #19 and it could cause depression, a decline, and his nutrition to decline. During an attempted phone interview on 11/19/2024 at 12:29 PM, the Medical Director did not answer the phone. During an interview on 11/19/2024 at 12:31 PM, RN D said Resident #19 received pain management prior to starting his wound care. RN D said Resident #19 had a low pain tolerance, and he did complain about pain during the wound care. RN D said she put the lidocaine on the wound prior to doing his wound care and he received hydrocodone 7.5 mg prior to his wound treatment. RN D said she barely removed the tape and Resident #19 hollered with pain, and she would ask him if he wanted her to stop and Resident #19 said to proceed. RN D said the lidocaine relieved some of Resident #19's pain. RN D said Resident #19 described the pain to the wound as sore. RN D said she did not report to the doctor Resident #19 was having pain because he had pain every single time they did the wound care. RN D said the doctor was notified initially and that was why they had the order for the lidocaine and hydrocodone. RN D said Resident #19 wanted them to continue with the wound care because he knew it had to be done. RN D said she stopped and asked him if he wanted her to stop, but he had been having pain with wound care since his admission to the facility. RN D said pain was uncomfortable and it affected someone intensely. RN D said it was not good for the residents to have pain and everybody had a different type of pain. During an interview on 11/19/2024 at 1:27 PM, the Wound Care NP's wound evaluation for 11/12/2024 was requested from the DON and not received upon exit of the facility. During an interview on 11/19/2024 at 2:11 PM, the DON said pain medications should be administered 30 minutes prior to wound care. The DON said lidocaine should be applied to Resident #19's wound bed prior to wound care. The DON said in the past she had assessed Resident #19's pain and talked to him about what he wanted them to do. The DON said Resident #19 was having pain and they increased his pain medication hydrocodone 5 mg to 7.5 mg a few days ago. The DON said it was hard to judge Resident #19's pain because even if they got a wipe and just touched him and started turning him, he had the same type of expression of pain as he did during wound care. The DON said ever since the wound was debrided last week (11/12/2024) the wound had been more sensitive and sharper. The DON said the pain medication was increased to 2 tabs today (11/19/2024). The DON said prior to today the nurses had not notified her Resident #19 was having increased pain to his wound. The DON said the nurses should have called the doctor and let him know he was debrided, and the pain medication was no longer sufficient. The DON said if there was a change in condition the nurses should notify the doctor. The DON said they were not going to stop Resident #19 from hollering out. The DON said if Resident #19 was saying the pain medication was not working, they needed to make sure the medication was changed. The DON said the nurses should be assessing the pain and asking the residents if it was something new, where the location was, had the intensity changed, if it was acute or chronic pain, and ask the resident if the medication was effective. The DON said they would also try alternatives for pain relief such as a low air loss mattress, ice pack, repositioning, pain patches. The DON said she did not think their pain assessment included the type of pain the patient was experiencing such as if it was throbbing or burning or what type of pain. The DON said it was hard with someone that was bedbound to do more interventions. The DON said Resident #19 was not receiving therapy for his wound, but he was receiving physical therapy to maintain his mobility. The DON said if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an attempted phone interview on 11/20/2024 at 11:49 AM, the Medical Director did not answer the phone. During an interview on 11/20/2024 at 12:06 PM, the Wound Care NP said last Tuesday (11/12/2024) was the first time he had seen Resident #19, and he may have debrided Resident #19's wound but he was not sure because he usually did not debride on the first visit. The Wound Care NP said Resident #19 had yelled out due to the pain during the first visit, but they asked him if he wanted them to stop and Resident #19 replied no. The Wound Care NP said the way Resident #19 acted during the wound visit this week (11/19/2024) was the example of how he had acted the previous week. The Wound Care NP said, not that I remember he did not have any pain. The Wound Care NP said he only used lidocaine spray when he debrided wounds, therefore he did not use the lidocaine spray on Resident #19 on 11/19/2024. The Wound Care NP said when people are premedicated they do a lot better. The Wound Care NP said Resident #19 had been premedicated on the visit for 11/19/2024. The Wound Care NP said when people received pain medications prior to the wound care visit they did better and were less sensitive. The Wound Care NP said if a person was reporting pain and burning pain, they needed to address the pain with medications. The Wound Care NP said the facility should consider giving Resident #19 pain medications prior to his treatment because he was sensitive to pain. The Wound Care NP said the mental anticipation of pain was making Resident #19's pain more severe. The Wound Care NP said if the current medications being used for pain during wound care were not working, they needed to see what we need to do, increase the dose or have additional medication to help the pain. The Wound Care NP said the facility was responsible for contacting the facility's medical director to obtain orders for pain medication. During an interview on 11/20/2024 at 3:22 PM, the Administrator said if a resident was having pain, he expected the nurses to contact the doctor. The Administrator said they wanted to keep pain as low as feasibly possible. The Administrator said some residents had concerns regarding the use of medications for pain, but they should give them over the counter medications and try to abide by their wishes. The Administrator said it was important for the residents' pain to be addressed because pain affected the resident's quality of life in a dramatic fashion. The Administrator said increased pain could be a sign of something emergent and that could be the only warning sign of a condition. Record review of the facility's policy titled, Pain Management Program Policy, revised 01/2023, indicated, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .4. The facility will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Obtain orders for pharmaceutical interventions, pain medications, and or non pharmaceutical interventions such as heat, cold, massage and relaxation etc. and/or refer to therapy for skilled therapeutic interventions . With a new onset of pain, complete a pain evaluation in the EMR. Determine an appropriate pharmacological intervention under the direction of the physician or a non pharmacological intervention. Re-evaluate the resident after 45 min to one hour to determine if your intervention has been effective and document outcome in the EMR/Progress Notes and ensure new orders and updated care plan are completed .The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment .If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .

Based on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice for 1 of 3 residents (Resident #19) reviewed for pain. The facility failed to ensure Resident #19 received adequate pain management during wound care after he reported increased pain following a wound debridement (removal of dead or unhealthy tissue from the wound to promote the healing process) by the Wound Care NP on 11/12/2024. This failure could place residents at risk for experiencing unnecessary pain and a decreased quality of life. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #19 was a [AGE] year-old male initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included pressure ulcer of sacral region, stage 4 (sore that extends below the subcutaneous fat into the deep tissues, including muscle, tendons, ligaments, and bone in the lower back, buttocks area) and pain. Record review of Resident #19's Quarterly MDS assessment dated [DATE] indicated he was understood by others and was able to understand others. The MDS assessment indicated Resident #19 had a BIMS score of 15, which indicated his cognition was intact. The MDS assessment indicated Resident #19 was dependent for showering/bathing, toileting hygiene, and required supervision or touching assistance for personal hygiene. The MDS assessment indicated Resident #19 received pain medications as needed. The MDS assessment did not indicate Resident #19 received non-medication intervention for pain. The MDS assessment indicated Resident #19 experienced pain occasionally, it occasionally affected his sleep, and it rarely or not at all interfered with his therapy and day-to-day activities. Record review of Resident #19's care plan with a target date of 01/21/2025 indicated he had acute/chronic pain related to low backpain, gout (pain, swelling of the joints), and rhabdomyolysis (muscle injury or breakdown). Interventions included to administer allopurinol, Tylenol, oxycodone as per orders to give half an hour before treatments or care, anticipate the residents need for pain relief and respond immediately to any complaint of pain, and evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition. Resident #19's care plan indicated he had a stage 4 pressure injury/ulcer to left buttock related to obesity, immobility, and refusal of care. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, administer treatments as ordered and monitor for effectiveness, and to treat pain as per orders prior to treatment/turning to ensure the resident's comfort. Record review of Resident #19's Order Summary Report dated 11/19/2024 indicated: Oxycodone 10 mg give 1 tablet by mouth every 4 hours as needed for severe pain may use oxycodone 5 mg 2 tablets to equal 10 mg with a start date of 03/19/2024. Tylenol give 1000 mg by mouth every 8 hours as needed for pain with a start date of 03/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 with a start date of 09/29/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound (around the wound) with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD (gauze dressing used to reduce the growth of bacteria), cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/12/2024. Wound left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri-wound with normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with normal saline moistened Kerlix AMD, cover with gauze and abdominal pad, secure with tape, change daily every day shift with a start date of 11/13/2024. Hydrocodone-Acetaminophen 5-325 mg give 2 tablets by mouth every 24 hours as needed for pain related to pressure ulcer of sacral region, stage 4 give prior to wound care treatments with a start date of 11/19/2024. Hydrocodone-Acetaminophen 7.5-325 mg give 2 tablets by mouth every day shift related to pain give daily prior to wound care with at start date of 11/19/2024. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/10/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2 cm, width 1.4 cm, depth 2.5 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's Wound-Weekly Observation Tool dated 11/12/2024 indicated he had a stage 4 pressure ulcer to the left buttock which he admitted with. The measurements were length 2.9 cm, width 1.4 cm, depth 2.3 cm. The wound had undermining (a wound complication that occurs when the edges of the wound separate this creates a pocket of dead space beneath the skin, the damage extends underneath). The Wound-Weekly Observation tool indicated Resident #19 had pain prior to wound treatment. The rating of the resident's pain was left unanswered. Pain interventions included pain medication prior to treatment and lidocaine cream applied in the wound bed. Record review of Resident #19's progress notes dated 11/12/2024-11/19/2024 did not indicate Resident #19's wound was debrided by the Wound Care NP, and they did not indicate Resident #19 had increased pain. Record review of Resident #19's November 2024 MAR indicated. is this resident in pain? 0 indicated no pain, 1-3 indicated mild pain, 4-6 indicated moderate pain, 7-10 indicated severe pain. 11/12/2024: day shift, evening shift, and night shift indicated 0 (no pain). 11/13/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/14/2024: day shift and evening shift indicated 0 (no pain), night shift indicated 4 (moderate pain). 11/15/2024: day shift 1 (mild pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/16/2024: day shift 4 (moderate pain), evening shift 4 (moderate pain), night shift 0 (no pain). 11/17/2024: day shift 0 (no pain), evening shift 3 (mild pain), night shift 0 (no pain). 11/18/2024: day shift 5 (moderate pain), evening shift 0 (no pain), night shift 0 (no pain). Record review of Resident #19's November 2024 MAR indicated, Norco 7.5-325 mg (Hydrocodone-Acetaminophen) give 1 tablet by mouth every 6 hours as needed for pain related to pressure ulcer of sacral region, stage 4 order date 09/29/2024: Administered 11/13/2024 for pain level of 5, 10:08 AM and was effective. Administered 11/14/2024 for pain level of 4, 8:56 AM and was effective. Administered 11/15/2024 for pain level of 4, 7:30 AM and was effective. Administered 11/15/2024 for pain level of 4, 5:47 PM and was effective. Administered 11/17/2024 for pain level of 9, 9:32 AM and was effective. Administered 11/18/2024 for pain level of 5, 9:01 AM and was effective. Record review of Resident #19's November 2024 MAR indicated; Tylenol Oral Tablet (Acetaminophen) give 1000 mg by mouth every 8 hours as needed for pain order date 03/19/2024: Administered 11/17/2024 for pain level of 8, 5:05 AM and was effective. Administered 11/18/2024 for pain level of 8, 4:59 AM and was effective. Administered 11/18/2024 for pain level of 3, 10:15 AM and was effective. Record review of Resident #19's November 2024 TAR indicated: Apply lidocaine 5% to wound center prior to procedure. Cleanse wound and peri wound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 10/30/2024, discontinued date 11/12/2024. The TAR indicated this was completed daily from 11/1/2024-11/11/2024. Lidocaine External Cream 5 % Apply to L buttocks topically every day shift for pain control & apply prior to wound care and leave for 2 minutes order date 06/15/2024 discontinued date 11/11/2024. The TAR indicated this was completed daily from 11/1/2024-11/10/2024. Wound #1 to left buttock apply lidocaine 5% to wound center prior to procedure. Cleanse wound and periwound with non-cytotoxic agent-normal saline, apply barrier cream around wound, apply collagen with silver, finish packing with NS moistened Kerlix AMD, cover with gauze and abdominal pad, secure with medipore tape change daily every day shift order date 11/12/2024. The TAR indicated this was completed daily from 11/13/2024-11/18/2024. During an interview on 11/18/2024 at 11:32 AM, Resident #19 said the wound care doctor had debrided his wound last week (11/12/2024), and he had been having increased pain during wound ever since. Resident #19 said the pain was while the wound care was being performed. Resident #19 said the pain did not affect his daily activities, eating, or sleep. Resident #19 said he had been asking the nurses to up his pain medication because every nerve ending is on fire. Resident #19 said they had been offloading the wound to help the pain. Resident #19 said he used to be an RN, so he was not big on narcotics (he tried not to use a lot of narcotic medications). Resident #19 said when he could he used Tylenol extra strength which usually took his pain away, but when they did the wound care, he wanted the narcotics because he did not want to hurt. Surveyor asked Resident #19 if observation of wound care could be done. Resident #19 said surveyor was going to get to listen to him holler and curse because the wound care was painful. Resident #19 said today's (11/18/2024) wound care had been completed, but surveyor could observe the wound care tomorrow (11/19/2024) since it was completed daily. Resident #19 said he could not refuse to have the wound care performed because his insurance required him to be compliant with the doctor's orders. During an observation of wound care with the Wound Care NP and LVN B on 11/19/2024 starting at 10:04 AM, Resident #19 was in bed. The Wound Care NP removed Resident #19's dressing and Resident #19 hollered out due to the pain. The Wound Care NP asked if Resident #19 wanted him to stop. Resident #19 said no to continue. The Wound Care NP continued, removed the old dressing, and measured the wound. The Wound Care NP did not apply any spray or creams to Resident #19. The Wound Care NP left, and LVN B started the wound treatment. LVN B started cleaning the wound and Resident #19 hollered out and said he had been in pain ever since the wound was debrided. LVN B asked Resident #19 if he wanted her to stop and he said no. LVN B continued and applied collagen, and Resident #19 continued to holler and said, it feels like somebody's taken a blow torch to my ass, careful please it's very sensitive. LVN B stopped and asked Resident #19, Can you take it?. Resident #19 said don't stop keep going. LVN B continued to pack the wound and Resident #19 again said feels like a torch to my butt. LVN B continued and finished the wound care. During an interview on 11/19/2024 at 10:57 AM, LVN B said Resident #19 received two hydrocodone 5-325 mg tablets prior to his wound care treatment today (11/19/2024). LVN B said Resident #19 started seeing the wound care NP last Tuesday (11/12/2024), and the wound care NP debrided Resident #19's wound on 11/12/2024. LVN B said ever since it was debrided Resident #19 had been hollering and screaming more with the wound care. LVN B said she had not contacted the doctor until yesterday afternoon (11/18/2024) and received an order for 2 hydrocodone tablets before wound care treatments. LVN B said Resident #19 was receiving oxycodone, but it was changed to hydrocodone because his insurance would not cover the oxycodone. LVN B said the order for oxycodone should have been discontinued from Resident #19's orders. LVN B said they used lidocaine prior to performing the wound care to help the pain, but when the wound care NP did his wound visits he used lidocaine spray, so she did not apply the lidocaine to Resident #19's wound prior to wound care today (11/19/2024). LVN B said she did not notice the wound care NP did not spray Resident #19 with lidocaine. LVN B said since Resident #19 had been hollering with pain she should have contacted the doctor to have his pain during wound care addressed when she noticed he had increased pain. LVN B said Resident #19 had been complaining of having a burning type of pain and said it was a burning sensation. LVN B said the lidocaine gel helped with the burning sensation, but Resident #19 was still complaining of pain. LVN B said Resident #19's pain tolerance was not very good, and he had a low pain tolerance. LVN B said pain was what the resident said it was. LVN B said she had not reported to the doctor that Resident #19 was having a burning type of pain. LVN B said Resident #19's pain was better today (11/19/2024), but he was still hurting therefore the medication was not effective. LVN B said she would contact the doctor to let him know the medication was not effective during wound care. LVN B said it was important for pain to be adequately addressed because they did not want to hurt Resident #19 and it could cause depression, a decline, and his nutrition to decline. During an attempted phone interview on 11/19/2024 at 12:29 PM, the Medical Director did not answer the phone. During an interview on 11/19/2024 at 12:31 PM, RN D said Resident #19 received pain management prior to starting his wound care. RN D said Resident #19 had a low pain tolerance, and he did complain about pain during the wound care. RN D said she put the lidocaine on the wound prior to doing his wound care and he received hydrocodone 7.5 mg prior to his wound treatment. RN D said she barely removed the tape and Resident #19 hollered with pain, and she would ask him if he wanted her to stop and Resident #19 said to proceed. RN D said the lidocaine relieved some of Resident #19's pain. RN D said Resident #19 described the pain to the wound as sore. RN D said she did not report to the doctor Resident #19 was having pain because he had pain every single time they did the wound care. RN D said the doctor was notified initially and that was why they had the order for the lidocaine and hydrocodone. RN D said Resident #19 wanted them to continue with the wound care because he knew it had to be done. RN D said she stopped and asked him if he wanted her to stop, but he had been having pain with wound care since his admission to the facility. RN D said pain was uncomfortable and it affected someone intensely. RN D said it was not good for the residents to have pain and everybody had a different type of pain. During an interview on 11/19/2024 at 1:27 PM, the Wound Care NP's wound evaluation for 11/12/2024 was requested from the DON and not received upon exit of the facility. During an interview on 11/19/2024 at 2:11 PM, the DON said pain medications should be administered 30 minutes prior to wound care. The DON said lidocaine should be applied to Resident #19's wound bed prior to wound care. The DON said in the past she had assessed Resident #19's pain and talked to him about what he wanted them to do. The DON said Resident #19 was having pain and they increased his pain medication hydrocodone 5 mg to 7.5 mg a few days ago. The DON said it was hard to judge Resident #19's pain because even if they got a wipe and just touched him and started turning him, he had the same type of expression of pain as he did during wound care. The DON said ever since the wound was debrided last week (11/12/2024) the wound had been more sensitive and sharper. The DON said the pain medication was increased to 2 tabs today (11/19/2024). The DON said prior to today the nurses had not notified her Resident #19 was having increased pain to his wound. The DON said the nurses should have called the doctor and let him know he was debrided, and the pain medication was no longer sufficient. The DON said if there was a change in condition the nurses should notify the doctor. The DON said they were not going to stop Resident #19 from hollering out. The DON said if Resident #19 was saying the pain medication was not working, they needed to make sure the medication was changed. The DON said the nurses should be assessing the pain and asking the residents if it was something new, where the location was, had the intensity changed, if it was acute or chronic pain, and ask the resident if the medication was effective. The DON said they would also try alternatives for pain relief such as a low air loss mattress, ice pack, repositioning, pain patches. The DON said she did not think their pain assessment included the type of pain the patient was experiencing such as if it was throbbing or burning or what type of pain. The DON said it was hard with someone that was bedbound to do more interventions. The DON said Resident #19 was not receiving therapy for his wound, but he was receiving physical therapy to maintain his mobility. The DON said if a resident's pain was not managed properly, it could affect their mood and their day-to-day activity. During an attempted phone interview on 11/20/2024 at 11:49 AM, the Medical Director did not answer the phone. During an interview on 11/20/2024 at 12:06 PM, the Wound Care NP said last Tuesday (11/12/2024) was the first time he had seen Resident #19, and he may have debrided Resident #19's wound but he was not sure because he usually did not debride on the first visit. The Wound Care NP said Resident #19 had yelled out due to the pain during the first visit, but they asked him if he wanted them to stop and Resident #19 replied no. The Wound Care NP said the way Resident #19 acted during the wound visit this week (11/19/2024) was the example of how he had acted the previous week. The Wound Care NP said, not that I remember he did not have any pain. The Wound Care NP said he only used lidocaine spray when he debrided wounds, therefore he did not use the lidocaine spray on Resident #19 on 11/19/2024. The Wound Care NP said when people are premedicated they do a lot better. The Wound Care NP said Resident #19 had been premedicated on the visit for 11/19/2024. The Wound Care NP said when people received pain medications prior to the wound care visit they did better and were less sensitive. The Wound Care NP said if a person was reporting pain and burning pain, they needed to address the pain with medications. The Wound Care NP said the facility should consider giving Resident #19 pain medications prior to his treatment because he was sensitive to pain. The Wound Care NP said the mental anticipation of pain was making Resident #19's pain more severe. The Wound Care NP said if the current medications being used for pain during wound care were not working, they needed to see what we need to do, increase the dose or have additional medication to help the pain. The Wound Care NP said the facility was responsible for contacting the facility's medical director to obtain orders for pain medication. During an interview on 11/20/2024 at 3:22 PM, the Administrator said if a resident was having pain, he expected the nurses to contact the doctor. The Administrator said they wanted to keep pain as low as feasibly possible. The Administrator said some residents had concerns regarding the use of medications for pain, but they should give them over the counter medications and try to abide by their wishes. The Administrator said it was important for the residents' pain to be addressed because pain affected the resident's quality of life in a dramatic fashion. The Administrator said increased pain could be a sign of something emergent and that could be the only warning sign of a condition. Record review of the facility's policy titled, Pain Management Program Policy, revised 01/2023, indicated, The facility will ensure that residents receive the treatment and care in accordance with professional standards of practice, the comprehensive care plan, and the resident's choices, related to pain management .2. The facility will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain. 3. The facility will identify the characteristics of pain such as location, intensity, frequency, pattern, and severity .4. The facility will identify any situations or interventions where an increase in the resident's pain may be anticipated, for example, wound care, ambulation, or repositioning. Obtain orders for pharmaceutical interventions, pain medications, and or non pharmaceutical interventions such as heat, cold, massage and relaxation etc. and/or refer to therapy for skilled therapeutic interventions .For pain that is not managed through the current care plan, whether pharmaceutical or non-pharmaceutical, the resident should be assessed for new causes of the pain and/or the need for a change in frequency, dose or a new intervention. Break through pain may require the use of a PRN or additional type of pain medication .7. Resident pain should also be assessed prior to dressing changes (wound care) and properly medicated (typically 30 minutes or more before wound care) to reduce or alleviate pain appropriately. Resident may also benefit from Physical Therapy wound care modalities to reduce pain with wound care .With a new onset of pain, complete a pain evaluation in the EMR. Determine an appropriate pharmacological intervention under the direction of the physician or a non pharmacological intervention. Re-evaluate the resident after 45 min to one hour to determine if your intervention has been effective and document outcome in the EMR/Progress Notes and ensure new orders and updated care plan are completed .The ongoing evaluation of the status (presence, increase or reduction) of a resident's pain is vital, including the status of underlying causes, the response to interventions to prevent or manage pain, and the possible presence of adverse consequences of treatment .If pain has not been adequately controlled, it may be necessary to reconsider the current approaches and revise or supplement them as indicated .

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure: the toaster was clean. the fryer and oil were clean. An opened loaf of bread was labeled and stored properly. Opened enchilada sauce was stored properly. An opened box of corn dogs was stored properly. An opened box of bacon was stored properly. A container of leftover beans dated [DATE] was discarded. An opened ,d+[DATE] gallon of chocolate milk with a best by date of [DATE] was discarded. The temperature of the top freezer in the dining room was monitored. The top freezer did not have brown residue in it. These failures could place residents at risk for foodborne illness. Findings included: During an observation of the kitchen on [DATE], starting at 9:14 AM, accompanied by the Dietary Manager the following observations were made: Cooking area the fryer had oil that was dark with many crumbs in the oil and around the fryer. the toaster had many crumbs in the bottom and around it. Dry storage room an opened loaf of bread with no open date on it, the end of the bag had been tucked up underneath it, it was not sealed properly. opened enchilada sauce container dated ,d+[DATE] (no year) label instructed to refrigerate after opening. Right Freezer opened corn dog box was not sealed properly, corn dogs had freezer burn on them. Refrigerator in the kitchen opened box of bacon not properly sealed. container with leftover beans dated [DATE]. Milk box ,d+[DATE] gallon of chocolate milk opened with a best by date [DATE]. During an observation and interview on [DATE] at 11:52 AM, the refrigerator in the dining room did not have a thermometer in the top freezer. There were 18 loaves of frozen bread in the top freezer. There was thick brown residue inside the top freezer on the second shelf of the door which had also leaked onto the bottom of the top freezer. Dietary Aide K said there was not a thermometer in the top freezer, and there had not been one in there. Dietary Aide K said they had been checking the temperature of the bottom part of the refrigerator but not the top freezer. The Dietary Manager said the dietary staff should be monitoring the temperature of all the freezers and refrigerators daily. The Dietary Manager said she thought the dietary aides were checking the temperature of the freezer. The Dietary Manager said she was not aware the freezer did not have a thermometer, but it should have its own separate thermometer for the dietary staff to monitor the temperatures. The Dietary Manager said she was not aware of the top freezer having brown residue, and that the dietary staff should be cleaning the top freezer and refrigerator. The Dietary Manager said she would take care of it. During an attempted phone interview on ,d+[DATE] at 2:37 PM, Dietary Aide K did not answer the phone. During an attempted phone interview on [DATE] at 2:38 PM, [NAME] L did not answer the phone. During an interview on [DATE] at 2:29 PM, the Dietary Manager said the fryer and oil were dirty because they only cleaned it once a week, and she had cleaned it last week. The Dietary Manager said all the cooks were responsible for cleaning the fryer and oil, but she was the one that cleaned it. The Dietary Manager said it was important for the fryer and oil to be clean so the food would taste better. The Dietary Manager said if food was labeled to refrigerate after opening it should be placed the refrigerator after opening it. The Dietary Manager said it was important to follow the instructions to prevent the residents from getting sick. The Dietary Manager said everything in the freezer and refrigerator that had been opened should be stored in a Ziploc bag or something closed, it should not be left exposed. The Dietary Manager said it was important to ensure food was stored sealed to prevent freezer burn and because it could make someone sick and freezer burn did not taste good. The Dietary Manager said whoever opened the item should make sure it was stored properly, and that it was a team effort. The Dietary Manager said ultimately, she was supposed to make sure food was stored properly. The Dietary Manager said she was supposed to check every day, but if she was the cook, she did not have the time to check. The Dietary Manager said the person that opened the food should label it, seal it, and date it. The Dietary Manager said it was important to open it, seal it, and date it to prevent rodents and bugs. The Dietary Manager said they had a milk man that brought them milk and placed it in the milk box. The Dietary Manager said he took out the old milk and replaced it with new milk, but they should not have trusted him to do that. The Dietary Manager said she could not say they had been checking the milk for expiration dates. The Dietary Manager said she thought they could store leftovers for 7 days that she was not aware it was 72 hours. The Dietary Manager said it was important to discard food because it could cause people to be sick. The Dietary Manager said she went through the fridge daily to ensure everything was discarded promptly. The Dietary Manager said the toaster was cleaned weekly, but it should be cleaned before if they noticed it was dirty. The Dietary Manager said it was important for the toaster to be clean to prevent buildup because it could catch on fire and to prevent pests. The Dietary Manager said she was not thinking about the refrigerator and freezer in the dining room being separate and requiring separate temperature checks. The Dietary Manager said proper temperatures and monitoring the temperatures was important to prevent freezer burn and for food not to thaw out and go bad. The Dietary Manager said the temperatures not being monitored could result in the residents getting bad food and they could have diarrhea, vomiting, and e. coli (bacteria can cause serious food poisoning or other diseases). During an interview on [DATE] at 3:31 PM, the Administrator said anytime the fryer was visibly splashed, it should be cleaned. The Administrator said the frying oil should be clean. The Administrator said he expected for the food to be covered and sealed, and if possible dated. The Administrator said it was important for the food to be protected from direct exposure. The Administrator said milk should be thrown out past its best by date. The Administrator said he expected for all items in the kitchen to be dated when opened, so if anything went past the date where there was a risk for contamination, they should get rid of it and replace it. The Administrator said he expected for temperatures on the freezer and refrigerators to be monitored and each to have its own thermometer. The Administrator said this allowed them to better safeguard the resident's health by preventing serving them anything spoiled and unsanitary. The Administrator said it was important to check the temperatures to ensure they were kept below the FDAs regulated safe temperatures. The Administrator said it was important for there to be cleanliness in the kitchen to ensure it was a sanitary environment and keeping the area free of crumbs and dirt avoided attracting vermin and insects to keep the kitchen a more sanitary area. Record review of the facility's Weekly Cleaning Log for [DATE], indicated there were no initials listed next to the fryer to indicate it had been cleaned in the month of [DATE], and the toaster was not listed on the cleaning log. Record review of the facility's undated policy titled, Dry Storage, indicated, .9. If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened. If the product was removed from its original container, then the product should also have the name of the product. If using large bags to seal open items in their original packaging, the bag maybe reused, but needs to be re-dated. IF the food is directly in the bag, the bag must be labeled and dated, and when the bag is emptied, it should be discarded. Bags must be sealed .11. Bags of bread products should be closed and dated with the date that it was opened . Record review of the facility's undated policy titled, Refrigerator and Freezer Storage, indicated, .All left over foods should be labeled and dated with the date in and the date out (date the food is to be discarded) -this date can be no more than 72 hours after it was put in the refrigerator .All expired foods must be removed from the refrigerator and freezer .If an item is opened, the food must be tightly sealed. It should be dated with the date that it was opened .The refrigerator and freezers should have inside thermometers. The temperature should be recorded twice a day . Record review of the facility's undated policy titled, Developing A Cleaning Schedule, indicated, Purpose: To establish and maintain the kitchen in a sanitary manner. Procedure: Manager will use either the approved [NAME] cleaning schedule Form that has been modified to meet their facility, or develop a cleaning schedule for their facility. Must have a form for Daily, Weekly and monthly, to assure that all areas of the kitchen are cleaned .

Based on interview and record review the facility failed to ensure residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 1 resident (Resident #13) reviewed for dialysis. The facility failed to keep ongoing communication with the dialysis facility for Resident #13 on 09/12/2024, 09/14/2024, 09/21/2024, 09/28/2024, 10/10/2024, 10/12/2024, 10/19/2024, 10/26/2024, 11/02/2024, and 11/09/2024. These failures could place residents at risk for complications and not receiving proper care and treatment to meet their needs. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was usually understood by others and usually understood others. The MDS assessment indicated Resident #13 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting, showering/bathing self, and supervision or touching assistance with personal hygiene. Resident #13's MDS assessment in Section O, 0110J1 did not indicate she received dialysis while a resident at the facility. Record review of Resident #13's Order Summary report dated 11/19/2024 indicated resident to receive dialysis 3 days a week on Tuesday, Thursday, and Saturday at the dialysis center with a start date of 08/24/2024. Record review of Resident #13's care plan reviewed 11/19/2024 indicated she required hemodialysis related to renal failure. Resident #13's care plan indicated to encourage resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday. Record review of Resident #13's Dialysis Communication Forms for September 2024, October 2024, and November 2024 indicated there was no communication forms for 09/12/2024, 09/14/2024, 09/21/2024, 09/28/2024, 10/10/2024, 10/12/2024, 10/19/2024, 10/26/2024, 11/02/2024, and 11/09/2024. During an interview on 11/19/2024 at 4:33 PM, Dialysis RN F said she was the charge nurse at the dialysis clinic, and Resident #13 received treatments on Tuesday, Thursday, and Saturday. Dialysis RN F said sometimes they received a communication sheet for Resident #13 and sometimes they did not. Dialysis RN F said the dialysis communication sheets were completed to communicate with the facility if there were any problems with the patient during dialysis and any changes with orders. Dialysis RN F said vital signs (blood pressure, heart rate) and weights were also wrote on the communication sheet to monitor the patient for changes and so the facility had an accurate weight for the patient. During an interview on 11/20/2024 at 9:43 AM, LVN A said Resident #13's dialysis communication sheets should be completed every time she went to dialysis. LVN A said the dialysis communication sheets were used to communicate with the dialysis clinic regarding Resident #13's dialysis treatments. LVN A said Resident #13's scheduled dialysis days were Tuesday, Thursday, and Saturday. LVN A said about three weeks ago Resident #13 had been moved rooms to her side, and she may have missed some (missed filling out dialysis communication sheets) when she was moved over. LVN A said it was important for the dialysis communication sheets to be filled out, so the dialysis clinic knew who Resident #13's nurses were in case they needed something or needed to report anything abnormal and for the dialysis clinic to know who they needed to get in touch with for any questions. During an interview on 11/20/2024 starting at 11:32 AM, LVN G said she completed dialysis communication sheets for Resident #13. LVN G said she did not remember if she had missed some or not, but if she had missed some it might have been a mistake. LVN G said it was important for them to use the dialysis communication sheets to ensure they were not missing anything, for any changes in orders, and to see if Resident #13 had any changes from her baseline. During an interview on 11/20/2024 at 10:44 AM, Dialysis RN F said in September 2024, October 2024, and November 2024 the only missed treatments for Resident #13 were on 09/03/2024, 09/07/2024, and 11/14/2024. During an interview on 11/20/2024 at 2:45 PM, the DON said the nurses should be sending the dialysis communication form for proper communication with the dialysis clinic, so they knew what was going on with the resident. The DON said she did not have a monitoring system in place to ensure this was being done. The DON said if communication with the dialysis clinic was not occurring the dialysis clinic would not know if there were any changes with the residents. During an interview on 11/20/2024 at 3:20 PM, the Administrator said the nurse on the hall was responsible for sending the communication form and communicating with the dialysis clinic. The Administrator said the DON was over the nurses and should monitor this. The Administrator said it was important for the dialysis communication forms to be completed to ensure they were aware of the residents' condition if the appointment went bad or if they were having issues, it gave them information to better prepare the residents for the next treatment. Record review of the facility's policy titled, QA-Dialysis Protocol, revised 08/11/2020, indicated, The following steps are being taken to ensure that the facility has an effective and functional protocol . 2. When a resident is sent to dialysis center, a transfer sheet (communication sheet) will accompany the resident to dialysis center . 3. On completion of the treatment at dialysis center a communication form will be sent with resident on return .

Based on interview and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 15 residents (Residents #29), reviewed for care plans. The facility failed to revise Resident #29's care plan to reflect the need for weekly weights and ensure plus three times a day for his weight loss. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Record review of the Resident #29's order summary report dated 11/20/24, indicated Resident #29 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety, protein-calorie malnutrition (inadequate intake of food such as a source of protein, calories, and other essential nutrients), muscle wasting and atrophy (loss of muscle mass and strength), and dysphagia (difficulty swallowing). The order summary report indicated Resident #29 had the following orders: *Enhanced diet, mechanical soft texture, honey thickened consistency, large portions, Nutra freeze cup, with lunch and dinner, double desserts related to unspecified protein-calorie malnutrition with an order start date of 10/17/24. *Ensure Plus three times a day combine with 4 pumps of the simply thick to bring to honey thick consistency with a start date of 09/13/24. *Weekly weight one time a day every Wednesday with a start date 08/28/24. Record review of Resident #29's quarterly MDS assessment dated [DATE], indicated Resident #29 was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #29 had a BIMS score of 0, indicating his cognition was severely impaired. Resident #29 was independent with eating. The MDS assessment indicated Resident #29 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months. Resident #29 was on a mechanically altered diet. Record review of Resident #29's comprehensive care plan revised on 09/27/24, indicated Resident #29 had a potential nutritional problem related to moderate nutritional risk evaluation and weight loss. The care plan interventions indicated for regular diet, mechanical soft texture honey thickened consistency, large protein portions, Nutra freeze cup with lunch and dinner and double desserts. The care plan failed to address Resident #29's orders for weekly weights and ensure plus three times a day. During an interview on 11/20/24 at 1:47 PM, LVN A said Resident #29's care plan should reflect the weekly weights and the ensure plus. LVN A said Resident #29's care plan should be updated so it was known to all staff and charge nurses Resident #29 was being monitored for weight loss. LVN A said failure to update Resident #29's care plan could cause Resident #29 to not receive his supplement or his weekly weight not be obtained. LVN A said she was unsure of who was responsible for updating the care plans. During an interview on 11/20/24 at 1:55 PM, the DON said she expected Resident #29's weight loss interventions to be under his nutrition care plan so staff was aware of what was going on. The DON said since the orders for Resident #29's weekly weight and ensure plus were on his MAR, staff was still able to do the interventions to ensure Resident #29 did not have a weight loss. The DON said the MDS nurse was responsible for ensuring the care plans were updated. During an interview on 11/20/24 at 2:15 PM, the Administrator said he expected the residents' care plans to be based on their assessments to ensure their goals were reached. The Administrator said if the goals changed, then the care plan should be adjusted to reflect the changes. The Administrator said the care plan interventions should have been updated as the care plan was a record, they could use to gage the effectiveness of interventions for future references. The Administrator said the DON and MDS Coordinator were responsible for ensuring the care plans were being updated. During an interview on 11/20/24 at 3:19 PM, the MDS Coordinator said she reviewed physician orders daily and updated the care plan according to the physician's orders. The MDS Coordinator said she also updated the care plans according to the MDS schedule. The MDS Coordinator said she was responsible for updating the care plans. The MDS Coordinator said she missed putting Resident #29's interventions for his weight loss on the care plan. The MDS Coordinator said it was important to ensure the care plans were updated so the CNA's could have properly taken care of the residents. Record review of the facility's policy Care plans- Comprehensive Person-Centered reviewed 2023, indicated . A comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . 8. The comprehensive, person-centered care plan will: a. include measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychological well-, being . 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents conditions change .

Based on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 2 dining rooms (back dining room) reviewed for cleanliness of the physical environment. The facility failed to ensure the windowsill in the back dining room was free of cobwebs, bugs, and dust from 11/18/24 to 11/20/24. This failure could place residents at risk for a decreased quality of life and an unsanitary environment. The findings included: During an observation on 11/18/24 at 11:51 AM, the windowsill of the back dining room had numerous cobwebs, dead bugs, and a thick layer of gray dust. During an observation on 11/19/24 at 8:34 AM, the windowsill of the back dining room had numerous cobwebs, dead bugs, and a thick layer of gray dust. During an observation on 11/20/24 at 10:31 AM, the windowsill of the back dining room had numerous cobwebs, dead bugs, and a thick layer of gray dust. During an interview on 11/20/24 beginning at 1:03 PM, the Housekeeping Supervisor stated the housekeeping staff were responsible for ensuring the back dining room was cleaned. The Housekeeping Supervisor stated the housekeeping staff worked together to clean the back dining room. The Housekeeping Supervisor stated she worked the floor along with her housekeeping staff. The Housekeeping Supervisor stated cleaning the dining room included: the blinds, windowsills, and walls. The Housekeeping Supervisor stated she should have cleaned the windowsill each time the dining room was cleaned but she had not had time this week. The Housekeeping Supervisor stated it was important to ensure the windowsills were free from cobwebs, bugs, and dust to prevent cross contamination and to ensure the environment was cleaned. During an interview on 11/20/24 beginning at 2:51 PM, the Administrator stated the housekeeping staff were responsible for ensuring the back dining room was cleaned. The Administrator stated the windowsills should have been cleaned at least 3 - 4 times per week. The Administrator stated the facility had recently taken the decorations away to add the fall decorations but hadn't gotten to cleaning the windowsill yet. The Administrator stated the Housekeeping Supervisor was responsible for monitoring to ensure the windowsills were cleaned. The Administrator stated it was important to ensure the windowsills were free from cobwebs, bugs, and dust so it was more hygienic. The Administrator stated it was also important to maintain the cleanliness of the facility to promote resident happiness and comfort. Record review of the Homelike Environment policy, revised February 2021, reflected the facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include .clean, sanitary and orderly environment .

Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #198) reviewed for incontinence. The facility failed to ensure Resident #198 was provided prompt incontinent care on 11/18/24 when his bed sheets and clothing were wet up to his shoulders and were brown around the edges of the wet spots. These failures could place residents at risk for urinary tract infections, skin breakdown, and a decreased quality of life. The findings included: Record review of the face sheet dated 11/20/24, reflected Resident #198 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction affecting his right dominant side (weakness or paralysis of the right side after having a stroke). The face sheet reflected Resident #198 developed a urinary tract infection on 11/13/24. Record review of the admission MDS assessment, dated 11/05/24, reflected Resident #198 had clear speech and was usually understood by others. The MDS reflected Resident #198 was usually able to understand others. The MDS reflected Resident #198 had a BIMS score of 14, which indicated no cognitive impairment. The MDS reflected Resident #198 had no behaviors or refusal of care. The MDS reflected Resident #198 required substantial/maximal assistance with toileting hygiene (helper does more than half the effort). The MDS reflected Resident #198 was frequently incontinent of urine. Record review of the comprehensive care plan, revised on 11/13/24, reflected Resident #198 had a urinary tract infection. Record review of the comprehensive care plan, revised on 11/18/24, reflected Resident #198 was incontinent of his bladder. The interventions included: staff to perform incontinent care during daily care and as needed .change clothing as needed after incontinence episodes. Record review of the SBAR assessment dated [DATE], reflected Resident #198 had a suspected UTI. The assessment reflected Resident #198 had symptoms which included increased confusion, and urinary frequency. The assessment reflected the physician ordered blood work and a urinalysis. Record review of the culture and sensitivity report dated 11/12/24, reflected Resident #198 had a high range of Enterococcus Faecalis (pathogen) detected in his urine sample. Record review of the order summary report dated 11/20/24, reflected Resident #198 had an order, which started on 11/13/24, for Levaquin (antibiotic) 500 mg by mouth one time a day for a urinary tract infection. Record review of the MAR dated November 2024 reflected Resident #198 received Levaquin (antibiotic) 500 mg by mouth one time a day for a urinary tract infection. The MAR indicated the order was started on 11/13/24 and was scheduled to end on 11/22/24. During an observation and interview on 11/18/24 beginning at 9:27 AM, Resident #198 was lying in the bed with the head of his bed elevated slightly. Resident #198's sheets were visible wet near his shoulders and the edges of the wet spots on the sheets were brown. Resident #198 stated he wanted assistance getting out of the bed. Resident #198 stated he used his urinal when he was able to reach it. Resident #198 stated he had been wet all night. Resident #198 said he was not affected by his sheets being wet. During an observation and interview on 11/18/24 beginning at 9:35 AM, CNA M and CNA N entered Resident #198 and provided incontinent care. Resident #198 had his urinal under the blankets that was filled with urine. CNA M removed the urinal and told Resident #198 she would have to change his incontinent brief because it was tore to pieces. CNA M and CNA N agreed that Resident #198's bed and bedsheets were wet up to his shoulders. During an interview on 11/19/24 beginning at 3:23 PM, CNA N stated Resident #198 normally used his urinal, but he leaked around it most of the time. CNA N said Resident #198 did not normally require a full bed or linen change due to urine incontinence. CNA N said she was unsure when the night crew completed their last round. CNA N said she normally started her rounds after breakfast. CNA N said she had just started rounding at approximately 9:30 AM when they changed Resident #198. CNA N said it was important to ensure Resident #198 was changed promptly after urination to prevent stinging from the urine and skin breakdown. CNA N stated it could have made Resident #198 smell if it was not cleaned up. During an attempted telephone interview on 11/19/24 at 4:30 PM NA P did not answer the phone. Surveyor was unable to leave a voicemail related to a full voicemail box. A brief text message was sent, and no response was obtained upon exit of the facility. During an interview on 11/19/24 beginning at 4:37 PM, CNA O said rounds were completed typically every 2 - 3 hours. CNA O stated she worked double shifts on evening and night shifts. CNA O said she did not work with Resident #198 on the early morning of 11/18/24. CNA O said NA P was assigned to Resident #198's hall. CNA O stated the last round was started on 11/18/24 at approximately 3:45 AM. During an attempted telephone interview on 11/20/24 at 9:16 AM NA P did not answer the phone. Surveyor was unable to leave a voice message related to the mailbox being full. No return call upon exit of the facility. During an interview on 11/20/24 beginning at 10:36 AM, CNA M stated she worked on the day shift. CNA M said she normally started rounds after breakfast. CNA M said Resident #198 sometimes required a full linen bed change due to incontinence. CNA M said Resident #198 used his urinal. CNA M stated on 11/18/24 at approximately 9:30 AM was the first time she had laid eyes on Resident #198. CNA M said she was unsure what time night shift completed their rounds. CNA M said rounds should have been completed at least every 2 hours. CNA M said it was important to ensure Resident #198 was changed promptly after urination to prevent skin breakdown, redness, or open areas. CNA M said not changing Resident #198 promptly after urination could have made his UTI worse. During an interview on 11/20/24 beginning at 1:37 PM, LVN B said incontinent rounds should have been completed at least every 2 hours. LVN B said Resident #198 required total assistance with incontinent care. LVN B said Resident #198 should have been checked at least every 2 hours. LVN B stated she was responsible for monitoring to ensure the CNAs completed their rounds every two hours. LVN B said she looked at the residents first thing in the morning when she arrived, at approximately 7 AM to ensure everything was okay. LVN B stated the CNAs did not report Resident #198 had required a full linen bed change related to incontinence or that his bed had brown rings. LVN B said she expected the CNAs to report those things to her. LVN B said she was unsure what time night shift completed their last rounds. LVN B said it was important to ensure prompt incontinent care was performed to prevent skin breakdown and prevent infections from becoming worse. During an interview on 11/20/24 beginning at 2:18 PM, the DON stated she expected the facility staff to ensure incontinent rounds were completed. The DON stated rounds were constantly completed by the day shift staff. The DON stated she expected night shift to start the last round at approximately 4:30 AM to 5 AM. The DON stated the last round should not have been started any earlier than 4:30 AM and if it was, that was not the normal routine. The DON stated the day shift crew normally started their first rounds after breakfast at approximately 8 AM to 8:30 AM. The DON stated it was important for prompt incontinent care to have been performed to avoid adverse effects such as skin breakdown. The DON stated not performing prompt incontinent would have had no effect on Resident #198's urinary tract infection. During an interview on 11/20/24 beginning at 2:51 PM, the Administrator stated he expected incontinent rounds to have been completed at the start of their shift, during their shift, and at the end of their shift. The Administrator stated if there was down time, they should have been rounding. The Administrator stated the first round and last round were non-negotiable. The Administrator stated the nurse on the hall was responsible for monitoring to ensure incontinent round were completed. The Administrator stated residents who were found wet to their shoulders with the wet spots brown around the edges should have been reported to the charge nurse. The Administrator stated it was important to ensure residents were provided prompt incontinent care to maintain their comfort. The policy for bladder incontinence was requested and not provided upon exit of the facility. During an interview during the exit conference on 11/20/24 beginning at 4:25 PM, the Regional Nurse stated she spoke with NA P regarding Resident #198. The Regional Nurse stated NA P reported he checked Resident #198 at approximately 4:45 AM on 11/18/24 and provided care at that time. No documentation was provided by the Regional Nurse.

Based on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 2 residents (Resident #35) reviewed for trauma-informed care The facility failed to adequately assess Resident #35's history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization. The findings included: Record review of Resident #35's face sheet dated 11/20/24, indicated a [AGE] year-old male who admitted to the facility initially on 08/24/22 and readmitted on [DATE]. Resident #35 had diagnosis of paranoid schizophrenia (mental disorder characterized by disruptions in thought processes, perceptions, emotional responsiveness, and social interactions), tracheostomy (an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs), post-traumatic stress disorder (a mental health condition that's caused by an extremely stressful or terrifying event), personality disorder (mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood and relating to others) and major depression (mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Record review of Resident #35's quarterly MDS assessment dated [DATE], indicated Resident was usually understood and usually understood others. The MDS assessment indicated Resident #35 had a BIMS score of 13, indicating his cognition was intact. The MDS assessment indicated Resident #35 had a diagnosis of Post Traumatic Stress Disorder. Record review of Resident #35's comprehensive care plan revised on 11/19/24, indicated Resident #35 had the potential to be physically aggressive related to anger (PTSD), and poor impulse control. The care plan interventions included for psychiatric consult as indicated, and to document observed behavior and attempted interventions in behavior log. The care plan did not address Resident #35's triggers for his PTSD. Record review of the psychiatric progress notes dated 10/28/24, indicated Resident #35 had a medical necessity related to anxiety disorder, paranoid schizophrenia, personality disorder, and post-traumatic stress disorder. The progress note indicated the goals were to reduce anxiety through weekly psychotherapy with emphasis on coping with depression and anxiety, while identifying triggers. Record review of Resident #35's initial social history assessment with an effective date of 08/24/22 and completed by the previous SW, indicated Resident #35 had a psychiatric history and had a psychiatric admission 7 months previously for a crisis regarding his family member's health. The social history assessment did not indicate his PTSD diagnosis or his triggers. During an interview on 11/19/24 at 2:37 PM, Resident #35 said he had a diagnosis of PTSD because in 1978 he was at a party, had been intoxicated and some men took him to a room and held him down. He said they blindfolded him, was given a gun and was told to shoot. Resident #35 said he heard screaming and was extremely bothered by it. Resident #35 said his triggers were that he could not stand being in an enclosed area, the blinds being closed, or being by himself . Resident #35 did not indicate if he had any triggers while at the facility. During an interview on 11/19/24 at 2:52 PM, LVN A said she was unsure if Resident #35 had a diagnosis of PTSD. LVN A reviewed Resident #35's EMR and said Resident #35 did have a diagnosis of PTSD. LVN A said there were no documented triggers on Resident #35's care plan and she was not aware of any triggers Resident #35 had. LVN A said Resident #35 was being seen by psychiatric services for his schizophrenia diagnosis and behaviors. LVN A said the trauma assessments were completed by the social worker. LVN A said she would assume if a resident had a diagnosis of PTSD, then his triggers should be documented so staff was aware. LVN A said failure to identify Resident #35's triggers could cause him to become unsafe, agitated, and potentially become a danger to himself. During an interview on 11/19/24 at 3:03 PM, the SW said she had been working at the facility for 11 months. The SW said the trauma assessments were completed on admission and as needed. The SW said she was aware of Resident #35's diagnosis of PTSD but was unfamiliar with his triggers. The SW said staff should be aware of Resident #35's triggers to know how to handle them. The SW said the MDS Coordinator was responsible for updating the care plans. The SW said the identified triggers should be on the care plan so the behavior could be prevented. During an interview of 11/19/24 at 3:11 PM, the MDS Coordinator said she was responsible for updating the care plans. The MDS Coordinator said she was aware of Resident #35's diagnosis of PTSD but was unsure of his triggers. The MDS Coordinator said if a resident had a diagnosis of PTSD, then the identified triggers should be on their comprehensive care plan to ensure the staff knew what set them off and how to care for the resident. During an interview on 11/20/24 at 12:09 PM, CNA N said she was unaware of Resident #35's diagnosis of PTSD or any triggers. CNA N said staff should be aware of any triggers so they could know how to care for the resident. CNA N said the nurse was responsible for relaying any identified triggers to the CNAs. During an interview on 11/20/24 at 1:55 PM, the DON said Resident #35 had never said anything to her about trauma or triggers in his life at any time. The DON said staff needed to be aware of any triggers so Resident #35 could have a good quality of life. The DON said trauma assessments were completed by the SW on admission. The DON said it was never brought to her attention Resident #35 had a diagnosis of PTSD and if they had known, they would have put the proper measures in place. During an interview on 11/20/24 at 2:15 PM, the Administrator said he was not personally aware of Resident #35's diagnosis of PTSD. The Administrator said Resident #35 had attention seeking behavior and had a tendency of making up a lot of things . The Administrator said Resident #35 had said some things he was unsure of if they were factually correct or were told to just get a rise out of someone. The Administrator said Resident #35 had never spoken to him about any triggers. The Administrator said he took mental distress very seriously. He said it was important to identify someone's triggers so they could know what to avoid and be ready for when those triggers occurred to provide the resident with comfort and solace. The Administrator said social services was responsible for ensuring the trauma assessments were completed with the updated care plan with triggers in place. The Administrator said he was unsure of when the trauma assessments were to be completed but assumed on admission or during annual review. Record review of the facility policy Trauma-Informed and Culturally Competent Care reviewed January 2023, indicated . To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization . Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful, or life threatening and that has lasting adverse effects on the individuals functioning and mental, physical, social, emotional, or spiritual well-being Resident screening. 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events . 3. Screening may include information such as: a. trauma history, including type, severity and duration . f. historical mental health diagnosis . 4. Utilize initial screening to identify the need for further assessment and care. Resident Care planning. 1. Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. 2. Identify and decrease exposure to triggers that may re-traumatize the resident .

Based on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 linen cart reviewed for infection control. The facility failed to ensure Laundry Aide H completely covered the linen cart while delivering the residents clean clothing on 11/20/2024. This failure could place residents at risk for cross-contamination and the spread of infection. Findings included: During an observation on 11/20/2024 at 8:10 AM, Laundry Aide H was observed going down the hallway passing out the residents clean clothing with the clothing exposed. Laundry Aide H had the linen cart halfway uncovered with a blanket. During an interview with the Housekeeping Supervisor and Laundry Aide H on 11/20/2024 at 11:56 AM, Laundry Aide H said when she was passing the clean laundry, she should make sure the linen cart was completely covered and the clothes were not exposed. Laundry Aide H said she thought the blanket she had used over the linen cart had covered the clothes enough. Laundry Aide H said the linen cart with the clean clothes should be covered because of germs. The Housekeeping Supervisor said when the laundry aides were passing the clean laundry out to the residents, they should make sure the linen cart was completely covered. The Housekeeping Supervisor said they should use a flat white sheet to ensure the clothes were completely covered to prevent cross contamination. During an interview on 11/20/2024 at 3:28 PM, the Administrator said when the residents' clothes were passed on the linen cart it should be covered. The Administrator said they did not want clothes exposed to pathogens, dirt or anything that was going to undermine the sanitization process in between the laundry room and getting to the residents' closets. Record review of the facility's policy titled, Departmental (Environmental Services) - Laundry and Linen, reviewed January 2023, indicated, Purpose The purpose of this procedure is to provide a process for the safe and aseptic handling, washing, and storage of linen . Clean linen will remain hygienically clean (free of pathogens in sufficient numbers to cause human illness) through measures designed to protect it from environmental contamination, such as covering clean linen carts .

Based on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 6 residents (Resident #13 and Resident #41) reviewed for pharmacy services. The facility failed to ensure Resident #13's amlodipine (medication that lowers blood pressure) was not administered when her blood pressure was outside of the ordered parameters on 11/16/24. The facility failed to ensure Resident #41's carvedilol (medication that lowers blood pressure) was not administered when her blood pressure was outside of the ordered parameters on 11/09/24. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. Findings included: 1. Record review of a face sheet dated 11/20/2024 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis) and hypertension (high blood pressure). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was usually understood by others and usually understood others. The MDS assessment indicated Resident #13 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting, showering/bathing self, and supervision or touching assistance with personal hygiene. Record review of Resident #13's Order Summary report dated 11/19/2024 indicated an order for amlodipine 10 mg give 1 tablet by mouth one time a day hold for systolic blood pressure (top number and refers to the amount of pressure experienced by the arteries when the heart beats) <100 (less than 100) or diastolic blood pressure (bottom number and refers to the amount of pressure while the heart is resting) <60 (less than 60). Record review of Resident #13's care plan reviewed 11/19/2024 did not address management of Resident #13's hypertension. Record review of Resident #13's November 2024 MAR indicated: Amlodipine 10 mg give 1 tablet by mouth one time a day hold for systolic blood pressure <100 or diastolic blood pressure <60 with an order date of 09/09/2024. On 11/16/2024 Resident #13's blood pressure was 99/71, which indicated the systolic blood pressure was less than 100. The medication was marked as administered by LVN G. 46928 2. Record review of Resident #41's face sheet dated 11/20/24, indicated an [AGE] year-old female who admitted to the facility on [DATE] with diagnoses which included cerebral infarction (condition that occurs when blood flow to the brain is blocked, resulting in brain tissue death), atrial fibrillation (irregular heart rhythm), essential hypertension (high blood pressure), and hyperlipidemia (excess of lipids or fats in the blood). Record review of Resident #41's quarterly MDS assessment dated [DATE], indicated Resident #41 was sometimes understood and sometimes understood others. The MDS assessment indicated Resident #41 had a BIMS score of 02, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #41 had an active diagnosis of hypertension. Record review of Resident #41's comprehensive care plan dated 09/23/24, indicated Resident #41 had altered cardiovascular status related to atrial fibrillation, hypertension, and hyperlipidemia. The care plan interventions indicated to give carvedilol as ordered. Record review of Resident #41's order summary reported dated 11/20/24, indicated Resident #41 had an order for carvedilol 25 mg tablet give one tablet two times a day related to essential hypertension and to hold if systolic blood pressure less than 100, diastolic blood pressure less than 60, or heart rate less than 55 with an order date of 06/19/24. Record review of Resident #41's medication administration record dated 11/1/24- 11/30/24, indicated Resident #41 had orders for carvedilol 25mg one tablet by mouth two times a day for essential hypertension with instructions to hold for SBP less than 100, DBP less than 60, or HR less than 55. * On 11/09/24 for AM dose, Resident #41's blood pressure was 95/65. The medication administration record had a check mark which indicated Resident #41 was administered a carvedilol 25mg tablet outside the ordered parameters by LVN G. During an interview on 11/20/2024 starting at 11:32 AM, LVN G said she did not hold Resident #13's amlodipine. LVN G said she administered Resident #13's blood pressure medication when Resident #13's blood pressure was 99/71 on 11/16/2024. LVN G said she was aware Resident #13's orders were to hold for systolic blood pressure <100. LVN G said she administered the amlodipine even though Resident #13's blood pressure was low because she knew when Resident #13 went to dialysis her blood pressure went up, so she needed it. LVN G said she had administered Resident #41's carvedilol when her blood pressure was 95/65. LVN G said she was aware Resident #41's orders instructed to hold blood pressure for systolic blood pressure <100. LVN G said she administered the carvedilol because Resident #41's blood pressure went up later in the day. LVN G said the nurses that had trained her instructed her to give blood pressure medication if the resident's blood pressure was out of parameters, but it was borderline. LVN G said to her knowledge Resident #13 and Resident #41 had not been affected by her administering the blood pressure medications with their blood pressures out of the required parameters. LVN G said it was different nurses who trained her. LVN G said if residents received blood pressure medication when the blood pressure was lower than the required parameters, their blood pressures could go down more, they might have to go to the ER, or get even more sick. During an interview on 11/20/2024 at 3:04 PM, the DON said if during medication administration a resident's blood pressure was low the nurses could call the doctor, and he could advise them or they could hold the medication, go back later, and check the blood pressure to see if it had gone up. The DON said if the resident's blood pressure was not within parameters, the nurses should not give the medication, they should hold it. The DON said Resident #13's amlodipine besylate should not have been administered if her blood pressure was 99/71, and the doctors order was to hold for systolic blood pressure <100. The DON said Resident #41's carvedilol should not have been administered if her blood pressure was 95/65, and the doctors order was to hold for systolic blood pressure <100. The DON said in the past she had in serviced the nurses and let them know that they should follow the parameters ordered by the doctor. The DON said she did not review resident's MARs, and she had no system in place for monitoring the nurses to ensure they were administering medications within the required parameters. The DON said administering blood pressure medications when the blood pressure was not within the required parameters could result in the blood pressure being lowered more and in lethargy (drowsy, tired, decreased alertness) and syncope episodes (fainting). During an interview on 11/20/24 at 3:42 PM, the Administrator said he expected the nurses to follow proper administration protocols for all medications. If the blood pressure was out of range the nurses should not give the medication until the blood pressure was back in range. The Administrator said the DON was responsible for providing oversight to ensure the nurses were properly administering medications. The Administrator said on the weekend the RN supervisor should monitor the nurses and report to the DON any issues. The Administrator said it was important for the parameters to be followed because it can throw it (blood pressure) in the opposite direction. The Administrator said if the blood pressure was high or low it could cause the opposite problem for the resident. Record review of the facility's policy Medication Administration dated 07/08/24, indicated . Medications are administered in a safe and timely manner, and as prescribed . 11. The following information is checked/verified for each resident prior to administering medications: a. allergies to medications; and b. vital signs, if necessary .

Based on interview and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 15 residents (Resident # 13) reviewed for MDS assessment accuracy. The facility failed to ensure Resident # 13's dialysis treatments were accurately reflected on her Quarterly MDS assessment with an ARD of 10/28/2024. This failure could place residents at risk of not receiving care and services to meet their needs. Findings included: Record review of a face sheet dated 11/20/2024 indicated Resident #13 was a [AGE] year-old female initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included end stage renal disease (kidneys cease functioning on a permanent basis). Record review of the Quarterly MDS assessment dated [DATE] indicated Resident #13 was usually understood by others and usually understood others. The MDS assessment indicated Resident #13 had a BIMS score of 10, which indicated her cognition was moderately impaired. The MDS assessment indicated Resident #13 required partial/moderate assistance with toileting, showering/bathing self, and supervision or touching assistance with personal hygiene. Resident #13's MDS assessment in Section O, 0110J1 did not indicate she received dialysis while a resident at the facility. Record review of Resident #13's Order Summary report dated 11/19/2024 indicated resident to receive dialysis 3 days a week on Tuesday, Thursday, and Saturday at the dialysis center with a start date of 08/24/2024. Record review of Resident #13's care plan reviewed 11/19/2024 indicated she required hemodialysis related to renal failure. Resident #13's care plan indicated to encourage resident to go for the scheduled dialysis appointments on Tuesday, Thursday, and Saturday. Record review of Resident #13's Dialysis Communication Forms indicated she went to dialysis on 10/22/2024 and 10/24/2024. During an interview on 11/20/2024 at 2:41 PM, the DON said she was the RN that signed the MDS assessments. The DON said there was a care plan review tab that she used so she could review the MDS assessments before signing them. The DON said if dialysis was on the MDS they should have checked it for Resident # 13 because she received dialysis. The DON said she did not know if she had just missed it or what. The DON said it was important for the MDS to be accurate so they knew who triggered (required special monitoring) and they could monitor them. The DON said she did not know how the MDS not being accurate could negatively affect the residents. During an interview on 11/20/2024 at 3:19 PM, the MDS Coordinator said Resident #13's dialysis should have been coded on the MDS assessment. The MDS Coordinator said she just missed it. The MDS Coordinator said it was important to code the MDS assessments accurately to ensure the MDS accurately reflected the resident's status for accurate reimbursement and to make sure the MDS assessment painted the picture of the resident's care and services. During an interview on 11/20/2024 at 3:17 PM, the Administrator said he expected for the MDS to be accurate, and it should reflect what was being done at the facility. The Administrator said he expected for the MDS Coordinator and the DON to complete the MDS assessments accurately. The Administrator said it was important for the MDS to be coded accurately so it accurately reflected what they did and what the residents needs were and for them to be reimbursed properly. Record review of the facility's, MDS Coding Policy, reviewed January 4, 2023, indicated, .utilize the most up to date Resident Assessment Instrument (RAI) manual for determination of coding each section of the Resident Assessment, timely and accurately. The most current RAI manual may be found on the CMS.gov website. Record review of the Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated .O0110J1 code peritoneal or renal dialysis which occurs at the nursing home or at another facility .

Based on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 15 residents (Resident #12) reviewed for reasonable accommodations. The facility failed to ensure Resident #12's call light was within reach while in bed. This failure could place residents at risk for a delay in assistance and decreased quality of life. Findings include: Record review of a face sheet dated 11/20/2024 indicated Resident #12 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included unspecified sequelae of unspecified cerebrovascular disease (residual neurological effects of a stroke), vascular dementia unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety (a condition caused by the lack of blood that carries oxygen and nutrient to a part of the brain and it causes problems with reasoning, planning, judgment, and memory), and acquired absence of the right and left leg above the knee, Record review of the Quarterly MDS assessment dated [DATE] indicated, Resident #12 was sometimes understood by others and sometimes understood others. The MDS assessment indicated Resident #12 had a BIMS score of 00, which indicated his cognition was severely impaired. The MDS assessment indicated Resident #12 was dependent on staff for toileting, showering/bathing self, and personal hygiene. The MDS assessment indicated Resident #12 was dependent for rolling and transfers. Record review of the care plan revised 08/05/2024 indicated Resident #12 was a high risk for falls to anticipate and meet his needs, be sure his call light was within reach, encourage the resident to use it for assistance as needed, and he needed a prompt response to all his requests for assistance. During an observation and interview on 11/18/2024 at 2:07 PM, Resident #12 was in his bed and said he needed assistance with his TV. Instructed Resident #12 to use his call light for staff assistance. Resident #12 said, I ain't got one. Upon observation of Resident #12's call light it was on the floor by the edge of his nightstand out of his reach. Surveyor stopped MA C to assist Resident #12. During an observation on 11/19/2024 at 8:03 AM Resident #12's call light was on the floor by the edge of his nightstand out of his reach. During an observation and interview on 11/19/2024 at 3:21 PM, CNA E said Resident #12 was able to use a call light. CNA E said they should be checking the residents to ensure they had their call lights every round and at least every 2 hours. CNA E said it was important for the residents to have their call light accessible to them in case they needed assistance. CNA E said if they did not have their call light accessible to them, they were not getting the care they needed at the moment. CNA E went into Resident #12's room and pulled the call light off the floor where it laid close to the edge of the nightstand beside Resident #12's bed out of his reach. CNA E gave Resident #12's call light to him, asked him to press it, to ensure it was functioning properly. Resident #12 activated the call light, and it was functioning. During an interview on 11/20/2024 at 3:00 PM, the DON said when the staff left the room, they should make sure the call light was within reach. The DON said she had made rounds and ensured all the residents call lights were within reach, so she knew at one point he had it. The DON said sometimes when Resident #12 turned and repositioned himself he knocked it off the bed onto the floor. The DON said all the staff were responsible for making sure call lights were within reach. The DON said if the call light was not within reach, they would not be able to push the call light to get the staff's attention. During an interview on 11/20/2024 at 3:26 PM, the Administrator said all residents should have their call light within reach, and if it was not within arm's reach, it was in the wrong spot. The Administrator said typically the CNAs were responsible for ensuring the residents' call lights were within reach, but anyone moving the resident or repositioning them could ensure their call light was within reach. The Administrator said it was important for the residents to have their call lights within reach because it was their only means of communication. The Administrator said the residents could need something small or they could be choking so they needed to have their call light so staff could respond in a timely and efficient manner. Record review of the facility's policy titled, Resident Call System, reviewed 03/28/2023, indicated, Policy Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation Policy Interpretation and Implementation 1. Each resident is provided with a means to call staff directly for assistance from his/her bed .

Based on observation, interview, and record review the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 2 of 3 (Resident #s 26 and 29) residents reviewed for care plans. The facility failed to ensure Resident #26's comprehensive care plan addressed that she required a daily application of a right hand splint. The facility failed to ensure Resident #29's comprehensive care plan addressed that she received Cymbalta (antidepressant), Trazodone (antidepressant), and Lorazepam (antianxiety). These failures could place residents at risk of not receiving necessary medications and services. The findings included: 1) Record review of a face sheet dated 10/10/2023 indicated Resident #26 was a [AGE] year-old female, who admitted to the facility on [DATE] with the diagnoses of a stroke with right-sided paralysis, dementia, and a right-hand contracture (tightening of tissue causing the fingers to bend forward). Record review of the Significant Change MDS dated [DATE] indicated Resident #26 was sometimes understood and sometimes understood others. The MDS indicated Resident #26's BIMS score was a 3 indicating severe cognitive deficit. The MDS indicated Resident #26 did not display rejection of care. The MDS indicated Resident #26 required extensive assistance of two staff with bed mobility, dressing, and transfers. The MDS indicated Resident #26 had functional limitation in range of motion on one side with the upper and lower extremities. Record review of an Orders-Administration Note dated 9/13/2023 indicated Resident #26 had a physician's order dated 9/13/2023 for a right-hand splint to be applied after breakfast and removed before lunch daily. Record review of the administration record dated October 2023 indicated Resident #26's right hand splint was applied daily. Record review of a comprehensive care plan dated 7/01/2022 indicated Resident #26 had an alteration in musculoskeletal status related to a contracture of the right hand. The care plan indicated Resident #26 would be free of pain and free of injuries or complications. The interventions of the care plan failed to indicate Resident #26 was to wear a splint to her right hand. Record review of a Therapy Screening Form dated 8/07/2023 indicated Resident #26 had limited range of motion to her right upper extremity and was at risk for contractures. Record review of an Occupational Therapy Discharge Summary dated 9/06/2023 indicated Resident #26 met the goal to safely wear a resting hand splint on her right hand and right wrist for up to 2 hours with minimal symptoms of redness, swelling, discomfort, or pain. During an observation on 10/09/2023 at 9:51 a.m., revealed Resident #26 was not wearing a right-hand splint. During an observation on 10/09/2023 at 10:56 a.m., revealed Resident #26 was not wearing a right-hand splint. During an observation on 10/10/2023 at 10:46 a.m., revealed Resident #26 was not wearing a right-hand splint. During an interview on 10/10/2023 at 9:30 a.m., Resident #26's family member said he visited Resident #26 every day. The family member said the hand splint had not been placed on Resident #26 for numerous days. During an interview on 10/10/2023 at 2:43 p.m., the MDS coordinator reviewed the entire comprehensive care plan and said she believed she discontinued the care plan for Resident #26 to wear the right hand/wrist splint when she discontinued restorative care. The MDS coordinator said she was responsible for the care planning of splints. The MDS coordinator said she updated the care plans as she reviewed the 24-hour report and after receiving daily updates. The MDS coordinator said Resident #26's hand contracture could worsen without the splint application to her right hand/wrist. During an interview on 10/10/2023 at 2:16 p.m., LVN A said she was Resident #26's nurse. LVN A said she was responsible for applying Resident #26's right-hand splint as ordered. LVN A said she had documented today on the electronic record she applied Resident #26's splint but she said she failed to correct the documentation when Resident #26's refused the splint. LVN A said she documented the application of the splint on 10/09/2023 but she failed to apply Resident #26's right-hand splint. LVN A said contractures could worsen without application of the splints. During an interview on 10/11/2023 at 12:01 p.m., the DON said she communicated with the MDS coordinator for care plan needs. The DON said the care plan directed Resident #26's care needs including the right-hand splint. The DON said she expected the right-hand splint to be applied, monitored, removed, and a skin check completed daily as ordered. The DON said she had not monitored the placement of the splints daily. During an interview on 10/11/2023 at 12:49 p.m., the Administrator said every resident should have a care plan, the care plan must be updated to better treat the residents. The Administrator said the care plan needs were discussed in the morning meeting and the care plan was updated at that time. The Administrator said the MDS coordinator was responsible for ensuring the care plan was updated and the DON was responsible for monitoring. The Administrator said when the care plan was not updated then an aspect of the resident's care could go underserved or at a provided at a suboptimal level. The Administrator said he expected Resident #26's right hand splint to be in place as ordered to prevent loss of range of motion increasing the right-hand contracture. 45879 2.Record review of Resident #29's face sheet, dated 10/10/23 indicated Resident #29 was an [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia (the loss of cognitive functioning - thinking, remembering, and reasoning), major depression (a mood disorder that causes a persistent feeling of sadness), and generalized anxiety (a feeling of fear, dread, and uneasiness). Record review of Resident #29's quarterly MDS assessment, dated 09/05/23, indicated Resident #29 was usually understood and usually understood by others. Resident #29's BIMs score was 05, which indicated she was cognitively severely impaired. Resident #29 required extensive assistance with toileting, personal hygiene, transfer, dressing, bed mobility, bathing, and eating. The MDS indicated she had 5 days of antidepressant medication and 1 day of antianxiety medication during the 7-day look-back period. Record review of Resident #29's physician's orders dated 08/17/23 indicated, Cymbalta 60mg, give 1 tablet by mouth at bedtime for depression. Record review of Resident #29's physician's orders dated 09/08/23 indicated, Lorazepam 0.5mg, give 1 tablet by mouth twice a day for anxiety. Record review of Resident #29's physician's orders dated 07/05/23 indicated, Trazodone 50mg, give 1 tablet by mouth at night for depression. Record review of Resident #29's MAR record dated 10/01/23 through 10/11/23 revealed Resident #29 received Cymbalta 60mg, Lorazepam 0.5mg, and Trazodone 50mg as ordered. Record review of Resident #29's comprehensive care plan, dated 06/06/22, revealed Resident #29's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not addressed in the resident's care plan. During an interview on 10/10/23 at 3:05 p.m., the MDS coordinator verbally confirmed Resident #29's diagnoses of major depressive disorder with medications use of Cymbalta and Trazadone and generalized anxiety disorder with the medication use of Lorazepam were not addressed by the resident's care plan. The MDS coordinator said she was responsible for ensuring the care plans were updated. The MDS coordinator said the diagnoses and medication should have been listed in Resident #29's care plan and those omissions were an oversight. The MDS coordinator said the nurses/caregivers may not be aware of how to properly care for Resident #29 because her diagnoses and/or medications were not listed in her plan of care. During an interview on 10/11/23 at 11:20 a.m., the ADON said any nurse could add things to a resident's care plan. She said the MDS nurse was responsible for the care plans and the DON was the overseer of care plans. The ADON said they had morning meetings and clinical meetings Monday through Friday where they talked about changes and sometimes the MDS nurse would add or update care plans during those meetings. She said it was important to have a care plan for the care of each resident. She said the intent of the care plan was for staff to be able to meet the resident's needs. During an interview on 10/11/23 at 12:03 p.m., the DON said the MDS nurse was responsible for ensuring care plans were updated with any changes. She said the MDS nurse came to the morning meetings and had access to the resident's orders and the 24-hour report to update the resident's care plans as needed. She said she was not sure where the breakdown occurred for Resident #29's care plan which had not been implemented with her current diagnoses and medications. The DON said care plans should be complete and accurate to ensure residents receive proper care. During an interview on 10/11/23 at 12:49 p.m., the Administrator said he expected all residents to have a care plan. He said they talked about the resident's care and needs during the morning meeting, and he expected the care plan to be updated to reflect the resident's care. He said the MDS nurse was responsible, and the DON was the overseer of care plans. He said the facility needed to tailor a care plan for each individual resident because all resident needs were not the same. He said without care plans being accurate, it was his opinion that care could be missed. Record review of a policy, Care Plans, Comprehensive Person-Centered, dated 10-2022 and reviewed January 2023 indicated a comprehensive, person-centered care plan that included measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. 8. The comprehensive, person-centered care plan will: . b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

Based on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident #1) reviewed for abuse in that: Resident #1 was gotten out of bed against his wishes, made to sit up all night on 2/24/23 by the orders of LVN A. Resident #1 was threatened, and emotionally abused on 2/24/23 by LVN A and LVN E. Resident #1 said he was being punished for hollering out. The noncompliance was identified as PNC. The IJ began on 2/24/23 and ended on 3/4/23. The facility corrected the noncompliance before the survey began. This failure placed residents at risk for continued abuse, fear, and intimidation. Findings included: Record review of Resident #1's face sheet dated 8/8/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. Some of his diagnoses were Hemiplegia (Paralysis on one side of the body) following a stroke, mild cognitive impairment, abnormal posture, anxiety disorder, and schizoaffective disorder bipolar type. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated his cognitive status was moderately impaired. His bed mobility was extensive assistance with two people. Resident #1 required the assistance of two people for transfers. Record review of Resident #1's care plan initiated on 10/22/21 with a focused area of behaviors related to frequently yelling out instead of using the call light, attention seeking, as evidence by asking to have pillow fluffed multiple times within minutes of doing so. A history of climbing out of bed and screaming when up in chair wanting to go back to bed within less than 30 minutes of being up. Some of the interventions were to be supportive of all needs and requests to maintain comfort. Encourage him to sit up for as long as possible. If multiple requests were made to go back, please put him back to bed. Maintain a calm, restful safe environment. A focused area of ADL self-care performance deficit related to left sided hemiplegia. Resident #1 required extensive assistance of two staff for positioning and tuning in bed for proper body alignment as necessary. The resident had limited range of motion of the left upper extremity, hand, and lower extremity. Resident #1 required extensive assistance by 2 staff for dressing toilet use and transfers. The resident was transferred by Hoyer lift. Record review of a Social Services note dated 7/13/23 indicated Resident #1 preferred to stay in bed, but occasionally went to the dining room and participated in activities. Written by the social worker. Record review of the Provider Investigation report dated 3/11/22 indicated Resident #2 crawled to Resident #1's bed and was trying to hit him with a remote. He was verbally aggressive towards Resident #1 and threatening to kill him. Resident #1 was hollering for staff. The staff intervened and Resident #2 was removed and taken to the emergency room for evaluation. Record review of a general in service dated 2/23/23 (prior to the incident) indicated an in-service on abuse and neglect. The sign in sheet indicated LVN A and LVN E attended. Record review of the Provider Investigation Report dated 2/27/23 indicated during an investigation the facility was made aware of an additional concern related to LVN A and LVN E. During the investigation of LVN E's treatment of residents, there was an incident that arose regarding LVN A. The allegations regarding LVN A were substantiated. The police were notified, life satisfaction rounds were conducted with residents, and staff questionaries to identify if this happened elsewhere. The LVN A and LVN E were terminated. The report contained a statement dated 2/24/23 written by CNA B that indicated Resident #1 pulled his light a few times. This annoyed LVN A and LVN E to the point they wanted him out of bed. Around 12:00 a.m. CNA B and CNA D got Resident #1 up and they would not let us put him down until closer to 7 :00 a.m. While he was up, they kept telling him to shut up. The nurses laughed at him along with torturing him with past events of a former roommate beating Resident #1 up for talking. They proceeded to say, if you don't shut up Resident #2 was going to come and get you again. The Report contained a statement dated 3/1/23 by Resident #1 written by the Administrator. The statement indicated CNA D took him to the front lobby on Friday night 2/24/23 as punishment from the nurses for hollering. He said LVN A did not like it when he hollered. He said LVN A said, You remember that guy that beat you up? Well, I am gone bring him out here if you don't stop hollering. A statement dated 2/27/28 written by CNA D indicated on the 11 to 7 shift on 2/24/23 Resident #1 was on his call light quite a bit. About 12:00 a.m. LVN A said to get him up. He was not yelling when they got him up but yelled the rest of the night. The aide said she did not hear everything, but the nurses were hollering back to him from the nurses' station. She said they said something about an old roommate that had beat him up. The statement said CNA D and CNA B put Resident #1 to bed about 6:30 a.m. the aide said she returned to work at 3:00 p.m. on 2/26/23 and was told the resident slept all day and did not eat. She said he did not wake up to pull his light until 9:00 p.m. A statement with no date written by LVN A indicted Resident #1 was sitting in the front dining room and frequently yelled out nurse. This nurse told him to quiet down because there were 3 or 4 other residents close to him. At the desk myself and LVN E was talking about the time his former roommate hit him with a remote due to his constant loud yelling. During an interview on 8/8/23 at 10:25 a.m. with Resident #1 and the Administrator, Resident #1 said he was doing fine now. He said remembered the incident that occurred a few months ago when two aides were told to get him up and put him in his chair around 11:00 p.m. or so, it was after the night shift came in. He said they got him up and he did not really want to get up. He said when he was asked to be put to bed, they would not put him to bed until morning. He said he could not put himself to bed, so he just had to sit there all night. Resident #1 said LVN A did that as punishment because she knew he did not like to stay up long. Resident #1 said LVN A threatened him with his former roommate beating him up if he did not stop hollering. The resident said he was upset by the incident and began to cry. After leaving the room, the Administrator said he did not know what upset Resident #1 more, the incident with LVN A up all night or the threat of Resident #2 beating him up. The Administrator said due to Resident #1 being upset he did not want to dig too deeply into his feelings, but it was obvious he was still upset by the whole thing. During a telephone interview on 8/2/23 at 11:50 a.m., CNA B said she heard LVN A talking to Resident #1 on 2/24/23. She said she heard LVN A threaten Resident #1 with someone beating him up. CNA B said LVN A told her and CNA D to get Resident #1 up and would not let them put him to bed all night. She said he did not like to stay up long. According to her, Resident #1 wanted to lay back down. CNA B said when they told LVN A he wanted to lay down, LVN A told them not to put Resident #1 back to bed until daylight. She said Resident #1 was dependent on staff and could not put his self-back to bed. CNA B said she did not report the incident but had been in-serviced on reporting abuse after the incident happened. During an interview on 8/2/23 at 1:14 p.m., CNA C said she worked at the facility for 4 years. She said Resident #1 liked attention and would holler for help. She said she heard about them getting him up and keeping him up all night. She said when Resident #1 got up, after about 10 minutes, he wanted to lay back down. She said Resident #1 liked to stay in the bed. CNA C said if they kept him up all night, it would have been punishment for him. She said Resident #1 told her, LVN A made him get up and stay up all night because he was hollering, as a punishment. She said Resident #1 was dependent on staff and could not put his self-back to bed. During a telephone interview on 8/8/23 at 1:55 p.m., CNA D said Resident #1 yelled down the hall quite often. He was not yelling down the hallway on the night of 2/24/23She said when they arrived at work at 11:00 p.m. that night Resident #1 was pulling the call light quite a bit. They had only been at work a short time and he had pulled the light about 5 times. LVN A said if Resident #1 pulled the call light again she wanted her and CNA B to get him up. CNA D said he pulled the light again and LVN A told them to get him up. Resident #1 said he did not want to get up. She said they told LVN A he did not want to get up and LVN A told them to get him up anyway. CNA D said after about 2 hours Resident #1 wanted to go to bed. She said LVN A said do not put him to bed. CNA D said after about another hour and a half he asked again and LVN A said no. She said Resident #1 was dependent on staff and could not put himself self-back to bed. She said LVN A told them not put him to bed until day light. CNA D said Resident #1 was sliding out of his chair. She said Resident #1 was in a high-backed wheelchair and kept sliding down and they had to pull him up. CNA D said she did not hear all the comments that night between LVN A and LVN E. She said she heard parts of the conversation about a former roommate beating Resident #1 up and they were laughing. CNA D said she was sure Resident #1 could hear them. He was sitting in the entry way area not too far from the nurse's station. They were talking loudly, and she heard them from a couple of rooms down the hallway. She said she was doing what she was instructed to do by her nurse. She said she did not think too much of it at the time, but it was abuse. She did not report the incident but had been counseled and in-serviced since the incident. During an interview on 8/2/23 at 11:29 a.m., the Administrator said he was investigating another abuse allegation regarding LVN E and discovered LVN A was abusive to Resident #1. The Administrator said on the night of 2/24/23, LVN A had told aides to get Resident # 1 out of bed due to his hollering out and to keep him up. He said LVN A also threatened Resident #1 by telling him a former roommate was going to beat him up. The Administrator said when he spoke to Resident #1, and Resident #1 said he felt like he was being punished. The Administrator said he did not know the exact date he found out about the incident, the staff did not come and report the abuse. When he was asked about LVN E, then CNA B and CNA D started to talk about the incident with Resident #1. He said it may be a day or two later when he found about the abuse to Resident #1. The Administrator said he started the investigation into LVN E on the morning of 2/25/23 because it was reported that morning. The two aides worked mostly nights and weekends. He said when he was informed what had happened to Resident #1, LVN A was suspended immediately. He said he terminated LVN E not because he could prove that she had abused a resident but because there were so many negative statements about her behavior all together on 3/4/23. He terminated LVN A because the abuse was substantiated on 3/4/23. He referred both their license, in serviced staff, and took the incident to QIPP. He said he completed the in-service and had the staff to take a test to ensure their knowledge of what was considered abuse, and when to report abuse. They were told if a resident did not want to get up then do not force them. If the nurse insisted, to contact him to determine what needed to be done on 3/4/23. During an interview on 8/18/23 at 2:10 p.m. CNA C said she worked at the facility for 4 years. She said they had in services all the time about abuse and neglect. Abuse was making a resident do something against their will. She said Resident #1 did not like to get up and the staff do not make him get up. CNA C said occasionally they can talk him into getting up, but Resident #1 did not like to stay up long. She said he had been like that ever since she had been at the facility. CNA C said the facility bought him a fancy wheelchair, give pain meds, but he still did not like to get up. She said if a nurse told her to get him up and he did not want to get up, She would call the abuse coordinator. CNA C said they should make him get up, they must honor the resident wishes. She said putting Resident # 1 in his chair and making him stay there could be a restraint. CNA C said Resident #1 could not get out of the chair without assistance. She said they were serviced on reporting and not doing things against resident wishes. Record review of the facility corrective actions prior to the initiation of the survey revealed: Record review of a QIPP worksheet dated 3/14/23 indicated the identified concern was two nurses involved in the mistreatment of residents. The alleged perpetrator was suspended pending investigation on 2/25/23. Systemic Actions were the corporate nurse and facility administrative staff completed a thorough investigation on abuse neglect, mistreatment, involuntary seclusion on 3/4/23. In-services were completed on 3/4/23 to include detailed discussion on abuse triggers, abuse scenarios as well as what to do when you encounter a situation where you feel the resident is being mistreated. Monitoring was initiated and complete on 6/9/23. LVN A and LVN E were both suspended on 2/26/23 and both were terminated on 3/4/23. Record review of an in service dated 3/4/23 indicated the Administrator presented the topic Abuse, Neglect, Mistreatment, and Involuntary Seclusion. The in-service sign in sheet had 51 signatures to include CNA B and CNA D. Record review of a time sheet for LVN A indicated she worked full shifts on 2/24/23 and 2/25/23- from 11p to 7a. The time sheet indicated that her last day at work was 2/25/23 at 7:18 a.m. Record review of a time sheet for LVN E indicated she worked full a shift on 2/24/23 from 11p- 7a. The time sheet indicated that her last day at work was 2/24/35 at 7:17 a.m. Interviews were conducted LVNs on 8/2/23 between 10:43 a.m. and 4:41 p.m. about the training they received in regard to abuse, restraints and seclusion: At 10:43 a.m. LVN H At 11:02 a.m. LVN I At 8/2/23 at 3:58 p.m. LVN G At 8/2/23 at 4:41 p.m. LVN J The LVNs said she had received an in service on abuse with a focus on seclusion. They informed to always honor the residents' rights and wishes. If a resident did not want to get up, do not make them got up, and do not force them to stay up in a chair. The nurses said they knew better than to make a resident do things against their will, and if they did that was abuse. They would not intentionally place a resident alone, in a room or a chair, if they were dependent on staff to meet their needs they would take care of the residents needs. They said they had received in services many times on abuse and neglect and was familiar with what constituted abuse, who to report to and to report immediately. Record review of the Abuse Prohibition Policy last revised March 2023 indicated the intent of this protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The policy indicated the facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents. The definition of abuse means the willful infliction of injury, withholding or misappropriation or property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Training of all new and current employees will receive training and reinforcement on all aspects of abuse probation program. Training will include prohibiting and preventing all forms of abuse, identifying what constitutes all forms of abuse, recognizing signs and symptoms of all abuse, and reporting all forms of abuse. Prevention of abuse included facility staff will immediately correct, intervene in reports, or identified situation in which abuse/neglect is at risk for occurring. Protection indicated all residents will be immediately protected from harm.

Based on interview and record review, the facility failed to ensure residents were free from physical restrains for 1 of 5 residents (Resident #1) reviewed for restraints in that: Resident #1 was gotten out of bed against his wishes, made to sit up all night in his wheelchair on 2/24/23 by the orders of LVN A. Resident #1 wanted to lay back down but was not allowed to do so and he was totally dependent on staff for assistance. Resident #1 said he was being punished for hollering out. The noncompliance was identified as PNC. The IJ began on 2/24/23 and ended on 3/4/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for being restrained against their will. Findings included: Record review of Resident #1's face sheet dated 8/8/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. Some of his diagnoses were Hemiplegia (Paralysis on one side of the body) following a stroke, mild cognitive impairment, abnormal posture, anxiety disorder, and schizoaffective disorder bipolar type. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated his cognitive status was moderately impaired. His bed mobility was extensive assistance with two people. Resident #1 required the assistance of two people for transfers. Record review of Resident #1's care plan initiated on 10/22/21 with a focused area of behaviors related to frequently yelling out instead of using the call light, attention seeking, as evidence by asking to have pillow fluffed multiple times within minutes of doing so. A history of climbing out of bed and screaming when up in chair wanting to go back to bed within less than 30 minutes of being up. Some of the interventions were to be supportive of all needs and requests to maintain comfort. Encourage him to sit up for as long as possible. If multiple requests were made to go back, please put him back to bed. Maintain a calm, restful safe environment. A focused area of ADL self-care performance deficit related to left sided hemiplegia. Resident #1 required extensive assistance of two staff for positioning and tuning in bed for proper body alignment as necessary. The resident had limited range of motion of the left upper extremity, hand, and lower extremity. Resident #1 required extensive assistance by 2 staff for dressing toilet use and transfers. The resident was transferred by Hoyer lift. Record review of a Social Services note dated 7/13/23 indicated Resident #1 preferred to stay in bed, but occasionally went to the dining room and participated in activities. Written by the social worker. Record review of the Provider Investigation report dated 3/11/22 indicated Resident #2 crawled to Resident #1's bed and was trying to hit him with a remote. He was verbally aggressive towards Resident #1 and threatening to kill him. Resident #1 was hollering for staff. The staff intervened and Resident #2 was removed and taken to the emergency room for evaluation. Record review of a general in service dated 2/23/23 (prior to the incident) indicated an in-service on abuse and neglect. The sign in sheet indicated LVN A and LVN E attended. Record review of the Provider Investigation Report dated 2/27/23 indicated during an investigation the facility was made aware of an additional concern related to LVN A and LVN E. During the investigation of LVN E's treatment of residents, there was an incident that arose regarding LVN A. The allegations regarding LVN A were substantiated. The police were notified, life satisfaction rounds were conducted with residents, and staff questionaries to identify if this happened elsewhere. The LVN A and LVN E were terminated. The report contained a statement dated 2/24/23 written by CNA B that indicated Resident #1 pulled his light a few times. This annoyed LVN A and LVN E to the point they wanted him out of bed. Around 12:00 a.m. CNA B and CNA D got Resident #1 up and they would not let us put him down until closer to 7 :00 a.m. While he was up, they kept telling him to shut up. The nurses laughed at him along with torturing him with past events of a former roommate beating Resident #1 up for talking. They proceeded to say, if you don't shut up Resident #2 was going to come and get you again. The Report contained a statement dated 3/1/23 by Resident #1 written by the Administrator. The statement indicated CNA D took him to the front lobby on Friday night 2/24/23 as punishment from the nurses for hollering. He said LVN A did not like it when he hollered. He said LVN A said, You remember that guy that beat you up? Well, I am gone bring him out here if you don't stop hollering. A statement dated 2/27/28 written by CNA D indicated on the 11 to 7 shift on 2/24/23 Resident #1 was on his call light quite a bit. About 12:00 a.m. LVN A said to get him up. He was not yelling when they got him up but yelled the rest of the night. The aide said she did not hear everything, but the nurses were hollering back to him from the nurses' station. She said they said something about an old roommate that had beat him up. The statement said CNA D and CNA B put Resident #1 to bed about 6:30 a.m. the aide said she returned to work at 3:00 p.m. on 2/26/23 and was told the resident slept all day and did not eat. She said he did not wake up to pull his light until 9:00 p.m. A statement with no date written by LVN A indicted Resident #1 was sitting in the front dining room and frequently yelled out nurse. This nurse told him to quiet down because there were 3 or 4 other residents close to him. At the desk myself and LVN E was talking about the time his former roommate hit him with a remote due to his constant loud yelling. During an interview on 8/8/23 at 10:25 a.m. with Resident #1 and the Administrator, Resident #1 said he remembered the incident that occurred a few months ago when two aides were told to get him up and put him in his chair around 11:00 p.m. or so, it was after the night shift came in. He said they got him up and he did not really want to get up. He said when he was asked to be put to bed, they would not put him to bed until morning. He said he could not put himself to bed, so he just had to sit there all night. Resident #1 said LVN A did that as punishment because she knew he did not like to stay up long. Resident #1 said LVN A threatened him with his former roommate beating him up if he did not stop hollering. The resident said he was upset by the incident and began to cry. After leaving the room, the Administrator said he did not know what upset Resident #1 more, the incident with LVN A up all night or the threat of Resident #2 beating him up. The Administrator said due to Resident #1 being upset he did not want to dig too deeply into his feelings, but it was obvious he was still upset by the whole thing. During a telephone interview on 8/2/23 at 11:50 a.m., CNA B said she heard LVN A talking to Resident #1 on 2/24/23. She said she heard LVN A threaten Resident #1 with someone beating him up. CNA B said LVN A told her and CNA D to get Resident #1 up and would not let them put him to bed all night. She said he did not like to stay up long. According to her, Resident #1 wanted to lay back down. CNA B said when they told LVN A he wanted to lay down, LVN A told them not to put Resident #1 back to bed until daylight. She said Resident #1 was dependent on staff and could not put his self-back to bed. CNA B said she did not report the incident but had been in-serviced on reporting abuse after the incident happened. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 1:14 p.m., CNA C said she worked at the facility for 4 years. She said Resident #1 liked attention and would holler for help. She said she heard about them getting him up and keeping him up all night. She said when Resident #1 got up, after about 10 minutes, he wanted to lay back down. She said Resident #1 liked to stay in the bed. CNA C said if they kept him up all night, it would have been punishment for him. She said Resident #1 told her, LVN A made him get up and stay up all night because he was hollering, as a punishment. She said Resident #1 was dependent on staff and could not put his self-back to bed. During a telephone interview on 8/8/23 at 1:55 p.m., CNA D said Resident #1 yelled down the hall quite often. He was not yelling down the hallway on the night of 2/24/23She said when they arrived at work at 11:00 p.m. that night Resident #1 was pulling the call light quite a bit. They had only been at work a short time and he had pulled the light about 5 times. LVN A said if Resident #1 pulled the call light again she wanted her and CNA B to get him up. CNA D said he pulled the light again and LVN A told them to get him up. Resident #1 said he did not want to get up. She said they told LVN A he did not want to get up and LVN A told them to get him up anyway. CNA D said after about 2 hours Resident #1 wanted to go to bed. She said LVN A said do not put him to bed. CNA D said after about another hour and a half he asked again and LVN A said no. She said Resident #1 was dependent on staff and could not put himself self-back to bed. She said LVN A told them not put him to bed until day light. CNA D said Resident #1 was sliding out of his chair. She said Resident #1 was in a high-backed wheelchair and kept sliding down and they had to pull him up. CNA D said she did not hear all the comments that night between LVN A and LVN E. She said she heard parts of the conversation about a former roommate beating Resident #1 up and they were laughing. CNA D said she was sure Resident #1 could hear them. He was sitting in the entry way area not too far from the nurse's station. They were talking loudly, and she heard them from a couple of rooms down the hallway. She said she was doing what she was instructed to do by her nurse. She said she did not think too much of it at the time, but it was abuse. She did not report the incident but had been counseled and in-serviced since the incident. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 11:29 a.m., the Administrator said he was investigating another abuse allegation regarding LVN E and discovered LVN A was abusive to Resident #1. The Administrator said on the night of 2/24/23, LVN A had told aides to get Resident # 1 out of bed due to his hollering out and to keep him up. He said LVN A also threatened Resident #1 by telling him a former roommate was going to beat him up. The Administrator said when he spoke to Resident #1, and Resident #1 said he felt like he was being punished. The Administrator said he did not know the exact date he found out about the incident, the staff did not come and report the abuse. When he was asked about LVN E, then CNA B and CNA D started to talk about the incident with Resident #1. He said it may be a day or two later when he found about the abuse to Resident #1. The Administrator said he started the investigation into LVN E on the morning of 2/25/23 because it was reported that morning. The two aides worked mostly nights and weekends. He said when he was informed what had happened to Resident #1, LVN A was suspended immediately. He said he terminated LVN E not because he could prove that she had abused a resident but because there were so many negative statements about her behavior all together on 3/4/23. He terminated LVN A because the abuse was substantiated on 3/4/23. He referred both their license, in serviced staff, and took the incident to QIPP. He said he completed the in-service and had the staff to take a test to ensure their knowledge of what was considered abuse, and when to report abuse. They were told if a resident did not want to get up then do not force them. If the nurse insisted, to contact him to determine what needed to be done on 3/4/23. During an interview on 8/18/23 at 1:50 p.m. the Activity Director said they had in services all the time on abuse and neglect. She said just today, there was an Inservice that came up on her computer about abuse and neglect and when to report. She said they were to report any suspicion of abuse immediately to the Administrator. The Activity Director said if the Administrator was not there, they call him. She said they were not allowed to use restraints in the facility. She said restraints could be chemical, locking someone in a chair, or side rails. She said Resident #1 did not like to get up a lot. If someone put him in a chair and would not lay him down, it was a restraint because he could not lay down by himself. During an interview on 8/18/23 at 2:10 p.m. CNA C said she worked at the facility for 4 years. She said they had in services all the time about abuse and neglect. Abuse was making a resident do something against their will. She said Resident #1 did not like to get up and the staff do not make him get up. CNA C said occasionally they can talk him into getting up, but Resident #1 did not like to stay up long. She said he had been like that ever since she had been at the facility. CNA C said the facility bought him a fancy wheelchair, give pain meds, but he still did not like to get up. She said if a nurse told her to get him up and he did not want to get up, She would call the abuse coordinator. CNA C said they should make him get up, they must honor the resident wishes. She said putting Resident # 1 in his chair and making him stay there could be a restraint. CNA C said Resident #1 could not get out of the chair without assistance. She said they were serviced on reporting and not doing things against resident wishes. During an interview on 8/18/23 at 2:13 p.m. CNA F said she worked at the facility for [AGE] years. She said she was aware of what abuse and neglect was, when, and who to report to. CNA F said if a nurse told her to do something to a resident that was not right, she would report her. She said they were in serviced on involuntary seclusion. CNA F said a restraint-could be holding someone against their will and not allowing them to do what they wanted. She said if a resident wanted to lay down and could be a restraint. She said Resident #1 could not lay down himself. CNA F said it was the resident right, to lay down or to get help. Record review of the facility corrective actions prior to the initiation of the survey revealed: Record review of a QIPP worksheet dated 3/14/23 indicated the identified concern was two nurses involved in the mistreatment of residents. The alleged perpetrator was suspended pending investigation on 2/25/23. Systemic Actions were the corporate nurse and facility administrative staff completed a thorough investigation on abuse neglect, mistreatment, involuntary seclusion on 3/4/23. In-services were completed on 3/4/23 to include detailed discussion on abuse triggers, abuse scenarios as well as what to do when you encounter a situation where you feel the resident is being mistreated. Monitoring was initiated and complete on 6/9/23. LVN A and LVN E were both suspended on 2/26/23 and both were terminated on 3/4/23. Record review of an in service dated 3/4/23 indicated the Administrator presented the topic Abuse, Neglect, Mistreatment, and Involuntary Seclusion. The in-service sign in sheet had 51 signatures to include CNA B and CNA D. Record review of a time sheet for LVN A indicated she worked full shifts on 2/24/23 and 2/25/23- from 11p to 7a. The time sheet indicated that her last day at work was 2/25/23 at 7:18 a.m. Record review of a time sheet for LVN E indicated she worked full a shift on 2/24/23 from 11p- 7a. The time sheet indicated that her last day at work was 2/24/35 at 7:17 a.m. Interviews were conducted LVNs on 8/2/23 between 10:43 a.m. and 4:41 p.m. about the training they received regarding abuse, restraints and seclusion: At 10:43 a.m. LVN H At 11:02 a.m. LVN I At 8/2/23 at 3:58 p.m. LVN G At 8/2/23 at 4:41 p.m. LVN J The LVNs said she had received an in service on abuse with a focus on seclusion. They informed to always honor the residents' rights and wishes. If a resident did not want to get up, do not make them got up, and do not force them to stay up in a chair. The nurses said they knew better than to make a resident do things against their will, and if they did that was abuse. They would not intentionally place a resident alone, in a room or a chair, if they were dependent on staff to meet their needs they would take care of the residents needs. They said they had received in services many times on abuse and neglect and was familiar with what constituted abuse, who to report to and to report immediately. Record review of the facility's Policy on Restraints and Involuntary seclusion last revised October 2022 and reviewed in March 2023. The policy indicated residents have the right to be free from any physical restrains imposed for the purposes of discipline or convenience and when not required to treat the residents' medical conditions. Residents have the right to function at the highest practicable level in the least restrictive environment possible. Restraints will never be used for the discipline or staff convenience. A physical restraint is any manual method, or physical, or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Discipline is defined as any action taken by the facility for the purpose of punishing or penalizing the resident. Record review of the Abuse Prohibition Policy last revised March 2023 indicated the intent of this protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The policy indicated the facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents. The definition of abuse means the willful infliction of injury, withholding or misappropriation or property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Training of all new and current employees will receive training and reinforcement on all aspects of abuse probation program. Training will include prohibiting and preventing all forms of abuse, identifying what constitutes all forms of abuse, recognizing signs and symptoms of all abuse, and reporting all forms of abuse. Prevention of abuse included facility staff will immediately correct, intervene in reports, or identified situation in which abuse/neglect is at risk for occurring. Protection indicated all residents will be immediately protected from harm.

Based on interview and record review, the facility failed to ensure they implemented the written policies and procedures that prevented abuse and neglect for (Resident #1) in that: Resident #1 was gotten out of bed against his wishes, made to sit up all night on 2/24/23 by the orders of LVN A. Resident #1 was threatened, and emotionally abused on 2/24/23 by LVN A and LVN E. The staff failed to prevent and protect Resdient#1 from continued abuse and involuntary seclusion. Resident #1 said he was being punished for hollering out. The noncompliance was identified as PNC. The IJ began on 2/24/23 and ended on 3/4/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse, fear, and intimidation. Findings included: Record review of Resident #1's face sheet dated 8/8/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. Some of his diagnoses were Hemiplegia (Paralysis on one side of the body) following a stroke, mild cognitive impairment, abnormal posture, anxiety disorder, and schizoaffective disorder bipolar type. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated his cognitive status was moderately impaired. His bed mobility was extensive assistance with two people. Resident #1 required the assistance of two people for transfers. Record review of Resident #1's care plan initiated on 10/22/21 with a focused area of behaviors related to frequently yelling out instead of using the call light, attention seeking, as evidence by asking to have pillow fluffed multiple times within minutes of doing so. A history of climbing out of bed and screaming when up in chair wanting to go back to bed within less than 30 minutes of being up. Some of the interventions were to be supportive of all needs and requests to maintain comfort. Encourage him to sit up for as long as possible. If multiple requests were made to go back, please put him back to bed. Maintain a calm, restful safe environment. A focused area of ADL self-care performance deficit related to left sided hemiplegia. Resident #1 required extensive assistance of two staff for positioning and tuning in bed for proper body alignment as necessary. The resident had limited range of motion of the left upper extremity, hand, and lower extremity. Resident #1 required extensive assistance by 2 staff for dressing toilet use and transfers. The resident was transferred by Hoyer lift. Record review of a Social Services note dated 7/13/23 indicated Resident #1 preferred to stay in bed, but occasionally went to the dining room and participated in activities. Written by the social worker. Record review of the Provider Investigation report dated 3/11/22 indicated Resident #2 crawled to Resident #1's bed and was trying to hit him with a remote. He was verbally aggressive towards Resident #1 and threatening to kill him. Resident #1 was hollering for staff. The staff intervened and Resident #2 was removed and taken to the emergency room for evaluation. Record review of a general in service dated 2/23/23 (prior to the incident) indicated an in-service on abuse and neglect. The sign in sheet indicated LVN A and LVN E attended. Record review of the Provider Investigation Report dated 2/27/23 indicated during an investigation the facility was made aware of an additional concern related to LVN A and LVN E. During the investigation of LVN E's treatment of residents, there was an incident that arose regarding LVN A. The allegations regarding LVN A were substantiated. The police were notified, life satisfaction rounds were conducted with residents, and staff questionaries to identify if this happened elsewhere. The LVN A and LVN E were terminated. The report contained a statement dated 2/24/23 written by CNA B that indicated Resident #1 pulled his light a few times. This annoyed LVN A and LVN E to the point they wanted him out of bed. Around 12:00 a.m. CNA B and CNA D got Resident #1 up and they would not let us put him down until closer to 7 :00 a.m. While he was up, they kept telling him to shut up. The nurses laughed at him along with torturing him with past events of a former roommate beating Resident #1 up for talking. They proceeded to say, if you don't shut up Resident #2 was going to come and get you again. The Report contained a statement dated 3/1/23 by Resident #1 written by the Administrator. The statement indicated CNA D took him to the front lobby on Friday night 2/24/23 as punishment from the nurses for hollering. He said LVN A did not like it when he hollered. He said LVN A said, You remember that guy that beat you up? Well, I am gone bring him out here if you don't stop hollering. A statement dated 2/27/28 written by CNA D indicated on the 11 to 7 shift on 2/24/23 Resident #1 was on his call light quite a bit. About 12:00 a.m. LVN A said to get him up. He was not yelling when they got him up but yelled the rest of the night. The aide said she did not hear everything, but the nurses were hollering back to him from the nurses' station. She said they said something about an old roommate that had beat him up. The statement said CNA D and CNA B put Resident #1 to bed about 6:30 a.m. the aide said she returned to work at 3:00 p.m. on 2/26/23 and was told the resident slept all day and did not eat. She said he did not wake up to pull his light until 9:00 p.m. A statement with no date written by LVN A indicted Resident #1 was sitting in the front dining room and frequently yelled out nurse. This nurse told him to quiet down because there were 3 or 4 other residents close to him. At the desk myself and LVN E was talking about the time his former roommate hit him with a remote due to his constant loud yelling. During an interview on 8/8/23 at 10:25 a.m. with Resident #1 and the Administrator, Resident #1 said he remembered the incident that occurred a few months ago when two aides were told to get him up and put him in his chair around 11:00 p.m. or so, it was after the night shift came in. He said they got him up and he did not really want to get up. He said when he was asked to be put to bed, they would not put him to bed until morning. He said he could not put himself to bed, so he just had to sit there all night. Resident #1 said LVN A did that as punishment because she knew he did not like to stay up long. Resident #1 said LVN A threatened him with his former roommate beating him up if he did not stop hollering. The resident said he was upset by the incident and began to cry. After leaving the room, the Administrator said he did not know what upset Resident #1 more, the incident with LVN A up all night or the threat of Resident #2 beating him up. The Administrator said due to Resident #1 being upset he did not want to dig too deeply into his feelings, but it was obvious he was still upset by the whole thing. During a telephone interview on 8/2/23 at 11:50 a.m., CNA B said she heard LVN A talking to Resident #1 on 2/24/23. She said she heard LVN A threaten Resident #1 with someone beating him up. CNA B said LVN A told her and CNA D to get Resident #1 up and would not let them put him to bed all night. She said he did not like to stay up long. According to her, Resident #1 wanted to lay back down. CNA B said when they told LVN A he wanted to lay down, LVN A told them not to put Resident #1 back to bed until daylight. She said Resident #1 was dependent on staff and could not put his self-back to bed. CNA A said she did not report the incident but had been in-serviced on reporting abuse after the incident happened. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 1:14 p.m., CNA C said she worked at the facility for 4 years. She said Resident #1 liked attention and would holler for help. She said she heard about them getting him up and keeping him up all night. She said when Resident #1 got up, after about 10 minutes, he wanted to lay back down. She said Resident #1 liked to stay in the bed. CNA C said if they kept him up all night, it would have been punishment for him. She said Resident #1 told her, LVN A made him get up and stay up all night because he was hollering, as a punishment. She said Resident #1 was dependent on staff and could not put his self-back to bed. During a telephone interview on 8/8/23 at 1:55 p.m., CNA D said Resident #1 yelled down the hall quite often. He was not yelling down the hallway on the night of 2/24/23She said when they arrived at work at 11:00 p.m. that night Resident #1 was pulling the call light quite a bit. They had only been at work a short time and he had pulled the light about 5 times. LVN A said if Resident #1 pulled the call light again she wanted her and CNA B to get him up. CNA D said he pulled the light again and LVN A told them to get him up. Resident #1 said he did not want to get up. She said they told LVN A he did not want to get up and LVN A told them to get him up anyway. CNA D said after about 2 hours Resident #1 wanted to go to bed. She said LVN A said do not put him to bed. CNA D said after about another hour and a half he asked again and LVN A said no. She said Resident #1 was dependent on staff and could not put himself self-back to bed. She said LVN A told them not put him to bed until day light. CNA D said Resident #1 was sliding out of his chair. She said Resident #1 was in a high-backed wheelchair and kept sliding down and they had to pull him up. CNA D said she did not hear all the comments that night between LVN A and LVN E. She said she heard parts of the conversation about a former roommate beating Resident #1 up and they were laughing. CNA D said she was sure Resident #1 could hear them. He was sitting in the entry way area not too far from the nurse's station. They were talking loudly, and she heard them from a couple of rooms down the hallway. She said she was doing what she was instructed to do by her nurse. She said she did not think too much of it at the time, but it was abuse. She did not report the incident but had been counseled and in-serviced since the incident. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 11:29 a.m., the Administrator said he was investigating another abuse allegation regarding LVN E and discovered LVN A was abusive to Resident #1. The Administrator said on the night of 2/24/23, LVN A had told aides to get Resident # 1 out of bed due to his hollering out and to keep him up. He said LVN A also threatened Resident #1 by telling him a former roommate was going to beat him up. The Administrator said when he spoke to Resident #1, and Resident #1 said he felt like he was being punished. The Administrator said he did not know the exact date he found out about the incident, the staff did not come and report the abuse. When he was asked about LVN E, then CNA B and CNA D started to talk about the incident with Resident #1. He said it may be a day or two later when he found about the abuse to Resident #1. The Administrator said he started the investigation into LVN E on the morning of 2/25/23 because it was reported that morning. The two aides worked mostly nights and weekends. He said when he was informed what had happened to Resident #1, LVN A was suspended immediately. He said he terminated LVN E not because he could prove that she had abused a resident but because there were so many negative statements about her behavior all together on 3/4/23. He terminated LVN A because the abuse was substantiated on 3/4/23. He referred both their license, in serviced staff, and took the incident to QIPP. He said he completed the in-service and had the staff to take a test to ensure their knowledge of what was considered abuse, and when to report abuse. They were told if a resident did not want to get up then do not force them. If the nurse insisted, to contact him to determine what needed to be done on 3/4/23. During an interview on 8/18/23 at 1:50 p.m. the Activity Director said they had in services all the time on abuse and neglect. She said just today, there was an Inservice that came up on her computer about abuse and neglect and when to report. She said they were to report any suspicion of abuse immediately to the Administrator. The Activity Director said if the Administrator was not there, they call him. She said they were not allowed to use restraints in the facility. She said restraints could be chemical, locking someone in a chair, or side rails. She said Resident #1 did not like to get up a lot. If someone put him in a chair and would not lay him down, it was a restraint because he could not lay down by himself. During an interview on 8/18/23 at 2:10 p.m. CNA C said she worked at the facility for 4 years. She said they had in services all the time about abuse and neglect. Abuse was making a resident do something against their will. She said Resident #1 did not like to get up and the staff do not make him get up. CNA C said occasionally they can talk him into getting up, but Resident #1 did not like to stay up long. She said he had been like that ever since she had been at the facility. CNA C said the facility bought him a fancy wheelchair, give pain meds, but he still did not like to get up. She said if a nurse told her to get him up and he did not want to get up, She would call the abuse coordinator. CNA C said they should make him get up, they must honor the resident wishes. She said putting Resident # 1 in his chair and making him stay there could be a restraint. CNA C said Resident #1 could not get out of the chair without assistance. She said they were serviced on reporting and not doing things against resident wishes. During an interview on 8/18/23 at 2:13 p.m. CNA F said she worked at the facility for [AGE] years. She said she was aware of what abuse and neglect was, when, and who to report to. CNA F said if a nurse told her to do something to a resident that was not right, she would report her. She said they were in serviced on involuntary seclusion. CNA F said a restraint-could be holding someone against their will and not allowing them to do what they wanted. She said if a resident wanted to lay down and could be a restraint. She said Resident #1 could not lay down himself. CNA F said it was the resident right, to lay down or to get help. Record review of the facility corrective actions prior to the initiation of the survey revealed: Record review of a QIPP worksheet dated 3/14/23 indicated the identified concern was two nurses involved in the mistreatment of residents. The alleged perpetrator was suspended pending investigation on 2/25/23. Systemic Actions were the corporate nurse and facility administrative staff completed a thorough investigation on abuse neglect, mistreatment, involuntary seclusion on 3/4/23. In-services were completed on 3/4/23 to include detailed discussion on abuse triggers, abuse scenarios as well as what to do when you encounter a situation where you feel the resident is being mistreated. Monitoring was initiated and complete on 6/9/23. LVN A and LVN E were both suspended on 2/26/23 and both were terminated on 3/4/23. Record review of an in service dated 3/4/23 indicated the Administrator presented the topic Abuse, Neglect, Mistreatment, and Involuntary Seclusion. The in-service sign in sheet had 51 signatures to include CNA B and CNA D. Record review of a time sheet for LVN A indicated she worked full shifts on 2/24/23 and 2/25/23- from 11p to 7a. The time sheet indicated that her last day at work was 2/25/23 at 7:18 a.m. Record review of a time sheet for LVN E indicated she worked full a shift on 2/24/23 from 11p- 7a. The time sheet indicated that her last day at work was 2/24/35 at 7:17 a.m. Interviews were conducted LVNs on 8/2/23 between 10:43 a.m. and 4:41 p.m. about the training they received regarding abuse, restraints, and seclusion: At 10:43 a.m. LVN H At 11:02 a.m. LVN I At 8/2/23 at 3:58 p.m. LVN G At 8/2/23 at 4:41 p.m. LVN J The LVNs said she had received an in service on abuse with a focus on seclusion. They informed to always honor the residents' rights and wishes. If a resident did not want to get up, do not make them got up, and do not force them to stay up in a chair. The nurses said they knew better than to make a resident do things against their will, and if they did that was abuse. They would not intentionally place a resident alone, in a room or a chair, if they were dependent on staff to meet their needs they would take care of the residents needs. They said they had received in services many times on abuse and neglect and was familiar with what constituted abuse, who to report to and to report immediately. Record review of the facility's Policy on Restraints and Involuntary seclusion last revised October 2022 and reviewed in March 2023. The policy indicated residents have the right to be free from any physical restrains imposed for the purposes of discipline or convenience and when not required to treat the residents' medical conditions. Residents have the right to function at the highest practicable level in the least restrictive environment possible. Restraints will never be used for the discipline or staff convenience. A physical restraint is any manual method, or physical, or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Discipline is defined as any action taken by the facility for the purpose of punishing or penalizing the resident. Record review of the Abuse Prohibition Policy last revised March 2023 indicated the intent of this protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The policy indicated the facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents. The definition of abuse means the willful infliction of injury, withholding or misappropriation or property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Training of all new and current employees will receive training and reinforcement on all aspects of abuse probation program. Training will include prohibiting and preventing all forms of abuse, identifying what constitutes all forms of abuse, recognizing signs and symptoms of all abuse, and reporting all forms of abuse. Prevention of abuse included facility staff will immediately correct, intervene in reports, or identified situation in which abuse/neglect is at risk for occurring. Protection indicated all residents will be immediately protected from harm.

Based on interview and record review, the facility failed to ensure they implemented the written policies and procedures that prevented abuse and neglect. (Resident #1) CNA B and CNA D did not report the abuse of Resident #1 to the Administrator. The administrator discovered the abuse while investigation another abuse allegation. The facility failed to ensure the abuse of Resident #1 was reported within 2 hours as required by their policy. The noncompliance was identified as PNC. The IJ began on 2/24/23 and ended on 3/4/23. The facility corrected the noncompliance before the survey began. This failure could place residents at risk for continued abuse, fear, and intimidation. Findings included: Record review of Resident #1's face sheet dated 8/8/23 indicated he was a [AGE] year-old male who admitted to the facility on [DATE]. Some of his diagnoses were Hemiplegia (Paralysis on one side of the body) following a stroke, mild cognitive impairment, abnormal posture, anxiety disorder, and schizoaffective disorder bipolar type. Record review of Resident #1's quarterly MDS assessment dated [DATE] indicated his cognitive status was moderately impaired. His bed mobility was extensive assistance with two people. Resident #1 required the assistance of two people for transfers. Record review of Resident #1's care plan initiated on 10/22/21 with a focused area of behaviors related to frequently yelling out instead of using the call light, attention seeking, as evidence by asking to have pillow fluffed multiple times within minutes of doing so. A history of climbing out of bed and screaming when up in chair wanting to go back to bed within less than 30 minutes of being up. Some of the interventions were to be supportive of all needs and requests to maintain comfort. Encourage him to sit up for as long as possible. If multiple requests were made to go back, please put him back to bed. Maintain a calm, restful safe environment. A focused area of ADL self-care performance deficit related to left sided hemiplegia. Resident #1 required extensive assistance of two staff for positioning and tuning in bed for proper body alignment as necessary. The resident had limited range of motion of the left upper extremity, hand, and lower extremity. Resident #1 required extensive assistance by 2 staff for dressing toilet use and transfers. The resident was transferred by Hoyer lift. Record review of a Social Services note dated 7/13/23 indicated Resident #1 preferred to stay in bed, but occasionally went to the dining room and participated in activities. Written by the social worker. Record review of the Provider Investigation report dated 3/11/22 indicated Resident #2 crawled to Resident #1's bed and was trying to hit him with a remote. He was verbally aggressive towards Resident #1 and threatening to kill him. Resident #1 was hollering for staff. The staff intervened and Resident #2 was removed and taken to the emergency room for evaluation. Record review of a general in service dated 2/23/23 (prior to the incident) indicated an in-service on abuse and neglect. The sign in sheet indicated LVN A and LVN E attended. Record review of the Provider Investigation Report dated 2/27/23 indicated during an investigation the facility was made aware of an additional concern related to LVN A and LVN E. During the investigation of LVN E's treatment of residents, there was an incident that arose regarding LVN A. The allegations regarding LVN A were substantiated. The police were notified, life satisfaction rounds were conducted with residents, and staff questionaries to identify if this happened elsewhere. The LVN A and LVN E were terminated. The report contained a statement dated 2/24/23 written by CNA B that indicated Resident #1 pulled his light a few times. This annoyed LVN A and LVN E to the point they wanted him out of bed. Around 12:00 a.m. CNA B and CNA D got Resident #1 up and they would not let us put him down until closer to 7 :00 a.m. While he was up, they kept telling him to shut up. The nurses laughed at him along with torturing him with past events of a former roommate beating Resident #1 up for talking. They proceeded to say, if you don't shut up Resident #2 was going to come and get you again. The Report contained a statement dated 3/1/23 by Resident #1 written by the Administrator. The statement indicated CNA D took him to the front lobby on Friday night 2/24/23 as punishment from the nurses for hollering. He said LVN A did not like it when he hollered. He said LVN A said, You remember that guy that beat you up? Well, I am gone bring him out here if you don't stop hollering. A statement dated 2/27/28 written by CNA D indicated on the 11 to 7 shift on 2/24/23 Resident #1 was on his call light quite a bit. About 12:00 a.m. LVN A said to get him up. He was not yelling when they got him up but yelled the rest of the night. The aide said she did not hear everything, but the nurses were hollering back to him from the nurses' station. She said they said something about an old roommate that had beat him up. The statement said CNA D and CNA B put Resident #1 to bed about 6:30 a.m. the aide said she returned to work at 3:00 p.m. on 2/26/23 and was told the resident slept all day and did not eat. She said he did not wake up to pull his light until 9:00 p.m. A statement with no date written by LVN A indicted Resident #1 was sitting in the front dining room and frequently yelled out nurse. This nurse told him to quiet down because there were 3 or 4 other residents close to him. At the desk myself and LVN E was talking about the time his former roommate hit him with a remote due to his constant loud yelling. During an interview on 8/8/23 at 10:25 a.m. with Resident #1 and the Administrator, Resident #1 said he remembered the incident that occurred a few months ago when two aides were told to get him up and put him in his chair around 11:00 p.m. or so, it was after the night shift came in. He said they got him up and he did not really want to get up. He said when he was asked to be put to bed, they would not put him to bed until morning. He said he could not put himself to bed, so he just had to sit there all night. Resident #1 said LVN A did that as punishment because she knew he did not like to stay up long. Resident #1 said LVN A threatened him with his former roommate beating him up if he did not stop hollering. The resident said he was upset by the incident and began to cry. After leaving the room, the Administrator said he did not know what upset Resident #1 more, the incident with LVN A up all night or the threat of Resident #2 beating him up. The Administrator said due to Resident #1 being upset he did not want to dig too deeply into his feelings, but it was obvious he was still upset by the whole thing. During a telephone interview on 8/2/23 at 11:50 a.m., CNA B said she heard LVN A talking to Resident #1 on 2/24/23. She said she heard LVN A threaten Resident #1 with someone beating him up. CNA B said LVN A told her and CNA D to get Resident #1 up and would not let them put him to bed all night. She said he did not like to stay up long. According to her, Resident #1 wanted to lay back down. CNA B said when they told LVN A he wanted to lay down, LVN A told them not to put Resident #1 back to bed until daylight. She said Resident #1 was dependent on staff and could not put his self-back to bed. CNA B said she did not report the incident but had been in-serviced on reporting abuse after the incident happened. She said if anything like that happened again she would let the Administrator know immediately. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 1:14 p.m., CNA C said she worked at the facility for 4 years. She said Resident #1 liked attention and would holler for help. She said she heard about them getting him up and keeping him up all night. She said when Resident #1 got up, after about 10 minutes, he wanted to lay back down. She said Resident #1 liked to stay in the bed. CNA C said if they kept him up all night, it would have been punishment for him. She said Resident #1 told her, LVN A made him get up and stay up all night because he was hollering, as a punishment. She said Resident #1 was dependent on staff and could not put his self-back to bed. During a telephone interview on 8/8/23 at 1:55 p.m., CNA D said Resident #1 yelled down the hall quite often. He was not yelling down the hallway on the night of 2/24/23She said when they arrived at work at 11:00 p.m. that night Resident #1 was pulling the call light quite a bit. They had only been at work a short time and he had pulled the light about 5 times. LVN A said if Resident #1 pulled the call light again she wanted her and CNA B to get him up. CNA D said he pulled the light again and LVN A told them to get him up. Resident #1 said he did not want to get up. She said they told LVN A he did not want to get up and LVN A told them to get him up anyway. CNA D said after about 2 hours Resident #1 wanted to go to bed. She said LVN A said do not put him to bed. CNA D said after about another hour and a half he asked again and LVN A said no. She said Resident #1 was dependent on staff and could not put himself self-back to bed. She said LVN A told them not put him to bed until day light. CNA D said Resident #1 was sliding out of his chair. She said Resident #1 was in a high-backed wheelchair and kept sliding down and they had to pull him up. CNA D said she did not hear all the comments that night between LVN A and LVN E. She said she heard parts of the conversation about a former roommate beating Resident #1 up and they were laughing. CNA D said she was sure Resident #1 could hear them. He was sitting in the entry way area not too far from the nurse's station. They were talking loudly, and she heard them from a couple of rooms down the hallway. She said she was doing what she was instructed to do by her nurse. She said she did not think too much of it at the time, but it was abuse. She did not report the incident but had been counseled and in-serviced since the incident. She said if anything like that happened again she would let the Administrator know immediately. She said if anything like that happened again, she would let the Administrator know immediately. During an interview on 8/2/23 at 11:29 a.m., the Administrator said he was investigating another abuse allegation regarding LVN E and discovered LVN A was abusive to Resident #1. The Administrator said on the night of 2/24/23, LVN A had told aides to get Resident # 1 out of bed due to his hollering out and to keep him up. He said LVN A also threatened Resident #1 by telling him a former roommate was going to beat him up. The Administrator said when he spoke to Resident #1, and Resident #1 said he felt like he was being punished. The Administrator said he did not know the exact date he found out about the incident, the staff did not come and report the abuse. When he was asked about LVN E, then CNA B and CNA D started to talk about the incident with Resident #1. He said it may be a day or two later when he found about the abuse to Resident #1. The Administrator said he started the investigation into LVN E on the morning of 2/25/23 because it was reported that morning. The two aides worked mostly nights and weekends. He said when he was informed what had happened to Resident #1, LVN A was suspended immediately. He said he terminated LVN E not because he could prove that she had abused a resident but because there were so many negative statements about her behavior all together on 3/4/23. He terminated LVN A because the abuse was substantiated on 3/4/23. He referred both their license, in serviced staff, and took the incident to QIPP. He said he completed the in-service and had the staff to take a test to ensure their knowledge of what was considered abuse, and when to report abuse. They were told if a resident did not want to get up then do not force them. If the nurse insisted, to contact him to determine what needed to be done on 3/4/23. During an interview on 8/18/23 at 1:50 p.m. the Activity Director said they had in services all the time on abuse and neglect. She said just today, there was an Inservice that came up on her computer about abuse and neglect and when to report. She said they were to report any suspicion of abuse immediately to the Administrator. The Activity Director said if the Administrator was not there, they call him. She said they were not allowed to use restraints in the facility. She said restraints could be chemical, locking someone in a chair, or side rails. She said Resident #1 did not like to get up a lot. If someone put him in a chair and would not lay him down, it was a restraint because he could not lay down by himself. During an interview on 8/18/23 at 2:10 p.m. CNA C said she worked at the facility for 4 years. She said they had in services all the time about abuse and neglect. Abuse was making a resident do something against their will. She said Resident #1 did not like to get up and the staff do not make him get up. CNA C said occasionally they can talk him into getting up, but Resident #1 did not like to stay up long. She said he had been like that ever since she had been at the facility. CNA C said the facility bought him a fancy wheelchair, give pain meds, but he still did not like to get up. She said if a nurse told her to get him up and he did not want to get up, She would call the abuse coordinator. CNA C said they should make him get up, they must honor the resident wishes. She said putting Resident # 1 in his chair and making him stay there could be a restraint. CNA C said Resident #1 could not get out of the chair without assistance. She said they were serviced on reporting and not doing things against resident wishes. During an interview on 8/18/23 at 2:13 p.m. CNA F said she worked at the facility for [AGE] years. She said she was aware of what abuse and neglect was, when, and who to report to. CNA F said if a nurse told her to do something to a resident that was not right, she would report her. She said they were in serviced on involuntary seclusion. CNA F said a restraint-could be holding someone against their will and not allowing them to do what they wanted. She said if a resident wanted to lay down and could be a restraint. She said Resident #1 could not lay down himself. CNA F said it was the resident right, to lay down or to get help. Record review of the facility corrective actions prior to the initiation of the survey revealed: Record review of a QIPP worksheet dated 3/14/23 indicated the identified concern was two nurses involved in the mistreatment of residents. The alleged perpetrator was suspended pending investigation on 2/25/23. Systemic Actions were the corporate nurse and facility administrative staff completed a thorough investigation on abuse neglect, mistreatment, involuntary seclusion on 3/4/23. In-services were completed on 3/4/23 to include detailed discussion on abuse triggers, abuse scenarios as well as what to do when you encounter a situation where you feel the resident is being mistreated. Monitoring was initiated and complete on 6/9/23. LVN A and LVN E were both suspended on 2/26/23 and both were terminated on 3/4/23. Record review of an in service dated 3/4/23 indicated the Administrator presented the topic Abuse, Neglect, Mistreatment, and Involuntary Seclusion. The in-service sign in sheet had 51 signatures to include CNA B and CNA D. Record review of a time sheet for LVN A indicated she worked full shifts on 2/24/23 and 2/25/23- from 11p to 7a. The time sheet indicated that her last day at work was 2/25/23 at 7:18 a.m. Record review of a time sheet for LVN E indicated she worked full a shift on 2/24/23 from 11p- 7a. The time sheet indicated that her last day at work was 2/24/35 at 7:17 a.m. Interviews were conducted LVNs on 8/2/23 between 10:43 a.m. and 4:41 p.m. about the training they received regarding abuse, restraints, and seclusion: At 10:43 a.m. LVN H At 11:02 a.m. LVN I At 8/2/23 at 3:58 p.m. LVN G At 8/2/23 at 4:41 p.m. LVN J The LVNs said she had received an in service on abuse with a focus on seclusion. They informed to always honor the residents' rights and wishes. If a resident did not want to get up, do not make them got up, and do not force them to stay up in a chair. The nurses said they knew better than to make a resident do things against their will, and if they did that was abuse. They would not intentionally place a resident alone, in a room or a chair, if they were dependent on staff to meet their needs they would take care of the residents needs. They said they had received in services many times on abuse and neglect and was familiar with what constituted abuse, who to report to and to report immediately. Record review of the facility's Policy on Restraints and Involuntary seclusion last revised October 2022 and reviewed in March 2023. The policy indicated residents have the right to be free from any physical restrains imposed for the purposes of discipline or convenience and when not required to treat the residents' medical conditions. Residents have the right to function at the highest practicable level in the least restrictive environment possible. Restraints will never be used for the discipline or staff convenience. A physical restraint is any manual method, or physical, or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. Discipline is defined as any action taken by the facility for the purpose of punishing or penalizing the resident. Record review of the Abuse Prohibition Policy last revised March 2023 indicated the intent of this protocol was intended to assist in the prevention of abuse, neglect, and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion, and financial abuse. The policy indicated the facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and misappropriation of property or finances of residents. The definition of abuse means the willful infliction of injury, withholding or misappropriation or property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or anguish. Any employee who becomes aware of an allegation of abuse, neglect, or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. Training of all new and current employees will receive training and reinforcement on all aspects of abuse probation program. Training will include prohibiting and preventing all forms of abuse, identifying what constitutes all forms of abuse, recognizing signs and symptoms of all abuse, and reporting all forms of abuse. Prevention of abuse included facility staff will immediately correct, intervene in reports, or identified situation in which abuse/neglect is at risk for occurring. Protection indicated all residents will be immediately protected from harm. The facility will orient new staff to the reporting requirements upon hire and annually notify covered individuals that the obligation is to comply with reporting requirements. Each individual shall report immediately, but not later than 2 hours after forming the suspicion, , if the events that cause suspicion result in serious bodily injury, or not later than 24 hours if the events tat cause the suspicion do not result in serious bodily harm.

Based on interview and record review the facility failed to ensure care and services were provided to prevent elevated blood sugar episodes for 1 of 14 residents reviewed for diabetes care. (Resident #2) The facility did not assess blood glucose levels and revise interventions for Resident #2 from February - April 2012. Resident #2 was admitted to the hospital 04/19/12 with [DIAGNOSES REDACTED]. These failures likely resulted in Resident #2's hospitalization and could place 13 residents receiving glucometer checks at risk of low and elevated blood sugars. Findings included: Physician orders dated January 2012 indicated Resident #2, admitted [DATE] had [DIAGNOSES REDACTED]. The orders required Resident #2 to receive a finger stick blood glucose every morning at 6:30 a.m. Physician orders dated February- April 2012 indicated had a [DIAGNOSES REDACTED]. A MDS dated [DATE] indicated Resident #2 was [AGE] years old, totally dependent for bed mobility, locomotion, eating and personal hygiene. She had unclear speech, not comatose with some cognitive impairment. The MDS made no mention of a [DIAGNOSES REDACTED]. A care plan dated 01/25/12 indicated Resident #2 had unstable blood sugars related to diabetes. The goals were for blood sugars to be below 120, not to require additional insulin, and to have a Hemoglobin A1C below 6. Care plan approaches included: obtain finger stick blood sugars as ordered, administer oral diabetic agents as ordered, and observe for signs of low or elevated blood sugar. The January 2012 MAR indicated [REDACTED] *01/26/12 - 155 *01/27/12 - 150 *01/28/12 - 158 *01/29/12 - 211 *01/30/12 - 161 *01/31/12 - 182 Normal RR 70-110. February - April 2012 MARs indicated Resident #2 had no documentation of finger stick blood glucose checks. Nursing notes for Resident #2 included the following documentation: *03/30/2012 at 9:00 a.m., the resident was awake, alert and up in her wheelchair. She occasionally had crying spells and was delusional at times. Resident #2 was discharged from OT ... The resident required extensive assist of staff times two for bed mobility and transfers. She was fed by staff, had tremors and generalized weakness ...Her vital signs were 150/80, 102, 20 and temperature of 98.7. *03/31/2012 at 12 midnight no changes at this time. The next documentation in the nurse notes was 17 days later. *04/17/12 at 8:00 p.m. there was a new order for a diet change to pureed foods. *04/18/12 at 3:00 p.m. a Stage II was noted to the resident's right hip. The physician and family were notified. *04/18/12 at 3:00 p.m., the NP was there to see the resident. *04/18/12 at 4:30 p.m., new orders were received from the doctor for a CBC, CMP and UA with C &S in a.m. Resident resting in bed, eyes closed, responds verbally to questions, confused conversation and temperature of 98.2. *04/19/12 at 10:30 a.m., doctor aware that NP was here yesterday. Resident continues to decline. Respirations unlabored, decreased level of consciousness, difficult to arouse resident and give medications. Family aware and conference was set up to discuss palliative care. *04/19/12 at 4:00 p.m., resident spit medications out. Medications were wasted and temperature was 98.7. A urinalysis laboratory report dated 04/19/12 and delivered at 4:36 p.m. indicated Resident #2 had a urine glucose level equal to or over 1000. Normal reference range was negative. A nursing note dated 04/19/12 at 9:15 p.m., indicated the laboratory results were called to the NP five hours after they were received. A blood sugar check was completed and was over 600. The results were reported to the NP and orders were received to transfer Resident #2 to the emergency room for evaluation. The resident's vital signs were 136/60 blood pressure, 100 pulse, 18 respirations, 99 degree Fahrenheit temperature. Oxygen saturation was 87 percent (normal 90 - 100) on room air. Oxygen saturation increased to 90 percent when two liters of oxygen was applied per nasal cannula. EMS was notified of order for transfer. The nursing note dated 04/19/12 at 9:25 p.m., indicated the ambulance was at the facility to transfer Resident #2 to the hospital. An EMS patient care report dated 04/19/12 indicated a call was received from the facility due to loss of consciousness of Resident #2. The facility reported a blood sugar check was completed that read "HI" and the resident's oxygen saturation was "at round 90" on their simple face mask. The facility reported there was no history of diabetes. The EMS field primary impression was elevated blood sugar levels. An emergency room physician note dated 04/20/12 at 12:13 a.m., indicated Resident #2 was admitted [DATE] with [DIAGNOSES REDACTED]. The physician note indicated the following laboratory reports were completed on 04/19/12 at 10:17 p.m.: Glucose 1161 (RR 70-110) BUN 116 (RR 7-17) Sodium 171 (RR 137-145) Chloride 130 (RR 100-108) A laboratory report dated 04/19/12 timed 10:40 p.m., indicated a glucose level of greater than or equal to 1000. A hospital physician progress notes [REDACTED]. During an interview on 04/28/12 at 5:09 p.m., the DON said Resident #2 was doing poorly for several days. She said she was not drinking or eating well. She said Resident #2's blood sugars were supposed to be checked once a day. The DON indicated she wrote the initial order for daily blood sugar checks and she had no knowledge of the order being discontinued. She said a prudent nursing judgment would not call for blood sugar checks to be discontinued within the first 14 days of admission. The DON said there were no physician orders to discontinue the blood sugar checks for Resident #2. The DON said the blood sugars checks were not carried over on the physician orders. She said she did not know why the error was not caught during review of the physician orders. During an interview on 04/28/12 at 5:49 p.m., LVN A said Resident #2's blood sugars were taken in the morning by the night shift staff. LVN A said she received the UA result on 04/19/12 for Resident #2. She said the UA result was over 1000. She said she "vaguely" remembered the resident was a "diabetic" but the resident was not receiving insulin. She said she called the NP and then performed a finger stick blood sugar check for Resident #2. She said the reading was over 600 and the NP wanted the resident sent to the hospital. LVN A said she took the order for the laboratory on 04/18/12. She said the laboratory results were received on 04/19/12 at 4:36 p.m. on the fax machine in the DON's office. She said she picked the results up around 9:00 p.m. She said the only time she really looked at laboratory results were when there were orders to be done immediately. During an interview on 04/28/12 at 6:08 p.m., LVN B indicated she worked the night shift. She said the new MARs which included the blood sugar sheets were prepared by "someone in the DON's office" the first of every month. She said she went by the prepared MAR indicated [REDACTED]. If the blood sugars were documented they would be on the MARS. During an interview on 04/28/12 at 7:26 p.m., LVN D said Resident #2 had not ate, drank or swallowed well for about 2 weeks prior to being admitted to the hospital 4/19/12. She said she did not know Resident #2 was to receive a daily finger stick to monitor her blood sugar. She said she had never considered Resident #2's decline might be a complication of her diabetes and had never performed a blood sugar for Resident #2. During an interview on 04/28/12 at 6:20 p.m., the primary care physician for Resident #2 said he did not recall this specific resident but he would only discontinue blood sugar checks on a resident who had a hemoglobin A1C of 6.5 or previous blood sugars that were perfect. He said his standard protocol for not taking blood sugars on a diet controlled diabetic was if the resident had hemoglobin A1C results over 7.0 with re-checks every 3 months or hemoglobin AC1 results less than 7.0 and with re-checks every 6 months. During an interview on 04/28/12 at 7:54 p.m., the DON said there was not a system for ensuring nurses were checking resident MARS for accuracy. She said they had not consulted Resident #2's physician about not having parameters for her blood sugars on admission. The facility blood glucose monitoring policy dated July 2007 indicated, "each resident with a diabetic care plan intervention shall have a diabetic care/communication flow sheet. The tool would be for communication and to consolidate different aspects of the diabetic residents' physician driven plan of care. The flow sheet shall contain some of the following items: *Frequency of monitoring *Rotation of monitoring sites *Standard reporting of results *Reporting time frames for out of range readings (<60 and >300) *Reporting of readings per physician order *Actions taken if out of range readings occur (i.e. reorder blood glucose level if physician does not call prior to next lab)" The April 2012 diabetic monitoring sheets indicated 13 residents received glucometer checks.