Every finding on record at Laurel Health & Rehabilitation Center

Based on interview and record review, the facility failed to ensure medications were free from unnecessary use by administering Narcan (naloxone) without a physician order or documented clinical indication for 1 (#4) of 1 resident reviewed for unnecessary medications. The failure resulted in precipitated opioid withdrawal symptoms, increased resident distress, and hospitalization, and the resident received additional medical treatment. Findings include: Review of a facility-reported incident submitted to the State Survey Agency on 5/18/26 showed resident #4, a hospice resident receiving comfort-focused treatment, was found unresponsive, and a staff member administered Narcan (naloxone). The report showed resident #4 was transported to the hospital related to a change in condition and monitoring for response to Narcan treatment. Review of resident #4's diagnosis list included diagnoses of chronic obstructive pulmonary disease (COPD), opioid dependence, anxiety disorder, chronic pain, and polyneuropathy.Review of resident #4's hospice admission orders showed the resident was admitted to hospice services on 2/24/26 for COPD and was prescribed morphine sulfate for comfort-focused symptom management.Review of resident #4's physician orders and medication administration records showed resident #4 was prescribed the following medications: - oxycodone hcl 5 mg every four hours as needed for pain,- fentanyl transdermal patch 50 mcg/hr every 72 hours, increased on 5/10/26 to 75 mcg/hr every 72 hours,- morphine sulfate 20 mg/ml dosing up to 20 mg per hour as needed for pain and shortness of breath.Review of resident #4's electronic health record did not show a physician order authorizing Narcan, or standing orders for Narcan use.During an interview on 7/29/26 at 3:10 p.m., staff member C stated there were no physician orders authorizing Narcan administration for resident #4.During an interview on 7/29/26 at 2:20 p.m., staff member G stated resident #4 had longstanding opioid use and required increasing pain medication for symptom management.During a telephone interview on 8/5/26 at 2:30 p.m., returned in response to a 7/29/26 interview request, staff member O stated resident #4's roommate notified her resident #4 was unresponsive. Staff member O stated she found resident #4 slumped near the edge of the bed and attempted to arouse her with a sternal rub. Staff member O stated, Coming from an ICU setting, it looked like an overdose to me, and staff member O retrieved Narcan nasal spray from the medication cabinet and administered to resident #4 without a physician order. Staff member O stated approximately five to ten minutes after the Narcan administration, resident #4 became more active, began flailing, and exhibited jerking movements of the upper extremities. Staff member O stated resident #4 appeared to be in respiratory distress, pushed the oxygen mask away, and was not following commands. Staff member O stated she called 911 and notified hospice after EMS arrived. Staff member O stated the hospice nurse told her Narcan should not have been administered.Review of the EMS patient care record, dated 5/17/26, showed the ambulance crew arrived at the facility at 7:47 p.m., and found the resident on the floor being held upright by staff and in obvious respiratory distress. The report showed the resident was gasping, unable to speak or follow commands, and exhibited exaggerated involuntary jerking movements. The EMS patient care record showed facility staff reported resident #4's blood pressure was 80/40 prior to their arrival, and hospital transport was delayed as the staff had not yet contacted hospice. The record showed resident #4 was transported from the facility utilizing lights and sirens at 8:25 p.m. The EMS patient care record documented findings were consistent with opioid withdrawal following Narcan administration. Review of hospice records, dated 5/17/26, included documentation that the facility nurse reported resident #4 received Narcan after receiving a fentanyl patch and morphine earlier that day. Hospice documentation showed Narcan was administered inappropriately. The hospice record also showed resident #4 convulsed, became restless, experienced labored breathing, was transferred to the emergency department, where she received multiple doses of lorazepam and morphine, was admitted to the hospital, and a morphine infusion was initiated.Review of the facility policy titled, Medication Ordering and Receiving from Pharmacy Provider, showed:3.5 HOUSE-SUPPLIED (FLOOR STOCK) MEDICATIONS .5. Floor stock items are not to be administered without a current order from the resident's prescriber.

Based on interview and record review, the facility failed to ensure an effective system for timely reporting of allegations of abuse and neglect following a previous F609 deficiency for the same concern. The facility's continued failure to timely report allegations after implementing corrective measures demonstrated ineffective administrative oversight and failure to implement, monitor, and sustain the reporting process for 9 (#s 4, 5, 9, 10, 11, 12, 13, 14 and 16) of 19 residents. The failure placed residents at risk for delays in notification, investigation, protection, and response following allegations of abuse or neglect.Review of the facility's previous F609 deficiency dated 1/29/26 showed the facility was cited for late reporting for allegations of neglect and abuse for three residents. The facility submitted a plan of correction for the deficient practices identified. During an interview on 7/29/26 at 10:40 a.m., staff member A stated, I'm still learning . there's been a lot going on here . The administrator further stated, . I need to develop a system, so I know when they are due.Review of the facility's Plan of Correction for the previous F609 deficiency cited during the 1/29/26 survey showed, Administrator was educated on 1/31/26 by Executive Director using abuse policy which included: Definitions of abuse, screening, training, prevention, identification, investigation, protection, reporting and response, and coordination with QAPI. Administrator or designee will educate all staff on the abuse policy by 2/22/2026. The Administrator or DON will audit risk management reports, grievance forms, and clinical progress notes as needed in addition to oral reports of allegations of abuse as problems are identified. The [Facility Corporation] Abuse Critical Element Pathway will be used as an audit tool to ensure all components for abuse reporting, protection, and investigation are met for all allegations. Critical Element Pathways will be reviewed at QAPI monthly and by Interdisciplinary team as needed in between QAPI meetings for three months to identify any issues and ensure continued compliance.The facility's period of interdisciplinary team monitoring for continued compliance was 2/22/26 through 5/22/26.The current complaint investigation showed the facility administrator and staff continued to report allegations of abuse or neglect throughout the plan of correction monitoring period, with eight of the nine late reports identified during the complaint investigation as occurring between 2/22/26 and 5/22/26.Despite the facility's previous F609 deficiency and implementation of corrective measures, nine additional late reports were identified. The recurrence of the same or similar reporting failure demonstrated that the facility's administrative oversight was not effectively overseeing the abuse reporting process or implementing measures to prevent deficient practices and sustain the corrections for ongoing compliance. Review of the State Survey Agency's information for the facility showed staff member A took over the Administrator position as of 5/19/25, and obtained the Administrator's license on 12/19/19. A review of the Montana Code Annotated, 2025, Title 52, Chapter 3, Part 8, shows a mandatory person includes (not all inclusive): (e) a person who maintains or is employed by a roominghouse, retirement home or complex, nursing home, group home, adult foster care home, adult day-care center, or assisted living facility or an agency or individual that provides home health services or personal care in the home;

Based on interview and record review, the facility failed to ensure Facility-Reported Incidents were reported to the State Survey Agency within the required timeframe for 2 (#s 10 and 14), and failed to submit the results of investigations to the State Survey Agency within the required five-working-day timeframe for 9 (#s 4, 5, 9, 10, 11, 12, 13, 14 and 16) of 19 residents reviewed for Facility-Reported Incidents. The failures delayed the State Survey Agency's receipt of information necessary to evaluate the facility's response to allegations involving resident safety, placing residents at increased risk due to delayed regulatory oversight. Findings include:During an interview on [DATE] at 10:40 a.m., staff member A stated she was responsible for submitting both the initial reports and the investigative findings for all of the facility's reported incidents to the State Survey Agency within the required timeframes. Staff member A acknowledged several investigative findings were submitted late and stated, I'm still learning . there's been a lot going on here.1. Review of a Facility-Reported Incident involving resident #14 showed the facility reported an allegation of neglect that occurred on [DATE]. Review showed the facility did not submit the required initial report to the State Survey Agency until [DATE], exceeding the required reporting timeframe. Review further showed the facility submitted the investigative findings to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.2. Review of a Facility-Reported Incident involving resident #10 showed the facility reported an allegation of verbal abuse that occurred on [DATE]. Review showed the facility did not submit the required initial report to the State Survey Agency until [DATE], exceeding the required reporting timeframe. Review further showed the facility submitted the investigative findings to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.3. Review of a Facility-Reported Incident submitted to the State Survey Agency on [DATE] showed the facility reported an allegation of resident-to-resident verbal abuse involving resident #9 and resident #16. The incident occurred on [DATE]. Review showed the investigative findings were submitted to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.4. Review of a Facility-Reported Incident submitted to the State Survey Agency on [DATE] showed the facility reported the unauthorized administration of Narcan to resident #4. The incident occurred on [DATE]. Review showed the investigative findings were submitted to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.5. Review of a Facility-Reported Incident submitted to the State Survey Agency on [DATE] showed the facility reported an incident involving cardiopulmonary resuscitation (CPR) initiated for resident #12 when a POLST was not readily available. The incident occurred on [DATE]. Review showed the investigative findings were submitted to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.6. Review of a Facility-Reported Incident submitted to the State Survey Agency on [DATE] showed the facility reported an allegation of staff-to-resident abuse involving resident #11. The incident occurred on [DATE]. Review showed the investigative findings were submitted to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.7. Review of a Facility-Reported Incident submitted to the State Survey Agency on [DATE] showed the facility reported an allegation of resident-to-resident verbal abuse involving resident #5 and resident #13. The incident occurred on [DATE]. Review showed the investigative findings were submitted to the State Survey Agency on [DATE], exceeding the required five-working-day reporting timeframe.Review of a facility policy titled, Abuse Reporting and Response, last updated [DATE], showed:Policy Statement. The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source, in accordance with state and federal law .The Executive Director or designee reports alleged violations to the State Survey Agency and other officials in accordance with state law .The Center reports the results of all investigations to the Executive Director and to other officials, in accordance with state law, including to the State Survey Agency, within five working days of the incident.

Based on interview and record review, the facility failed to provide timely toileting and activities of daily living (ADL) assistance for 3 (#s 2, 5, and 6) of 6 sampled residents who required staff assistance with toileting and personal care. The failure resulted in resident #2 remaining on the toilet for a prolonged period and residents #5 and #6 not receiving required toileting and ADL assistance, placing the residents at risk for discomfort, loss of dignity, unmet care needs, pain, skin impairment, and injury. Findings include:1. Review of a Facility Reported Incident, submitted to the State Survey Agency on 4/22/26, showed resident #2 was reported to have been left unattended on the toilet for approximately 30 minutes.Resident #2:During an interview on 7/28/26 at 3:12 p.m., NF3 stated he recalled the incident when resident #2 was left in the bathroom because he was very upset. NF3 stated resident #2 remained on the toilet for nearly two hours, not approximately 30 minutes as reported by the facility, and had been calling out for help. NF3 stated resident #2 tried to get himself off the toilet because he was getting so sore and managed to get to his seated walker. He was then able to hit the call light but could not do anything more. NF3 stated resident #2 was cognitively very good. Once in a while he would repeat a question, but he was very aware of what was going on. NF3 stated resident #2 was unable to reach the call light while seated on the toilet because of his limited mobility, and staff was aware he could not reach the call light when they placed him on the toilet. NF3 stated resident #2 had little to no muscle tone at that point, and trying to hold himself up in that position for all that time; that was hard on him. NF3 stated resident #2 told him he had been calling out for help and . finally a nurse heard him and came in and helped him. NF3 stated resident #2 did not have open wounds from sitting all that time but was very sore for several days afterward.During an interview on 7/29/26 at 3:22 p.m., staff member G stated, Residents should never be left on the toilet more than five minutes because they can fall. Staff member G stated CNAs should remain nearby to hear when the resident was ready to be removed from the toilet. Staff member G stated, It can depend on the resident, though; I know my residents and how long they usually are in the bathroom. Staff member G further stated, Thirty minutes is too long and can cause skin breakdown and can make it hard for the resident to stand with assist after sitting too long.During an interview on 7/29/26 at 3:40 p.m., staff member F stated she did not like to leave her residents' rooms when they were on the toilet and said, That is when injuries happen. It is easy to get pulled away to help another CNA or resident, and then your resident on the toilet is at risk. I am very protective of my residents. Staff member F stated 30 minutes on the toilet would be excessive.During a telephone interview initiated during the survey period, with a return call on 8/5/26, staff member H stated resident #2 was independent in the bathroom and often only needed assistance with his belt buckle while dressing. Staff member H stated she did not assist resident #2 to the bathroom on the day of the incident. Staff member H stated resident #2 was able to use his walker to go to the bathroom independently and would often remain in the bathroom for long periods of time. Staff member H stated resident #2 was able to clean himself after toileting and could reach the call light in the bathroom if needed.Review of a facility-provided written statement from staff member I showed, . When I entered resident #2's room, he was sitting on his walker without pants on. He asked if I could help him . It appeared he moved from the toilet to the walker without being cleaned . This took place around 12:00 p.m., I believe.Review of the facility's investigation of the incident, dated 4/22/26, showed staff member H stated she assisted resident #2 to the toilet at approximately 11:30 a.m. The investigation did not identify why staff member H failed to return to assist resident #2 off the toilet in a timely manner, and no written statement from staff member H was included in the investigative file.Review of resident #2's diagnosis list showed diagnoses included low back pain, constipation, and overactive bladder.Review of resident #2's Quarterly MDS assessment, with an assessment reference date of 5/16/26, showed resident #2 was dependent on staff for toileting and toileting hygiene, requiring moderate to maximal assistance, and required supervision or touch assistance for toilet transfers.Review of resident #2's care plan, initiated on 11/23/25 and revised on 4/19/25, showed he was at risk for falls and had a previous fall. The care plan did not show any fall interventions related to bathroom safety.2. Review of a Facility Reported Incident, submitted to the State Survey Agency on 6/19/26, showed the facility reported an allegation of neglect after residents #5 and #6 did not receive required toileting and activities of daily living assistance during the day shift on 6/12/26.Resident #5:Review of the facility's investigation, dated 6/19/26, showed the allegation was substantiated. The investigation concluded the assigned CNA failed to provide the required toileting and ADL assistance to resident #5 during the day shift on 6/12/26.During an interview on 7/29/26 at 4:38 p.m., staff member F stated CNAs are expected to check and change dependent residents at least every two hours, and sooner if needed.During an interview on 7/29/26 at 5:15 p.m., resident #5 stated she filed a grievance about the CNA who never came back to help me. Resident #5 stated NF2 repeatedly told her she would return to clean her up but never did. Resident #5 stated, She (NF2) doesn't work here anymore.Review of resident #5's diagnosis list showed diagnoses including metabolic encephalopathy, anxiety disorder, multiple vertebral fractures, cerebrovascular accident, and polyneuropathy.Review of resident #5's Quarterly MDS assessment, with an assessment reference date of 6/22/26, showed a BIMS score of 15; cognitively intact, complete dependence on staff for toileting hygiene, and maximal assistance for personal hygiene.Review of resident #5's care plan showed interventions, last revised 5/21/26, for pain related to wounds and chronic back and lower extremity discomfort, and interventions, last revised 7/1/26, for frequent urinary incontinence.Resident #6:During an interview on 7/29/26 at 5:40 p.m., resident #6 stated he recalled the incident (on 6/12/26) stating, . I wasn't changed, and I wasn't even asked if I wanted to get up.During an interview on 7/29/26 at 3:55 p.m., staff member M stated, We check on every resident at least every two hours all day long and change them as needed; no exceptions. They need that, or they can get skin breakdown. I would definitely report to the Director of Nursing if another CNA was not caring for their residents.Review of resident #6's diagnosis list showed diagnoses including chronic obstructive pulmonary disease, heart failure, cognitive communication deficit, and wheelchair dependence.Review of resident #6's care plan showed interventions revised on 4/10/26 for maximal assist from staff for toileting hygiene and bladder incontinence, and interventions revised on 8/15/25 for moderate assist for personal hygiene and dependence on staff for wheelchair locomotion.Review of resident #6's Quarterly MDS assessment, with an assessment reference date of 6/8/26, showed a BIMS score of 9 for moderate cognitive impairment; moderate to maximal assistance required for toileting and personal hygiene and moderate assistance required for repositioning.Review of NF2's written statement, undated, showed NF2 stated she checked on residents #5 and #6 every two hours, but they did not want to be changed and did not want to get up.Review of staff member N's written statement, dated 6/12/26, showed residents #5 and #6 stated they had not been changed, and when they requested assistance, NF2 repeatedly stated she would return but did not. Staff member N's written statement showed both residents were saturated with urine when she provided their care at approximately 3:00 p.m.Review of the facility's investigation, dated 6/19/26, showed the allegations for resident #s 5 and 6 were substantiated. The investigation concluded the assigned CNA failed to provide the required toileting and ADL assistance to residents #5 and 6 during the day shift on 6/12/26.A request was made on 7/30/26 for the facility's policies regarding toileting assistance and activities of daily living. The requested policies were not provided by the end of the survey.

Based on interview and record review, the facility failed to implement a system to ensure a resident's current Physician Orders for Life-Sustaining Treatment (POLST) form was immediately available to staff during a medical emergency for 1 (#12) of 5 sampled residents reviewed for advance directives. The failure resulted in CPR being initiated despite the resident's documented wishes to forgo resuscitation. Findings include:Review of a facility-reported event showed resident #12 experienced a cardiac arrest on [DATE]. Nursing staff initiated cardiopulmonary resuscitation (CPR) after they were unable to locate the resident's POLST documenting a Do Not Resuscitate (DNR) order. The event documentation showed CPR was discontinued after EMS arrived and the resident's son confirmed the resident had a completed POLST directing no resuscitation.During an interview on [DATE] at 2:30 p.m., NF1 stated he provided the resident's signed POLST to the facility at the time of admission. He stated he believed the facility had the document and expected staff would honor his mother's wishes. NF1 stated facility staff called him while CPR was in progress because they could not locate the POLST. He stated, I gave it to you when I came. You need to stop. NF1 stated he was saddened his mother underwent CPR despite her documented wishes to decline resuscitation. During an interview on [DATE] at 2:55 p.m., staff member K stated admission documents, including signed POLST forms, were forwarded to the medical records department for scanning into the electronic health record. She stated the original POLST was not maintained on the nursing unit during the scanning process. Staff member K stated the time between receipt of the POLST and availability in the electronic health record ranged from a couple of days to a couple of weeks, depending on the volume of records awaiting scanning. She stated the resident's POLST was located in the medical records office a few days after the event.During an interview on [DATE] at 3:02 p.m., staff member O stated she assisted in locating the resident's POLST on the evening of the event. She stated staff were unable to locate the document in the resident's electronic health record and initiated CPR because the resident's code status could not be verified.During an interview on [DATE] at 3:10 p.m., staff member G stated the facility used the code status documented in the hospital discharge orders to establish a resident's code status when a resident was admitted without a signed POLST.During a telephone interview on [DATE] at approximately 4:15 p.m., staff member B stated the facility's process at the time of the incident contributed to the failure to ensure the POLST was available in the electronic health record when needed. Staff member B stated the facility implemented changes after the [DATE] event to improve the visibility and accessibility of POLST forms within the electronic health record.Review of resident #12's electronic health record showed a hospital discharge referral, dated [DATE], documented the resident's code status as DNR (Do Not Resuscitate) and showed a signed POLST accompanied the referral documents. Review of the admission paperwork showed a completed POLST, dated [DATE], and an Advance Directive, dated [DATE], were included with the admission documents.Review of a facility document titled Advanced Directive, last revised on [DATE], showed:Policy Statement: It is the policy of this facility that residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive .2. During the admission process, the facility identifies if the resident has an advance directive or medical orders related to life-sustaining treatment. If the resident does, a copy is requested and kept in the resident's medical record, accessible to the physician and care staff .

Based on observation, interview, and record review, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (#3) of 9 sampled residents reviewed for abuse or neglect. The failure resulted in an incomplete investigation that did not demonstrate the facility adequately evaluated the allegation, determined the facts, or documented findings and corrective actions, placing residents at risk for unaddressed abuse and inadequate protection. Findings include:Review of a Facility Reported Incident, submitted to the State Survey Agency on 7/15/26, showed the facility reported an allegation of verbal abuse involving resident #3. The report included documentation of concerns that two night shift staff members were not gentle with care, and one staff member was described as sour (unfriendly disposition). During an observation and interview on 7/29/26 at 7:17 a.m., resident #3 was observed lying in bed. Resident #3 stated, Some people here aren't very nice . I do feel safe here. Resident #3 did not remember the specific incident. During an interview on 7/29/26 at 5:05 p.m., staff member A stated she was responsible for making sure the investigation documentation was complete and timely. Staff member A stated she could not locate additional investigative documentation for this incident, and stated, There is so much to learn here.Review of resident #3's Quarterly MDS assessment, with an assessment reference date of 6/8/26, showed resident #3 had a BIMS score of 13, reflecting intact cognition.Review of the investigative summary documentation from the Bounds system (abuse/incident reporting system) showed the investigation included initiation of 72-hour psychosocial monitoring and a follow-up interview with resident #3, during which resident #3 stated she felt safe.Review of the Facility-Reported Incident investigative file provided by the facility did not include documentation supporting interviews with the accused staff members, other residents, witnesses, or staff identified as knowing about the allegation. The investigative documentation available for review also did not include records supporting the facility's investigative findings. Although the facility reported that these investigative activities and actions had occurred, supporting documentation was not included in the investigative file provided to the surveyor for review.Review of resident #3's electronic health record did not show documentation of the 72-hour psychosocial monitoring referenced in the investigative documentation.A request was made on 7/28/26 for the complete investigative file. No additional investigative documentation was provided by the end of the survey.

Based on interview and record review, the facility failed to provide supervision and assistance during bathing and transfers consistent with the resident's assessed needs and care plan for 1 (#14) of 3 residents sampled for falls. The failure resulted in resident #14 falling forward from a shower chair, placing the resident at risk for injury. Findings include:Review of a Facility-Reported Incident submitted to the State Survey Agency on 2/10/26 showed resident #14 sustained a fall on 2/2/26 at approximately 7:45 a.m. after completing a shower. Documentation showed the resident stated he attempted to dry his feet while seated in a shower chair and slipped from the chair onto the floor. The resident was assessed immediately following the fall, and no injuries were reported.During an interview on 7/29/26 at 3:59 p.m., staff member M stated resident #14 had several falls while he was here (at facility). Staff member M stated, For this fall, [resident #14] had been brought back to his room in the shower chair. The shower aide left the room to get some clean towels or gown, and when he came back, the resident had fallen off the shower chair and was on the floor. Staff member M stated residents should never be left alone in a shower chair because the chair is not stable and may be wet and slippery.Review of resident #14's nursing progress note, dated 2/2/26, showed: . Nurse finds resident side lying on the ground, shower chair behind him. Resident states, 'I was trying to dry my feet and fell forward.' . Resident has no c/o.Review of resident #14's diagnosis list showed diagnoses including CVA with hemiparesis, epilepsy, and traumatic brain injury. Review of resident #14's care plan, updated on 3/30/26, showed the resident had a history of falls and remained at elevated risk for falls. The care plan did not show interventions prior to the resident's fall related to needing standby assistance at all times. Review of the facility's investigation for resident #14's fall from the shower chair, completed 2/18/26, showed resident #14 required maximum assistance for transfers according to the resident's care plan. The investigation determined the shower chair was functioning properly and no environmental hazards were identified. The investigation further concluded the supervision and assistance provided during bathing did not align with the resident's assessed needs or care plan and that this variance from established bathing and transfer safety procedures contributed to the resident's fall.

Based on interview and record review, the facility failed to provide pharmacy services that ensured stock emergency medications were obtained, available, and administered only as authorized by physician orders for 1 (#4) of 1 resident reviewed for pharmacy services. The failure increased the risk residents could receive emergency medications without appropriate authorization or clinical indication. Findings include:Review of a facility-reported incident submitted to the State Survey Agency on 5/18/26 showed resident #4, a hospice resident receiving comfort-focused treatment, was found unresponsive, and the nurse administered Narcan (naloxone). Review of resident #4's electronic health record did not show a physician order authorizing Narcan. The electronic health record also lacked nursing documentation identifying that Narcan was administered, the dose, route, time of administration, the indication for use, source of the medication, or the resident's response to the Narcan.During a telephone interview on 8/5/26 at 2:30 p.m., following a voice mail request for interview on 7/29/26, staff member O stated she retrieved Narcan nasal spray (2mg) from the medication cabinet because, I knew she was on hospice, but coming from an ICU setting, it looked like an overdose to me (referring to resident #4's status at the time of the event). Staff member O stated she did not obtain a physician order before administering the medication. Staff member O stated she did not sign the medication out of the stock medication cabinet because she didn't really see anywhere to do so, and stated, With [Agency name] shifts you get like 10 minutes orientation. During an interview on 7/29/26 at 2:45 p.m., staff member A stated she was unable to locate standing physician orders authorizing Narcan administration.During an interview on 7/29/26 at 3:10 p.m., staff member C stated there were no physician orders authorizing Narcan administration, and the facility did not maintain standing physician orders for Narcan. Staff member C stated the medication may have been obtained from the facility's emergency medication kit.During a telephone interview on 7/30/26 at 8:49 a.m., staff member D stated the facility had never maintained standing physician orders authorizing Narcan administration. Staff member D stated, It might be a good idea, though.Review of email documentation provided by the facility following the survey showed communication between the contracted pharmacy and the facility regarding the development and implementation of protocols that were not previously in place for access to and use of the emergency kit (e-kit) medications and house-supplied stock medications related to Narcan administration.Review of facility education documentation, titled, Narcan (Naxolone) Administration in Hospice Residents, dated 5/18/26 to 5/20/26, showed:Before administering Narcan, the nurse must first verify a current physician/provider order and review goals of care.Review of the facility policy titled Medication Ordering and Receiving from Pharmacy Provider, dated 1/25, showed: . 3.4 EMERGENCY PHARMACY SERVICE AND EMERGENCY KITS (E-KITS)POLICY .7. When an emergency or stat medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, checks the resident's allergies, and removes the required non-controlled medication from the emergency kit. Emergency medications are only administered with a valid prescriber's order.

Based on interview and record review, the facility failed to implement and maintain an antibiotic stewardship program in order to promote the appropriate use of antibiotics. This deficient practice increased the risk for residents to develop drug-resistant organisms and/or complications. Findings include:During an interview and record review on 1/28/26 at 2:40 p.m., staff member P stated the facility Infection Preventionist was not available during the week of the survey. Staff member P reported the facility did not have an antibiotic stewardship program in place. Staff member P stated the Infection Preventionist tracked infections but did not address specific laboratory results and sensitivity of infectious agent to the antibiotic ordered by the physician. Staff member P was not able to locate an antibiogram or audits for the infections. Resident #21 reported she was being treated for a facility acquired E. Coli urinary tract infection. Refer to F880. Review of the facility's Line Listing for Infections by Resident, dated 10/1/25, reflected 40 percent of the infections for the month of October were urinary tract infections. Review of the facility's Infection Preventionist Job Description, updated March 2025, reflected:- .9. Directs antibiotic stewardship activities within the community to inform strategies to improve antibiotic use by tracking antibiotic doses, adherence to evidence-based published criteria, and reviewing antibiotic resistance patterns in the community.Review of the facility's policy, Antimicrobial Stewardship Program (ASP), updated March 2018, reflected:- .d. Infection Preventionist: Monitors and supports ASP activities through rounds, audits, review of physician/provider orders, documentation, and available Antibiogram, pharmacy reports, and clinical reports. Reviews antibiotic resistance patterns: i. Monitors HAI MDRO's on monthly line listing, center map, and infection control report looking for increased rates and/or trends. ii. Compares Center Antibiogram for commonalities with reports.

Based on interview and record review, the facility failed to utilize and maintain a QAPI system to identify performance improvement issues related to grievances, abuse and neglect allegations, Bowel and Bladder care for dependent residents, and infection control; and failed to show how the QAPI committee was involved in addressing these quality of care issues and the lack of policies and procedures which could negatively affect many, or all, of the residents residing at the facility. Findings include:During an interview and record review on 1/28/26 at 2:45 p.m., staff member A stated the facility met monthly to discuss any concerns the department managers had. Staff member A stated the department managers did not bring data to the meetings. Staff member A stated the meeting was, more of a conversation type meeting where the managers can bring their issues in their department forward and we talk about ideas to resolve them. Staff member A stated the departments do not present on trends based on data. Staff member A stated the QAPI group did look at customer satisfaction surveys and Quality Measures. Staff member A did not have minutes, or documentation to present for the last QAPI meeting. Staff member A stated the QAPI group had not discussed concerns around abuse and neglect, grievances, infection control, or antibiotic stewardship. Staff member A stated the Infection Preventionist discussed any concerns she had but no data was presented to evaluate for trends. Staff member A did not have any root-cause analyses to review for areas of concern. Staff member A stated the facility did not have any performance improvement plans for the past twelve months. Review of the facility's, Appendix 4A: QAA Committee Agenda and Attendance Sheet, dated February 2018, reflected seven primary areas of data presentation with 49 specific items to be covered, including resident satisfaction, employee satisfaction, education and training, quality care, operational quality, and PPS trends. Review of a facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 3/2025, showed:- . Neglect . Staff repeatedly ignoring resident's needs for assistance with ADLs, resulting in residents . being left in fecal material or urine. 8. Coordination with QAPI, The Center has written policies and procedures that define how staff will communicate and coordinate situations of abuse, neglect, misappropriation of resident property, and exploitation with the QAPI program.Review of the facility's, QAPI Plan, updated October 2018, reflected:- . Improvement changes and decisions are based on data and measurements versus opinions and ideas. The Center collects data that is accurate, reliable, and valid for the area of focus.

Based on interview and record review, the facility failed to have an annual improvement project that focuses on high risk or problem-prone areas identified through the data collection and analysis. Findings include: During an interview and record review on 1/28/26 at 2:45 p.m., staff member A did not have minutes, or documentation to present for the last QAPI meeting, only an agenda/attendance sign in sheet. Staff member A stated the QAPI group had not discussed concerns around abuse and neglect, grievances, infection control, dental needs, bathing, activities for disabled residents, care planning, or antibiotic stewardship. Staff member A stated the facility did not have any performance improvement plans for the past twelve months.Review of the facility's, QAPI Plan,, dated October 2018, reflected:- . The Quality Assurance (QAA) Committee oversees the Center QAPI program. They are tasked with identifying areas requiring performance improvement, collecting data, developing and implementing corrective action, and creating monitors to determine and validate changes are effective and sustained.

Based on observations, interviews, and record review, the facility failed to ensure infection control practices were followed when providing incontinence care for 1 (#21); hand hygiene practices were followed for 1 (#7); posted PPE requirements were followed for 1 (#21); transporting of dirty linens; storage of clean linens; and maintained cleanable surfaces for 34 sampled residents. These deficient practices place all residents at increased risk of infection. Findings include: 1. During an interview on 1/26/26 at 4:41 p.m., resident #21 stated she often was left wet with a pad added to her brief at night so the staff would not have to change her brief so often. Resident #21 stated she was currently on antibiotics for a urinary tract infection. Resident #21 stated one CNA always wiped from back to front and right after she worked, she developed the E. Coli urinary tract infection.During an observation and interview on 1/27/26 at 1:30 p.m., staff member K was assisting resident #21 off the toilet and cleaning her peri-area and anus. Staff member K entered and began cares without wearing appropriate PPE for Enhanced-Barrier Precautions. Staff member K put on gloves, and began cleaning resident #21's anus, using multiple wipes from behind the resident while she stood up. Staff member K did not clean resident #21's vaginal or front area. Staff member K pulled resident #21's brief and pants up and assisted her back to her wheelchair. Afterwards, staff member K was asked about the Enhanced-barrier Precautions sign on the room door. Staff member K stated, Hum, and shrugged his shoulders. When asked about cleaning resident #21's front peri-area, staff member K stated, Well, she's big so I can't really reach through from the back, but I try a little. Review of resident #21's,Care Plan, revision date 12/30/25, reflected resident #21 required maximal assist with toileting hygiene and required the use of a sit-to-stand for transfers. Resident #21 required cares in pairs (two staff members for care). Resident #21's care plan reflected resident #21 was on an antibiotic for a urinary tract infection. Resident #21's care plan also reflected: Follow Enhanced Barrier Precautions posted at my door, r/t lower extremity wounds when high contact care is being provided in resident room.During an interview on 1/28/26 at 2:02 p.m., staff member M stated resident #21 frequently reported a lot of concerns, including staff not changing her brief and putting pads in her brief. 2. During an observation and interview on 1/27/26 at 1:30 p.m., staff member I and J brought resident #7 to her room to toilet her. Staff member I and J completed hand hygiene and put on gloves. Staff member I was running the sit-to-stand while staff member J was assisting to remove resident #7's soiled brief. Resident #7 stated she was finished toileting, and staff member J began to clean resident #7 from front to back. Staff member J stopped and changed her gloves without hand hygiene. Staff member J then assisted resident #7 to put on a clean brief and redress. Staff member J did not complete hand hygiene between dirty and clean tasks. Afterwards, staff member J stated she forgot to complete hand hygiene before putting on new gloves.3. During an observation on 1/27/26 at 12:25 p.m., staff member I was noted to be carrying dirty linen down the hall up against her body, not bagged and touching her scrub top. 4. During an observation and interview of the laundry facilities on 1/27/26 at 10:42 a.m., with staff member P found the clean bagged pillows were being stored in the dirty linen room on a shelf next to dirty linen bins. Staff member P stated the staff should not be storing clean items in the dirty linen, including the clean pillows. Staff member P stated he was unable to locate audits or documentation of the Infection Preventionist completing rounds of the laundry area or storage rooms.5. During an observation and interview of the storage rooms on 1/27/26 at 10:45 a.m., with staff member P the following was noted:- Two boxes of nasal cannulas on the floor,- A box of Trach tubes on the floor,- A full shelf of ABD pads one inch off the floor, - Two boxes of lidocaine patches on the floor,- Five catheter bags on the floor,- Clean towel blankets stored on a full shelf from the floor to the ceiling five inches away from the bathtub and uncovered,- Nutrition room counter was waterlogged and no longer a cleanable surface, and- Nutrition room linoleum mat on floor was cut four cm short down two walls exposing unfinished flooring, and a hole in the mat in front of the refrigerator was twelve cm by four cm in size, exposing an uncleanable surface. Review of the facility's, CNA Competency-Peri-Care, Female, updated May 2015, reflected: . 10. Separate the labia, clean the area using one downward stroke (front to back). Do not wipe the same area of the washcloth/wipe for more than one pass.14. Apply soap to newly mitted washcloth or wipe. Clean the rectal/peri-area from the vagina to the anus in one downward wipe.Review of the facility's policy, Handwashing/Hand Hygiene, updated August 2025, reflected:- . Examples of situations when hand hygiene is performed, includes but is not limited to: . d. Before and after assisting a resident with personal care activities. (e.g. oral care, incontinent care, dressing, grooming, bathing). and . r. After removing gloves.Review of the facility's policy, Soiled Laundry and Bedding, dated May 2015, reflected:- . 2. Place contaminated laundry in a bag or container at the location where it is used and do not sort or rinse at the location of use.13. Clean laundry is not stored with dirty or soiled laundry. b. Clean linen is stored in a room or cart that has a cover over the clean linens to prevent contamination while waiting to be used.Review of the facility's policy, Personal Protective Equipment (PPE) Work Practices, updated May 2015, reflected:- . 1. Employees are required to use PPE in accordance with Standard and Transmission-Based Precautions, as defined by the Centers for Disease Control.

Based on interviews and record review, the facility failed to ensure grievances either voiced or provided to the facility were followed up on and resolved, and this was a system failure, to include: not assisting with verbal grievances, not identifying concerns and resolving them, not notifying the party filing the grievance of the resolution, not documenting steps taken to resolve the grievance, and not maintaining the grievance for 3 years from the date the grievance decision was issued for 1 (#21) of 34 sampled residents. This deficient practice affected all residents with grievances related to concerns or quality-of-care issues, which could negatively affect many or all of the residents residing at the facility. Findings include:During an interview on 1/26/26 at 4:41 p.m., resident #21 stated she had filed several complaints over the past couple of months. Resident #21 stated she filed grievances regarding the staff behavior, positioning during incontinence care, and dietary concerns. Resident #21 also stated she reported grievances for bringing resident #7 to the dining room without toileting her first because she had urinated in her chair several times a week. Resident #21 stated she had only received a response to one grievance. Resident #21 stated she complained regularly to the staff nurses and CNAs about the pain caused by the night shift CNA's incontinence care. Resident #21 stated she did not attend resident council because nothing gets done when residents complain. Resident #21 stated she was very loud and demanding to get her needs met, as it seemed the only way to get a response, but she worried about resident #7 who could not really speak up and get attention when needed.During an interview on 1/28/26 at 1:00 p.m., staff member A stated the grievance forms were missing from 10/7/25 through 1/25/26. Staff member A stated NF4 was responsible for the grievances and no longer worked at the facility. Staff member A stated the day after she left, everything was gone (documents). Staff member A stated NF4 would collect the grievances from the grievance box and would bring the grievances to her immediately for review. Staff member A stated she did not know why the 21 grievances completed by residents between 6/12/25 and 10/7/25 had not been investigated, resolved with the resident involved, and signed off by her. During an interview on 1/28/26 at 2:37 p.m., NF4 stated she did not know where the grievances were. NF4 stated she received an average of three grievances a week and turned them into staff member A. NF4 stated she was not in charge of collecting the grievances from the grievance box and did not know how many would be in the grievance box a week. NF4 stated the three grievances she received a week was in addition to those in the grievance box. NF4 stated she received and turned in at least 15 grievances from 11/1/25 to 12/31/25. Review of the facility's Grievance Forms received, dated 6/12/25 - 1/26/26, reflected:- No grievance forms from 10/8/25 through 1/26/26, and- 21 of 39 Grievance forms received contained complaints from residents, but no investigation, resolution, or person notified of resolution.Review of Center Grievance Official sign posted, updated March 2025, reflected Staff member A was the grievance Official. The sign reflected:- 2. The Administrator oversees the grievance procedure and coordinates the center system for collecting, tracking, and responding to grievances.,- . 9. The Administrator/designee routes the Grievance form to the appropriate department manager, who reviews the grievance, responds within five business days, and returns the Grievance Form to the Administrator., - . 10. The person with the grievance has the right to a written decision regarding his/her grievance., and - . 14. Grievance forms/investigations are maintained for a minimum of three years.

Based on interview and record review, the facility failed to provide evidence to show the facility took action to acknowledge and resolve, or attempt to resolve, all concerns brought forth by the resident council. The failure affected any resident who had concerns that remained unresolved, or who had an interest in the council's activities. Findings include:During an observation of the facility's Resident Council meeting on 1/28/26 at 11:01 a.m., staff member C was observed asking the residents, How are things going? Staff member C did not read aloud the previous meeting minutes and did not follow up on the previous month's concerns. Unidentified residents in attendance reported ongoing and unresolved concerns with missing laundry, meals being served cold, and call lights not being answered in a timely manner.During an interview on 1/28/26 at 11:59 a.m., staff member C stated she had recently been assigned as the resident council's staff liaison. Staff member C stated she transcribed the Resident Council's meeting minutes and would follow up with departments in which residents voiced concerns. Staff member C stated the follow-up with the department was verbal and was not provided in writing. Staff member C stated she did not file a grievance form. Staff member C stated she would then follow up with the residents at the next scheduled monthly meeting to see if their concerns had been resolved.During an interview on 1/28/26 at 1:00 p.m., staff member A stated that facility grievance forms were unavailable for the period 10/7/25 through 1/25/26, and 21 grievances during the period of 6/12/25 through 10/7/25 had not been investigated. Staff member A stated NF4 had been responsible for the grievances and no longer worked at the facility. Staff member A stated that the day after NF4 left, everything (documents) from her office was gone. While she was employed, NF4 would collect the grievances from the grievance box and would bring the grievances to her immediately for review. Staff member A stated she did not know why the 21 grievances completed by residents between 6/12/25 and 10/7/25 had not been investigated, or a written response provided to residents.During a telephone interview on 1/28/26 at 2:37 p.m., NF4 stated that during her time employed by the facility, she received an average of three grievances a week and turned them into staff member A. NF4 stated she was not in charge of collecting the grievances from the grievance box and did not know how many would be in the grievance box a week. NF4 stated that the three grievances she received a week ago were not from the grievance box. NF4 stated she received and turned in at least 15 grievances from 11/1/25 to 12/31/25. A review of the Resident Council meeting minutes, dated January 2025 through January 2026, showed the Resident Council had discussed the following concerns, which would have required follow-up and resolution:On 4/21/25, the Resident Council discussed concerns regarding late medications, CNA's not providing snacks or coffee on request, long call light times, incontinence care, food and coffee palatability, meal tickets being missed for food orders, and spicy food served multiple days in a row.On 5/19/25, the Resident Council discussed concerns regarding long call light times, long wait times for bathroom assistance, poor food palatability, missing or incorrect laundry, and garbage bins not being emptied.On 6/23/25, the Resident Council discussed concerns regarding long call light times, staff playing on phones and not answering call lights, cold food, delayed food delivery, poor food palatability, lack of available coffee at 6:00 a.m., missing or incorrect laundry, and garbage bins not being emptied.On 7/24/25, the Resident Council discussed concerns regarding long call light times, delayed food delivery, poor food palatability, lack of available coffee at 6:00 a.m., missing or incorrect laundry, and poor room cleaning.On 8/18/25, the Resident Council discussed concerns regarding grievance forms not being responded to, staff not completing assigned tasks, limited administration contact, prolonged call light times, smaller portion sizes, staff not reviewing or following resident slip menus, frequent serving of beans and rice, poor food palatability, and incorrect laundry delivery.In November 2025 (date not specified), the Resident Council discussed concerns regarding call light response times and missing laundry items.On 12/15/25, the Resident Council discussed concerns regarding food temperature, CNAs not warming food on request, CNA care concerns, long call light times, laundry not being picked up consistently, and incorrect laundry delivery.On 1/19/26, the Resident Council discussed concerns regarding availability of CNA staff for care, CNA care concerns, food temperature, poor housekeeping, missing and incorrect laundry delivery, TV or bed controls, and wheelchairs left out of reach.Review of the facility's Grievance Forms received, dated 6/12/25 - 1/26/26, reflected:- No grievance forms from 10/8/25 through 1/26/26, and- 21 of 39 Grievance forms received and reviewed by the survey team contained complaints from residents, but no investigation, resolution, or person notified of a resolution was documented on the form. There was no grievance identified as being submitted related to resident council concerns.Review of a Center Grievance Official sign, which was posted publicly, updated March 2025, reflected that staff member A was the grievance Official. The sign reflected:- 2. The Administrator oversees the grievance procedure and coordinates the center system for collecting, tracking, and responding to grievances .- 9. The Administrator/designee routes the Grievance form to the appropriate department manager, who reviews the grievance, responds within five business days, and returns the Grievance Form to the Administrator.- 10. The person with the grievance has the right to a written decision regarding his/her grievance.- 14. Grievance forms/investigations are maintained for a minimum of three years.

Based on observations, interviews, and record review, the facility failed to ensure residents were free from abuse and/or neglect for 5 (#s 7, 11, 18, 21, and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #7 feeling intimidated and scared to return to her room; on-going psychosocial distress with resident #11 feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident); resident #21 having her head hit the wall during peri care (with fear of a repeat event occurring); and neglecting to provide resident #s 7, 18 and 21 proper toileting care, which may have contributed to a urinary tract infection for resident #21. Findings include:1. During an observation and interview on 1/27/26 at 9:46 a.m., resident #11 stated on the night of 12/28/25, resident #62 came into her room, held her arms down, tried to get into her bed with her, and yelled, You know who I am, repeatedly at resident #11. Resident #11 stated, (She) screamed for help for quite some time, and no one came. Resident #11 showed her arms were held above her head, crossed, and held down. She stated she tried to hit resident #62, but that did not work. She stated she tried to hit him with her water cup next. She stated she would have hit him with her cane if she could have, but it was across the room. She stated resident #62 had been in her room two other times. Both times, resident #62 had urinated in her toilet and then left. Resident #11 stated she was scared and upset that this happened, and was fearful resident #62 would return to her room at night again and harm her. Resident #11 stated she was concerned he could potentially sexually assault her or make advances toward her. She stated she thought the facility had moved his room away from hers and was not aware resident #62 was still in the room next door. During an observation on 1/27/26 at 10:00 a.m., residents #11 and #62's rooms were located side by side in the hallway, rooms [ROOM NUMBERS]. During an interview on 1/28/26 at 8:59 a.m., staff members A and B stated they were able to find some staff statements from the Facility Reported Incident with residents #11 and #62. Staff members A and B stated they were unable to find any resident interviews on what occurred the night of 12/28/25. Review of a facility document, not titled and dated 12/28/25, showed: I [staff member V] CNA went to lunch at 2:20 a.m. I returned at 2:47 a.m. I went to my hall and found [Resident #62] in . (another resident's room) . [Resident #11]'s light was on, and she was yelling for help. She was very upset and said that a man was trying to get into bed with her, she also said that she hit him and yelled for help and threw water at him I noticed water all over the room. [sic] During an interview on 1/27/26 at 4:43 p.m., staff member R stated they never knew anything about the situation that occurred with resident #11 and resident #62 on 12/28/25. Staff member R stated they usually were in close communication with the physicians about any incidents that occurred in the facility. Staff member R stated they also did not know anything about resident #11's feelings and did not feel safe around resident #62. During an interview on 1/29/26 at 2:20 p.m., staff member A stated residents #11 and #62's rooms were not moved apart from one another prior to 1/28/26 because the facility was unaware that resident #11 felt unsafe. 2. During an interview on 1/26/26 at 4:20 p.m., resident #7 was crying while telling staff member J, who was pushing her to room, Please don't make me go in my room, I'm scared to go in there, please don't take me in there. Staff member J told resident #7 she could stay in the hallway. Resident #7 stated, I dread going in there, my roommate wants everything her way for her comfort, not mine. There is so much confusion in that room. It's depressing me, my roommate often uses the TV so loud I can't rest and gets mad when I go in the room. She always wants her needs to be the priority. Resident #7 stated she reported her concerns to CNAs and nurses, but no one listened to her. During an observation on 1/27/26 at 1:30 p.m., staff member I and J brought resident #7 to her room to toilet her. As the staff entered resident #7's room, the roommate yelled, Now what?! The roommate became agitated with the staff and resident #7. The two staff members explained to the roommate they were only in the room to toilet resident #7. The roommate growled at the staff and returned to her bed. Review of resident #7's Care Plan, with a revision date of 12/27/25, reflected resident #7 required dependent assistance with toileting, and transfers required the use of a Hoyer lift. Resident #7 was hard of hearing, had expressive aphasia, and depression. 3. During an interview on 1/26/26 at 4:41 p.m., resident #21 stated she often was left wet with a pad added to her brief at night so the staff would not have to change her brief so often. Resident #21 stated she was currently on antibiotics for a urinary tract infection because CNAs were not changing her during the night. Resident #21 stated staff kept hitting her head on the wall when changing her. Resident #21 stated she required a two-person assist for turning during the brief changes, but when they could not locate help, the staff would try to turn her alone, causing her pain and hitting her head on the wall repeatedly. Resident #21 stated the night CNA would answer her call light and say she would come back, but neglected to return, leaving resident #21 wetting herself and her bed, on 1/25/26. Resident #21 stated the CNAs came in and yelled at her and said, Why did you wet yourself? Resident #21 stated the CNA then added a pad to her brief and stated, I don't want to have to change you every two hours. Resident #21 stated she reported the care concerns to the nurse and CNAs the morning of 1/26/26, about the CNA yelling at her, neglecting to toilet her, the brief changes, and then placing a pad in her brief. Review of resident #21's Care Plan, with a revision date of 12/30/25, reflected resident #21 required maximal assist with toileting hygiene and required the use of a sit-to-stand for transfers. Resident #21 required care in pairs (two staff members for care). Resident #21's care plan reflected resident #21 was on an antibiotic for a urinary tract infection. Review of resident #21's MDS, dated [DATE], reflected resident #21 was on an antibiotic for a urinary tract infection. Review of the facility matrix, dated 1/27/26, reflected resident #21 was on an antibiotic for a urinary tract infection. During an interview on 1/28/26 at 2:02 p.m., staff member M stated resident #21 frequently reported a lot of concerns including staff neglecting toilet her or not using two people to change her brief causing her pain, her hitting her head on the wall, staff putting pads in her brief to avoid changing her, dietary complaints, call light times, and many more. Staff member M stated she reported resident #21's concerns to the nurse on duty when she heard them. 4. During an interview on 1/28/26 at 2:02 p.m., staff member M stated she arrived on shift on 1/26/26, and when she went to resident #18's room, she found him diagonally in his bed with his feet dangling off the bed. Staff member M stated it was about 9:00 a.m. when she found him. Staff member M stated resident #18 was soaked with urine from his shoes to his shoulders, his bed was soaked, and urine was pooling in the bed. Staff member M stated that resident #18 was still dressed in the same clothing from the day before. Staff member M stated the staff tried to get him up at 8:30 a.m., but he refused, so they left him there soaked. Staff member M stated that resident #18 did not have a history of soaking his bed. Staff member M stated it appeared resident #18 was neglected, left unattended all night, and the next morning without care. Staff member M stated resident #18 did not resist getting up and cares provided when she attempted to get him cleaned up. Staff member M stated she reported the incident to staff member L. Review of resident #18's MDS, dated [DATE], reflected resident #18 had a BIMS (Brief Interview of Mental Status) was a three (Severe problems with thinking and memory). Resident #18 required maximal assistance for toileting, maximal assist with dressing, and maximal assistance with walking. Resident #18 was noted to have incontinence of bladder and bowel. During an interview on 1/28/26 at 9:04 a.m., staff member L stated she frequently would receive complaints about resident cares on the night shift being neglected, including, [Resident #21's] concerns with staff not transferring her correctly, hitting her head on the wall because they only use one staff instead of two, hurting [Resident #21's] back with the way the CNAs would roll her in the bed, soaked beds, using pads in briefs, food preferences not met, medications not given on time were a few of the more common concerns reported. Staff member L stated she would re-educate the CNA staff when able, but often the staff were travel agency staff. Staff member L stated she did not report the care concerns to management because she felt education was the best option. During an interview on 1/28/26 at 2:13 p.m., staff member N stated she frequently came on shift to find residents in soaked beds. Staff member N stated the soaked beds were usually on the [NAME] Hall because [NAME] Hall required a lot of checks and changes. Staff member N stated she would report the neglected resident care and soaked beds to the nurse on duty or write up a grievance. During an interview on 1/28/26 at 2:20 p.m., staff member O stated she would commonly find residents neglected, including no oral care done, poor peri care, and soaked beds when she would come on shift. Staff member O stated resident #21 would complain staff were not putting her peri cream on, and that she was not getting her brief changed at night. Staff member O stated resident #7 was soaked on the morning of 1/26/26, and resident #7 did not have proper peri-care, causing the folds around her pannus to become red and inflamed. Staff member O stated she would report to her nurse or write a grievance, but usually nothing was ever done about it because most of the staff were travel staff. During an interview on 1/28/26 at 9:57 a.m., with staff members A and B, staff member A stated NF4 was no longer employed by the company, and many records were missing, including grievances and investigations. Staff member A stated she was not able to locate any grievances or complaints reported to management for residents #s 7, 18, or 21 for the concerns outlined above. Staff members A and B both stated they were not aware of resident #18 being soaked with urine, resident #21's concerns with toileting, pads in her briefs, hitting her head on the wall, or a CNA yelling at her, and they were not aware of resident #7's fear of her roommate until the surveyor brought the concerns forward. During an interview on 1/28/26 at 2:37 p.m., NF4 stated that grievances were the responsibility of the administrator, and she had no part in the grievances. NF4 stated that the only thing she did was to go out and interview residents if she was told to do so by the administrator. NF4 stated she did not know if grievances or complaints came in for residents #7, 18, or 21. Review of the facility policy, Abuse Reporting and Response, updated October 202, reflected: [sic] -The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. 1. Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director. . 3. Reports of alleged violations by others such as staff, residents, visitors, other healthcare providers, or others do not need to be explicitly characterized as abuse, neglect, mistreatment, or exploitation in order to require reporting, investigation, and further necessary steps. [sic] Review of a facility policy titled, Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation, updated 3/2025, showed: -Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse ., -Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. Review of a facility policy titled, Abuse Policies and Procedures, dated 5/2025, showed: . Investigation: thorough investigation - Determine if the abuse, neglect, exploitation, and/or mistreatment has occurred and determine the extent and cause. Protection: Suspend and/or remove the alleged perpetrator from patient care area immediately. Protect residents from physical and psychosocial harm during and after an investigation.

Based on observation, interview, and record review, the facility failed to ensure proper ADL (Activities of Daily Living) cares were completed, specifically for 1 (#28) who was not receiving toenail care while her roommate #5 received toenail care biweekly; and for 3 (#s 11, 59, and 77) were not receiving showers from the facility. This deficient practice resulted in a resident feeling unclean and unkept. Findings include: 1. During an observation and interview on 1/26/26 at 4:07 p.m., resident #28 stated she only had her toenails clipped once in the time that she had been in the facility. Resident #28's feet were notably odorous from a distance once her socks and shoes were removed. She stated she had been at the facility for about three months. Resident #28's roommate (resident #5) stated she had her toenails clipped twice a week during her showers. During an interview on 1/28/26 at 1:47 p.m., staff member S stated resident #28 should have her toenails clipped biweekly or at least weekly by a nurse as resident #28 was a diabetic. Staff member S stated they usually had a reminder on the TAR reminding staff to complete this task, but there was no order present for resident #28. Staff member S stated this was the nurses' responsibility to complete and to call the physician for an order. Staff member S stated the wound care nurse, or the admitting nurse could have also put an order in so that it was not forgotten. Review of resident #28's EHR showed an admission date of 11/3/25. During an interview on 1/29/2026 at 2:05 p.m., staff member P stated the facility did not have an ADL policy. 2. During an interview on 1/28/2026 at 1:40 p.m., resident #11 and NF7 stated the facility was not giving the weekly baths that were promised to resident #11 and resident #59. NF7 and resident #11 stated the only showers they would receive were from hospice, when they came in once a week. Review of a facility document showing: Shower Days, not dated, showed showers were given to the Lilac hallway on Wednesdays and Saturdays. Both residents #11 and #59 were located in the Lilac hallway. Review of resident #11's EHR showed two documented bed baths in the past 30 days (on 12/31/25 and 1/27/26). Review of resident #59's EHR showed three documented bed baths in the past 30 days (1/7/26, 1/14/26, and 1/21/26). Review of resident #59's hospice Patient Communication Log showed showers were given on 1/7/26, 1/14/26 and 1/21/26. During an interview on 1/28/26 at 4:22 p.m., staff member T stated they were unaware of any complaints from residents regarding showers. Staff member T stated if a shower was not done that day, they would text the oncoming staff member to remind them to complete this task. Staff member T stated a shower sheet was completed after a shower and then this was given to a nurse so that this could be documented in the EHR. During an interview on 1/29/26 at 2:15 p.m., staff member A stated hospice came in once a week for resident #11. Review of a facility document, no title or date, showed: No specific policy on showers. Residents are asked preferences/choices and center attempts to meet them . 4. During an interview on 1/29/26 at 11:30 a.m., NF5 stated resident #77 was admitted to the facility on [DATE] for end-of-life care. NF5 stated she visited resident #77 on 12/9/25, six days after he was admitted to the facility. NF5 stated resident #77 voiced concerns regarding not having his teeth brushed or taking a shower since his arrival at the facility. NF5 stated resident #77's toothbrush was still sealed in the original package, indicating the toothbrush had not been used. NF5 stated she provided resident #77's oral care during her visit. NF5 stated a hospice aide was sent to the facility the following day to provide resident #77 a bed bath. During an interview on 1/29/26 at 2:10 p.m., staff member H stated if a resident was receiving hospice service, the hospice aide would be responsible for providing the resident with their scheduled shower or bath during their stay at the facility. Staff member H stated the facility could also provide the service, but the resident would need to ask. A review of resident #77's comprehensive care plan dated 12/3/25, showed: Problem: I have an ADL self-care performance deficit I have forgetfulness, weakness, adult failure to thrive . Interventions/Tasks: . BATHING/SHOWERING PREFERENCES: . FREQUENCY: 2 times per week . BATHING/SHOWERING: Dependent assist of staff with bathing. ORAL HYGIENE: Substantial/Maximal Assist . [sic] A review of resident #77's shower log showed the resident received a shower on 12/10/25, 12/17/25, and 12/24/25. On 1/28/26 a request was made for a facility shower policy. No documentation was received from the facility by the end of the survey.

Based on observations, interviews, and record review, the facility failed to report allegations of neglect and abuse to the State Survey Agency for 3 (#s 7, 18, and 21) of 34 sampled residents. This deficient practice resulted in resident #7 having fear of going to her room, resident #21 had fear of having her head hit the wall during care sessions, and for resident #21 voiced fear of having her head hit the wall during care (recurrent), and neglect of care related to care and services not being provided as needed for #s 7, 18, and 21. Refer to F600 for more information on failure to prevent abuse/neglect. Findings include:1. During an observation and interview on 1/26/26 at 4:20 p.m., resident #7 was crying while telling staff member J, who was pushing her in her wheelchair to her room, Please don't make me go in my room, I'm scared to go in there, please don't take me in there. Resident #7 stated, I dread going in there, my roommate wants everything her way . It's depressing to me . Staff leave me in there. Resident #7 stated she reported her concerns to the CNAs and nurses, but nothing was done about it. Due to the lack of response by the facility on her concerns, resident #7 continued to have ongoing fear and psychosocial harm. 2. During an interview on 1/26/26 at 4:41 p.m., resident #21 stated she reported the hitting of her head on the wall (she required a two-person assist), the CNA yelling at her, and placing a pad in her brief to the nurse and CNAs the morning of 1/26/26. Resident #21 stated she often was left wet with a pad added to her brief at night so the staff would not have to change her brief so often. Resident #21 stated the night of 1/25/26, the CNA answered her call light and said she would come back but neglected to return until resident #21 had wet herself and her bed. Resident #21 stated the CNA came in and yelled at her, Why did you wet yourself? Resident #21 stated the CNA then added a pad to her brief and stated, I don't want to have to change you every two hours. Review of resident #21's MDS, dated [DATE], reflected resident #21 was on an antibiotic for a urinary tract infection. During an interview on 1/28/26 at 2:02 p.m., staff member M stated resident #21 frequently reported a lot of neglect concerns, including staff not changing her or not using two people to change her brief, causing her pain, staff hitting her head on the wall during care, staff putting pads in her brief, dietary complaints, and call light times. Staff member M stated she reported resident #21's concerns to the nurse on duty when she heard of them. Staff member M did not report the concerns of abuse or neglect to the Administrator. It was found the care concerns voiced by resident #21 were not reported or addressed by the facility as abuse or neglect of care. 3. During an interview on 1/28/26 at 2:04 p.m., staff member M stated she arrived on shift on 1/26/26, and when she went to resident #18's room around 9:00 a.m., and she found him diagonally in his bed, and his feet were dangling off the bed. Staff member M stated resident #18 was urine-soaked from his shoes to his shoulders, his bed was urine-soaked, and urine was pooling in the bed. Staff member M stated resident #18 was still dressed in the same clothing from the day before. Staff member M stated that the staff tried to get him up at 8:30 a.m., that day, but he refused, so they left him there in that condition. Staff member M stated resident #18 did not have a history of soaking his bed with urine. Staff member M stated it appeared resident #18 was left unattended all night, and the next morning, without care. Staff member M stated she reported the neglect of care concerns to staff member L. The neglect was not reported to the Administrator. During an interview on 1/28/26 at 2:13 p.m., staff member N stated she frequently came on shift to find residents in urine-soaked beds. Staff member N stated she reported the soaked beds to the nurse on duty when this occurred. During an interview on 1/28/26 at 2:20 p.m., staff member O stated she would commonly find residents would not have oral care done, there was poor peri care, and or staff member O would find urine-soaked resident beds when she would come on shift. Staff member O stated resident #21 would complain staff were not putting her peri cream on, and that she was not getting her brief changed at night. Staff member O stated resident #7 was soaked on the morning of 1/26/26, and resident #7 did not have proper peri-care causing the folds around her pannus to become red and inflamed. Staff member O stated she reported her concerns to her nurse. During an interview on 1/28/26 at 9:57 a.m., with staff member A and B, staff member A and B both stated they were not aware of resident #18 being soaked with urine, resident #21's concerns with toileting, pads in her briefs, hitting her head on the walls, or a CNA yelling at her, and were not aware of resident #7's fear of her roommate until the surveyor brought the concerns forward. Staff member A stated these concerns would qualify as allegations to be reported to the State Survey Agency for neglect and/or abuse. During an interview on 1/28/26 at 2:13 p.m., staff member M stated facility staff were given abuse education very frequently, but staff member M still did not know what specific instances the facility was required to report to the State Survey Agency or what they were required to report to administration. Staff member M stated they felt more education would be helpful specifically showing the line of what needed to be reported with examples and what did not need to be reported. Staff member M stated the line for knowing what to report or not to report was not clearly defined in the facility. Review of Facility reported incidents, from 1/7/25 through 1/25/26, reflected no reports for residents #s 7, 18, and 21's allegations and or the neglect of care concerns noted above. Review of the facility policy, Abuse Reporting and Response, updated October 202, reflected: [sic] -The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. 1. Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director. . 3. Reports of alleged violations by others such as staff, residents, visitors, other healthcare providers, or others do not need to be explicitly characterized as abuse, neglect, mistreatment, or exploitation in order to require reporting, investigation, and further necessary steps. [sic]

Based on interview and record review, the facility failed to exercise reasonable care for the protection of a resident's property from loss or theft for 1 (#6) of 34 sampled residents. This deficient practice placed resident #6 at risk for continued loss of personal property and lack of resolution for reported concerns. Findings include: During an interview on 1/29/26 at 9:03 a.m., resident #6 stated that approximately six months earlier two shirts were taken from her clothes closet and five additional shirts were never returned from the facility's laundry service. Resident #6 stated she reported the missing items to facility staff. Resident #6 stated housekeeping searched for the items for a short period but did not locate any of the missing clothing. Resident #6 stated no facility staff have followed up with her since the report of missing items. During an interview on 1/29/26 at 11:00 a.m., staff member A stated if a resident's personal belongings were lost or stolen at the facility, she would expect the facility to replace the items. Staff member A stated resident #6's lost or stolen items should have been reported by staff using a grievance form and submitted to management. Staff member A stated she did not know why the required forms were not completed by facility staff. Review of the facility grievance forms dated 6/5/25 through 1/25/26, failed to show a grievance form was completed for resident #6's lost or stolen property. Review of the facility document titled, NOTICE OF THEFT AND LOSS CONTROL POLICY, dated October 2017, showed: The center makes reasonable efforts to safeguard resident property and valuables in accordance with state and federal guidelines. Suspected theft or loss of resident property is timely and thoroughly investigated. The following policies apply to the theft and/or loss of resident property: . 1. Center staff are oriented to theft and loss investigative procedures upon hire and during regular inservice training. 2. Any staff member who receives a report of a missing item from a resident, resident's family, or person acting on behalf of the resident completes a Grievance Form and forwards it to the Social Services Department. 3. Upon receipt of the Grievance Form, the Social Services Department initiates an investigation and/or searches for the missing item. 4. Results of the investigation or search are documented on the Grievance Form and communicated to the individual who sustained the loss or his/her responsible party. [sic]

Based on interview and record review, the facility failed to fully investigate an abuse allegation for 2 (#s 11 and 62) of 34 sampled residents. This deficient practice resulted in psychosocial distress for resident #11 who was feeling scared due to the physical and verbal abuse (with fear of a repeat event occurring with a fellow resident). Findings include: During an observation and interview on 1/27/26 at 9:46 a.m., resident #11 stated on the night of 12/28/25, resident #62 came into her room, held her arms down, tried to get into her bed with her, and yelled, You know who I am, repeatedly at resident #11. Resident #11 stated, (She) screamed for help for quite some time, and no one came. Resident #11 showed her arms were held above her head, crossed, and held down. She stated she tried to hit resident #62 but that did not work. She stated she tried to hit him with her water cup next. She stated she would have hit him with her cane if she could have but it was across the room. She stated resident #62 had been in her room two other times. Both times, resident #62 had urinated in her toilet, and then left. Resident #11 stated she was scared and upset that this happened and was fearful resident #62 would return to her room at night again and harm her. Resident #11 stated she was concerned he could potentially sexually assault her or make advances toward her. She stated she thought the facility had moved his room away from hers and was not award resident #62 was still in the room next door.Review of a facility policy titled, Abuse Investigation, updated 10/22, showed: . 2. The Center identifies and interviews involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.During an interview on 1/27/2026 at 3:52 p.m., staff members A and B stated they did not have staff or resident interviews for the Facility Reported Incident that occurred on 12/28/25 with residents #s 11 and 62.During an interview on 1/28/2026 at 8:59 a.m., staff members A and B stated they now were able to find some staff statements from the Facility Reported Incident with resident #s 11 and 62 (shown below). Staff member A stated they did not consider the incident with resident #s 11 and 62 to be abuse and this was why their rooms were still located next to each other (until it was brought to the facility's attention by the survey team). Staff member A stated the facility should have taken further action to investigate further which included staff and resident interviews, along with removing resident #11 from the potential abuse perpetrator during the investigation process.Review of a facility document, not titled and dated 12/28/25, showed: I [staff member V] CNA went to lunch at 2:20 a.m. I returned at 2:47 a.m. I went to my hall and found [resident #62] in . (another resident's room) . [Resident #11]'s light was on, and she was yelling for help. She was very upset and said that a man was trying to get into bed with her, she also said that she hit him and yelled for help and threw water at him I noticed water all over the room. [sic]

Based on interview and record review, the facility failed to permit each resident to remain in the facility and not transfer or discharge the resident from the facility without written notice and a safe discharge plan for 1 (#72) of 3 discharged residents subsampled. Findings include:Review of resident #72's Clinical Census EHR, no date, reflected resident #72 admitted to the facility on [DATE] and discharged from the facility on 12/5/25.Review of resident #72's EHR Progress Notes, dated 11/29/25 - 12/10/25, reflected:-Resident #72 left the facility at 12:30 p.m. on 12/5/25. Resident #72 did not return by midnight. Resident #72 had left the facility with a friend.-Resident #72 called the facility at 1:40 a.m. and left a voicemail stating her car broke down on the way back from visiting her mother and would call again in the morning.-Resident #72's sister called the facility on 12/6/25 and stated resident #72 had car trouble and would not make it back to the facility today but would hopefully make it back by tomorrow.-On 12/7/25 at 10:00 a.m., resident #72's female friend called the facility and stated she was picking up resident #72 to bring her back to the facility and NF4 told resident #72's friend the resident could not return to the facility and would need to be taken to the emergency room for evaluation. NF4 stated resident #72 had been gone for three midnights and had been discharged from the facility. NF4 stated resident #72 would need to be seen in the emergency room and screened to determine whether the facility and provider would be willing to readmit her due to her noncompliance and elopement. -The care manager of [Hospital Name] reached out to the facility for information on resident #72's previous stay in long-term care, cognition and ADL needs.During an interview on 1/28/26 at 7:55 a.m., staff member A stated she was not aware NF4 told resident #72 and her family that she could not return and needed to go to the emergency room. Staff member A stated resident #72 had not been gone for three midnights and should have been allowed to return. Staff member A stated she could not find any documentation the case manager at [Hospital Name] received a response to the communication request for information on resident #72. Staff member A stated the discharge was not planned and no discharge documents were available. Staff member A stated resident #72 did sign out on the resident sign out log on the day she left and the facility was aware she had left to go downtown but became concerned when she did not return the evening of 12/5/25.Review of the facility admission Packet page 9, no date, reflected:-6.2 Termination by the Center. The Center may terminate this agreement and the Resident's stay by providing written notice to the Resident Group or a family member. The Center shall initiate the Resident's transfer or discharge through the Resident, the Resident Group, the Resident's Attending Physician, appropriate agencies, or other known responsible party .

Based on interview and record review, the facility failed to ensure 1 (#3) of 14 sampled residents was free from a significant medication error requiring hospitalization . Resident #3 was given 22.5 mls of Methadone instead of the ordered 10 mls. Findings include: Review of a facility reported incident, dated 3/8/23, showed a medication error resulted in resident #3 being transferred to the emergency room from the wound clinic. Investigation for the incident showed the resident was to receive 10 mls of Methadone, but received 22.5 mls. Review of the incident showed the dosage of Methadone had been changed from 22.5 mls to 10 mls on 3/6/23 upon return from a hospital stay. Review of resident #3's Nursing Progress Notes, dated 3/6/23 to 3/7/23, showed the resident asked for his morning dose of Methadone. Staff member G documented the resident received the medication per the instructions, 22.5 mls daily. Staff member G documented when she went to record the medication administration she realized the order had changed to 10 mls with lunch. Resident #3 left for an appointment at the wound clinic after administration of the medication. Review of resident #3's Narcotic Record showed the resident was administered 22.5 mls of Methadone on 3/6/23. There was not a dose of Methadone documented on 3/7/23. Review of resident #3's Medication Administration Record, dated 3/1/23 through 3/31/23, showed the resident received a dose of 10 mls of Methadone on 3/7/23 with instructions to note the change in dosage. Review of resident #3's Progress Notes, dated 3/7/23 at 10:21 a.m., showed the facility called the wound clinic and was told the resident was sent to the emergency room by the provider. A Progress Note, dated 3/7/23 at 4:08 p.m., showed the resident was admitted to the hospital. Review of resident #3's After Visit Summary, dated 3/13/23, showed the resident was admitted to the hospital for Methadone overdose. During an interview on 10/12/23 at 11:42 a.m., staff member B stated any new medications and/or changes are on the report ran in the mornings. Staff member B stated there is a check process that should be used by the nurses administering medication. The process is to look at the Medication Administration Record when taking the medication out, and check again before administering. Staff member B stated the nurses were to run a report daily and if they have been off for a few days, they should run a report from the last time they worked to the day of their current shift. Staff member B stated when a new medication or a change in a medication dosage happened, the resident went on alert charting and the nurses were to document in alert charting any adverse effects. The facility provided documentation to show immediately following the event, the staff responsible, and others, were educated on proper procedures to prevent medication errors. The facility extablished a monitoring system for quality assurance reviews, and the quality assurance and performance improvement committee reviewed the concerns related to the medication error and the ongoing audits in the monthly meeting. Notes were provided for the review.

Based on observation, interview, and record review, the facility failed to provide routine and emergent necessary pharmaceutical services to residents; failed to have a functioning system in place to accurately manage the ordering, administering, monitoring, and reconciliation of medications, including controlled substances, for 6 (#s 1, 2, 3, 4, 5, 6) of 8 sampled residents. This failure resulted in harm and potential for more harm to residents receiving medications from the facility. An Immediate Jeopardy was called on [DATE] at 4:59 p.m., in the presence of the facility administrator, administrator in training, the RN, DDCO, and the facility AGACNP-BC, MSN, Chief Nursing Officer. The IJ pertained to F755 - Pharmacy services. The IJ was cited at the severity and scope of L, and upon removal of the immediacy, lowered to an H. Findings include: 1. [MEDICATION(S)] Patches During an interview on [DATE] at 9:30 a.m., NF2 stated there had been many issues with [MEDICATION(S)] patches for several residents at the facility. Some instances of the [MEDICATION(S)] patches and other medications missing, were due to possible drug diversion. NF2 stated a provider, the medical director, ombudsman, and facility staff, had a meeting at the end of [DATE], but NF2 did not know if anything was implemented to fix the problem with the missing medications. a. During an interview on [DATE] at 4:20 p.m., NF1 stated resident #1 had multiple discrepancies with his [MEDICATION(S)] patch specifically in [DATE]. There were several instances of provider notifications where the [MEDICATION(S)] patch was missing and could not be found, and requests to get a new patch to replace the missing one. One time, a [MEDICATION(S)] patch was found on the resident with a date over 13 days old. There were no new orders or patches provided during that time, and no new documentation on new patches. The resident went that time without proper pain management or assessment. Upon a provider skin inspection, on [DATE], three patches equaling a double dose of [MEDICATION(S)] were found at one time on the resident. Two, 12 mcg patches on the back of one shoulder and one 25 mcg patch on the front of the same shoulder. The dates on the three patches were not matching the dates in the resident's MAR for the administration of them. The [MEDICATION(S)] patch order changes were not accurate. Resident #1 went to the pain clinic and had his 12 mcg patch increased to 25 mcg on [DATE]. There were mix ups with the order fulfillment and obtaining the correct dosed patches. At one point, another order for 50 mcg was entered incorrectly into the EHR without a provider order and documented as given. There was a later request for a [MEDICATION(S)] order to take a 25 mcg patch from the quebex machine, but the records showed a 50 mcg patch was pulled instead. During an observation and interview on [DATE] at 1:10 p.m., resident #1 was lying in bed without a shirt on. The left side of his chest, near the shoulder, had a clear patch with smeared initials on it. Resident #1 stated, about the patch, the facility staff changed the [MEDICATION(S)] pain patch two days ago. He stated as of recently, the staff had been more diligent with placing and checking the patch placement because they had some issues before, but he could not recall any specific issue or dates. Resident #1 stated he needed the pain patch for back pain around his tailbone due to a prior surgery. It was painful for the resident to sit up or transfer so the [MEDICATION(S)] patch helped take the edge off of the pain. During an interview on [DATE] at 10:19 a.m., NF4 stated resident #1 had several [MEDICATION(S)] patches ordered and changed, especially through [DATE]. Starting on [DATE], an increase from 12 mcg to 25 mcg [MEDICATION(S)] was ordered, but the order did not have the required information for a valid narcotic order. The pharmacy faxed the facility on [DATE] and [DATE], regarding the order not being valid, and needing clarification to dispense the medication. They also called a provider for the order clarification. An order was sent for the original 12 mcg [MEDICATION(S)] and then promptly canceled. On [DATE], a facility nurse called the pharmacy for a stat quebex machine order for a 25 mcg [MEDICATION(S)] patch order and was given a quebex code for controlled substances to get a patch from the quebex machine. A new order was written for 25 mcg [MEDICATION(S)] patches and this was filled on [DATE] and [DATE]. The pharmacy sent and delivered five pain patches, which included a 15 day supply, each time. During an interview on [DATE] at 9:37 a.m., staff member F stated she had mistakenly hit the wrong button entering in the 50 mcg [MEDICATION(S)] patch, when entering an order for 25 mcg patch, in [DATE]. Staff member F stated a 50 mcg [MEDICATION(S)] patch was never administered to resident #1, and the error was corrected the next day. Review of resident #1's [DATE] MAR, for the 72 hour [MEDICATION(S)] patch documentation, showed: - [MEDICATION(S)] Patch 12 mcg, ordered [DATE] to [DATE], removed and re-applied on ,d+[DATE], and removed and re-applied on ,d+[DATE]. - [MEDICATION(S)] Patch 25 mcg, ordered [DATE] to [DATE]. Applied on ,d+[DATE], removed and re-applied on ,d+[DATE], removed and re-applied on ,d+[DATE], and applied on ,d+[DATE]. - There was no order or documentation for any [MEDICATION(S)] patch for resident #1 from ,d+[DATE] to [DATE] on the MAR. - [MEDICATION(S)] Patch 50 mcg order was entered on ,d+[DATE] to ,d+[DATE]. The patch was applied on ,d+[DATE] but not removed until [DATE], per the EHR documentation. - [MEDICATION(S)] Patch 25 mcg ordered on ,d+[DATE] through [DATE]. The patch was applied on ,d+[DATE] and removed and re-applied on ,d+[DATE]. Review of the facility Incident Audit Report, dated [DATE], showed on [DATE] at nurse shift change, the nurses could not find resident #1's [MEDICATION(S)] patch and reported it. The nurses received an emergent order and quebex machine code to administer a new [MEDICATION(S)] patch that day for the resident. Review of resident #1's provider visit notes for [DATE] showed: - [DATE] - The provider called the pharmacy which had no verified current order for [MEDICATION(S)] patches for the resident. A facility nurse had submitted a refill request as the order was changed ,d+[DATE] to 25 mcg, and there were no more patches on ,d+[DATE], and the provider could not tell if the facility had used 25 mcg patches as ordered or doubled up on the left over of 12 mcg patches delivered on [DATE]. One additional 25 mcg patch was ordered to get resident #1 through the weekend. - [DATE] - There were two calls from the facility dated ,d+[DATE] regarding missing [MEDICATION(S)] patch for resident #1. It was confirmed with the facility DON that nursing staff were placing two 12 mcg patches, equaling 24 mcg, instead of the ordered 25 mcg, as of [DATE]. The provider/physician also observed patient with the DON and found two 12 mcg patches dated ,d+[DATE], and a 25 mcg patch dated ,d+[DATE], on the resident. The provider ordered the placement of one 25 mcg patch to be placed on resident #1 on [DATE]. - [DATE] - The facility only had one 25 mcg patch left. The current patch, per the facility nurse, was dated ,d+[DATE], and due to change on ,d+[DATE], but it wasn't. Resident #1 went eight days without a [MEDICATION(S)] patch, used prn pain medications, and did not have a pain assessment done prior to this event. - [DATE] - Upon exam, resident #1's [MEDICATION(S)] patch was dated ,d+[DATE], 13 days prior. No other patches were found in the search, and a new patch was ordered to be replaced on resident #1. - [DATE] - Review of [MEDICATION(S)] patch administration showed a 50 mcg patch on ,d+[DATE] at 6:07 p.m. and removed at 6:08 p.m. Then a 50 mcg patch was applied on [DATE]. Upon evaluation of the resident, a [MEDICATION(S)] patch dated ,d+[DATE] was observed, but the narcotics book showed the date of [DATE]. b. Review of resident #4's [DATE] MAR, for the 25 mcg [MEDICATION(S)] patch, to be administered every 72 hours, showed: - For the 25 mcg [MEDICATION(S)] patch there was no documentation of the removal or application of the patch on the scheduled days of ,d+[DATE] and ,d+[DATE]. - There was no EHR documentation of a [MEDICATION(S)] patch placement for the night shift of ,d+[DATE] and ,d+[DATE], or the morning shift of [DATE]. Review of resident #4's [DATE] MAR showed there was no documentation of a [MEDICATION(S)] patch placement on the morning shift of [DATE] or ,d+[DATE], or the night shift of ,d+[DATE], ,d+[DATE], ,d+[DATE], [DATE]. Review of resident #4's progress note, dated [DATE], showed, Resident notes with increased wandering, crying, and agitation. Wandering around facility. Resident checked and [MEDICATION(S)] patch not in place. Hospice notified. Awaiting orders and notice from CNA concerning [MEDICATION(S)] patch placement during visit. Review of a facility email on [DATE], to resident #4's hospice company, showed per a [DATE] meeting, the shower aide was no longer allowed at the facility and was under investigation for resident #4's [MEDICATION(S)] patches, which were found to be missing after she provided showers to resident #4. [MEDICATION(S)] patches would be removed by nursing staff, not CNA staff. c. Review of resident #5's [DATE] MAR showed: - [MEDICATION(S)] 75 mcg patch no removal or application of one on the scheduled days of ,d+[DATE] and [DATE]. - Monitor [MEDICATION(S)] Patch placement every shift, no documentation for night shift on ,d+[DATE] and ,d+[DATE], and day shift [DATE]. - There was no documentation for pain on the night shift for ,d+[DATE], ,d+[DATE], ,d+[DATE], and [DATE]. Review of resident #5's [DATE] MAR showed: - [MEDICATION(S)] Patch 75 mcg every 72 hours had no documentation for removal on ,d+[DATE], and [DATE]. - No documentation for checking the [MEDICATION(S)] patch placement on both shifts for ,d+[DATE], ,d+[DATE], and night shift of [DATE]. - There was no pain documentation on the morning shift ,d+[DATE] and [DATE], and night shift on ,d+[DATE], ,d+[DATE], and [DATE]. Review of resident #5's [DATE] MAR for the [MEDICATION(S)] patch 75 mcg every 72 hours showed: - No documentation for the [MEDICATION(S)] patch placement check and pain on the night shift [DATE]. - No documentation for staff witnessing of [MEDICATION(S)] patch destruction on ,d+[DATE] and [DATE]. d. Review of resident #6's [DATE] MAR, for the [MEDICATION(S)] patch 12 mcg every 72 hours, showed: - No [MEDICATION(S)] patch was placed from ,d+[DATE]-[DATE]. - Staff were monitoring the [MEDICATION(S)] patch placement but it was inconsistent with either a +/- alternately or an actual location. - Every shift pain monitoring for the month had checkmarks, but no pain rating or location for the entire month was documented. 2. New Admission Medications During an interview on [DATE] at 4:57 p.m., NF1 stated, resident #2 was admitted to the facility on [DATE], in the afternoon, and when a provider came for a visit on the morning of [DATE], the resident had not been given any of his medications. This included the new order of [MEDICATION(S)] since #2's admission the day before. The resident was sent back to the emergency room due to no lower leg pulses being felt and they were cold to the touch. The resident did not return to the facility. During an interview on [DATE] at 9:35 a.m., NF2 stated, resident #2 had been admitted to the facility and went back to the hospital the next day. The resident did not receive medications at the facility, as ordered. The facility had been having issues with medication ordering and receiving from the pharmacy. During an interview on [DATE] at 11:03 a.m., NF4 stated resident #2's orders were clarified at 4:15 p.m., on [DATE], with the facility and referring hospital. The resident had orders for several medications. Medications not in the facility quebex machine or stock were sent from a satellite pharmacy. The [MEDICATION(S)] was not sent, as the facility showed their quebex machine had several options to have the right dose to utilize immediately for resident #4. During an interview on [DATE] at 4:15 p.m., staff members A, C, and D stated resident #2 was mistakenly accepted and admitted , but he was input into the EHR system at the time of admission and any medications ordered would have been from the quebex, if on hand, or local satellite pharmacy to be given as ordered. During an interview on [DATE] at 12:20 p.m., staff member A stated the facility mistakenly accepted resident #2, instead of another resident, and could not stop #2's admission. The facility had contacted the facility provider and was told to keep him overnight, and the provider would be in to evaluate the resident in the morning. Review of resident #2's February 2022 MAR showed resident #2 was not given any medications for the duration of his stay from [DATE] to [DATE]. All medications listed showed as a blank area (no documentation), an X for not being ordered yet, or OO code meaning on order from the pharmacy. None of the medications were documented as given from admission to discharge to the hospital including: [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)] [MEDICATION(S)], [MEDICATION(S)], Tamsulosin, [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], Aspirin and Tylenol. There were also orthostatic vital signs that were not entered into the MAR. Review of resident #2's physician visit notes, dated [DATE], showed, No documentation in facility MAR to review when [MEDICATION(S)] or acetaminophen was last given as no medications are listed in MAR and patient is not able to tell me. Orders to transfer patient by AMR to emergency room for cool BLE with [CONDITION(S)] 3+, nonpalpable dorsalis pedis or posterior tibial pulses . Started amidarone 200 mg daily and [MEDICATION(S)]. Continued [MEDICATION(S)] 3.125 twice daily. Patient tells me he is concerned because he does not know what he got for medications last night causing him to have a difficult time sleeping. Patient reports nursing had a ziplock bag containing prescription bottles with medications he was given at discharge from the hospital and nursing handed this bag to patient and told him to take what he usually takes at night . The only medications in the med cart were the medications in the ziplock bag that the patient was given at discharge from the hospital. [Facility management] and nurse currently caring for patient are not able to clarify if patient had scheduled [MEDICATION(S)] yesterday or what medications patient has taken since arriving to SNF. 3. [MEDICATION(S)] During an interview on [DATE] at 4:45 p.m., NF1 stated resident #3 had been on [MEDICATION(S)] long term. NF1 had been notified by a facility nurse on [DATE] that resident #3 had missed her [MEDICATION(S)] doses since [DATE] and had elevated blood pressures. NF1 stated the last blood pressure reported to the provider at the time was ,d+[DATE]. During an interview on [DATE] at 9:45 a.m., NF2 stated resident #3 had not been given her [MEDICATION(S)] for several days after being on it long term, and she had symptoms of high blood pressure and abdominal pain, from not having the medication. The resident had gone to the hospital after. During an interview on [DATE] at 10:50 a.m., NF4 stated during [DATE] resident #3 only had PRN orders for [MEDICATION(S)], 20 pills in 14 days. The pharmacy delivered 18 pills and held two in case of emergency of delivery delays. All 20 were used. On [DATE] a facility nurse sent a refill request through the EHR. The pharmacy faxed the facility back that the order was not valid and had no refills available. On [DATE] the facility requested a quebex code for one dose to be given. Review of resident #3's blood pressures on [DATE] showed elevated blood pressure of ,d+[DATE] at 7:28 a.m., and on [DATE] at 7:07 a.m. it was ,d+[DATE], and at 3:54 p.m. it was at ,d+[DATE]. Review of resident #3's [DATE] MAR showed: - [MEDICATION(S)] 0.5 mg, give 0.25 mg twice a day [DATE] to [DATE]. The order showed the medication was not given for two doses on ,d+[DATE] and ,d+[DATE], morning doses on ,d+[DATE] and ,d+[DATE], and the evening dose on [DATE]. - [MEDICATION(S)] 0.5 mg, give 0.25 mg twice a day [DATE] - [DATE]. The order showed the medication was not given on the ,d+[DATE] evening dose, ,d+[DATE] for both doses, and ,d+[DATE] for the morning dose, before the resident's hospitalization which occurred in the evening. - [MEDICATION(S)] 0.5 mg, give 0.25 mg as needed order was not utilized on the same dates as the scheduled doses on ,d+[DATE], ,d+[DATE], ,d+[DATE], /,d+[DATE], ,d+[DATE], and [DATE]. Review of resident #3's progress notes showed: - ,d+[DATE] at 3:46 p.m., a provider notification of a blood pressure of ,d+[DATE], and the facility inability to get [MEDICATION(S)]. - ,d+[DATE] at 6:39 p.m., resident #3 stated, My daughter said if I go to the hospital I will get the meds I need. Resident #3 was sent to the hospital. A review of a facility and pharmacy communication showed: -[DATE] facility staff requested the refill of [MEDICATION(S)], as needed order, and the pharmacy replied the same day that the order was invalid as it had no refills, and the order was expired and could not be filled without a new provider order.

Based on observation, interview, and record review, the facility failed to ensure residents admitted with pressure ulcers received the necessary care and services, consistent with professional standards of practice, to promote healing and prevent infections of pressure ulcers, for 2 (#s 10 and 197) of 3 sampled residents. These deficient practices resulted in the delay in identification, assessment, and initiation of treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: A list of new admissions with wounds was reviewed. The residents were sampled from this list. 1. Resident #197 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #197's Discharge Summary from acute care, dated 8/13/21, showed the resident had unstageable bilateral ischial and sacral pressure ulcers and a deep tissue injury to his lower right shin. The wounds on resident #197's bilateral lower legs were described as venous stasis ulcers and generalized breakdown. Review of resident #197's Admission Nursing Evaluation, dated 8/25/21, showed the presence of pressure wounds on both buttocks, both heels, and the back of both lower legs. The wound on the top of the left foot was identified as a deep tissue injury. None of the wounds identified were measured or had staging completed. The Admission Nursing Evaluation, dated 8/25/21, was not completed until 12 days after admission and failed to accurately identify all wounds present on admission, and failed to assess all wounds, including the type of wound, stage, if a pressure ulcer, measurements, and the appearance of each wound. Comparison between the physician's description of resident #197's wounds on discharge from acute care and the initial nursing assessment at the facility showed discrepancies in location and type of wound. During an observation on 12/8/21 at 9:59 a.m., staff member D performed wound care on resident #197's left heel pressure ulcer. The wound care was performed using proper infection control techniques. Resident #197 reported his pain at 3/10 on the pain scale. The wound had a dark scab, with no drainage. The resident's left heel was wrapped and allowed to float with the resident's left calf resting on a pillow. Review of resident #197's ongoing wound assessments showed the following: -left heel pressure ulcer, suspected deep tissue injury measured 2.5 X 3 X 1 on 8/25/21 and increased in size to 5 X 6 on 12/8/21, with 100% eschar for both assessments, -right heel pressure ulcer, no ongoing assessment found, right below the knee amputation performed on 9/11/21, -right buttock pressure ulcer, Stage II and measured 4 X 1 X 01 on 9/2/21 and present on 11/14/21, no measurements or stage documented, -left buttock pressure ulcer, no ongoing assessment found, and -sacral pressure ulcer, Stage II and measured 12 X 8 X 0.1 on 9/22/21. Unable to determine changes in size or healing for right and left buttock pressure ulcers, right heel pressure ulcer, and sacral pressure ulcer due to lack of assessment data over time. Please Note: The wound measurements on the Admission Nursing Evaluation and the Weekly Wound Evlauation did not specify the unit of measure, cm or inches. Review of resident #197's Physician Orders for wound care for bilateral buttocks and sacrum: -8/13/21 - wound care orders for bilateral buttocks and sacrum, no frequency, -8/13/21 - 8/16/21, no orders for wound care found, -8/17/21 - 9/10/21, wound care right and left buttocks, no orders for wound care were found for the sacrum, -9/10/21 - 9/17/21, hospitalized , -9/18/21 - 10/12/21, no orders for wound care found, and, -10/13/21 - 11/24/21, wound care for bilateral buttocks and sacrum. Review of resident #197's MAR, TAR, and Wound TAR, dated 8/2021 through 11/2021, showed the following completion of wound care on his buttocks and sacrum: -August 2021, 15 opportunities, zero (0) completed, -September 2021, 17 opportunities, 17 completed, -October 2021, 13 opportunities, one (1) completed, and -November 2021, 24 opportunities, six (6) completed. Review of resident #197's Physician Orders for wound care for bilateral heels. No wound care orders for right heel pressure ulcer found. -8/13/21 - 9/1/21, no orders for wound care found, -9/2/21 - 9/10/21, wound care orders for left heel, -9/10/21 - 9/17/21, hospitalized , and -9/30/21 - present, wound care orders for left heel. Review of resident #197's MAR, TAR, and Wound TAR, dated 8/2021 through 11/2021, showed the following completion of wound care on his left heel. -August 2021, no wound care orders, -September 2021, 9 opportunities, eight (8) completed, -October 2021, 26 opportunities, seven (7) completed, and -November 2021, 31 opportunities, 11 completed. Refer to F684 Quality of Care, for details related to the venous stasis ulcers. 2. Resident #10 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident was admitted from a long term care hospital. Resident #10 was hospitalized on [DATE] and returned on 7/12/21. During an interview on 12/8/21 at 3:57 p.m., staff member D stated she found the wound vac connected to resident #10 and not turned on. Staff member D was not able to remember when this occurred. Review of resident #10's Skin/Wound Note, dated 8/4/21, showed staff member D found the wound vac connected to a wound on the resident's right side. The vacuum machine was not connected to a power supply. During an interview and observation, on 12/9/21 at 8:50 a.m., resident #10 was lying on his back with the head of his bed up slightly, looking at a laptop computer. When asked, resident #10 stated he felt his dressing had not been changed as often as it was ordered. He denied any specific staff was responsible. Resident #10 stated he had the ulcers for years and could not say if the slow healing was due to inconsistent dressing changes or not. Resident #10 stated he knew they (facility staff) got busy and his dressing change was not a high priority. Resident #10 stated he could not remember if he had a wound vac dressing when he returned in July of 2021. Review of resident #10's Re-admission Nursing Evaluation, dated 7/12/21, showed a wound vac dressing on his buttocks and no other skin issues. No measurements were documented. No Admission Nursing Evaluation was found from the 6/30/21 admission until his readmission on 7/12/21. Review of resident #10's Weekly Wound Evaluations showed the following: -8/30/21, right hip, surgical site, 16 X 1, -9/17/21, sacrum, failed flap, 16 X 1 X 1, -9/21/21, right hip, surgical site, 12 X 1.8 X 0.1, and -12/1/21, sacrum, failed flap, 3 X 2 X 0.8. No documentation of the appearance of the failed flap was found between admission on 6/30/21 and 8/30/21. Weekly wound assessments available did not indicate a consistent site being assessed. Review of resident #10's Physician's Orders for failed sacral flap wound care showed the following: -6/30/21 - 7/11/21, wound vac at 125 mmHg to be changed three times per week, -7/12/21 - 8/2/21, no wound vac orders found, -8/2/21 - 8/31/21, wound vac at 125 mmHg, hold from 8/13/21 to 8/20/21, -8/16/21-8/23/21, cleanse and apply Therahoney twice a week for one week, -8/30/21 - 10/6/21, cleanse and apply Therahoney, -10/8/21 - 10/26/21, [MEDICATION(S)] dressing, and -10/27/21 - 12/6/21, collagen dressing. Review of resident #10's MAR and TAR, dated 7/2021 through 11/2021, for the failed sacral flap wound, showed: -July 2021, no wound vac dressing changes found, -August 2021, 10 opportunities, two (2) completed, -September 2021, 16 opportunities, 15 completed, -October 2021, 16 opportunities, 15 completed, and -November 2021, 13 opportunities, eight (8) completed. 3. During an interview on 12/07/21 at 9:12 a.m., staff member D stated, If something is not charted in the TAR or progress notes, it is not charted anywhere else and most likely did not get done .there is a severe lack of communication between staff, no one knew what was going on when I started here. I am trying to make it better. They [facility staff] were not charting on wound care, so now I am trying to once a week. During an interview on 12/9/21 at 8:29 a.m., staff member C stated the skin assessment should be completed within several hours of a resident's admission, and she knew this was not being done consistently. Staff member C stated the admitting nurse should have been identifying the wounds, and then an RN should have been completing the measurements and staging. Staff member C stated the weekly assessments which include measurements and staging had not been done consistently due to staffing shortages. Staff member C stated some of the dressing changes were missed because nursing had not consistently looked at the TAR. A review of the facility's policy titled, Skin Integrity, dated 5/2019, showed the following: -For skin impairment identified with admission . the LN completes the following: a. Document skin impairment that includes measurements of size, color . on the Weekly Wound Evaluation. b. document on the Treatment Administration Record (TAR) after order is implemented. 9. Wounds are evaluated weekly by Center clinicians. are evaluated, measured, and findings documented in the medical record.

Based on interview and record review, the facility failed to comprehensively assess accurately and identify and assess non-pressure wounds present on admission, and failed to implement wound care and regular ongoing monitoring necessary to promote healing, and prevent worsening of venous stasis ulcers, and other non-pressure wounds for 2 (#s 31 and 197) of 4 sampled residents. The deficient practice had the potential to negatively affect wound healing. Resident #197's eventually required an amputation of his right lower leg. Findings include: A list of new admissions, and a list of all wound care orders since 7/1/21, showed resident #31 and resident #197 had venous or other non-pressure related wounds present on admission. 1. Resident #197 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #197's Admission MDS, with an ARD of 8/19/21, showed he had three Stage II pressure ulcers and two unstageable suspected deep tissue injuries. Review of resident #197's Discharge Summary from acute care, dated 8/13/21, showed the resident had venous stasis ulcers and generalized breakdown to both lower legs, and a deep tissue injury to his right lower shin. Review of resident #197's Admission Nursing Evaluation, dated 8/25/21, six days after the Admission MDS was completed, showed seven pressure injuries. None of the wounds were categorized as a deep tissue injury or a venous stasis ulcer. Comparison between the physician's description of resident #197's wounds on discharge from acute care, the Admission MDS, and the initial nursing assessment at the facility, showed discrepancies in location and type of wounds. None of the three documents showed measurements or general appearance for any of the wounds. During an interview on 12/8/21 at 1:12 p.m., staff member E stated she was responsible for completing the Admission MDS for resident #197. Staff member E stated she used hospital discharge records and nursing assessment documentation to complete the Skin Conditions section of the MDS. Staff member E stated if she was not able to find necessary documentation related to type of wound and staging, she asked a floor nurse to provide the needed information. When asked, staff member E was not able to find the wound information, type and staging, in the medical record. Staff member E stated if she got the information from a nurse, she usually wrote it down on her notes. Staff member E was not able to find any notes indicating who she got the information from with regard to the wounds which were present on admission. Review of resident #197's Physician Orders, dated 8/13/21 through 9/10/21 showed the following: -8/13/21 - 8/16/21, no orders for wound care of any kind, -8/17/21 - 8/27/21, orders for wound care on bilateral lower extremity venous stasis ulcers and generalized skin breakdown, and on the deep tissue injury on resident #197's anterior lower right shin, -8/27/21 - 9/2/21, order for wound care to dorsal right foot venous stasis ulcer and generalized skin breakdown on his bilateral lower extremities, and -9/2/21 - 9/14/21, order for wound care to dorsal right foot venous stasis ulcer. Review of resident #197's MAR, TAR, and Wound TAR, dated 8/2021 through 9/2021, showed the following completion of wound care on the resident's bilateral lower extremity wounds: -August 2021, 13 opportunities, one (1) completed, and -September 2021, 10 opportunities, 10 completed. No wound care was documented for resident #197 between 8/13/21 and 8/31/21. Review of resident #197's ongoing wound assessments for the venous stasis ulcers, generalized breakdown on both of his lower extremities, and the deep tissue injury to his lower right shin showed the following: Please Note: The wound measurements on the Weekly Wound Evaluation did not specify the unit of measure, cm or inches. - 8/13/21 - 8/25/21, no assessments of wounds were found, - 8/25/21, right dorsal foot, large open wound, 6.5 inches X 4.5 inches, with dark brown eschar 60% and slough 40%, moderate amount of foul smelling serosanguinous drainage, - 9/2/21, right dorsal foot, full thickness wound with exposed bone, slough, covered with necrotic eschar, 16 X 5.2 X 0.6, arterial wound with heavy foul smelling purulent drainage; and, - no assessment of the venous ulcers and generalized breakdown on resident #197's lower extremities was found, except as noted above. Review of resident #197's provider progress note, dated 9/2/21, showed the right dorsal foot wound was noted to have gangrene and necrosis of the bone. The resident was refusing surgical intervention on 9/2/21. Review of resident #197's medical record showed he returned back to the facility on [DATE] after having a below the knee amputation on his right leg performed on 9/11/21. 2. Resident #31 was admitted from acute care on 10/15/21 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident #31's Admission MDS, with an ARD of 10/21/21, showed one venous or arterial ulcer present on admission. Review of resident #31's After Visit Summary from acute care, dated 10/14/21, showed the resident had a chronic wound on her right lower extremity. Review of resident #31's Admission Nursing Evaluation, dated 10/22/21, showed no wound dressings and no skin issues identified. Comparison of the Admission MDS, the After Visit Summary from acute care, and the initial nursing assessment did not show a consistent assessment of the wound on resident #31's right lower extremity Review of resident #31's provider progress note, dated 10/22/21, showed the dressing on the resident's right lower extremity was dated 10/14/21 and the provider requested the dressing be changed. Eight days had passed between the date on the wound dressing and the provider progress note. Review of resident #31's provider progress note, dated 10/26/21, showed the same dressing, dated 10/14/21, was still in place on the resident's right lower extremity. The provider asked the nurse to assess the wound before changing the dressing and ordered the dressing changes to be completed on Monday and Thursday each week. Review of resident #31's Skin/Wound progress note, dated 10/26/21, showed the first mention of the right lower extremity wound by nursing which included documentation of a dressing change. Review of resident #31's TAR, dated October 2021, showed a wound care order dated 10/28/21 and due on 10/28/21. The dressing change was not signed off as completed for 10/28/21. Review of resident #31's TAR, dated November 2021, showed wound care was not signed off as completed for five (5) of seven (7) opportunities. Review of resident #31's Skin/Wound progress note, dated 11/18/21, showed wound care being completed on the resident's right lower extremity wound. No other documentation of wound care was found in the nursing progress notes between 10/15/21 and 11/20/21. No Weekly Wound Evaluations were found in the medical record for resident #31. 3. During an interview on 12/07/21 at 9:12 a.m., staff member D stated, If something is not charted in the TAR or progress notes, it is not charted anywhere else and most likely did not get done .there is a severe lack of communication between staff, no one knew what was going on when I started here. I am trying to make it better. They [facility staff] were not charting on wound care, so now I am trying to once a week. During an interview on 12/9/21 at 8:29 a.m., staff member C stated the skin assessment should be completed within several hours of a resident's admission, and she knew this was not being done consistently. Staff member C stated the admitting nurse should have been identifying the wounds, and then an RN should have been completing the measurements and wound staging. Staff member C stated the weekly assessments which include measurements and staging had not been done consistently due to staffing shortages. Staff member C stated some of the dressing changes were missed because nursing had not consistently looked at the TAR. A request for staff education related to wound care provided in the past 12 months was requested. The only documents provided were dated 12/3/21 and discussed the steps taken when a new skin issue was identified. No education related to wound vac use or the difference between pressure ulcers and venous or arterial ulcers was found. A review of the facility's policy titled, Skin Integrity, dated 5/2019, showed the following: -For skin impairment identified with admission . the LN completes the following: a. Document skin impairment that includes measurements of size, color . on the Weekly Wound Evaluation. b. document on the Treatment Administration Record (TAR) after order is implemented. . 9. Wounds are evaluated weekly by Center clinicians. are evaluated, measured, and findings documented in the medical record.

Based on interview and record review, the facility failed to continue effective CPR¹ on a resident, when the resident was found unresponsive and designated as a full code status, until first emergency responders arrived and/or the resident was proclaimed deceased by a physician, for 1 (#1) of 6 sampled residents. Subsequently the resident passed away. IMMEDIATE JEOPARDY On [DATE] at 1:30 p.m., the facility Regional Director, Administrator, and Assistant Director of Nursing were notified that an Immediate Jeopardy existed in the area of F678 - Cardio-Pulmonary Resuscitation. Severity and Scope identified for the Immediate Jeopardy was identified to be at the level of J, and upon removal of immediacy lowered to a G. Findings include: Review of resident #1's POLST, dated [DATE], showed the following sections were selected by the resident, her legal guardian, and/or spouse: A. Perform Cardiopulmonary Resuscitation (CPR) Attempt Resuscitation if person has NO pulse and is not breathing. B. Medical Interventions: Provide Full Treatment, primary goal to prolong life by all medically effective means: in addition to treatments described below in 'Selective Treatment' and 'Comfort-focused Treatment', use intubation, advanced airway interventions, mechanical ventilation, and cardioversion, as indicated. Transfer to hospital, if indicated. Includes intensive care. C. Artificially Administered Nutrition, if feasible, always offer food and water by mouth. Provide Artificial nutrition by tube, long-term/permanent, if indicated. During an interview on [DATE] at 2:45 p.m., NF1 stated they had responded to a 911 call on [DATE] at 4:40 a.m., regarding CPR in progress at the facility. When they arrived, NF1 stated there were facility staff standing around resident #1, but no one was providing CPR. When NF1 asked why the facility staff stopped CPR on resident #1, one staff member shrugged and said, I don't know. A second facility staff member told NF1 that, They just couldn't handle it anymore. NF1 stated the EMT responders for the 911 call started CPR on the resident after they arrived at the facility, and did not stop providing CPR for resident #1 until an order was received from the physician to cancel CPR. During an interview on [DATE] at 1:35 p.m., staff member D stated resident #1 had returned from the ED on [DATE] around 3:45 a.m., and was brought to her room. Staff member D stated around 4:30 a.m., she was informed by an CNA that resident #1 was on the floor on top of the fall mat by her bed, and was unresponsive. Staff member D stated she checked resident #1 and noted the resident was not breathing and did not have a pulse, her arms were cool to touch, and her body was warm. The staff member said she then asked the CNA to help her move the resident off the fall mat and onto the floor, then she called for staff member E to assist her with resident #1. Staff member D said she stayed with resident #1 and began chest compressions but did not provide rescue breaths, while staff member E called 911. Staff member D stated when staff member E returned, staff member E started to provide chest compressions, while she went to the crash cart for the ambu bag. After she obtained the ambu bag off the cart, staff member D started to provide rescue breaths for resident #1, while staff member E provided the chest compressions. She stated they provided CPR for the resident for approximately 10 minutes. Staff member D said they stopped CPR on resident #1 when the first emergency responder, the police officer, entered the room. She said the police officer did not provide CPR for resident #1 when he arrived at the facility. Staff member D said they both (staff members D and E) had become tired from providing CPR and stopped providing CPR for resident #1 when the officer arrived and prior to the EMTs arrival. Staff member D said both herself and staff member E stopped performing CPR when staff member E became tired from performing chest compressions. Staff member D said she did not switch rescuer roles with staff member E to reduce staff member E's fatigue while performing chest compressions. During an interview on [DATE] at 3:30 p.m., staff member E stated she left staff member D with resident #1 and went to call 911. She believed staff member D was providing chest compressions while she went to call 911. She stated when she returned, she started performing chest compressions for resident #1, while staff member D got the ambu bag from the crash cart. She then continued chest compressions for resident #1 for approximately 10 minutes. She said she had become too tired to continue providing chest compressions for resident #1, and she stopped CPR. Staff member E said she did not switch roles with staff member D, who was providing the rescue breaths for resident #1, so she could rest between sets. Staff member E stated she stopped CPR because, I couldn't do it anymore. She said at that time both herself and staff member D discontinued CPR for resident #1. She said the officer did not provide CPR for resident #1 when he arrived, and they were not providing CPR for the resident prior to the arrival of the EMTs. Staff member E stated the EMTs did re-initiate CPR for resident #1 when they arrived at the facility. During an interview on [DATE] at 11:28 a.m., staff member A stated it was the expectation for staff to provide CPR for residents based on their established advance directives. If a resident was determined as a full code, CPR should be initiated by staff who were CPR certified and CPR should be continued until EMT arrive or the resident was proclaimed deceased by a provider. During an interview on [DATE] at 12:00 p.m., staff member B stated it was the expectation of staff to provide CPR for residents based on the resident's established advance directives. She said CPR should begin immediately, and should not stop until either the staff member(s) were relieved by another certified CPR provider, EMT, or the provider has determined the resident was deceased . She stated CPR should not be stopped for a resident who was a full code unless there was a risk to the rescuer's health. She said when there were two staff members who were both CPR certified providing CPR for a resident, it was the expectation and training of those staff members to switch roles between providing chest compressions and providing the rescue breaths, to reduce rescuer fatigue during CPR. Staff member B said the staff member who was providing chest compressions for resident #1, should have switched roles with the staff member who was providing the rescue breaths for resident #1 when the staff member providing the chest compressions became fatigued; instead of stopping the CPR for resident #1. During an interview on [DATE] at 1:30 p.m., NF2 stated he had responded to the 911 call from the facility regarding CPR in progress. NF2 said when he arrived on the scene, there were approximately ,[DATE] people in the resident's room. He said no one was providing CPR for the unresponsive resident on the floor. NF2 said the EMTs did not arrive for another ,[DATE] minutes after his arrival. He said he did not provide CPR for the resident. NF2 said when the EMTs arrived they asked why no one was providing CPR for the resident, and nobody gave a response, except one facility staff member stated they were tired. NF2 said the EMTs started CPR upon their arrival, and did not stop CPR until the provider gave the order to stop. Review of resident #1's EMS Incident Report Form, dated [DATE], showed, Called emergent to (Facility) for (resident #1) CPR in process. Staff member met us at the front door and stated that pt was in the ED last night because she is COVID positive and wasn't feeling good. States that they sent her back without doing anything because her 02 was good . States that they went to check on her at 0255 and thought she was sleeping so they didn't wake her up. at 0355 went back in and found her pulseless and apneic. States that they pulled her to the floor and started CPR . One staff member stated she is a full code another stated she was a DNR and the 3rd staff member stated she did not know. When I entered the pt's room I found several staff members standing around the pt. No CPR was being doing (sic) no 02 ventilation was being done and no AED was on the patient or in the room. When asked why they were not doing CPR, one staff member stated, We just couldn't handle it anymore. They were unable to tell me when CPR was started or when it was stopped. Staff was unable to tell me anything else about the pt. Staff left the room and did not come back. Pt supine on the floor. Pt is unresponsive, pulseless, and apneic. GCS of 3. Airway-clear, breathing-absent, circulation-no pulse, skin-cyanotic, cool and dry. No rigor or lividity noted to pt. Arrive- Report from staff, CPR was started. Placed pt on monitor and pads. Oral airway was placed and BVM with 02 was used end tidal CO2 was placed. IO was started in R lower leg with saline on a pressure bag was hung. BG was taken. 3 rounds of EPI were pushed ,[DATE] minutes apart, ongoing CPR throughout. No ROSC, pt asystole throughout, called for cancel orders. (Physician) gave the order, called the coroner, cleared call (sic). Review of resident #1's Progress Notes, dated [DATE] at 3:52 a.m., showed, Resident returned from (Hospital) ER at 0345 by (emergency transport system). Review of resident #1's Progress Notes, dated [DATE] at 4:36 a.m., showed, This nurse asked CNA to obtain a set of vitals on resident. CNA came back to report that resident was on her fall mat and non responsive. Upon arrival this nurse checked pulse and there was none present. Residents hands were cold and pale, while the rest of her body was slightly warm. This nurse and CNA moved resident to the floor and nurse began chest compressions. RN retrieved crash cart. RN began compressions while this nurse administered breaths for around 10 minutes when police officer arrived and (EMT Services) shortly after. (EMT Services) then took over care. (EMT Services) continued with resuscitation effort until ordered to stop by ER doctor. (EMT Services) left building at 0520. (EMT Services) called coroner prior to leaving. Family notified of death. (sic) A review of the facility's policy and procedure titled, COVID-19 CPR Administration, with a revision date of [DATE], showed: 3. Multiple-Provider CPR. a. Provide chest compressions: i. the compressor exposes chest. ii. the compressor performs chest compressions . b. Deliver ventilations: i. The airway manager seals the BVM mask and simultaneously opens the airway to a past-neutral position using the head-tilt/chin-lift technique . c. Switch positions: i. the providers smoothly switch positions about every 2 minutes. This should take less than 10 seconds. ii. The compressor calls for a position change by saying, 'switch' in place of the number 1 in the compression cycle. d. Continue CPR: i. The compressor provides 30 chest compressions at the proper rate and depth . ii. The airway manager maintains an open airway and seals the mask . iv. The providers continue performing cycles of CPR (30 compression/2 ventilations) switching roles about every 2 minutes. The switch should take less than 10 seconds. e. Rotate providers to prevent fatigue, as needed during the switch. 4. Stopping CPR: a. Continue CPR use until: i. Other trained providers arrive and relieve you. ii. You see signs of return of spontaneous circulation (ROSC), such as spontaneous movement or breathing. iii. You are presented with a valid do not resuscitate (DNR) order. iv. You are too exhausted to continue. ¹ Hazinski, M. F. (2016). For 2020 Supported Basic life support: Provider Manual. Dallas, Texas: American Heart Association. Source States: Out-of- Hospital [MEDICAL CONDITION]: Chain of Survival . Resuscitation teams: Lay rescuers are expected to recognize the patient's unresponsiveness, call for help, and activate the emergency response system. They initiate CPR and use an AED (if available) until a team of EMS providers takes over resuscitation and then transports the patient to an ED and/or cardiac catheterization laboratory, before the patient is transferred to an ICU for continued care . 2-Rescuer CPR: Rescuer 1 (compressions) .Switch compressors about every 5 cycles or every 2 minutes (or more frequently if fatigued). Take less than 5 seconds to switch. Rescuer 2 (breaths): . When only 2 rescuers are available, switch compressors about every 5 cycles or every 2 minutes, taking less than 5 seconds to switch. Foundational Facts: Effective Team Performance to Minimize Interruptions in Compressions: Effective teams communicate continuously. If the compressor counts out loud, the rescuer providing breaths can anticipate when breaths will be given. This will help rescuer prepare to give breaths efficiently and minimize interruptions in compressions. Also, the count will alert both rescuers when the time for a switch is approaching. It is hard work to deliver effective chest compressions. If the compressor tires, chest compressions won't be as effective. To reduce rescuer fatigue, switch compressors about every 5 cycles (or every 2 minutes) or sooner if needed .

Based on interview and record review, the facility failed to conduct ongoing diabetic assessments and ongoing monitoring for a resident experiencing a hyperglycemic event, and failed to follow physician orders [REDACTED].#52) of 38 sampled residents, which resulted in the resident being admitted to the hospital. Findings include: IMMEDIATE JEOPARDY On 11/29/18 at 9:43 a.m., the facility administrator and director of nursing were notified that an immediate jeopardy situation existed in the area of F600-Freedom from Abuse and Neglect and F684-Quality of Care. The severity and scope was identified to be at the level of J, and upon removal of the immediacy, lower to a G. The facility submitted a plan to remove the immediacy on 11/29/18 at 6:05 p.m., and the plan was accepted. Findings Include: During an interview on 11/29/18 at 7:30 a.m., staff member A stated on 11/27/18 at 10:00 a.m., an order was written for STAT (immediate) lab work to be completed for resident #52, related to diabetic management, but the lab work had not been completed until 6:00 p.m., that day. Staff member A stated she was not at the facility at 6:00 p.m. on 11/27/18. Staff member A stated she spoke with staff member B on 11/27/18, and wanted to know what was going on with resident #52. Staff member A stated resident #52 reported nausea and vomiting on 11/27/18. Staff member A stated an order for [REDACTED]. Review of the resident's clinical record did not show the STAT order was written. Staff member A stated the facility did not call staff member A back with results of the labs or the assessment. Staff member A stated on 11/28/18 at 12:00 p.m., staff reported an elevated blood sugar, and staff member A gave orders for the nurse to complete a physical assessment of the resident. Review of the resident's clinical record did not show an order was transcribed or that a physical assessment of the resident was completed. Review of resident #52's lab report, dated 11/27/18 at 7:00 p.m., showed an elevated blood glucose of 845. The reference range was 74-106. Review of resident #52's clinical record did not show documentation of ongoing assessments and monitoring of blood sugars from 11/27/18 at 7:00 p.m. until 11/28/18 at 7:00 a.m. Review of resident #52's MAR, dated 11/2018, showed the resident was to have blood glucose checks two times daily, three times per week. The MAR indicated [REDACTED]. Review of resident #52's nursing notes showed the following late entries. The resident's medical record lacked documentation of the resident's condition and status prior to the late entries: -11/27/18 at 6:00 p.m., Late Entry. Venipuncture for CBC, CMP drawn in lt (left) antecubital area and specimen sent to (facility name) lab. -Effective date 11/27/18, Late Entry written by staff member B. N[NAME] nurse received a call from (facility name) Lab that resident had a critical BG of 845. She stated to me this nurse (the night nurse) notified the provider of critical BG and provider gave new orders but did not want to give insulin to bring BG level down. The nurse and I questioned to one another the providers decision. (sic) -Effective date 11/27/18 at 10:00 a.m., Late Entry written by staff member B. This nurse visited with provider regarding resident. Resident expressed to provider she was not eating and not feeling well. Provider expressed that resident's BG's were running higher than normal so she was going to write order for labs. (sic) -Effective date 11/30/18 at 12:30 p.m. Late Entry for 11/28/18. Written by staff member F. This nurse spoke with DON at about 8:00 a.m. about resident. Was asked to do assessment (of resident). This nurse went and assessed resident. The clinical record did not show documentation of this assessment until the time of the late entry. At about 1200, this nurse took residents BG and it was 453. This nurse called and spoke with (name) at (facility name) long term care and (name) asked for vitals and weight from resident. this nurse did not know the CNA's had placed this in DON's office, so they were re-taken. Vitals were as follows: Temp 96.0, Resp: 18, BP: 160/72, P: 88, O2 92% 2L. At this time, (name) instructed this nurse to give 10 units of [MEDICATION NAME]. At this time resident was eating lunch. She had eaten her cup of jello and her egg roll. Weight CNA's had recorded was quite a bit lower than residents previous weight of 260.0, CNA's got 184.2, so this nurse asked the CNA's to get resident up and on the actual scale. Re-weigh was 256.0lbs. Vitals and weight called back into (name) at (facility name). This nurse was waiting for a callback from provider, when DON asked to speak with me. DON was on phone with provider and was instructed to send resident into hospital. (sic) Review of resident #52's Progress Notes, dated 11/27/18 at 10:04 a.m., written by staff member A, showed staff member A documented the resident was concerned regarding a blood glucose episode of 504 and reported she had severe nausea, and only had been able to tolerate one solid meal in the last seven days. Will order CBC, CMP, stat. On 11/28/18, staff member A gave orders to transfer resident #52 to the hospital due to an elevated blood glucose of 453, nausea, and thirst. The resident had not returned to the facility as of 12/4/18. Hospital records were requested, however had not been received. Review of the facility's [DIAGNOSES REDACTED]/[MEDICAL CONDITION] Recommended Guidelines Policy, showed the following: -3.if blood glucose is above 350 mg/dl, notify physician per the parameters. a. administer insulin per physician order. b. Re-check blood glucose in 1 hour. c. Notify physician if blood glucose remains above 350 mg/dl . During an interview on 11/29/18 at 11:55 a.m., staff member H stated if a resident's blood glucose level is high she would repeat the test then call the doctor. Staff member H stated, I think I would call the doctor if the blood glucose level is around 380. Staff member H stated when the physician's orders [REDACTED]. Staff member H stated she would follow the order from the doctor to ensure the blood glucose level lowered and would keep a close eye on the resident. If the blood sugar was still elevated staff member H would call the physician to let them know.

Based on interview and record review, the facility failed to ensure a diabetic resident was monitored following a hyperglycemic event, failed to conduct ongoing physical assessments, and failed to obtain the resident's blood for a provider ordered STAT (immediate) lab, in a timely manner. This failure resulted in the resident being transferred out of the facility to the hospital, for 1 (#52); and failed to administer scheduled medications for 1 (#707) of 39 sampled and supplemental residents, which resulted in the resident being transferred and admitted to the hospital; and failed to follow physician orders [REDACTED].#s 5 and 264) out of 38 sampled residents which had the potential for a negative outcome. IMMEDIATE JEOPARDY On 11/29/18 at 9:43 a.m., the facility administrator and director of nursing were notified that an immediate jeopardy existed in the area of F600-Free from Abuse and Neglect and F684-Quality of Care, related to the care and serviced provided to resident #52 for diabetic management. The severity and scope was identified to be at the level of J, and upon removal of the immediacy, would lower to a G. A plan to remove the immediacy was provided on 11/29/18 at 6:05 p.m., and accepted. Findings Include: 1. Hyperglycemic Event: During an interview on 11/29/18 at 7:30 a.m., staff member A stated on 11/27/18 at 10:00 a.m., an order was written for STAT (immediately) lab work to be done for resident #52, but the lab work had not been done until 6:00 p.m. Staff member A stated she was not at the facility at 6:00 p.m. on 11/27/18. Staff member A stated she spoke with staff member B on 11/27/18 and wanted to know what was going on with resident #52. Staff member A stated resident #52 reported nausea and vomiting on 11/27/18. Staff member A stated an order for [REDACTED]. Review of the resident's clinical record did not show the order for the vital signs, weight, or physical assessment were written. Review of the clinical record did not show documentation the assessment was completed. Staff member A stated the facility did not call back with results. Staff member A stated on 11/28/18 at 12:00 p.m., nursing staff reported an elevated blood sugar and staff member A gave orders to do a physical assessment. Review of the clinical record did not show an order was written or a physical assessment was completed. Review of resident #52's nursing notes showed the following late entries. The staff working at the time of the diabetic event for resident #52 failed to document in the resident's medical record, timely: -11/27/18 at 6:00 p.m., Late Entry. Venipuncture for CBC, CMP drawn in lt (left) antecubital area and specimen sent to (facility name) lab. (sic) -Effective date 11/27/18 Late Entry written by staff member B. N[NAME] nurse received a call from (facility name) Lab that resident had a critical BG of 845. She stated to me this nurse that she notified the provider of critical BG and provider gave new orders but did not want to give insulin to bring BG level down. The nurse and I questioned to one another the providers decision. (sic) -Effective date 11/27/18 at 10:00 a.m., Late Entry written by staff member B. This nurse visited with provider regarding resident. Resident expressed to provider she was not eating and not feeling well. Provider expressed that resident's BG's were running higher than normal so she was going to write order for labs. (sic) -Effective date 11/28/18 at 8:00 a.m., Late Entry written by staff member F showed this nurse spoke with DON at about 0800. Was asked to do a physical assessment. This nurse went and assessed resident. (sic) There was a lack of clinical documentation in the resident's medical record to show ongoing monitoring and physical assessments had been completed to address the resident's medical concerns and status. Review of resident #52's Progress Notes, dated 11/27/18 at 10:04 a.m., written by staff member A, showed the resident reported she was concerned regarding a blood glucose episode of 504 and reported to staff member A that she had severe nausea, and only had been able to tolerate one solid meal in the last seven days. Will order CBC, CMP, stat. (sic) Review of resident #52's lab report, dated 11/27/18 at 7:00 p.m., showed an elevated blood glucose of 845. Reference range was 74-106. Review of the resident's clinical record did not show any documented blood sugars until 11/28/18 at 7:00 a.m., which was 514. There was no documentation in the resident #52's medical record of ongoing physical assessments or monitoring from 11/27/18 at 7:00 p.m., immediately following the elevated blood glucose level, until 11/28/18 at 7:00 a.m Review of resident #52's MAR, for (MONTH) (YEAR), failed to showed there were 6 out of 18 times when an ordered blood glucose test was not completed during the month. Review of resident #52's clinical record showed the facility failed to monitor a resident with diabetes following a lab reported blood glucose of 845, failed to conduct ongoing assessment for a resident who was experiencing a hyperglycemic episode, and failed to obtain and send blood for a STAT ordered lab in a timely manner. During an interview on 11/29/18 at 11:15 a.m., staff member B stated a physical assessment had been completed for resident #52, on 11/27/18, however there was no documentation in the resident's medical record. Staff member B stated she .did not document the assessment. (sic) On 11/28/18, staff member A gave orders to transfer resident #52 to the hospital for an elevated blood sugar of 453, and complaints of nausea and thirst. The resident had not returned to the facility as of 12/4/18. The resident's medical record lacked documentation on the resident's condition upon transfer to the hospital. A request was made for medical records from the hospital, however the records had not been received. During an interview on 12/3/18 at 3:54 p.m., staff member D stated facility staff should have done a better job in assessing and monitoring blood sugars for resident #52. 2. Scheduled Medications During an interview on 11/27/18 at 8:19 a.m., staff member G stated resident #707 had been admitted to the facility after being hospitalized in the Intensive Care Unit; his [DIAGNOSES REDACTED]. Staff member G stated facility staff failed to administer medications prescribed to resident #707, and the resident was transported back to the hospital the following day, and was in respiratory distress but was in a stable condition. During an interview on 11/28/18 at 2:04 p.m., staff member B stated resident #707 had not been given his evening doses of prescribed medications, and the resident .declined and was sent back to the hospital. Staff member B stated she spoke to the staff member that had worked with resident #707, and the staff member could not explain why scheduled medications had not been provided. Staff member B stated resident #707 had to be transported back to the hospital via the Emergency Medical Services (EMS) and he did not return to the facility. During an interview on 12/4/18 at 8:03 a.m., NF2 stated resident #707 had been hospitalized for [REDACTED]. She stated the resident required scheduled doses of [MEDICATION NAME] to prevent fluid build up in his lungs. NF2 stated when she arrived the day after resident #707 had been admitted to the facility, he was having difficulty breathing. NF2 stated resident #707 required the use of a [MEDICAL CONDITION] machine at night, and a [MEDICAL CONDITION] machine during the day, to reduce the build up of CO2. A review of resident #707's Medication List from the hospital, on admission, dated 10/3/18, was reviewed in comparison to the facility physician orders [REDACTED].>a. Resident #707's (MONTH) (YEAR) MAR indicated [REDACTED]. - [MEDICATION NAME] 6 mg related to [MEDICAL CONDITION] - Sennosides 8.6 mg- 2 tablets related to constipation - [MEDICATION NAME] 100 mg related to constipation - [MEDICATION NAME] 12.5 mg related to hypertension - Sildenafil 10 mg related to right heart failure due to left heart failure - [MEDICATION NAME] inhaler related to acute [MEDICAL CONDITION] with [MEDICAL CONDITION] - Two does of [MEDICATION NAME] sulfate HFA related to acute [MEDICAL CONDITION] with [MEDICAL CONDITION] b. A review of resident #707's (MONTH) (YEAR) MAR indicated [REDACTED]. A review of resident #707's nurse's notes, dated 10/4/18 at 11:30 a.m., read, .Resident does not have his [MEDICAL CONDITION] on and did not wear it last night and therefore is compliant (sic) of increased shortness of breath. Per vital sign form, vial signs were normal at 0630. At this time vital signs; 119/55, 28, 123, 98.8, (oxygen saturation) 81-89% at 5 liters per minute of oxygen. Alert and oriented x 3- answers questions approximately (sic) .Fine scattered crackles in bases bilaterally, nasal flares noted .HR (heart rate) [MEDICAL CONDITION] at 123-125. 3+ non-[MEDICAL CONDITION] lower extremities bilaterally tight . 3. Monitoring Blood Glucose Levels a. During an interview on 11/29/18 at 2:30 p.m., resident #5 stated there had been a few times he did not think the nurses checked his blood glucose levels when they were supposed to. Review of resident #5's physician orders [REDACTED].<80 or >350 with an order date of 11/13/18. Review of resident #5's (MONTH) (YEAR) MAR indicated [REDACTED] - 11/13 at 2100 - 11/17 at 2100 - 11/27 at 2100 - 11/29 at 0700 During an interview on 11/29/18 at 3:00 p.m., staff member D stated, These blanks on the MAR means it was not done or not documented. b. During an interview on 11/29/18 at 2:30 p.m., staff Member L stated the facility's process for checking blood glucose was to notify their provider if the blood glucose level was less than 70, or greater than 300, unless otherwise ordered. When asked what the process was when you receive a physician's orders [REDACTED]. Review of resident #264's (MONTH) (YEAR) MAR, showed two blanks on the 10th and 11th where a BG was to have been done at 3:00 a.m. for three nights, and a blank on the 25th for CBG Check (AC) before meals. During an interview on 12/4/18 at 9:59 a.m., staff member H stated, If it (MAR) is blank it means it didn't get done. Review of the facility's [DIAGNOSES REDACTED]/[MEDICAL CONDITION] Recommended Guidelines Policy showed the following; - .3.if blood glucose is above 350 mg/dl, notify physician per their parameters. a. administer insulin per physician order. b. Re-check blood glucose in 1 hour. c. Notify physician if blood glucose remains above 350 mg/dl.

Based on observation, interview, and record review, facility staff failed to provide a scheduled pain medication to 1 (#58) of 38 sampled residents, which caused the resident to complain of uncontrolled pain to his coccyx and legs, became tearful, isolated himself in his room during activities and meals, and refuse to be repositioned in bed by the staff; and, staff failed to monitor pharmacological, and non-pharmacological interventions, for 1 (#213) which caused the resident to complain of pain; and failed to provide adequate pain control for 2 (#s 40 and 263) of 38 sampled residents. Findings include: 1. Scheduled Pain Medication During an observation and interview on 11/26/18 at 1:44 p.m., resident #58 stated he was admitted to the facility with severe, uncontrolled pain to pressure ulcers on his coccyx, and muscle spasms to both of his legs and hips. Resident #58 stated staff were not always consistent with providing scheduled pain medication and his pain was consistently a seven to eight of ten (severe) on the pain scale. Resident #58 stated he was often in too much pain to attend any activities or go to the dining room for meal or leave his room in general, and frequently stayed in his bed. The resident stated he was able to self-transfer to and from his bed with minimal assistance by staff when his pain was managed. He stated staff rarely reassessed and monitored the efficacy of medications provided. Resident #58 stated staff were supposed to have him sign off on his Medication Administration Record (MAR) when doses of [MEDICATION NAME] were given. The resident stated staff were not consistent with ensuring scheduled doses of pain medication were administered, and pain management was not provided. Resident #58 was lying in bed, and became tearful when discussing his pain. He stated he enjoyed visiting with other residents, but his pain was too bad for him to leave his room. During an interview on 11/26/18 at 2:29 p.m., staff member B stated staff had not been consistent with providing adequate pain management for resident #58. Staff member B stated all scheduled medications were to be documented in the MAR when medications were provided. Staff member B stated staff were required to document doses administered in the Controlled Substances/Narcotic Record Book, in the resident's medical records, or in the MAR when medications were refused. Resident #58 was admitted to the facility with [DIAGNOSES REDACTED]. The resident had a suprapubic catheter, [DEVICE], and [MEDICAL CONDITION], all potentially contributing to pain. A review of resident #58's (MONTH) (YEAR) MAR showed orders for scheduled doses of [MEDICATION NAME] 20 milligrams (mg)/ milliliter (ml) to be administered every three hours related to chronic pai[DIAGNOSES REDACTED], with a start date of 10/31/18. Staff failed to administer, document, and monitor pain once on 11/16/18, and four times on 11/21/18. Staff documented a pain scale of 7 or higher 110 times on the MAR during the month. Staff failed to document a pain scale 21 times. A review of resident #58's (MONTH) (YEAR) Treatment Administration Record (TAR) showed orders for staff to evaluate resident's pain levels every 3 hours and offer PRN (as needed) doses of [MEDICATION NAME] every day and night; start date of 8/17/2018 at 6:00 p.m. Staff failed to document a pain assessment 12 times on the TAR. A review of resident #58's nurse's notes, dated 11/8/18 at 2:27 p.m., read, Resident frequently complains of pain/discomfort related to bottom. Complain with meds today. Resident refused to be repositioned when asked by staff, has been on his bottom. Will monitor. A review of resident #58's nurse's notes, dated 11/16/18 at 11:04 p.m., read, .Resident has increased pain .Resident continues to lay on bottom. A review of resident #58's nurse's notes, dated 11/21/18 at 10:17 p.m., read, .Resident continues to have significant pain related to wounds. During an interview on 11/27/18 at 2:50 p.m., staff member I stated resident #58 was evaluated for pain management on 11/5/18. The resident's [MEDICATION NAME] IR (immediate release) had been increased to 160 mg per day; 20 mg to be given every 3 hours. Staff member I stated resident #58 continued to complain of increased episodes of pain, and staff member I wanted the muscle relaxant, [MEDICATION NAME], to be given for additional pain relief. Staff member I reviewed resident #58's MAR, and stated, He has not been getting the [MEDICATION NAME] according to the documentation. A review of resident #58's Clinician Progress notes, dated 11/5/18, read, Chief Complaint: Patient (sic) is being seen for discussion of pain management, care conference with Supportive Care .Orders were given to nursing to ensure that they are bringing him all of his medications as ordered .Patient to try [MEDICATION NAME] for additional pain relief . A review of resident #58's Care Plan for Pain, modified on 8/26/18, showed intervention of, Evaluate effectiveness of routine/PRN pain medication. A review of resident #58's Pain Evaluation, dated 8/13/18, showed the Resident Condition included, Wounds/Ulcer, Depression, Bone pain, Joint pain, Muscle pain, Soft tissue pain, End Stage Disease Process and Immobility. Staff were to administer [MEDICATION NAME] 1.25 ml every 3 hours, [MEDICATION NAME] 4 mg every 4 hours PRN, Tylenol 975 mg three times daily, and [MEDICATION NAME] 150 mg twice daily. The type of pain was listed as, Sharp, burning, soreness, and tearing. Staff did not complete the Pain Scale section of the evaluation. Staff listed the Pain Effects, Quality of Life, ADL Function, Depression, Rehabilitation, Appetite, Independence, and Mobility. During an interview on 12/3/18 at 4:00 p.m., staff member D stated the Annual Education Calendar for Pain Assessment and Management was scheduled for (MONTH) (YEAR). Staff member D stated it was unfortunate that this area was not reviewed with facility staff sooner. 2. Lack of monitoring and assessing pain a. During an interview on 11/26/18 at 4:26 p.m., resident #213 stated she had [MEDICAL CONDITION] and constantly had pain. She stated she has had pain since admission to the facility. She stated the facility was putting Bonfire on her knees to try and help, but they were not doing much else. During an interview on 11/28/18 at 2:48 p.m., staff member B stated resident #213 was a 7 out of 10 (severe) on the pain scale for pain when she was admitted to the facility, the provider said there was not much the facility could give her for pain due to her [DIAGNOSES REDACTED]. Staff member B stated I do not see a lot of visual signs of pain with her, and I do not notice that she complains of pain. The interventions we have for her are Biofreeze for her knee, relaxing and repositioning and PRN Tylenol. During an observation on 11/28/18 at 3:55 p.m., resident #213 got up from a chair in the common area, using her walker. The resident was wincing in pain and moaning while trying to stand. Review of resident #213's medical record showed she was admitted to the facility on [DATE]. There was not a Pain Evaluation completed until 11/27/18. The Pain Evaluation showed: - Resident Condition - Joint Pain, - Does the resident have pain? - Yes, - Pain Type - Aching, burning, worse in cold, worse with heat, worse at night, - What does the pain feel like? - Visceral (generalized), - Pain Scale - Moderate (Non-distractible; no relief w/ conservative strategies), - Onset - Chronic, - Pain Effects - activities, ADL Function, - What improves Pain? - stay off feet, Biofreeze, - What makes Pain worse? - cold weather, being on feet too long, - Is Resident satisfied with current pain control? - No, - Are there indications of the source of pain on physical evaluation? - Yes, - Wants Icy hot and was rubbing knees. Review of resident #213's Pain Management Flowsheet showed it was blank. During an interview on 11/28/18 at 2:48 p.m., staff member B stated if PRN medications were given, or non-pharmacological interventions were done, and then staff should be monitoring for effectiveness on the Pain Management Flowsheet. Staff member B stated, I am aware that resident #213's 'Pain Management Flowsheet' is not filled out, it should be, and I have already done some staff education on that last night. Review of resident #213's (MONTH) (YEAR) MAR showed orders for, Tylenol ER 500 mg-1000 mg Q6 PRN-Not to exceed 3000 mg/24 hr. Resident #213 was given 5 doses of Tylenol, but staff failed to monitor the efficacy of the medication provided on the Pain Management Flow Sheet. The lack of monitoring of resident #213's pain resulted in the resident to have uncontrolled pain. b. During an interview on 11/27/18 at 9:36 a.m., resident #40 stated, I'm just uncomfortable right now. I have frequent pain, lots and lots. I get [MEDICATION NAME] - it's not adequate. Resident #40 stated I asked about aquatic therapy at (hospital name) but that hasn't progressed. She stated, I have to ask for the [MEDICATION NAME], I have arthritis strength Tylenol scheduled. The resident stated when she received the pain medication, she said they usually don't come back to ask if it helped. During an interview on 12/3/18 at 12:25 p.m., staff member D stated resident #40 asked for her PRN [MEDICATION NAME] to be given at 6:00 a.m., automatically. They give her scheduled [MEDICATION NAME] and then ask about pain. Resident #40's stated she usually had pain, and rated it at about a 7-5 of 10 (moderate to severe), and non-pharmacological interventions that were offered included repositioning and [MEDICATION NAME] gel, which was scheduled at 6:00 a.m. and 8:00 p.m. Staff member D stated staff also were to try diversional activities, such as her tablet. Staff member D stated scheduled [MEDICATION NAME] had not been available for resident #40 since 11/20/18. Staff member D stated she had called the pharmacy to inquire about the availability of the [MEDICATION NAME], and she was told the insurance would not pay for the medication. She stated the pharmacy was working on a pre-authorization and an alternate order. Staff member D did not receive an alternative order and said that they are giving resident #40 the prn ordered [MEDICATION NAME] 10/325, 1-2 tabs, Po q4 hours, for PRN pain (NTE 5 tabs/day). Review of resident #40's MAR, for (MONTH) and (MONTH) (YEAR), showed [MEDICATION NAME] Gel 1% had been signed off as administered nine times. Review of resident #40's Pain Evaluation, dated 10/15/18, showed the resident reported her pain at a Severe level (7) that requires escalated interventions. The resident's pain had resulted in changes in her ADL Function and Mobility. Under Section O, What improves Pain, the document showed pain medications and rest with movement, made pain worse. Review of resident #40's multidisciplinary progress notes, dated 11/21/18, showed the [MEDICATION NAME] medication was not available, that the pharmacy was notified, and the insurance will no longer pay for the medication. Staff requested for an order for [REDACTED]. During an interview on 12/4/18 at 8:59 a.m., resident #40 stated her pain had not been well controlled over the past week, and she also stated that she only has a PRN medication available for pain. d. During an interview on 11/26/18 at 4:00 p.m., with resident #263, the resident stated she had MSA (multi system atrophy), and she had pain. She stated only one nurse applied the doctor ordered Ben Gay to her back and knees. Resident #263 was tearful while speaking about the pain and management of the pain. During an interview on 11/28/18 at 11:33 a.m., staff member M stated resident #263 complained of pain during care, and this was all the time. Staff member M stated she would report resident #263's pain to the nurse, when the resident had complaints of pain. During an interview on 12/03/18 at 2:00 p.m., staff member N stated resident #263 very seldom took anything for pain. Review of resident #263's Pain Management Flow Sheet, for (MONTH) (YEAR), showed no documented alternatives, for oral pain medications, were offered to resident #263. Review of resident #263's (MONTH) (YEAR) MAR, showed no [MEDICATION NAME] had been given for pain. Review of the resident's pain monitoring, for the same dates, showed resident #263's pain level was between 2 and 5 almost daily, using the 0-10 scale. There was no entry for the physician ordered Icy Hot, which had been order by the physician on 10/22/18, on the MAR. Review of resident #263's Pain Evaluation, dated 09/24/18, recorded no pain after resident interview. The Pain Evaluation included arthritis as a resident condition, and Tylenol 325 mg 1 to 2 every 4 hours as needed for pain under section IIIc1. Review of resident #263's Care Plan, updated 8/16/18, showed back pain was addressed for the resident with interventions that included the evaluation of the effectiveness of routine/PRN pain medication, the provision of diversional activities, reposition for resident's comfort, educate resident on the cause of pain, (pain) management plan, and the expectations and possible side effects. A review of the facility's policy, Pain Management, read, 1. Residents are evaluated by a Licensed Nurse (LN) at admission using the Pain Evaluation, as needed (PRN) medication review, and record review. 2. Residents' pain level is evaluated every shift by the LN .a. Pain level is monitored and documented on the MAR using the Wong-Baker Pain Scale. 3. When pain is not adequately controlled by current regimen, I, or if there is newly identified pain, the LN contacts the physician for consideration of new or modified treatment orders. 4. The Pain Management Flowsheet is initiated. The LN documents the pain evaluation for their shift on the Flowsheet unless an alternative frequency is deemed appropriate by the physician . 7. When a PRN dose is administered, the LN should document on the reverse side of the MAR or in appropriate location in the electronic medical record, the medication given, the reason, and the pain evaluation scale. After the PRN medication has had time to take effect, the LN documents results/effectiveness. Documented response to PRN medication, may include a post administration pain scale evaluation to assist in determining effectiveness of the current regimen.

Based on observation, interview, and record review, the facility failed to identify and prevent abuse in the form of neglect and potential misappropriation of property for 2(#s 6 and 14) of 15 sampled residents. The facility failed to provide pain medication in a timely manner which put residents at risk of increased pain levels and harm (See F 309). The facility also failed to prevent verbal abuse for 1 (#13) of 15 sampled residents. Findings include: 1. Resident #13 was admitted to the facility with [DIAGNOSES REDACTED]. During an interview on 8/31/17 at 8:06 a.m., staff member D said an incident had occurred on 8/30/17 around 8:40 p.m. between resident #13 and staff member Q. Staff member D said staff member Q was verbally abusive in regards to resident #13. Staff member D said staff member Q did not verbally abuse resident #13 to his face, but staff member Q did verbalize her opinions of resident #13 loud enough so he could hear them. Staff member D said staff member Q was suspended pending an investigation into the situation, but she was sure staff member Q would be terminated. Staff member D said she was notified of the allegation on 8/30/17 around 9:15 p.m. Staff member D returned to the facility, relieved staff member Q of her duties and sent her from the facility. During an interview on 8/31/17 at 8:30 a.m., resident #13 said he and staff member Q got into it because staff member Q would not give him his asthma inhaler. Resident #13 said he went to his room, slammed his door, and heard staff member Q tell another staff member He is such a f--cking a--hole. Resident #13 said staff member Q said several more choice things about him, but he stayed in his room, and tried to stay cool. During an interview on 8/31/17 at 5:20 p.m., staff member D said staff member Q had received abuse training on 8/30/17 at 6:00 p.m., along with everyone else on the evening shift. 2. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was admitted to the facility with a stage 4 pressure ulcer of his sacrum and a history of [MEDICAL CONDITION] infection. His last MDS with an ARD of 6/7/17 showed he was cognitively intact with a BIMS of 15. During an interview on 8/30/17 at 1:45 p.m., Staff member F said she would have Resident #6 in his room at 2:30 p.m. so that an assessment could be done of his sacral pressure ulcer. She said the resident was on scheduled pain medications and that he should not require additional pain medication to be examined. During an observation at 2:30 p.m., on 8/30/17, resident #6 was heard angrily yelling in the unit dining room from the hallway. He was observed seated in his wheelchair with agitated body movements. He was addressing Staff member F, who was in front of him with a filled medication cup and a drink cup with straw in her hand. He was saying that he had repeatedly requested his pain medications that morning and had not received them. He said he had not been given any pain medication since the night before. He took the medication staff member F had for him and immediately then yelled, Please make them give me my pain medications on time! After calming some, he said he had not received his 8:00 a.m. or 12:00 noon scheduled pain medications. He said he has had to repeatedly request to receive scheduled pain meds. He said today his moderate pain levels at the time of his requests increased to severe levels by the time he received his scheduled medications. A review of resident #6's MARS on 8/30/17, at 2:55 p.m., showed documentation for a prior order for [MEDICATION NAME] that had been discontinued. The current order for resident #6's scheduled pain med was found on the resident's TARS record. It was for [MEDICATION NAME] 10 mg , one tab, four times a day. Doses were scheduled to be given four times a day at 8:00 a.m., 12:00 noon, 5:00 p.m., and 9:00 p.m. The 8:00 a.m. and 12:00 p.m. doses for 8/30/17 had been initialed as having been given. However, it was noted there were no initials in the record to show the resident had been given his 12:00 noon dose on 8/28/17. The form did not record exact times given. There were 2 corresponding narcotic reconciliation records, page #13 and #22 in the narcotic book for resident #6. The pages had not been used one at time with sequential documentation. Tablets had been given from different cards on the same day. They showed the following dates and times [MEDICATION NAME] 10 mg had been administered: 8:00 a.m. 12:00 p.m. 5:00 p.m. 9:00 p.m. 8/26 9:30 a.m. 12:30 p.m. 6:00 p.m. 11:00 p.m. 8/27 9:10 a.m. 12:25 p.m. 4:45 p.m. 11:30 p.m. 8/28 8:00 a.m. no entry 5:00 p.m. 9:00 p.m. 8/29 8:00 a.m. no entry 5:00 p.m. 11:30 p.m. 8/30 8:30 a.m. 13:30 p.m. Comparing the actual times [MEDICATION NAME] was given to the times the medication was scheduled to be given, showed that over a period of five days, out of 14 administrations, the medication was given over an hour late 7 times and not given at all twice. During an observation on 8/30/17 at 2:35 p.m., staff member F drew a line through the last entry of 13:30 p.m. and wrote beside it 2:30 p.m. with her initials and the word error. She did this with the surveyor next to her watching. She said she had simply forgotten to give resident #6 his 12:00 noon dose. Staff member F was asked to open the narcotic box, and the reconciliation record of the remaining available balances for each card were verified to be correct and remaining in punch cards on the drug cart. Observation of the resident's sacral pressure ulcer was delayed to assure the resident's comfort after he had taken pain medication. At 5:00 p.m. on 8/30/17, a brief verbal description of this event was reported to staff members B, C, D, and G. A review of resident #6's nurses progress notes on 8/31/17 did not show documentation of this event or mention the resident's complaint about not receiving his pain medications on time. During an interview on 8/31/17 at 5:00 p.m., resident #6 said he had received all of his pain meds and had been comfortable through the day. 3. Resident #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #14 had scheduled and PRN pain medication prescribed. Review of resident #14's Quarterly MDS, with an ARD of 5/10/17, showed that the BIMs was coded a 15. During an interview on 8/30/17 at 2:00 p.m., resident #14 stated that 3 staff members, most times, were 2 hours late with their administration of her medications. During another interview on 8/31/17 at 3:00 p.m., the resident said there are 3 staff members that are most always late with her medications, including her pain medications. In the morning, the resident stated her pain is an 8 which is considered severe on a scale from 0-10. Resident #14 also stated that sometimes her medications that are scheduled at 8:00 a.m. may not get to her until 10:00 a.m. or 11:00 a.m. The resident went on to say that her next scheduled medications had to be given later than the next scheduled time due to her 8:00 a.m. medications being administered late. Resident #14 has scheduled [MEDICATION NAME] for twice a day at 8:00 a.m. and 12:00 a.m. The resident also had an as needed [MEDICATION NAME] ordered every 4 hours for pain. Resident #14 said that she lets the facility staff know that she needs her medications and nothing happens. Also, she stated that she had told the CNAs on duty to tell her nurse that she needs her medications. The resident stated that when the nurse came in, the nurse said she was not told.

Based on observation, interview, and record review, the facility failed to manage residents pain with prescribed and as needed medications in a timely manner which increased the residents severity of pain for 3 (#s 6, 12, and 14) of 15 sampled residents; and caused 2 (#s 6 and 12) residents to yell, curse, become tearful, grimace, and not want to leave their room. This deficient practice had the potential of affecting all the resident receiving pain medication. Findings include: 1. Resident #6 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He was admitted to the facility with a stage 4 pressure ulcer of his sacrum and a history of [MEDICAL CONDITION] infection. His last MDS with an ARD of 6/7/17 showed he was cognitively intact with a BIMS of 15. During an observation on 8/29/17 at 11:25 p.m., staff member J administered resident #6's 9:00 p.m. scheduled dose of [MEDICATION NAME], for pain. Staff member L was in the resident's room because the resident was yelling and cussing at staff member J. The medication, for pain, was administered by staff member J. The resident was yelling and stated the pain medication was administered 2.5 hours late. The resident complained of increased levels of pain, and he was visibly upset. He cussed at staff member J, stated to her that she was a[***]y nurse, was part of the problem, and needed to be canned. The resident was shaking his fist at staff member J. During an interview on 8/29/17 at 11:40 p.m., resident #6 stated he had requested, to staff member J, his 9:00 p.m. dose of scheduled [MEDICATION NAME] after his shower at 8:30 p.m. The resident stated at the time he requested the [MEDICATION NAME], his pain level was a 6 out of 10 on the pain scale, and he felt the pain creeping up. The resident stated that when staff member J administered the dose of [MEDICATION NAME], at 11:25 p.m., his pain level was a 10 of 10 on the pain scale, and he was in terrible pain. The resident stated he frequently had his pain medications administered late. During an interview on 8/29/17 at 11:45 p.m., staff member J stated the resident had requested the 9:00 p.m. dose of [MEDICATION NAME] after he had showered. The staff member stated the scheduled dose of medication was administered late. During an observation on 8/30/17 at 2:30 p.m., resident #6 was heard angrily yelling in the unit dining room from the hallway. He was observed seated in his wheelchair with agitated body movements. He was addressing Staff member F, who was in front of him with a filled medication cup and a drink cup with straw in her hand. He was saying that he had repeatedly requested his pain medications that morning and had not received them. He said he had not been given any pain medication since the night before. He took the medication staff member F had for him and then yelled, Please make them give me my pain medications on time! After calming some, he said he had not received his 8:00 a.m. or 12:00 noon scheduled pain medications. He said he has had to repeatedly request to receive scheduled pain meds. He said today his moderate pain levels at the time of his requests increased to severe levels by the time he received his scheduled medications. A review of resident #6's MARS on 8/30/17, at 2:55 p.m., showed documentation for a prior order for [MEDICATION NAME] that had been discontinued. The current order for resident #6's scheduled pain med was found on the resident's TARS record. It was for [MEDICATION NAME] 10 mg , one tab, four times a day. Doses were scheduled to be given four times a day at 8:00 a.m., 12:00 noon, 5:00 p.m., and 9:00 p.m. The 8:00 a.m. and 12:00 p.m. doses for 8/30/17 had been initialed as having been given. However it was noted, there were no initials in the record to show the resident had been given his 12:00 noon dose on 8/28/17. The form did not record exact times given. There were two corresponding narcotic reconciliation records, pages #13 and #22, in the narcotic book for resident #6. The pages had not been used one at time with sequential documentation. Tablets had been given from different cards on the same day. They showed the dates and times [MEDICATION NAME] 10 mg had been administered. Comparing the actual times [MEDICATION NAME] was given, to the times the medication was scheduled to be given, showed that over a period of five days out of 14 administrations, the medication was given over an hour late seven times and not given at all twice. 2. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of the resident's Admission MDS, with an ARD of 5/1/17, showed the resident was totally dependent on facility staff to assist with her activities of daily living. The resident had a BIMS of 13; cognitively intact. She had frequent pain, which interfered with her ability to sleep, and was coded as being a 6 out of 10 on the pain scale. She was admitted to the facility with two stage 2 pressure ulcers, and two stage 3 pressure ulcers. A review of resident #12's August 2017 MAR indicated [REDACTED]. a. During an observation and interview on 8/29/17 at 10:00 p.m., staff member J administered resident #12's 8:00 p.m. scheduled dose of [MEDICATION NAME] ER. The medication was administered 2 hours late. The resident complained of increased levels of pain, and became tearful. The resident stated her pain level had increased from a 7 out of 10 on the pain scale at 8:00 p.m., to a 9 out of 10 on the pain scale when administered at 10:00 p.m. The resident stated she frequently had problems getting her medications in a timely manner. She stated she often had to wait several hours to receive her scheduled pain medication. This caused her to have increased levels of uncontrolled episodes of pain. The resident stated she felt as though the facility staff did not like her, and purposely delayed the administration of pain medications. She stated this was the reason she stayed in her room most of the time. She stated she would hopefully return to her home soon, and stated she would be able to manage her pain better on her own. b. During an interview and observation on 8/30/17 at 1:55 p.m., resident #12 stated she had requested her noon dose of scheduled [MEDICATION NAME], at 11:30 a.m., and had not received her medication. The resident stated her pain level had increased from a 6 out of 10 on the pain scale at 11:45 a.m., to a 10 out of 10 on the pain scale. The resident stated she was experiencing a lot of pain, and couldn't hardly stand it. She was grimacing, and was lifting her upper body out of her wheelchair by pushing her arm down on the wheelchair side arms. The resident became tearful when she was discussing her issues with pain control. During an interview on 8/30/17 at 2:05 p.m., staff member F stated resident #12 had not requested the scheduled dose of [MEDICATION NAME] Immediate Release, for pain. The staff member stated she would, however, administer the resident's PRN dose of [MEDICATION NAME] immediately. During an interview on 8/30/17 at 2:45 p.m., resident #12 stated she had been told by staff member F that she had forgotten to administer the PRN dose of [MEDICATION NAME] at 11:30 a.m., when initially requested. The resident stated she was still in a lot of pain, and her pain was still a 10 out of 10 on the pain scale. The resident stated she was frequently administered scheduled, and PRN, medications late. She stated on frequent occasions, by the time she received her pain medications, her pain had escalated to a 10 out of 10 on the pain scale. A review of the facility's Controlled Substance Book, on 8/31/17 at 5:05 p.m., for the Prairie unit, book 1, page 26, read, (Resident #12) [MEDICATION NAME] IR, 15 mg, one tablet every 4 hours as needed for pain, line 8, 8/30/17 at 2:00 p.m., one dose. During an interview and record review on 8/31/17 at 4:45 p.m., staff member E stated she had administered all doses of [MEDICATION NAME] to resident #12. A review of the facility's Controlled Substance Book, on 8/31/17 at 5:05 p.m., for the Prairie unit, book 1, page 26, read, (Resident #12) [MEDICATION NAME] IR, 15 mg, one tablet every 4 hours as needed for pain, line 11, 8/31/17 at 12:40 p.m., one dose. At 5:06 p.m., staff member E stated she had forgotten to document a dose of [MEDICATION NAME], administered earlier that morning at 8:00 a.m. The staff member documented on line 12 of the Controlled Substance Book a late entry, documenting the [MEDICATION NAME] dose administered at 8:00 a.m. A review of the facility's policy, Medication Administration, pages 1 and 2, read, During Medication Pass: 5. The nurse follows the 5 Rights of Medication Administration: a Right Person b. Right Medication .c. Right Dose .Right Time: 8. Validated via MAR indicated [REDACTED].Right Route. 3. Resident #14 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview on 8/30/17 at 2:00 p.m., resident #14 stated that her medications most times are two hours late. There are two staff on days and one on evenings/nights that are late with her medications. During another interview on 8/31/17 at 3:00 p.m., the resident clarified that staff members E, I, and Q are most always late with her medications, including her pain medications. In the mornings, my pain is usually an 8 which is severe. Sometimes I do not get my scheduled 8 a.m. medications until 10 a.m. or 11 a.m., then my noon medications have to be given later. Resident #14 told staff that I need my medications and nothing happens. When the nurse comes in they say they were not told.

Based on observations, interviews, and record reviews, the facility quality assurance committee failed to conduct assessments and audits that effectively identified deficiencies and quality improvement changes needed in the area of medication administration, particularly in the area of narcotic administration for pain intervention. This failure had the potential to affect all residents in the facility. Findings include: During an interview on 8/29/17 at 2:35 p.m., staff member C said the facility QA committee had been meeting four times a year. The committee had undergone a turnover in staff members within the last two weeks and the new members were planning to meet on a monthly basis. Being a new member herself, staff member B stated she could provide copies of prior QA meetings but she did not know much about the concern topics the facility had been working on prior to her arrival to the facility the week before. Review of an Action Plan showed topics discussed for an AdHoc QAPI meeting held to review the results of investigation, findings and plan on 8/28/17. It showed the facility had begun abuse training for staff on 8/25/17 that would continue on 8/28/17, and included providing an abuse policy hand out to staff. It also showed that the facility had begun interviewing residents regarding pain management. Random call light audits were begun on 8/25/17, and grooming was to be observed on planned resident rounding to begin 8/28/17. In an interview on 8/31/17 at 11:40 a.m., staff member G stated the 8/25/17 QA meeting had been prompted by the facility's receipt of a complaint from a resident's family member. He stated the facility had begun to monitor resident MARS but had not completed the task yet. Observations, interviews, and record reviews, conducted from 8/28/17 through 8/31/17 showed the facility had deficiencies of medication administration concerning obtaining prescribed medications for residents, delivery of medications in a timely manner as prescribed, PRN pain medication administration, and documentation of pain medication effectiveness. Harm was observed on 8/29/17 and 8/30/17 as a result of pain medications not being provided at the scheduled times prescribed. A review of the facility's form for medication administration showed that scheduled medications were to be written with times at which they are given on the left side of the form. When the medications were administered, staff members wrote only their initials in spaces on the right side of the form. The actual time medications were administered was not written. Late medications, if given, were initialed in the same manner as those that had been given on time. Looking at the MARS showed whether medications had been given, but did not show if they had been given late. PRN medications were recorded differently. A separate PRN medication form was used and the time that the medication was actually given was also documented on the form. Narcotic reconciliation forms used by the facility also documented the actual times medications were given. During a meeting on 8/31/17 at 5:00 p.m., after a discussion concerning the need for medication audits to include PRN Pain Management Forms and Narcotic Reconciliation Sheets comparisons, staff members A and B stated they would discontinue the MARS audits they had been doing and do resident interviews and observational audits of medication pass in the future.

Based on observation, interview, and record review, the facility failed to ensure a resident received the correct insulin medication for 1 (#19) which resulted in low blood sugar readings, requiring interventions of glucose tablets; failed to follow blood pressure parameters established by the physician prior to administering medications for 1 (#1) of 21 sampled and supplemental residents. This deficient practice had the potential to affect all residents receiving medications at the facility. Findings include: 1. Resident #19 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #19's August 2017 Medication Administration Record [REDACTED]. - On 8/8/17, 8/16/17, 8/19/17, and 8/20/17, the resident did not receive her scheduled doses of Humalog, 5 units. The MAR indicated [REDACTED] - The August 2017 MAR indicated [REDACTED] - 20 episodes of blood sugar levels were recorded between 25 and 70 mg / dl - 14 episodes of glucose tablets being administered as an intervention - On 8/21/17, glucose tablets were not available, and staff provided 8 oz of orange juice. The resident's blood sugar levels were documented as 63 and 66 mg / dl after the juice, then lunch was served. During an interview on 9/7/17 at 3:25 p.m., NF1 stated resident #19 had been prescribed Humalog while residing at the facility. She stated resident #19 was a brittle diabetic with fluctuating blood sugar levels. NF1 stated the facility had contacted the physician's office on one occasion, to report blood sugar levels below 70 mg / dl, during August 2017. During an interview on 9/7/17 at 3:40 p.m., NF2 stated Humalog and [MEDICATION NAME] are almost interchangeable. He stated almost never, hardly ever, has anyone had a reaction when interchanging the two insulin medications. NF2 stated it is possible to require a dose reduction when administering one insulin type over another. Review of a Physician Progress Record, dated 8/25/17, and faxed to the State Agency on 9/7/17 at 2:54 p.m., read, Her (resident #19) glycemic control continues to be labile. Her current insulin doses are as follows: 1. [MEDICATION NAME] 10 units in the am (sic) and 4 units in the pm (sic). 2. Humalog base dose of 5 units at each meal. 3. Humalog, mealtime correction scale as follows: .I do not see these orders in the (facility MAR) at this time. I note that she has had a number of very low values within the last month .In fact, I could not determine a clear identifiable reason, from the records, for these lows. A review of Endocrinology Progress Notes, dated 9/7/17, and faxed to the State Agency on 9/7/17 at 5:12 p.m., read, She (resident #19) normally receives Humalog, but, for a period of several weeks recently, she had been on [MEDICATION NAME] instead At the time when I saw her in late August, it was my impression that she was on too much basal insulin, and I reduced her dose of [MEDICATION NAME] accordingly. I think that excessive basal insulin is a more likely explanation for the lows than the use of [MEDICATION NAME] versus Humalog. 2. Resident #1 was admitted to the facility in mid-August 2017 with [DIAGNOSES REDACTED]. A review of resident #1's August 2017 MAR indicated [REDACTED]. The following documents were reviewed: - The August 2017 MAR indicated [REDACTED]. Notes indicated staff were to HOLD FOR SBP (systolic blood pressure) less than 110. Staff failed to obtain a blood pressure reading, and administered the medication 6 times. - The August 2017 MAR indicated [REDACTED]. Notes indicated staff were to HOLD FOR SBP (systolic blood pressure) less than 120. Staff failed to obtain a blood pressure reading, and administered the medication 5 times. Staff administered the medication once when the SBP was documented as less than 120. - Nursing notes for August 2017 lacked evidence showing a blood pressure reading had been obtained prior to administering hypertension medications. During an interview on 8/29/17 at 11:45 a.m., staff member F stated medications for hypertension should not have been given if blood pressure readings were outside the parameters requested by the resident's physician. The staff member stated she was not sure why she administered the medications without checking for blood pressure reading prior to the administration. 3. Resident #12 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #12's August 2017 MAR indicated [REDACTED]. During an observation on 8/29/17 at 7:30 a.m., staff member F administered the insulin, [MEDICATION NAME], to the resident's left arm. The vial of insulin did not have an open date. During an interview on 8/29/17 at 8:20 a.m., staff member F stated all insulin vials should have a documented open date. The staff member stated if the insulin vial is not dated, the vial should be replaced with a new vial. She stated the vial of [MEDICATION NAME] should not have been used. During an observation on 8/29/17 at 10:30 p.m., staff member J administered the scheduled insulin medications, [MEDICATION NAME] and Levamir, to resident #12. Both doses of insulin were scheduled to be administered at 9:00 p.m. During an interview on 8/29/17 at 11:30 p.m., staff member J stated she was running behind which caused several scheduled doses of medications to be administered late. 4. Resident #16 was admitted to the facility with [DIAGNOSES REDACTED]. A review of resident #16's August 2017 MAR indicated [REDACTED]. The opened vial of insulin was dated 6/27/17; 63 days past the open date. During an interview on 8/29/17 at 11:00 p.m., staff member J stated the resident's 9:00 p.m. dose of [MEDICATION NAME] was going to be administered late. The staff member stated the scheduled dose of medication was administered late because she had forgotten to administer the dose of insulin. During an observation and interview on 8/29/17 at 11:03 p.m., staff member J was observed reading the open date of 6/27/17. She stated the resident's insulin was outdated, and that she would need to replace the vial of insulin prior to administering the resident's 9:00 p.m. dose of insulin. Staff member J stated she needed to check with another staff member, prior to administering the outdated insulin. The staff member stated it was probably okay to administer the insulin, but was not sure, and left the Prairie Lane unit. The staff member was observed entering the medication storage room where insulin was stored, and returned to the unit at 11:14 p.m., with a new vial of insulin. During an observation on 8/29/17 at 11:15 p.m., staff member J administered resident #16's 9:00 p.m. scheduled dose of [MEDICATION NAME]. During an interview on 8/29/17 at 11:17 p.m., staff member J stated she should not have administered the resident's scheduled dose of insulin at 9:00 p.m. on 8/28/17 and 8/27/17. 5. Resident #20 was to the facility with [DIAGNOSES REDACTED]. During an observation on 8/31/17 at 5:55 p.m., an opened vial of Humalog, 100 units/ ml, with the resident's name was discovered in the top drawer of the medication cart for the Meadow Lark unit. The vial of insulin did not have an open date. During an interview on 8/31/17 at 6:18 p.m., staff member I stated all insulin vials should have a documented open date. The staff member stated if the insulin vial is not dated, the vial should be replaced with a new vial. She stated the vial of [MEDICATION NAME] should not have been used. A review of the facility's policy, Medication Administration, page 1, read, h. The nurse checks insulin vials for date of opening and validating it is prior to the 28 day (sic) expiration limit. During Medication Pass: 5. The nurse follows the 5 Rights of Medication Administration: a Right Person b. Right Medication .c. Right Dose .Right Time: 8. Validated via MAR indicated [REDACTED].Right Route. Page 2, read, 8. The nurse obtains appropriate vital signs for designated medications (e.g. blood pressure for Hypertensive medications, pulse for cardiac medication, etc. as ordered by the physician). a. The licensed nurse follows parameters listed with the specific medication. Notifying the physician, as appropriate.

Based on interview, and record review, the facility failed to ensure all staff were trained and understood all seven components of abuse in accordance with the facility's abuse policies for 1 (#1) of 9 sampled residents. Findings include: During interviews conducted on 7/13/16, with staff members A, B, C, D, E, F, G, and H, management and direct care staff did not investigate or report an allegation of abuse that occurred in the facility on 6/18/16 around 11:15 a.m. See F223. During interviews conducted on 7/13/16, with staff members C, D, E, F, H, I, J, K, and L, none of the staff realized they were mandatory reporters and had to report alleged incidents of abuse to the appropriate State Agency. During an interview on 7/13/16 at 12:00 p.m., staff member C stated resident #1 told her about the abuse incident that occurred on 6/18/16. Staff member C said that conversation took place on 6/20/16. Staff member C did not report it to the State Agency. During an interview on 7/13/16 at 12:30 p.m., staff member B stated she had received a verbal report of the alleged abuse 6/18/16 from staff member E. Staff member B did not report the incident to the State Agency. During an interview on 7/13/16 at 1:00 p.m., staff member E said she contacted staff members A and B on 6/18/16. Staff member E said she told both of them about the abuse allegation involving resident #1, and staff member G's significant other. Staff member E said staff member A told her not to report the event to the State Agency. Staff member B told her to report it, and start the investigation. Staff member E said she followed staff member A's instructions, and did not report the event. During an interview on 7/13/16 at 3:05 p.m., staff member H said she saw staff member G's significant other talking to resident #1. Staff member H said she did not hear the conversation but when staff member G's significant other walked away from resident #1, she could tell something was wrong. Staff member H did not report her concerns to staff member E or to the State Agency. During an interview on 7/13/16 at 3:30 p.m., staff member D said she sent all the facility's incident reports to the State Agency. Staff member D said resident #1 told her about the abuse incident that happened on 6/18/16 on 6/21/16. Staff member D started filling out a grievance form for resident #1. Staff member D did not report the abuse incident to the State Agency. During an interview on 7/13/16 at 5:35 p.m., staff member I stated resident #1 told him about staff member G's significant other telling him to stay away from staff member G on 6/18/16. Resident #1 was upset at the time due to the incident. Staff member I said he reported what resident #1 had told him to staff member E. Staff member I said he could not believe staff members G and H stood by and did nothing to prevent the incident. During an interview on 7/13/16 at 10:05 a.m., staff member A said all staff received abuse training monthly at the All Staff Meeting. Staff member A said all staff are required to attend this meeting, and the meeting is held for every shift. Staff member A provided a document titled In-service/Education Summary. The document was dated 5/25/16, and covered multiple topics. One of the topics staff were educated on during this inservice was Abuse. Staff member A provided the facility's policies on Abuse. Facility policies showed: - Policy: Abuse, Neglect, and Misappropriation of Resident Property Prohibition Policy Statement: Each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion, and misappropriation of property. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family member and others who may have unsupervised access to residents. Definitions: Abuse: The willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. Verbal Abuse: The use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or with in their hearing distance regardless of their age, ability to comprehend or disability. Physical Abuse: The willful action of inflicting bodily injury or physical mistreatment. Physical abuse includes, but is not limited to striking with or without an object, slapping, pinching, choking, kicking, shoving, prodding, or the use of chemical restraint or physical restraints unless the restraints are consistent tent with licensing requirements and includes restraints that are otherwise being used inappropriately. Mental Abuse: Includes but is not limited to, coercion, harassment, inappropriately isolating a vulnerable adult from family, friends, or regular activity, and verbal assault that includes ridiculing, intimidating, yelling or swearing. Mandatory Reporter: Anyone who is an employee, manager, agent, operator, owner or contractor of a Medicare or Medicaid certified nursing facility, intermediate care facility, intellectual disabilities (ICF/ID) or hospice. Reasonable Cause to Believe: A mandated reporter thinks it is probable that an incident of abuse, abandonment, neglect, or financial exploitation happened. Probable means that based on information or evidence readily obtained from various sources, it is likely the incident occurred. Reason to Suspect or Reasonable Suspicion: A mandated reporter thinks, based on information readily obtained from various sources, it is possible that something happened. Procedure: 2. Training a. The Center trains each employee regarding the abuse prohibition policies and related policies and processes. 3. Prevention b. Center supervisors immediately intervene and correct reported or identified situations in which abuse, neglect or misappropriation of resident property and intervene as appropriate. 5. Investigation a. The Center conducts a thorough investigation of allegations of mistreatment, neglect or abuse, including injuries of unknown source and misappropriation of resident property in accordance with state and federal regulation. b. The Center reports allegations to the state survey and certification agency and appropriate state agency per state regulation. The Center reports investigation findings to the state survey and certification agency and appropriate state agency per state regulation within 5 working days of the event. If the allegation is verified, the report includes appropriate corrective action taken. 7. Reporting and Response b. The Center reports allegations and substantiated occurrences of abuse, neglect, misappropriation of property or injuries of unknown source to the state survey and certification agency and appropriate state agency and law enforcement officials in accordance with state regulation. -Policy: Abuse, Neglect, or Exploitation 13. Any staff member may notify the appropriate state agency of suspected/alleged abuse, neglect or exploitation without fear of retribution. It is the responsibility of each employee to assure compliance with state abuse or suspected abuse reporting regulations. a. If the Community Director or his/her designee does not report the incident to the State, a staff member should. However, the employee should first verify with the Community Director that the incident has not already been reported before contacting a state agency.

Based on observation, interviews, and record review, the facility failed to protect, investigate, and report, to the State Agency, the alleged abuse of 1 (#1) of 9 sampled residents; specifically from an individual who was not employed by the facility but was a significant other of a staff member. Findings include: Based on interviews on 7/13/16 from 9:00 a.m. to 5:30 p.m., with staff members A, B, C, D, E, G, H, and I, and resident #1, the following information was obtained: On 6/18/16 at around 11:15 a.m., the significant other of staff member G entered the facility to see her. Staff member G and staff member H were in the dining room preparing to pass medications at the noon meal. The significant other spoke to staff member G at her medication cart. The significant other then walked over to resident #1 which was when the event took place. During an interview and observation on 7/13/16 at 4:30 p.m., resident #1 said, This man was at staff member G's medication cart talking to her then he walked over to me. I was sitting at my place at the dining room table. He asked if I was (resident's name)? I told him Yes, that's me. Resident #1 stated the man told him that staff member G was his girlfriend, and said to resident #1 You had better leave my girlfriend alone, exhibiting how the man poked him on the left side of his body, below his collar bone. Resident #1 stated he was not afraid of the significant other. He said he was upset with and mad at staff member G's significant other. Review of resident #1's Quarterly MDS, with an ARD of 7/8/16, C0500, showed the resident had a BIMS (brief interview for mental status) of 15. This showed resident #1 was cognitively intact. Resident #1's current Quarterly MDS, with an ARD of 7/8/16, E0200(a), showed the resident had no physical behavioral symptoms directed towards others, and section E0200(b) showed the resident had no verbal behavioral symptoms directed towards others. During the interview, staff member G came into the dining room with her medication cart. Resident #1 asked to go someplace else to talk. After changing locations, the interview was continued. Resident #1 stated he used to talk to staff member G, and he had thought they were good friends. During an interview on 7/13/16 at 2:45 p.m., staff member G stated resident #1 was a nuisance, and he was always talking to her when she was trying to get her work done. During an interview on 7/13/16 at 10:05 a.m., staff member A said she did not file an incident report on the occurrence, which happened 6/18/16, because it involved a staff member's significant other. Staff member A said the facility's policy titled Montana Mandatory Reporting directed the facility to report abuse of a resident to the State Agency only if it involved the following: 1) Resident to resident abuse, 2) Staff to resident abuse, 3) Volunteer to resident abuse, or 4) Other employee to resident abuse. Staff member A stated she did not know she had to report resident abuse if an individual, not employed by the facility, abused a resident. See F226. During an interview on 7/13/16 at 12:00 p.m., staff member C said resident #1 told her about the 6/18/16 incident on 6/20/16. Staff member C also said resident #1 told her that he was not afraid of the individual who had threatened him. Staff member C said resident #1 was staying in his room more than he had before, and that he would not go down a hallway if staff member G was on that particular hallway. Staff member C stated she asked resident #1 why he was staying in his room all the time. He would tell her he did not feel well or that he just wanted to stay in his room. Staff member C said prior to this incident resident #1 was socially active with staff and other residents, and participated in event's occurring at the facility. Staff member C stated she asked staff members A and B what was being done about the incident, and if it had been reported to the State Agency. Staff member C said she was told by both staff A and B that it was not a reportable incident. Staff member C stated resident #1 repeatedly asked what was being done about the incident. Staff member C stated the incident needed to be investigated and reported to the State Agency. See F226. During an interview on 7/13/16 at 12:30 p.m., staff member B stated she received a text message on her phone from staff member E on 6/18/16. Staff member B stated she did not see the text message until later in the day on 6/18/16. Staff member B said she called and told staff member E to start the incident report and investigation. Staff member E told staff member B that she had already contacted staff member A, and was instructed by staff member A to do nothing. She was told by staff member A that it was not a reportable incident because it involved a person from outside the facility. Staff member B said she thought the process for reporting and investigating abuse might different in this situation since it involved a person from outside of the facility. Staff member B stated she thought the incident should have been reported and investigated by the facility. See F226 During an interview on 7/13/16 at 1:00 p.m., staff member E said a CNA (certified nursing assistant) told her about the incident with resident #1 and staff member G's significant other. The event occurred in the dining room. Staff member E said she sent a text message to staff member B. Staff member E said when she did not get a response from staff member B, she called staff member A. Staff member A said she would report the incident and interview staff on Monday. Staff member E said staff member B called later in the day on 6/18/16, and told staff member E told to start an investigation. Staff member A told staff member B that staff member A had said to do nothing about the event, and that she, staff member A, would do interviews on Monday. In a morning meeting on 6/22/16, staff member E stated that staff member A said the incident was not reportable to the State Agency. Staff member E said staff member C asked about an investigation into the incident several days later, and was told by staff member A to Leave it alone, she had handled it. During an interview on 7/13/16 at 2:45 p.m., staff member G said she saw her significant other talking to resident #1. Staff member G said she was not close enough to hear what her significant other said to the resident. Staff member G said she did not see her significant other direct any threatening behavior at resident #1. During an interview on 7/13/16 at 3:05 p.m., staff member H said she was in the dining room on 6/18/16 at the time of the incident between staff member G's significant other and resident #1. Staff member H said she was not close enough to hear what staff member G's significant other said to resident #1. Staff member H said they both appeared to be laughing, then staff member G's significant other said something to the resident, and the resident quit laughing. Staff member H said staff member G's significant other then left the dining room. Staff member H said she tried to follow up on the incident by asking staff member E about the status of the investigation. Staff member H was concerned about resident #1's behavior, stating it had changed since the incident occurred. Staff member H said resident #1 was staying in his room more, and did he not appear to be his usual happy self. During an interview on 7/13/16 at 3:30 p.m., staff member D stated when she received the Grievance Form from the resident on 6/21/16, the top section of the form had been completed. Staff member D said staff member A told staff member B and D to get rid of any notes, forms, or reports they may have on the 6/18/16 incident. Staff member D also said resident #1 avoided being in any area where staff member G was working. During an interview on 7/13/16 at 4:00 p.m., staff member F stated that she never heard staff member A tell other staff not to worry about the incident or that staff member A was taking care of it. Staff member F said, As a matter of fact (staff name) was questioning staff if the incident report, interviews, and paperwork was being completed. During an interview on 7/13/16 at 4:15 p.m., staff member A said the facility administrator was responsible for all abuse investigations being completed, and for reporting to the State Agency. During an interview on 7/13/16 at 5:35 p.m., staff member I said resident #1 told him about the incident when staff member I came on shift the afternoon of the event. Staff member I said he went to staff member E and reported the incident right away. Staff member I stated he was upset with staff member G and H because they were right there when the incident happened, and did nothing to protect resident #1 while he was getting reamed out by staff member G's significant other, and they did not report the incident to the charge nurse.

Based on interview, observation, and record review, the facility failed to evaluate, maintain, and promote the psycho-social status for 1 (#1) of 9 sampled residents. Findings include: Review of resident #1's current Annual MDS assessment, with an ARD of 1/11/16, F500(e) showed it was very important to resident #1 to do things with groups of people, and F500(f) showed it was very important for resident #1 to do his favorite activities. A record review showed the facility failed to identify, address or monitor the changes in resident #1's social behaviors. The behaviors started occurring after the resident was verbally and physically abused by staff member G's significant other on 6/18/16. During an interview on 7/13/16 at 12:00 p.m., staff member C said resident #1 was staying in his room more since the incident on 6/18/16. Staff member C said resident #1 would make excuses not to leave his room. These excuses included: he did not feel good or he was having problems with his [MEDICATION NAME] bag. Staff member C stated resident #1 was always out and about in the facility socializing, and participating in any events at the facility prior to the incident on 6/18/16. See F223. During an interview on 7/13/16 at 3:05 p.m., staff member H said resident #1 had started secluding himself in his room since the incident that occurred on 6/18/16 and was not his usual happy self. See F223. During an interview on 7/13/16 at 3:30 p.m., staff member D said resident #1 would not go into any hallway or room were staff member G was present. During an interview and observation on 6/18/16 at 4:30 p.m., with resident #1, staff member G entered the dining room where the interview was being conducted. Resident #1 did not want to continue the interview in the dining room and requested to complete it elsewhere.