Every finding on record at Liberty Community Living CTR

Based on observation, interview, and facility policy review, the facility failed to ensure food items were stored, dated, and maintained in accordance with professional food safety standards for one (1) of three (3) kitchen observations.Findings include:A review of the facility's Food Storage Areas Policy and Procedures, undated, revealed, .Dry storage areas will be kept in a condition which protects foods from infestation. Procedure: 1. All items must be stored at least 6 inches off the floor .Care of the Storeroom [ROOM NUMBER]. The staff will maintain care of the storeroom according to the following directions.b. New stock is placed in back of previously delivered items so that older stock will be issued first. C. Refrigerated and frozen foods are dated upon delivery. Foods with expiration dates are used prior to date on the package.On 12/1/25 at 10:30 AM, during an observation of the kitchen with the Dietary Manager (DM), the dry storage room contained two (2) dry storage bins holding rice and sugar that were not dated. A twenty-five (25) pound bag of [NAME] sugar and a twelve (12) pound bag of [NAME] coffee were stored directly on the floor. A sugar-free no-bake cheesecake mix and a box of powdered sugar were observed opened and stored in clear Ziploc bags without labels or dates. Nine (9) [NAME] Monte bananas stored in a box were black with dark brown spots; one banana was split open, black, and mushy. In the refrigerator, fifty (50) single-serve Hiland chocolate milk cartons were dated 10/27/25, and twenty (20) cartons were dated 11/20/25. Seventy-six (76) single-serve Daily sour cream packs stored in two brown boxes were dated 3/5/25.On 12/1/25 at 10:55 AM, during an interview with the DM, she acknowledged the expired chocolate milk and sour cream should have been discarded on the expiration date. She explained that serving expired dairy products could result in residents developing gastrointestinal illness. She reported she was responsible for checking behind dietary staff. She confirmed that no food items should be stored on the floor, that all refrigerated items should be labeled and dated, that the bananas should have been discarded, and that dry storage bins were required to be dated. She explained the purpose of dating and labeling food items was to prevent spoiled food from being served to residents.On 12/4/25 at 1:25 PM, during an interview, the Nursing Home Administrator (NHA) explained she expected the Dietary Department to follow facility policy and regulatory requirements to ensure resident safety. The NHA reported she expected dietary staff to rotate stock daily and remove all expired food items from the kitchen.

Based on observation, interview, record review, and facility policy review, the facility failed to provide an ongoing program of individualized activities to meet the physical, mental, and psychosocial needs of residents residing on the Dementia Unit for two (2) of two (2) sampled residents reviewed on the Alzheimer's Unit (Residents #9 and #63), with the potential to affect all nineteen (19) residents on the unit.Findings include: A review of the facility's, Life Connections Program, revised May 4, 2021, revealed, Policy .Procedures. Life Connection Programs should be designed as an ongoing resident-centered activities program that incorporates the residents' interests . Life Connections activity may be scheduled seven (7) days a week . Specialized activities will be available for residents with cognitive impairment .Resident #9A record review of the admission record revealed the facility admitted Resident #9 on 4/5/23 with diagnoses including Vascular Dementia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/30/25 revealed Resident #9 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated her cognition was moderately impaired.Resident #63A record review of the admission record revealed the facility admitted Resident #63 on 4/6/22 with diagnoses including Unspecified Dementia.A record review of the Quarterly MDS with an ARD of 9/18/25 revealed Resident #63 had a BIMS score of 3, which indicated her cognition was severely impaired.On 12/1/25 at 10:20 AM, during an observation of the Alzheimer's Unit dayroom, there were no activities in progress and many of the residents were sitting in the dayroom with the television on.On 12/3/25 at 12:07 PM, during an observation and interviews on the Alzheimer's Unit, the residents, including Residents #9 and #63, were seated in the dining hall eating lunch. No music or other sensory engagement was provided. Certified Nursing Assistant (CNA) #1 stated many residents had requested music during meals and that the unit's CD player had been removed some time ago. CNA #1 reported she had requested a replacement from administration, but none had been provided. Resident #9 stated music brought her peace when she was growing up and she desired it now more than ever. Resident #63 stated the residents needed music because it was soothing.On 12/3/25 at 12:46 PM, during an observation of the unit activity board and interview with Resident #9, there were two calendars posted, in which one was designated for daytime activities and one for evening activities. Neither calendar listed any times for when the activities would occur. The 12/3/25 Day calendar listed This Day in History, and the 12/3/25 Evening calendar listed Matching Cards, both without scheduled times. Resident #9 stated she did not know what This Day in History was and reported the only activity provided was watching television. She added that staff do not come to interact with them, nor do they perform the activities listed on the calendar.A record review of the Activity Calendar for December revealed a calendar for Morning Activities and Evening Activities with one activity listed per date and no specified time the activity was scheduled.On 12/3/25 at 12:48 PM, during an interview with CNA #1, she reported that no one comes to the unit to provide activities and that residents wake, eat, watch television, and sleep. She explained that the residents need some type of additional engagement, something that stimulates them, and commented that just because they have dementia, that does not mean they would not enjoy activities.On 12/3/25 at 12:51 PM, during an interview with CNA #2, she reported that although an activity calendar is posted, no activities are provided and residents remain in the dayroom watching television. She confirmed that no one from the activities department had come to the unit that day.On 12/3/25 at 1:00 PM, during an interview with Registered Nurse (RN) #1, Dementia Unit Manager, she confirmed that activities were not being provided on the unit. On 12/4/25 at 10:36 AM, during an interview with the Activities Assistant Coordinator, he confirmed he was responsible for Dementia Unit activities and acknowledged that many scheduled activities had not been conducted. He stated he was often assigned to other duties that prevented him from completing activities.On 12/4/25 at approximately 10:41 AM, during an interview with the Director of Nursing (DON), she stated she had identified that activities were not consistently provided on the Dementia Unit and had instructed the Activities Assistant Coordinator to conduct activities daily.On 12/4/25 at 10:57 AM, during an interview with the Administrator, she reported she was not aware that activities were not being conducted. She stated it was regulatory for residents to have activities every hour on the hour. She stated music was important to creating a pleasant environment and residents should have music when desired.

Based on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to store food in accordance with professional standards for food service safety related to food items not dated, exposed foods, and expired foods during an annual recertification survey on 8/22/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of ten (10) deficiencies cited. F812 Findings include:A review of the facility's, QAPI Plan, undated, revealed, .Aspects of service and care are measured against established performance goals. Key performance indicators are measured and trended on a quarterly basis. The QAPI Committee analyzes performance to identify and follow-up on areas of opportunity. The facility will utilize the best available evidence.to define and measure goals. The facility continually identifies opportunities for improvement and reviews the following areas to prioritize opportunities .Record review of the Provider History Report revealed the facility received a citation for F812 - Food Procurement, Store/Prepare/Serve-Sanitary with a Plan/Date of Correction of 10/18/2024.Record review of the CMS-2567 (a record that identifies the federal regulation in violation and describes the findings of noncompliance and the facility's plan of correction), with a survey date 8/22/24, revealed the facility received a citation for F812, .Based on observation, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, exposed foods, and expired foods in one (1) of two (2) kitchen observations.During the current recertification survey, the facility failed to ensure food items were stored, dated, and maintained in accordance with professional food safety standards for one (1) of three (3) kitchen observations.On 12/4/25 at 10:57 AM, during an interview with the Administrator, she stated she was unsure why the dietary department was cited again. During her meetings with the Dietary Manager, she indicated that everything was labeled and dated, and there were no expired foods on the shelves.

Based on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from invasion of personal privacy when the Administrator took and shared photographs of the resident without his consent for one (1) of 19 sampled residents. Resident #10 Findings Include:A review of facility's Residents Rights and Qualify of Life Policy and Procedure, undated, revealed, .All residents have the right to a dignified existence, self-determination and communication and access to people and services inside and outside the facility .A record review of the admission Record revealed the facility admitted Resident #10 on 10/12/25, with diagnoses including Quadriplegia. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/18/25 revealed Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact.On 12/01/2025 at 2:05 PM, in an interview, Resident #10 stated that the Administrator followed him in her personal vehicle when he left the facility to get a haircut on November 5, 2025. He stated that the Administrator took pictures of him and sent them to his mother without his permission. The resident expressed that this upset him and violated his right to privacy.On 12/03/2025 at 9:59 AM, in a phone interview with Resident #10's mother, she stated she had not heard from her son that day (11/5/25) and had asked a friend at the facility to check on him. She reported that the Administrator called her shortly afterward and stated that the resident had gone to get a haircut. The Administrator then texted her pictures of Resident #10 taken at a red light, stating she was watching him from her car. The mother confirmed she did not ask for pictures and stated she felt it was inappropriate and a violation of his privacy.On 12/03/2025 at 10:36 AM, in an interview with the Administrator, she confirmed that Resident #10 frequently leaves the facility independently in his power chair. She stated that on the day in question, she was aware the resident's mother was concerned after not hearing from him. The Administrator reported she took it upon herself to drive and look for the resident. She admitted she took pictures of him from her car and texted them to his mother. She stated she was not thinking about privacy at the time but acknowledged that it could be viewed as a violation of resident rights.On 12/04/2025, in an interview with the Director of Nursing (DON), she stated she had heard the resident mention something about photos being taken but was unaware of details. She confirmed that photos should not be taken of residents without their consent and doing so would be an invasion of privacy.

Based on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions related to oral hygiene (Resident #57) and Percutaneous Endoscopic Gastrostomy (PEG) care (Resident #70) for two (2) of 19 sampled residents. Findings Include:A review of the facility's Care Plan Policy and Procedure, undated, revealed, .Each resident's care plan will remain current and inform staff of resident's needs.Resident #57A record review of the admission Record revealed the facility admitted Resident #57 on 2/14/25 with diagnoses including Need for Assistance with Personal Care. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated her cognition was severely impaired.A record review of the Care Plan Report revealed Resident #57 had a care plan Focus of (Proper name of Resident) has an ADL self-care performance deficit. with Interventions/Tasks including Oral hygiene: setup/clean x's (times) 1 person assist.During an observation and interview on 12/1/25 at 2:29 PM, Resident #57 was lying in bed and reported she did not receive mouth care daily. She had visible discoloration and debris on her teeth. During an observation and interview on 12/3/25 at 3:23 PM, Resident #57 was in her room with her spouse present. Resident #57 explained that her teeth had not been brushed that day and her teeth had visible discoloration and she had a mouth odor.During an observation and interview on 12/3/25 at 3:50 PM, during an observation and subsequent interview, CNA #5 confirmed that Resident #57 had visible discoloration and debris on her teeth. She reported she brushed Resident #57's teeth that day but acknowledged she should have provided oral care more than once and further explained that Resident #57's teeth should be brushed after every meal.Resident #70A record review of the admission Record revealed the facility admitted Resident #70 on 2/11/25 with diagnoses including Dysphagia.A record review of the Order Summary Report revealed Resident #70 had a Physician's Order, dated 2/11/25 to clean the Percutaneous Endoscopic Gastrostomy (PEG) site daily with warm soap and water.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25 revealed Resident #70 required a staff assessment for mental status and that her cognitive skills for daily decision making was severely impaired. A record review of the Care Plan Report revealed Resident #70 had a care plan Focus of (Proper Name of Resident) has PEG tube to upper mid abdomen. with Interventions/Tasks of Clean peg site daily with warm soap and water cover with dry dressing every day.During an observation of PEG tube care on 2/3/25 at 2:05 PM, Licensed Practical Nurse (LPN) #2 removed Resident #70's PEG tube dressing and cleaned only the external PEG tubing with soap and water. She dried the tubing with a dry gauze. The LPN did not clean the PEG tube insertion site.During an interview on 12/3/25 at 3:28 PM, LPN #2 she confirmed that not cleaning the PEG insertion site could cause residue to build up around the entry site and cause an infection.During an interview on 12/4/25 at 11:56 AM, LPN #3/Care Plan nurse explained that care plan interventions are to be used by staff to provide care as it focuses on patient care. During an interview on 12/04/2025 at 12:10 PM, the Director of Nursing (DON) stated she expected staff to provide care according to the resident's care plan.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) care, including oral hygiene was provided for one (1) of one resident who required staff assistance with oral care, Resident #57.Findings include:A review of the facility's ADL Care of A Resident Policy And Procedure, undated, revealed .Resident ADL care will be provided to the resident according to the individualized resident needs .A record review of the admission Record revealed the facility admitted Resident #57 on 2/14/25 with diagnoses including Need for Assistance with Personal Care. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated her cognition was severely impaired.On 12/1/25 at 2:29 PM, during an observation and interview with Resident #57, the resident was lying in bed and reported she did not receive mouth care daily. She explained that when she requested oral care, staff told her they would return but did not do so. She reported her teeth were previously white and had become stained. An observation of Resident #57's mouth revealed visible discoloration and debris on the teeth. She reported the last time she received oral care was the prior Wednesday or Thursday.On 12/2/25 at 3:30 PM, during an observation of Resident #57 lying in bed, the resident reported she had been in bed most of the day and had not had mouth care that week.On 12/3/25 at 3:23 PM, during an observation and interview with Resident #57 at bedside with her spouse present, the resident reported her teeth had not been brushed that day. An observation revealed visible discoloration and mouth odor.On 12/3/25 at 3:45 PM, during an interview with Certified Nursing Assistant (CNA) #5, the CNA reported she was assigned to Resident #57 that day and had provided a bed bath and brushed the resident's teeth once. She explained Resident #57's teeth should be brushed after every meal.On 12/3/25 at 3:50 PM, during an observation and subsequent interview, CNA #5 confirmed that Resident #57 had visible discoloration and debris on the teeth. She reported she brushed Resident #57's teeth that day but acknowledged she should have provided oral care more than once.On 12/3/25 at 4:00 PM, during an interview with the Director of Nursing (DON), she explained that visible buildup on teeth develops over time and not within a few days. She reported her expectation was that Certified Nursing Assistants provide daily oral care, personal care, and hygiene according to individual resident needs.

Based on observation, interview, record review, and facility policy review, the facility failed to provide care and services in a manner to prevent complications for one (1) of three (3) residents reviewed for tube feeding and nutrition, Resident #70.Findings include:A review of the facility's Enteral Feeding Tube - Care of Procedure, undated, revealed, .Purpose: to prevent irritation and skin breakdown around feeding tube.Procedure.4. Clean skin around tube with warm water and soap or wound cleaner.A record review of the admission Record revealed the facility admitted Resident #70 on 2/11/25 with diagnoses including Dysphagia.A record review of the Order Summary Report revealed Resident #70 had a Physician's Order, dated 2/11/25 to clean the Percutaneous Endoscopic Gastrostomy (PEG) site daily with warm soap and water.A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25 revealed Resident #70 required a staff assessment for mental status and that her cognitive skills for daily decision making was severely impaired. On 12/3/25 at 2:05 PM, during an observation of PEG tube care performed by Licensed Practical Nurse (LPN) #2 for Resident #70, the LPN removed the PEG tube dressing and cleaned only the external PEG tubing by wiping from bottom to top on each side using gauze saturated with soap and water. She dried the tubing with a dry gauze. The LPN did not clean the PEG tube insertion site.On 12/3/25 at 3:28 PM, during an interview with LPN #2, she confirmed that not cleaning the PEG insertion site could cause residue to build up around the entry site and cause an infection.On 12/3/25 at 4:10 PM, during an interview with the Director of Nursing (DON), she stated the purpose of cleaning the PEG site correctly was to prevent infection. She reported the manner in which LPN #2 performed PEG care could cause infection and presented a cross-contamination issue.

Level IIBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications and biologicals were securely stored and properly labeled when a controlled substance returned by a resident was left unlabeled on a medication cart and when a wound care cart containing treatment chemicals was unlocked and accessible to residents for two (2) of three (3) medication/treatment carts reviewed. Findings Include:A review of the facility's Medication Storage Policy and Procedure, undated, revealed, .Policy: 1. Medications and biologicals will be maintained in a secured location only accessible to designated staff.On 12/2/25 at 1:33 PM, during an observation of a medication cart with Licensed Practical Nurse (LPN) #1, a loose pill was noted in a clear plastic sleeve labeled 12 PM but without the resident's name, drug name, strength, dosage, or any identifying information. LPN #1 identified the pill as Oxycodone-Acetaminophen Tablet 5-325 milligrams (mg) that Resident #10 had checked out when leaving the facility on pass and returned that morning. The pill had been placed on the cart without a label and without secure storage.On 12/2/25 at 1:35 PM, during an interview with LPN #1, she reported she placed the medication on the cart after the resident returned it and planned to notify the night nurse during shift report. When asked how other nurses would know what the medication was, she acknowledged they would not and confirmed that the medication could be administered in error or diverted since it was unlabeled and unsecured. She stated she should have asked the Director of Nursing (DON) how to handle the medication upon return.On 12/3/25 at 2:18 PM, during an observation and interview with LPN #2, the wound care cart on the 400 hall was observed. Although the cart appeared locked, with the lock pushed inward, all drawers opened freely. The cart contained wound treatment supplies including triple antibiotic ointment, calamine lotion, MediHoney, and Nystatin powder. LPN #2 confirmed she believed the cart was locked but realized it was fully accessible and acknowledged that residents, including cognitively impaired residents, could access the unsecured chemicals.On 12/4/25 at 9:27 AM, during an interview with the DON, she stated the returned Oxycodone 5 mg tablet for Resident #10 should have been destroyed by two nurses per facility policy and should not have been left on the medication cart. She explained the risks included medication error or diversion since the pill was unlabeled and unaccounted for. Regarding the wound care cart, the DON stated the cart had been unable to lock since September 2025 and should not have been stored on the hallway. She explained the interim process was for staff to pull treatments from the cart and store supplies in the medication room. The DON confirmed residents could ingest wound chemicals if the cart remained unlocked and acknowledged that wandering residents lived on the unit. The DON provided documentation showing the facility received a quote for a new cart on 9/12/25 and ordered a replacement on 11/18/25.A record review of the admission Record revealed the facility admitted Resident #10 on 10/12/25, with diagnoses including Quadriplegia. A record review of the Order Summary Report revealed Resident #10 had a Physician's Order, dated 10/10/24 for Oxycodone-Acetaminophen Tablet 5-325 milligrams.

Based on observation, interview, and record review, the facility failed to ensure a resident received a diet and follow-up dental care consistent with the resident's nutritional needs and edentulous status when the resident remained without dentures for over two (2) months and continued to receive regular-texture meals for one (1) of nineteen (19) sampled residents (Resident #76).Findings Include:On 12/01/2025 at 1:50 PM, in an interview, Resident #76 stated his teeth had been lost in the laundry. The facility had taken him to a dentist about a month ago for a fitting, but he had not heard anything further about replacement dentures.On 12/03/2025 at 12:35 PM, an interview and observation of Resident #76 revealed he had a lunch tray consisting of fried chicken, green beans, mashed potatoes, and cornbread. He reported difficulty chewing the meat without his teeth and stated that meals often included pork chops or other tough meats. He expressed that it was hard for him to cut and swallow food without dentures. The tray was identified as a regular diet with no accommodation for edentulism.On 12/04/2025 at 10:30 AM, in an interview with Resident #76's Certified Nurse Aide (CNA) #6, she stated that the resident feeds himself but frequently complains that meat on his tray is hard to chew. She confirmed he is receiving a regular diet and stated that he could probably benefit from an easier diet for people with no teeth. She further reported that she was aware he had an appointment for dentures a few months ago.On 12/04/2025 at 10:50 AM, in a phone interview with the receptionist at the dental office, she confirmed Resident #76 was seen on 09/11/2025 for an initial evaluation and limited x-ray, but was not fitted for dentures at that time. She stated there had been no follow-up from the facility, and as of 12/04/2025, he had not returned. She explained that the full denture process typically takes approximately two months and that the resident could have had his dentures by mid-November if the process had continued appropriately.On 12/04/2025 at 12:14 PM, in an interview with the Director of Nursing (DON), she confirmed that she was unaware the resident had not returned for a follow-up visit since the initial appointment in September. She explained that the transportation CNA is responsible for notifying the DON or nursing team after appointments and making arrangements for any required follow-up. She confirmed this did not occur for Resident #76.On 12/04/2025 at 2:07 PM, in an interview with the Administrator, she confirmed that the resident had not returned to the dental provider and that she personally contacted the office on 12/04/2025 to schedule a follow-up once she became aware. She stated the resident now has a same-day appointment.A record review of the admission Record revealed the facility initially admitted Resident #76 on 9/18/24 with diagnoses including Type 2 Diabetes Mellitus. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/10/2025 indicated Resident #76 had a Brief Interview for Mental Status (BIMS) score of 9, reflecting moderate cognitive impairment.A record review of the Order Summary Report revealed Resident #76 had a Physician's Order, dated 9/18/24, for a Regular diet, Regular texture, Regular consistency.

Based on observation, interview, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices during indwelling catheter care (Resident #6), and failed to follow hand hygiene, glove-use, surface sanitation, and Enhanced Barrier Precautions (EBP) requirements during enteral feeding tube care (Resident #70) for two (2) of three (3) residents reviewed for care. Findings include: A review of the facility's Hand Hygiene Policy and Procedure, dated 4/11/23, revealed, .Hand hygiene will be performed by all staff consistent with accepted standards of practice, to reduce the spread of infection and prevent cross contamination. A review of the facility's Isolation Policy and Procedure, undated, revealed, .Enhanced Barrier Precautions (EBP): 1. EBP Precautions are utilized for residents that have wounds and/or indwelling medical devices (Central line Catheter, feeding tube.).2. PPE (Gloves and gown prior to the high-contact care activity) is to be utilized.during high-contact resident care activities.g. Device care or use (Central line, urinary catheter, feeding tube.). Resident #6 On 12/2/25 at 1:50 PM, during an observation of catheter care performed by Certified Nursing Assistant (CNA) #3 for Resident #6, CNA #3 washed the soiled catheter tubing, rinsed it, and patted it dry while continuously wearing the same gloves. She then touched the resident's shoulder and thigh to reposition him without removing gloves or performing hand hygiene. On 12/2/25 at 1:55 PM, during an observation of perineal care provided by CNA #4 for Resident #6, CNA #4 removed a soiled brief after a bowel movement while wearing gloves and then used the bed remote with the same soiled gloves, contaminating environmental surfaces. On 12/2/25 at 1:56 PM, during an interview with CNA #4, she confirmed she should have removed soiled gloves and performed hand hygiene prior to touching environmental surfaces. She acknowledged the risk of spreading infections. On 12/2/25 at 2:01 PM, during an interview with CNA #3, she confirmed she should have removed gloves, performed hand hygiene, and reapplied clean gloves prior to repositioning Resident #6. She acknowledged the potential for the spread of infection from the catheter area. On 12/4/25 at 9:30 AM, during an interview with the Director of Nursing (DON), she stated her expectation was that staff change gloves and perform hand hygiene after each care task. The DON reported that CNA #3 could have spread infection from the catheter area and CNA #4 could have spread infection from fecal matter to surfaces in the resident's room. A record review of the admission Record revealed the facility admitted Resident #6 on 1/13/25 with diagnoses including Chronic Obstructive Pulmonary Disease. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/25 revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 8, indicating moderate cognitive impairment. A record review of Orders tab in the electronic medical record, revealed Resident #6 had a Physician's Order, dated 11/25/25 for catheter care. Resident #70 On 12/3/25 at 2:15 PM, during an observation of Percutaneous Endoscopy Gastrostomy (PEG) tube care performed by Licensed Practical Nurse (LPN) #2 for Resident #70, LPN #2 donned a gown and gloves at the entrance and performed hand hygiene before applying gloves. She then opened the clean supply cart multiple times and used the computer mouse while wearing gloves. She entered the room, placed supplies directly on the bedside table without sanitizing the surface or using a barrier, and pressed buttons on the feeding pump while wearing gloves. She removed the PEG dressing while still wearing the same gloves. She cleaned only the PEG tubing, not the insertion site. She removed gloves and reapplied clean gloves without performing hand hygiene. She dried the tubing with gauze, then again removed gloves, performed hand hygiene, and reapplied gloves. She removed a syringe from a storage bag and attempted to flush 150 cubic centimeters (cc) of water; when the water did not move, she used the plunger, met resistance, and exited the room to obtain a stethoscope. She removed her gown, gloves, and supplies upon exit. On 12/3/25 at 2:45 PM, during an observation of LPN #2 returning to Resident #70's room, she applied gloves without performing hand hygiene and not donning a gown before flushing the tube. She gathered supplies and exited the room without performing hand hygiene. On 12/3/25 at 3:28 PM, during an interview with LPN #2, she confirmed she did not sanitize the bedside table or place a barrier before placing supplies. She confirmed she touched the cart, computer mouse, and feeding pump with gloved hands. She stated she should have removed gloves and washed her hands before beginning PEG care and before re-gloving. She confirmed she removed the PEG dressing with contaminated gloves. She reported she did not perform hand hygiene frequently enough and stated the purpose of Enhanced Barrier Precautions was to protect residents from organisms present on staff clothing. On 12/3/25 at 4:10 PM, during an interview with the DON, she stated LPN #2 should have washed her hands before and after care and upon room entry. She stated the PEG site must be cleaned correctly to prevent infection. She stated a barrier should have been used before placing supplies on the bedside table. She stated Enhanced Barrier Precautions were expected during PEG tube care to protect residents from infection. She reported that the manner in which LPN #2 performed care presented a cross-contamination risk. A record review of the admission Record revealed the facility admitted Resident #70 on 2/11/25 with diagnoses including Dysphagia. A record review of the Order Summary Report revealed Resident #70 had a Physician's Order, dated 2/11/25 to clean the Percutaneous Endoscopic Gastrostomy (PEG) site daily with warm soap and water. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/30/25 revealed Resident #70 required a staff assessment for mental status and that her cognitive skills for daily decision making was severely impaired. A record review of the Enhanced Barrier Precautions signage posted on Resident #70's door revealed staff were to wear gown and gloves for high-contact care activities, including feeding tube care.

Based on interviews, record reviews, and facility policy review, the facility failed to employ proper bookkeeping techniques and prevent the commingling of resident funds for one (1) of four (4) residents reviewed with the potential to affect any residents who have or have had a resident trust fund. Resident #3 Findings include: Review of the facility policy titled, Freedom from Abuse, Neglect and/or Exploitation Prevention Plan - Education, revised 8/23/17, revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation by anyone, including, but not limited to, facility staff . Misappropriation of resident property - Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . On 11/14/24 at 1:46 PM, during a telephone interview, the Resident Representative (RR) for Resident #3 stated that she had been contacted by the current facility Business Office Manager (BOM) and was asked about her mother's funds, specifically the money earmarked for her mother's funeral expenses. The RR added that at the time of her mother's admission to the facility, her mother had three thousand, eight hundred dollars ($3800.00) in her bank account that had been saved to assist with her funeral expenses. The RR stated that she was told the entire amount of money in the resident's bank account could be deposited in a resident trust account at the facility and that the entire amount would be earmarked for funeral expenses and would be available at the time of the resident's death. The RR proceeded to explain that after a second call inquiring about the money in her mother's account, she had contacted the facility's former Administrator and asked to come in for a review of the resident's trust fund account. She stated that during her meeting with the former Administrator she observed withdrawal receipts from her mother's account that had her signature on them. The RR for Resident #3 stated that she, nor any family member had received any cash from the resident, as the resident's family bought all of her clothes and did not receive gifts from the resident. The RR stated that her mother did not possess the cognitive ability to manage cash in a safe, responsible manner. She also stated that during her meeting with the former Administrator, she told him that her signature had been forged and that there was fraud involved in the management of Resident #3's trust fund account. The RR stated that the former Administrator told her that he was going to continue to look into the situation and would handle it. On 11/14/24 at 2:07 PM, during a telephone interview, the former Administrator stated that the annual Medicaid audits of resident trust funds revealed there was an excess of three thousand dollars ($3,000.00), which had been 'earmarked' for funeral expenses that was gone from the trust fund account of Resident #3. He stated he could not recall the exact amount, but the record review of the resident's account statement and withdrawal receipts revealed several questionable withdrawals. He added that he had not reported anything to the State Agency (SA) because he was not sure if there was anything to report, although he confirmed that the resident's RR had told him that there were receipts with her name on them that she had not signed. He state that he had notified the Regional Director of Operations (RDO) who had told him that she would audit the resident trust accounts for misappropriation. He stated that following the RDO's audit, he had been reassured that all the resident's funds had been accounted for and therefore he had not reported any accusation of misappropriation to the SA. The former Administrator stated that his concerns came from withdrawals from Resident #3's account that included three (3) beauty shop charges listed for the same day, and receipts which stated, 'Gift Shop' and 'Snack Bar' because the facility did not have a gift shop or a snack bar. On 11/15/24 at 2:38 PM, during an interview with the current facility BOM, she stated that she was not able to locate receipts for several items listed on Trust Fund Disbursement Slips and Withdrawal Slips for Resident #3, including a specialty chair listed on a Resident Trust Fund Disbursement Slip dated 10/16/23. A record review of Resident #3's resident fund records revealed there was no receipt for any medical equipment or specialty chair to support the claim of purchase from the resident's trust fund account. On 11/18/24 at 4:42 PM, during a telephone interview the facility's former BOM explained she had limited training regarding management of resident trust fund accounts. She stated that if the resident had a need and funds in the account, she would shop on line, locate the item, have the resident sign a slip/receipt for withdrawal of funds necessary for the purchase, take the money from their account, buy an Online Vendor gift card and used the gift card to make purchases. She stated she also used or her own Online Vendor account to purchase the items online for residents and paid her bill with money removed from the resident's trust fund account. She stated that in October 2023, Resident #3 needed a wheelchair and the resident's RR verbally authorized use of funds from her account to order one. She said she had the resident sign a Resident Trust Fund Disbursement Slip on 10/16/24 for nine hundred fifty dollars ($950.00), used the resident's funds to purchase a wheelchair from an Online Vendor for six hundred forty-one dollars and forty-nine cents ($641.49) and purchased other items on her own without authorization that totaled approximately three hundred dollars. The former BOM stated, I may have been out of line on that. If I need to reimburse her on that I will be glad to, as that was my judgement call. She confirmed that there were no receipts for items she had purchased for the resident, including a specialty chair, in her Resident Fund Management Service (RFMS) folder, only screen shots of items that were purchased. The BOM confirmed that the screen shots were not actually receipts for the item as evidence that the item had indeed been purchased or received by the resident. On 11/18/24 at 5:30 PM, during an interview with the RDO, she revealed that she was the designee for the Administrator, who was out for the day. She stated that she had reviewed the account for Resident #3 on 8/29/24, as a result of questions raised by the resident's RR in which she matched Withdrawal Slips with the Resident Account Statement. She confirmed that she had not looked for vendor receipts for items purchased by the facility staff using the resident's trust funds. She said that the procedures employed by the former BOM were bad bookkeeping practices, and did not comply with current accounting standards. She confirmed that Resident #3 had severe cognitive impairment. On 11/20/24 at 5:15 PM, in a post survey telephone interview with the RR for Resident #3 revealed that she stated there had been no discussion in October 2024, or any time of using the resident's funds to purchase a wheelchair. Record review of the Admission Record for Resident #3 revealed the facility admitted the resident on 7/20/22. The resident had diagnoses that included Diabetes, Dementia, and Disorientation. Record review of the Quarterly Minimum Data Set (MDS) for Resident #3, with an Assessment Reference Date (ARD) of 8/29/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 3, which indicated severe cognitive impairment. Record review of the Quarterly MDS for Resident #3 with an ARD of 5/31/24, revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Record review of the Quarterly MDS for Resident #3 with an ARD of 3/02/24, revealed the resident had a BIMS score of 5, which indicated severe cognitive impairment.

Based on interviews, record review, and facility policy review, the facility failed to ensure residents were free from misappropriation of funds for one (1) of four (4) residents reviewed (Resident #3), with the potential to affect 53 residents who have a resident trust fund. Findings included: Review of the facility policy titled, Freedom from Abuse, Neglect and/or Exploitation Prevention Plan - Education, revised 8/23/17, revealed The resident has the right to be free from abuse, neglect, misappropriation of resident property and exploitation by anyone, including, but not limited to, facility staff . Misappropriation of resident property - Deliberate misplacement, exploitation, or wrongful, temporary or permanent use of a resident's belongings or money without the resident's consent . On 11/04/2024 at 1:46 PM, during a telephone interview, the Resident Representative (RR) for Resident #3 reported that the current facility Business Office Manager (BOM) contacted her regarding her mother's funds, specifically money earmarked for funeral expenses. She stated she met with the facility's former Administrator in September 2024 to review Resident #3's trust fund account and identified a Withdrawal Receipt dated 04/23/2024 for $650.00 for clothing. She stated that she had told the former Administrator that the signature on the receipt was forged. The RR also reported being unaware of withdrawals from the resident's account that depleted funds she had been told were earmarked for funeral expenses. She stated her mother did not possess the cognitive ability to manage cash responsibly. The RR also added that she, nor any family member had received any cash from the resident and that the resident's family bought all of Resident #3's clothes and did not receive gifts from the resident. A record review of the Resident Fund Management System (RFMS) Resident Statement and Resident Trust Fund Disbursement (RTFD) Slips and Withdrawal Receipts for Resident #3 revealed the following discrepancies: a debit dated 01/9/2024 described as Resident Advance Cash for $500.00 with no correlating slips or receipts, a debit dated 02/26/2023 described as Gift Shop for $500.00 with no correlating slips or receipts, a debit dated 02/27/2024 described as Resident Advance Cash for $150.00 with no correlating slips or receipts, a RTFD Slip dated 10/09/2023 described as cash for clothing for winter per RP (Responsible Party) and daughter for $175.00 signed by Registered Nurse (RN) #1 as witness (later denied by RN #1), and a Withdrawal Receipt dated 04/23/2024 described as Clothing for $650.00 signed by the Transportation Aide and Resident #3's RR (later denied by the Transportation Aide and RR). On 11/14/2024 at 2:07 PM, during a telephone interview, the former Administrator stated that a Medicaid audit revealed over $3,000 earmarked for funeral expenses was missing from Resident #3's trust fund. The RR informed him that some receipts had her name on them, but she had not signed them. On 11/18/2024 at 12:05 PM, during an interview, RN #1 denied signing the RTFD Slip dated 10/09/2023 for $175.00, noting her name was misspelled on the slip. On 11/18/2024 at 4:42 PM, during a telephone interview, the former BOM admitted she had limited training regarding management of resident trust fund accounts. She stated her normal procedure involved having residents sign slips or receipts for fund withdrawals and providing cash in the presence of a witness. However, she also admitted to disbursing cash to Resident #3 without witnesses, despite knowing the resident was cognitively impaired. She acknowledged using the resident's funds to purchase items online via her personal Online Vendor account and confirmed there were no receipts in the RFMS folder to substantiate purchases. On 11/20/2024 at 5:15 PM, during a telephone interview, the RR for Resident #3 stated there had been no discussion in October 2023, or any other time about using the resident's funds to purchase a wheelchair. A record review of Resident #3's Admission Record revealed the facility admitted the resident on 07/20/2022. The resident had diagnoses that included Diabetes, Dementia, and Disorientation. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/2024 revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment. A record review of Resident #3's Quarterly MDS with an ARD of 05/31/2024 revealed a BIMS score of four (4), which indicated severe cognitive impairment. A record review of Resident #3's Quarterly MDS with an ARD of 03/02/2024 revealed a BIMS score of five (5), which indicated severe cognitive impairment.

Based on observation, interviews, record reviews, and facility policy review, the facility failed to report allegations of misappropriation of resident property within 24 hours of notification of the allegation to the State Agency (SA) and local authorities for one (1) of four (4) residents reviewed with trust accounts. Resident #3 Findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, reviewed 10/2022, revealed, All reports of resident abuse . or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . If resident abuse, neglect, exploitation, misappropriation of resident property . is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law . The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. the state licensing/certification agency . e. Law enforcement officials .3b.within 24 hours of an allegation that does not involve abuse or result in serious bodily injury . On 11/14/2024 at 9:55 AM, during an interview and observation of Resident #3, the resident was observed in a black and green manual wheelchair labeled with her name. The resident was unable to meaningfully participate in the interview and responded to questions by stating, I'm going home or I want to go home. During a telephone interview on 11/14/2024 at 1:46 PM, the Resident Representative (RR) for Resident #3 stated that in September 2024, she informed the former Administrator her signature had been forged on a Withdrawal Receipt dated 04/22/2024 for $650.00, alleging fraud in the management of the resident's trust fund account. The RR stated that the former Administrator had told her that he would look into the situation, but as of the time of the survey, no funds had been reimbursed. The RR stated she had never authorized or discussed the purchase of medical equipment or clothing using the resident's funds. On 11/14/2024 at 2:07 PM, during a telephone interview, the former Administrator stated that the RR informed him of a receipt with her name, which she said she had not signed. He confirmed that no allegation of misappropriation had been reported to the State Agency (SA) or other agencies. On 11/15/2024 at 2:38 PM, during an interview, the current Business Office Manager (BOM), who started on 08/12/2024, stated that during an annual audit of resident trust fund accounts, a Medicaid Case Manager raised an inquiry about funds earmarked for burial expenses in Resident #3's account that could not be accounted for. She stated, They don't do that in this facility. On 11/18/2024 at 10:50 AM, during an interview, the Regional Director of Operations (RDO) stated that on 08/29/2024, she reviewed trust fund information but did not report allegations of misappropriation to the SA or other agencies. On 11/18/2024 at 12:05 PM, during an interview, Registered Nurse (RN) #1 denied signing the Resident Trust Fund Disbursement Slip dated 10/09/2023 for $175.00. She noted that her name was misspelled on the slip. On 11/18/2024 at 4:42 PM, during a telephone interview, the facility's former BOM admitted to limited training regarding managing resident trust fund accounts. She stated she was unaware of any funds earmarked for funeral expenses. She acknowledged providing cash withdrawals to residents without witnesses based on her judgment of the resident's cognition. On 11/18/2024 at 5:30 PM, during an interview, the RDO stated she reviewed Resident #3's account on 08/29/2024 due to questions from the RR. She confirmed she did not verify witness signatures on receipts or check for vendor receipts for items purchased using resident trust funds. She described the former BOM's practices as bad bookkeeping. On 11/22/2024 at 1:28 PM, during a post survey telephone interview, Licensed Practical Nurse (LPN) #1 stated she had never witnessed the former BOM give $1,000.00 cash to Resident #3. She noted the BOM sometimes asked her to sign withdrawal receipts after explaining the purpose but could not recall whether she signed any on 08/06/2024. A record review of Resident #3's Admission Record revealed the facility admitted Resident #3 on 07/20/2022. The resident's diagnoses included Diabetes, Dementia, and Disorientation. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/2024, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment.

Based on interviews, record review, and policy review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for one (1) of four (4) residents reviewed with trust fund accounts. Resident #3. Findings included: A review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation-Reporting and Investigating, reviewed 10/2022, revealed, All reports of resident abuse . or theft/misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported . Investigation Allegations . 1. All allegations are thoroughly investigated. The administrator initiates investigations. 2. Investigations may be assigned to an individual trained in reviewing, investigation, and reporting such allegations . 11. Upon conclusion of the investigation, the investigator records the findings of the investigation on approved documentation forms and provides the completed documentation to the administrator . Follow-Up Report . 1. Within five (5) business days of the incident, the administrator will provide a follow-up investigation report . During a telephone interview on 11/14/2024 at 1:46 PM, the Resident Representative (RR) for Resident #3 stated that in September 2024, the facility's Business Office Manager (BOM) contacted her regarding money missing from the resident's trust fund account and requested a meeting to review the account. The RR stated that during a meeting with the former Administrator, she observed Withdrawal Receipts with her name on them, which she said she had not signed or authorized. She informed the Administrator that her signature had been forged and alleged fraud in managing the resident's trust fund account. The Administrator indicated he would look into the situation and address it. On 11/14/2024 at 2:07 PM, during a telephone interview, the former Administrator confirmed the RR informed him of receipts with her name, which she said she had not signed. He stated he had notified the Regional Director of Operations (RDO), who audited the resident trust account for misappropriation but was unaware of further investigation. On 11/15/2024 at 2:38 PM, during an interview, the current BOM stated she was aware of concerns regarding Resident #3's trust fund account and was told an audit had been conducted. On 11/15/2024 at 4:40 PM, during an interview, the Transportation Aide reviewed the Withdrawal Receipts for Resident #3 and stated she had not signed the slips dated 03/29/2024 for $500.00 or 04/22/2024 for $650.00. She confirmed no one had previously asked her about her signature before the State Agency survey. On 11/18/2024 at 10:50 AM, during an interview, the RDO stated that on 08/29/2024, she pulled trust fund information to verify accuracy, ensuring resident Trust Fund Disbursement Slips/Withdrawal Slips were in place with witness signatures. She explained that cash withdrawals require witnesses and signatures on receipts/slips, and receipts for items purchased must be attached to the slips. However, she admitted not noticing unwitnessed slips, authenticating witness signatures, or checking for receipts or resident possession of purchased items during her audit. On 11/18/2024 at 12:05 PM, during an interview, Registered Nurse (RN) #1 denied signing the Resident Trust Fund Disbursement Slip dated 10/09/2023 for $175.00. She noted her name was misspelled on the slip and stated she was not asked about the signature before the survey. On 11/18/2024 at 6:15 PM, during a follow-up interview, the RDO once again confirmed the extent of her audit included matching withdrawals from resident trust fund account statements with receipts/slips but did not involve verifying witness signatures or ensuring items purchased with resident funds were in their possession. The RDO was unable to provide documentation of her audit. She stated that she had not done an investigation, as after auditing the trust account of ten (10) residents, she did not feel the need to do a thorough investigation. On 11/19/2024 at 5:18 PM, during a post survey telephone interview, the RR stated the RDO did not contact her to verify her signature on the receipts/slips for withdrawals from the resident's account. A record review of Resident #3's Admission Record revealed the facility admitted Resident #3 on 07/20/2022. The resident's diagnoses included Diabetes, Dementia, and Disorientation. A record review of Resident #3's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 08/29/2024, revealed a Brief Interview for Mental Status (BIMS) score of three (3), which indicated severe cognitive impairment.

Based on observation, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, exposed foods, and expired foods in one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy titled Labeling and Dating for Safe Storage of Food, revised [DATE], revealed .All products should be dated when opened . Use Use-By dates on all food once opened . When food is taken out of an original container . write . the Use-By date . The facility did not provide a policy that specifically addressed exposed food products. On [DATE] at 10:31 AM, an observation of the kitchen revealed Refrigerator #1, revealed the following: one (1) 46-ounce carton of orange juice with an open on date of [DATE] and a manufacturer's best if used by date of [DATE]; one (1) opened gallon of 1 percent milk with a manufacturer's best by date of [DATE] and a facility date of [DATE] with no indication of what the date meant; and one (1) five (5)-pound tub of pimento cheese spread with a facility opened on date of ,d+[DATE] and a manufacturer's use by date of [DATE]. An observation of Refrigerator #2 revealed the following: four (4) unopened gallons of whole milk with a manufacturer's best by date of [DATE]; one (1) plastic storage bag of cheese slices with the date rubbed off, leaving the date illegible; one (1) container of leftover beef and gravy with a facility use by date of [DATE]; and one (1) container of leftover rice with a facility use by date of [DATE]. An observation of the freezer revealed seven (7) four (4)-ounce cups of rainbow sherbet containing dairy that had been removed from the original box and had no date. An observation of the pantry revealed one (1) box of tea bags not individually wrapped, with the tea bags exposed. The dry bins revealed the lid on the sugar bin was not securely on the bin, leaving the sugar exposed. On [DATE] at 10:31 AM, during an interview, the Dietary Supervisor (DS) acknowledged the outdated, exposed, and undated foods. The DS stated it was her responsibility to monitor the foods for expiration dates and quality. She reported that it was the responsibility of the staff who opened the food item to write an opened on date on the food package. The DS further explained that she in-serviced the staff on kitchen safety once a month. On [DATE] at 12:52 PM, during an interview, the Administrator acknowledged he had been made aware of the expired, exposed, and undated food items that had been observed during the kitchen observation. The Administrator reported that his expectation was for the kitchen staff to regularly check the food, ensuring that foods are dated, labeled, and expired foods are removed from the kitchen.

Based on observation, interview, record review, and facility policy review, the facility failed to assist a resident with eating in a dignified manner during a dining observation, as evidenced by a Certified Nurse Aide (CNA) was observed standing over a resident while assisting the resident to eat during one (1) of two (2) meal observations. Resident #21 Findings Include: A review of the facility's policy titled Resident Rights, revised and implemented 11/28/16, revealed, .The resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . On 08/22/24 at 8:50 AM, during a dining observation, CNA #1 was observed standing while feeding Resident #21. On 08/22/24 at 9:05 AM, during an interview, CNA #1 acknowledged she was standing while feeding Resident #21. CNA #1 stated she was aware the proper way to assist a resident with feeding is to sit. CNA #1 reported she was not trained to sit during assisted feeding at this facility but had learned the importance of sitting while assisting residents while eating from her years of experience as a CNA. On 08/22/24 at 9:16 AM, during an interview, the Director of Nursing (DON) stated that CNAs are trained to position themselves in front of the residents, observe, and make eye contact during assisted feeding. The DON reported that the staff should not be standing while feeding but may sit depending on the resident's level. The DON confirmed that her expectation is to ensure the staff are trained to sit while performing assisted feedings. On 08/22/24 at 12:52 PM, during an interview, the Administrator acknowledged that a staff member had assisted the resident in feeding while standing. The Administrator stated that the staff would be in-serviced on the proper way to assist the residents in feeding. A record review of the facility's Admission Record revealed the facility admitted Resident #21 on 12/28/17. The resident's diagnoses included Vascular Dementia, Unspecified Severity, with Other Behavioral Disturbances, and Dysphagia, Pharyngoesophageal Phase. A record review of Resident #21's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 06/29/24 revealed a Brief Interview for Mental Status (BIMS) should not be conducted. Further review revealed the staff's assessment of the resident's cognitive status indicated the resident was severely impaired regarding cognitive skills for daily decision making.

Based on record review, staff interviews, and facility policy review the facility failed to provide the Notice of Medicare Non-Coverage letter indicating the resident was notified prior to Medicare coverage ending for two (2) of three (3) residents reviewed for beneficiary protection notification. (Resident #12 and Resident #34) Findings Include: Review of the facility's policy titled, Medicare Advanced Beneficiary Notice, with a review date of 7/24/23, revealed Residents are informed in advance when changes will occur in their bills. If the interdisciplinary team believes (upon admission or during the resident stay) that Medicare (Part A of the fee for service Medicare Program) will not pay for an otherwise covered skilled service(s), the resident (or representative) is notified in writing why the service(s) may not be covered and of the resident's potential liability for payment of the non-covered service(s) . Resident #12 Record review of the SNF (Skilled Nursing Facility) Beneficiary Protection Notification Review with a start date of 1/30/24 revealed last covered day of Part A Service was 2/22/24. However, the resident has remained in the facility. Record review Resident #12's Advance Beneficiary Notice of Non-coverage revealed the last covered treatment was 5/31/24. This document was not dated or signed by the resident or Resident Representative (RR). Review of the Admission Record of Resident #12 revealed the facility admitted the resident to the facility on [DATE]. The resident's diagnoses included Chronic Obstructive Pulmonary Disease, Parkinson's Disease, without Dyskinesia, and Heart Failure. Resident #34 Record review of the SNF Beneficiary Protection Notification Review with a start date of 2/5/24 revealed last covered day of Part A Service was 3/1/24. Record review Resident #34's Advance Beneficiary Notice of Non-coverage revealed the last covered treatment was 4/10/24. This document was not dated or signed by the resident or RR. Review of the Admission Record for Resident #34 revealed the facility admitted the resident to the facility on [DATE]. The resident's diagnoses included Malignant Neoplasm of Unspecified Part of Unspecified Bronchus or Lung and Adult Failure to Thrive. On 8/22/24 at 11:12 AM, in an interview with the Business Office Manager/Human Resources staff she stated she started working at the facility 8/12/24 and has had previous experience and knowledge of completing the Beneficiary Forms. She stated the forms are reviewed with the resident or RR a week before coverage ends and at that time, she gets them to sign it showing that they were informed. She stated the reason for it is to let the resident and the family know their options. She stated it should always be signed, it shows they were informed of options and coverage. She stated if the RR did not come to the facility, she would send it in a certified letter for them to sign upon receipt. On 8/22/24 at 12:49 PM, in an interview the Administrator he stated he became aware of the notices not being done according to policy upon the State Agency (SA) entrance to the facility. He stated he has already put things in place so that it will not happen again. He stated he expects his staff to follow policy.

Based on record review and interviews, the facility failed to provide safe, functional transportation that ensured a reasonably comfortable environment for residents during transport for one (1) of 21 sampled residents. Resident #52 Findings Include: During an interview on 08/19/24 at 11:14 AM, Resident #52 revealed that on 08/12/2024, he was transported two hours away from the facility in a transport van that did not have functioning air conditioning. He stated that during the morning transport, it was hot and stuffy, but not as bad as the afternoon ride back to the facility. He described the van as having no real windows in the back that could open, only two small vents that did not allow much air to circulate, making the trip very uncomfortable. As a quadriplegic, he was unable to fan himself, which added to his discomfort. He stated that on the ride home in the afternoon, the van was very hot, and he became very sweaty and lightheaded. He contacted his mother via video call, who noticed he was sweaty. Resident #52 told her he felt hot and weak. She advised the bus driver to pull over and give him some water that she had given him during the appointment. Resident #52 expressed that he felt the situation was handled improperly on the part of the Administrator, as no apology or explanation had been provided. A record review of the www.weatherunderground.com historical weather revealed the high temperature for 8/12/24 was 95 degrees. An interview with the transportation driver on 08/20/24 at 1:10 PM, revealed that the facility's transportation van had been without functioning air conditioning from 08/08/2024 through 08/13/2024. She stated that she informed the Administrator on 08/08/24 about the air conditioning issue but was instructed to continue transporting residents to their appointments, including Resident #52's appointment almost two hours away from the facility on 08/12/2024. She confirmed that during the return trip, the resident appeared hot and flushed, and she reported this to the nursing staff upon returning to the facility. During an interview on 08/20/24 at 01:30 PM, Resident #52's family member revealed that she met her son at his appointment on 08/12/2024 and noticed that he was hot and sweaty. The driver informed her that the air conditioning in the van was out, but she had been told to transport the resident to his appointment regardless. During the ride home, her son called her and stated that he was hot, and she noticed he was sweaty during the video call. She asked the driver to pull over and give her son some water that she had left with him. She reported the incident to the Ombudsman and the nursing home Administrator. In an interview with the Licensed Nursing Home Administrator (LNHA) on 08/21/24 at 11:14 AM, it was revealed that on the day of the incident, most of the administrative nurses, including himself, were out of the building for training sessions. He stated that he did not recall whether he had prior knowledge of the air conditioning issue but did receive a phone call on 08/12/2024 about it. He instructed the transportation driver to make an appointment to have the van repaired. The Administrator confirmed that the van was repaired on 08/13/2024 and acknowledged the resident's family member had contacted him via text message from the resident's mother. A record review of the Admission Record revealed that the facility admitted the Resident #52 on 1/25/2024, and he had current diagnoses including Quadriplegia and Hyperhidrosis (excessive sweating). A record review of the Comprehensive Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/28/2024 revealed Resident #52 had a Brief Interview for Mental Status (BIMS) summary score of 15, which indicated he was cognitively intact.

Based on observations and staff interviews, the facility failed to store and date respiratory equipment in a manner that prevented possible cross-contamination and consistent with professional standards of practice, as evidenced by, undated tubing and a face mask not being bagged when not in use, for two (2) of four (4) observations. Resident #171. Findings Include: A record review of the facility's Oxygen Administration policy, dated August 25, 2014, revealed Purpose: The purpose of the procedure was to provide guidelines for safe oxygen administration . The policy did not address handling and storage of oxygen tubing. On 08/19/24 at 11:41 AM, an observation of Resident #171 revealed that the oxygen tubing attached to the resident was not dated, and the face mask, which was not in use, was hanging from the wall and not placed in a bag. On 08/20/24 at 8:50 AM, duirng an observation revealed the oxygen tubing attached to Resident #171 remained undated, and the face mask, still not in use, continued to hang from the wall without being bagged. Record review of Resident #171's Order Summary Report with active orders as of 8/22/24, revealed an order dated 7/23/24 O2 (oxygen) BNC (by nasal cannula) at 4 LPM (liters per minute) cont. (continuously) every shift related to Chronic Obstructive Pulmonary Disease with Acute Exacerbation (J44.1). Record review of an order dated 3/11/24 revealed BiPAP (Bilevel Positive Airway Pressure) QHS (every hour of sleep) and PRN (as needed) .related to Chronic Obstructive Pulmonary Disease . A record review of Resident #171's Admission Record revealed the facility admitted the resident on 05/29/24, with an original admitted [DATE], and the resident had diagnoses including Chronic Obstructive Pulmonary Disease with Acute Exacerbation and Chronic Systolic (Congestive) Heart Failure. On 08/20/24 at 9:36 AM, during an interview, Licensed Practical Nurse (LPN) #1 stated the facility's policy requires replacing all respiratory tubing weekly, and the tubing should be dated and stored in a dated plastic bag when not in use. She mentioned that she had never seen a bag for storing the tubing since she began working at the facility. On 08/20/24 at 10:36 AM, during an interview, Assistant Director of Nursing (ADON) stated that nurses should review the oxygen tubing policy if unsure of the correct procedures. She confirmed that tubing is supposed to be changed weekly and turned off when not in use. She emphasized that the policy is in place to decrease the risk of potential or direct exposure to infectious diseases, air contaminants, and bacterial exposure. She stated that it is ultimately the responsibility of all nurses caring for residents on oxygen therapy. On 08/20/24 at 11:20 AM, during an interview, the Director of Nursing (DON) stated that both she and the ADON educate nurses on the care of oxygen tubing. She mentioned that new employees receive a copy of the policy and procedures on changing oxygen tubing and keeping it in a bag when not in use. The DON confirmed that it is the cart nurse's responsibility to change, label, and care for oxygen/nebulization tubing, with the tubing usually being changed on the Sunday night/Monday morning shift.

Based on observations, interviews and facility policy review the facility failed to prevent the potential for the spread of infection as evidenced by, facility staff observed transporting linen in an unsanitary manner for two (2) of six (6) hall observations. Findings Include: Review of the facility's policy titled, Departmental (Environment Services) - Laundry and Linen, revised August 2009, revealed .The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen . In Resident Rooms 1. Do not allow linen clean or soiled to touch clothing or uniform. 2. Handle all linen as though it is potentially infectious . On 08/21/24 at 10:20 AM, an observation of Certified Nursing Assistant (CNA) #2 revealed the CNA hugging clean linen to her uniform going down the 400 hall and placing it on the laundry cart in the hallway. The laundry consisted of bed linen, towels and pads. On 08/21/24 at 1:57 PM, in an interview with CNA #2, she stated she had 2 towels, 2 fitted sheets and 2 pads. She stated she was not paying attention to how she carried the laundry. She confirmed that her actions contaminated the laundry by carrying it against her uniform. On 08/21/24 at 12:54, CNA #1 was observed carrying 2 towels wrapped up in her arms against her uniform down the 100 hall. On 08/21/24 at 2:12 PM, in an interview with CNA #1 stated she was moving fast and was not thinking. She stated carrying the towels next to her uniform contaminated the towels. She stated she has been trained to carry the linen away from her uniform, she just forgot. On 08/21/24 at 2:20 PM, in an interview the Assistant Director of Nursing (ADON)/Infection Preventionist (IP) stated staff are supposed to transport clean and dirty laundry in a bag away from their uniform. She stated the uniform is considered dirty and by holding clean linen against their uniform, they contaminated the clean laundry, which could spread infection. On 08/22/24 at 12:56 PM, in an interview, the Administrator stated he expects the CNAs to follow policy when transporting linen. 47873

Based on interviews, record review, and policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from exiting the facility unnoticed and unsupervised through a remotely opened front door for one (1) of three (3) residents reviewed. Resident #1 Resident #1 was able to exit the front door when the door was opened remotely by staff to allow visitors to enter the facility at approximately 2:49 PM on 6/29/24. The facility staff were unaware of Resident's absence until approximately 3:00 PM, when the family member of another resident called the facility to report they saw the resident beside a two-lane highway, approximately 0.44 miles from the facility. The facility staff located the resident at approximately 3:02 PM, at the described location and the resident was returned to the facility, without incident. This situation was determined to be an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC), which began on 6/29/24, when Resident #1 exited the facility unnoticed and unsupervised. The facility Administrator was notified of the IJ on 7/10/24 at 10:15 AM and provided an IJ template. The facility provided an acceptable Removal Plan on 7/11/24, in which all corrective actions were completed by 7/1/24 and alleged the IJ was removed on 7/2/24. Based on the facility's implementation of corrective actions completed by 7/1/24, the SA determined the and IJ and SQC to be Past Non-Compliance (PNC) and the IJ was removed on 7/2/24, prior to the SA's entrance on 7/8/24. Findings include: Record review of the facility policy titled Emergency Procedure-Missing Resident with review date 3/2023 revealed . 1. Residents at risk for wandering and /or elopement will be monitored and staff will take necessary precautions to ensure their safety . Record review of the facility policy titled Elopement/Unsafe Wandering Plan dated February 7, 2012, revealed .It is the policy of this facility to protect the resident from harm while providing care in a manner that helps promote quality of life in a safe environment .Visual supervision may be necessary in some instances. The nursing staff will complete and document the visual checks as necessary . Record review of the Facility Investigation, completed by the Administrator revealed on 6/29/24, at approximately 3:00 PM, the facility received a telephone call from another resident's family telling them that they saw Resident #1 down the road approximately 0.44 miles from the facility. Staff members located the resident at approximately 3:02 PM and returned the resident to the facility per automobile, without incident, at 3:04 PM. Through the facility's investigation, it was determined that the front door was opened remotely by office staff members and Resident #1 assisted the visitors by holding the door open at approximately 2:49 PM. The door was not monitored at that time, and Resident #1 left the facility unnoticed. When returned to the facility, the resident was assessed, and no signs of injury or distress were noted. On 7/8/24 at 5:20 PM during an interview, Licensed Practical Nurse (LPN) #2 revealed on 6/29/24 she was on duty 7:00 AM through 7:00 PM at the facility and was assigned to the care of Resident #1. She stated that at 2:49 PM a resident's family was visiting and signed the resident out to go out on the front porch for a visit. She stated she believed that Resident #1 followed the family out of the front door unnoticed by the facility staff. She stated the last time she observed Resident #1 prior to the incident was just a few minutes before, in the hallway, near the nurses station. LPN #2 said Resident #1 was just hanging around. She described his demeanor prior to the elopement as calm and normal with no exit seeking behavior. She reported that at 3:00 PM, Certified Nurse Aide (CNA) #1 answered a telephone call from a family member of another resident and was told they had seen Resident #1 walking along the street outside the facility. She reported she and CNA #1 immediately took her personal vehicle and went to the area where the family member reported seeing the resident and observed him walking on the right side of the highway across from the post office. She said they stopped and asked the resident to get into the vehicle and he got in without complaint or delay and told the staff that he was walking to the store. Record review of the Admission Record for Resident #1 revealed the facility admitted the resident on 3/15/21. The resident had diagnoses of Cerebral infarction (stroke), Dementia and Disorientation. Record review of the Brief Interview for Mental Status (BIMS) for Resident #1 dated 7/1/24, revealed the resident had a BIMS score of 9, which indicated moderate cognitive impairment. Record review of the weather history for 6/29/24 on Weather Underground (wunderground.com) revealed at 2:53 PM the ambient outdoor temperature in the area was approximately 93 degrees Fahrenheit the humidity was 66%, wind speed was approximately seven (7) miles per hour and weather conditions were partly cloudy with no rain noted for the day. Record review of the Elopement Risk Evaluation dated 6/28/24 for Resident #1 (the most recent prior to his elopement) revealed Resident #1 had been assessed as At Risk for elopement. On 7/11/24 at 2:30 PM, an interview with the Minimum Data Set (MDS) Nurse stated wandering/elopement risks were assessed upon admission, quarterly, and as needed, using the MDS assessment and documented in the MDS and in the resident's electronic chart. She reported Resident #1 had an assessment indicating a wandering/elopement risk on 6/28/24, because he was independent with walking and had cognitive impairment. The nurse explained when the MDS staff enter those two (2) assessments, it automatically triggers a risk for wandering/elopement. On 7/11/24 during an interview at 3:00 PM, the Director of Nurses (DON) stated risk factors which contributed to the elopement of Resident #1 included the Resident #1's dementia and wandering behavior. She said that following the elopement Resident #1 told her that he had been trying to go to the store. She stated the facility Interdisciplinary Team (IDT) determined the cause of the elopement was that Resident #1, who had cognitive impairment, wanted to go to the store in town and his cognitive impairment caused a lack of safety awareness. The DON reported that circumstances around the incident included visitors and another resident's family members going in and out of the facility. On 7/11/24 at 3:45 PM, an interview with the Administrator revealed he was notified by nursing staff on 6/29/24 that Resident #1 had eloped from the facility and was reported walking along the two-way highway perpendicular to the street on which the facility was located shortly after 3:00 PM. He stated that he reported to the facility and initiated a thorough investigation during which he determined Resident #1 had exhibited no exit seeking behaviors prior to the elopement. He confirmed Resident #1 was assessed on 6/28/24 and had been determined to be an elopement risk. He confirmed a Quality Assessment and Improvement (QAPI) committee, including the Medical Director, himself (Administrator), the DON and Infection Preventionist was held on 6/29/24. The QAPI meeting included audits of the elopement books and review of the facility policies regarding wandering and elopement. Corrective Actions Taken: The facility took the following actions to address the incident and prevent any additional cognitively impaired residents from being able to leave the facility unnoticed and unsupervised. Upon return to the facility, on 6/29/24 at 3:04 PM, Resident #1 was placed on visual monitoring every 15 minutes and all other residents identified as an elopement risk were put on one-hour checks. On 6/29/23 at 3:15 PM, Resident #1's Resident Representative (RR) was notified of the incident. The Medical Director was notified of the elopement on 6/29/24 at 3:30 PM, and Resident #1's nurse completed a body audit. There were no signs and or/symptoms of injury, heat exhaustion, or dehydration, and the resident's vital signs were within normal limits. The Administrator arrived at the facility on 6/29/24 at 3:25 PM and checked all the exit doors for proper functioning and noted that all doors and windows were secure. The door codes were immediately changed as a precautionary measure and the perimeter was checked, including the outside of the building. The facility checked to make sure that there were no other residents unaccounted for on 3/29/24 at 3:30 PM. On 6/29/24 at 3:35 PM, the DON and Administrator initiated in-services on elopement/missing resident policies and procedures, including door monitoring and the emergency procedures for missing residents and began elopement drills on every shift. The staff were not allowed to work until completion of the in-services and elopement drills. The in-services and elopement drills will continue monthly for the next three (3) months. The DON, MDS Nurses, Licensed Nurses, and Social Worker began assessing all other residents for elopement risk on 6/29/24 at 3:52 PM. Assessments were completed by 6/30/24 at 4:30 PM and the 14 additional residents identified to be at risk for elopement were added to the facility's Elopement Books. The MDS Nurse updated the care plan for Resident #1 and all other residents identified as at risk for elopement. On 6/29/24 at 4:05 PM, an emergency QAPI committee meeting was held regarding the elopement of Resident #1. The committee reviewed the incident, actions taken, and the facility's policy on Elopement and Wandering, with no recommendations for change in the policy. Signs were placed on all exit doors on 6/29/24 at 4:17 PM, instructing visitors to notify staff of any resident seeking assistance in exiting the facility. By 6/30/24 at 6:32 PM, the Social Services Director and the DON ensured pictures in the facility's Elopement Books were current. On 7/1/24 at 8:00 AM, Resident #1 was assessed by the Psychiatric Nurse Practitioner, and added a new medication to manage Resident #1's increased anxiety. The facility alleges all corrective actions to remove the IJ were completed by 7/1/24, and alleges the IJ was removed on 7/2/24. Validation: The State Agency (SA) validated the Removal Plan on-site for the Complaint Investigation (CI) MS #25672 through record review and interviews. The SA determined all corrective actions were completed by 7/1/24 and the IJ was removed on 7/2/24.

Based on staff interviews, resident interview, record review and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice for administration of medication for two (2) of seven (7) resident care plans reviewed. Resident #1 and Resident #5. Findings Include: Record review of the facility's policy, Care Plan-Comprehensive, undated, revealed, Policy Statement: It is the policy of this facility to develop comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Procedure .2 .e. Identify the professional services that are responsible for each element of care . Record review of the facility's policy, Resident's Rights, dated 11/23/2016, .(iv) The right to receive the services and/or terms included in the plan of care . Review of the facility's policy, Medication Administration-General Guidelines, dated November 1, 2008, revealed, Policy: Medications are administered as prescribed with good principles and practices .B. Administration .2) Medications are administered in accordance with written orders of the attending physician .4) Medications are administered when they are prepared. Medications are not pre-poured. 5) Medications are administered without unnecessary interruptions. 6) The person who prepares the dose for administration is the person who administrators the dose. 7) Residents are identified before medication is administered. Methods of identification include a. checking identification band, b. checking photograph attached to the medical record, c. calling resident by name . Resident #1 Record review of Resident #1's Care Plan revealed Focus: The resident has hypertension ([CONDITION(S)]) r/t (related to) unknown etiology. Goal: The resident will remain free from s/sx (signs/symptoms) of hypertension through the review date. Interventions: Administer medication, supplements as ordered . Record review of Resident #1's Care Plan revealed Focus: (Formal Name Resident #1) has [CONDITION(S)] .Interventions: Administer medications as ordered. Monitor for side effects . Record review of Resident #1's Care Plan revealed Focus: The resident is on ASA (aspirin) therapy r/t [CONDITION(S)] .Interventions: Administer medications as ordered by physician . On 9/20/21 at 3:44 PM, in an interview with Licensed Practical Nurse (LPN) #1 stated Resident #2 was asleep and would not take her medication. She stated she placed Resident #2's medication in the top drawer of the medication cart. She stated she pulled Resident #1 ' s medications. She stated a Certified Nursing Assistant (CNA) came and asked her to help pull up a resident up in bed. She stated she placed Resident #1 ' s medication in the top drawer and locked the cart. She stated when she returned to the cart, she picked up the wrong medication cup by accident and gave Resident #1, Resident # 2's medication. She stated all of Resident #2's morning medications were given to Resident #1. She stated the Regional Nurse Consultant (RNC) was in the building and filled out an incident report. She went to the Nurse Practitioner (NP) who was in the facility, and told her what had happened. She stated the NP gave her an order to check blood pressure (BP) every 30 minutes and compare for the next two hours. She stated when she checked Resident #1's BP the 2nd time it was dropping and she phoned the NP and got an order to send the resident to the hospital and called an ambulance. She stated the NP gave her an order to start intravenous (IV) fluids and Registered Nurse (RN) #1 started the IV. She stated Resident #1 left by ambulance at 1500 (3 PM). She stated Resident #1 was seen at a local hospital. She stated Resident #1 could have had mood changes but the resident did not have any changes in mood. She stated her actions could have caused a problem. She stated the [MEDICATION(S)] could cause a change in his [CONDITION(S)] level. She stated the medications could cause the resident to have a change in his heart rhythm. She stated she checked all Resident #1's vital signs and they were all within normal range but she did not document the oxygen level and respirations.She stated she identifies a resident by room number, name, birthday and verbally calls the resident by name before she gives them their medications. She stated she did all the above, but that day she just had the wrong cup of medications in her hand. On 9/21/21 at 10:30 AM, in an interview with the Regional Nurse Consultant (RNC) she stated LPN #1 told her what had happened. She stated she told she her to tell the NP. She stated she went and talked to Resident #1. Resident #1 denied any side effects of the medication. She stated she got an order to start intravenous (IV) fluids and that she and RN #1 started the IV fluids. She stated the NP gave them an order to send the resident to the hospital. She stated she told LPN #1 to check vital signs and call 911. She stated LPN #1 should have done all vital signs and documented them. She stated LPN #1 was not sent home nor was she suspended. She stated she did a 1:1 in-service with LPN #1 on medication and wrote her up. She stated by LPN #1 giving Resident #1 the wrong medications, it caused his BP to drop. She stated it could have caused him to have mental changes as well from the medication error. On 9/21/21 at 11:24 AM, in an interview with the Director of Nursing (DON) stated LPN #1 should have done all vital signs, including respirations and oxygen level. She stated if the nurse did not document it then she did not do it. She stated LPN #1's actions could have caused the Resident to have an allergic reaction to the medication. She stated the resident could have had a drop in BP and pulse. She stated the resident could have had a decrease in level of consciousness, nausea, vomiting and diarrhea. She stated there is no excuse for the medication error. She stated a nurse should always check right route, date, time, and dosage on all medication passes. Review of the Performance Improvement Project meeting (PIP) revealed it was completed on 9/10/21, related to medication errors. On 9/22/21 at 11:11 AM, in an interview with Resident #1 stated he had been sent to the hospital one time. Resident #1 stated they gave him the wrong medication. He stated his blood pressure dropped from the medication. On 9/23/21 at 12:13 PM, during a phone interview with the NP revealed she was in the facility when LPN #1 gave Resident #1 the wrong mediations. She stated she gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that LPN #1 came back to her and she gave an order to send Resident #1 out to the local hospital. She gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She assessed resident and no distress was noted. She stated the resident's BP dropped. She stated the resident's heart rate could have slowed down. On 9/24/21 at 2:23 PM, in a phone interview with the Pharmacist, he stated Resident #1 was given three (3) anti-hypertensive medications. He stated the medications could cause the resident's BP to drop. He stated the risk factors are limited due to the fact the resident only received one dose of the medications. He stated the medication could cause the resident not to feel good. He stated the [MEDICATION(S)] could rarely cause any type of physical harm. He stated the resident would probably become less engaging and lethargic. He stated the resident would have to be given the medications over a long period of time to have an effect. He stated the resident would have to be given [MEDICATION(S)] for 10 days to have an effect. He stated [MEDICATION(S)] takes two hours to get in the blood stream and it would not have a long-term effect on the resident. He stated for [MEDICATION(S)] to cause liver failure the resident would have to be given it for 6 months. He stated the nurse realized she made a mistake and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the biggest risk is the resident had potential for falls. Resident #1's risk factors was low based on medications she received. Record review of the Order Summary Reported dated , September 22,2021, for Resident #1 revealed Aspirin tablet chewable 81 milligrams (MG )by mouth give one tablet one time a day, [MEDICATION(S)] 1 MG by mouth one time a day, Klor-Con 10 Extended Release 10 milliequiveliants (MEQ) ([MEDICATION(S)] ER) give 10 meq one time a day by mouth, Vitamin B1 tablet ([MEDICATION(S)] HCI) Give 200 mg by mouth one time a day, and [MEDICATION(S)] tablet 20 MG by mouth two times a day. Record review of Resident #1's September 2021 Medication Administration Record revealed Aspirin tablet chewable 81 milligrams (MG )by mouth give one tablet one time a day, [MEDICATION(S)] 1 MG by mouth one time a day, Klor-Con 10 Extended Release 10 milliequiveliants (MEQ) ([MEDICATION(S)] ER) give 10 meq one time a day by mouth, Vitamin B1 tablet ([MEDICATION(S)] HCI) Give 200 mg by mouth one time a day, and [MEDICATION(S)] tablet 20 MG by mouth two times a day was documented as given on 9/3/21 by LPN #1 Record review of Resident #2's Order Summary Report dated 9/13/21 revealed Resident # 2 had orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Health Status Note by LPN #1 dated 9/3/21 at 13:08 (1:08 PM), revealed Resident #1's blood pressure was 87/54 at 12:30 PM. NP gave orders to start Intravenous (IV) normal saline. The IV was started by RN #1 at 12:50 PM. BP was rechecked at 12:56 it was 93/56 and heart rate was 61. Will continue to monitor. Record review of the Health Status Note dated 9/3/21 at 17:05 (5:05 PM) revealed BP 86/53 heart rate 65 at 13:39 (1:39 PM), BP 85/60 HR 65 at 1400 (2:00 PM) and BP 76/50 and HR 61 at 14:27 (2:27 PM). Record review of the Health Status Note revealed Resident #1 was discharged from the hospital on 9/3/21 at 21:30. Record review of the Admission Record for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/21, Section C, revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated Resident #1 had moderate cognitive impairment. Review of the Physician diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 Record review of the incident report dated 9/12/21, prepared by the DON, revealed LPN #4 gave morning medication at 8:16 AM and two (2) hours later LPN #3 gave the same medications at 10:55 AM to Resident #5. Record review of LPN #2's handwritten investigation statement dated 9/13/21, revealed LPN #2 pre pulled the medication for Resident #5 on 9/11/21 and placed the cup in the medication cart with Resident #5's name on it for LPN #3 to give to the resident on 9/12/21. Record review of a Progress Note dated 9/12/21 at 10:50 AM, written by the DON revealed, I received a phone call from (Formal name of LPN #3).She states that she accidentally gave resident a second dose of her medication and was not aware that resident had already received meds from another nurse. I instructed nurse to do vital signs on pt immediately and call MD and RP to notify. I notified Administrator, (Formal Name). Record review of a Progress Note dated 9/12/21 at 14:30 (2:30 PM), written by the DON, revealed,Received call from nurse (Formal name LPN#3) stating that resident's BP is now 89/53. Instructed that I would call (Formal name of Physician) to notify of BP. Called (Formal name of Physician) and received order to give resident 1000 cc's (Cubic centimeters) of .45 Normal Saline at 125cc/hr (hour) and to continue to monitor. Order obtained and RN on duty notified of order. Record review of a Progress Note dated 9/13/21, at 8:00 AM revealed Resident #5 had been at the nursing station all morning with her head on the desk and had only eaten only a few bites of her breakfast and stated that she was not hungry. Her BP was 85/51 and her AM BP meds were held. Record review of a Progress Note dated 9/13/21, at 12:13 PM revealed Resident #5 remained at the nursing station and had only eaten only a few bites of her lunch. Record review of a Progress Note dated 9/14/21, at 8:01 AM revealed Resident #5 was found in the dining room vomiting. On 9/21/21 at 11:49 AM, in an interview with the DON stated LPN #2 asked LPN #3 to work for her on 9/12/21. LPN #3 agreed to work for LPN #2. LPN #2 was trying to help LPN #3 out by pre pulling medications and placing them in a cup, which is against facility policy. She stated the resident could have had adverse effects from receiving a double dose of medications. She stated it could have affected the residents BP, respiration, pulse and oxygen (O2) issues. [CONDITION(S)] medications can cause a decrease in level of consciousness, dizziness, and weakness. She stated LPN #3 should have never given medications she did not prepare. She stated LPN #3 did not know what was in the cup, since she did not prepare it. She stated Resident #5 was on the 400 hall and was moved to the 300 hall. She stated the nurse on the 300 hall had already given Resident #5's medication and signed the Medication Administration Record (MAR). She stated LPN #3 did not check the MAR or check with nurse on the 300 hall before giving medications. She stated, I don't know what kind of nurse would do that. She stated when a resident is moved to another hall the nurse on the that hall gives the medication. She stated LPN #3 did not check the MAR, compare the drugs in the cup with the MAR, or check to see if the MAR was signed nor did she ask the nurse on the 300 hall before giving the resident medication. She stated she has tried to contact LPN #3 by text message and phone call and has not been able to reach her. She stated she has tried three times to reach LPN #3. She stated LPN #3 text her and asked if she was on the schedule or not. She stated she text LPN #3 back and said no. On 9/21/21 at 12:11 PM, in a phone interview with LPN #3 she stated LPN #2 asked me to work for her. She put the medication in the cup for me to give to the residents. She stated she thought Resident #5 was still on the hall. She stated she watched LPN #2 put the pills in the cup the day before. She stated she did not know the facility policy. She stated moving residents to other halls happens all the time. She stated the nurse on the hall was supposed to go down the hall where the resident has been moved to give the resident medications. She stated she checked the MAR, and it was not signed. She stated she thought the resident was still her resident. She stated she looked at the MAR and compared it to the medication in the cup. She stated she knows the pills and what they look like. She stated she knows the pills in the cup were correct pills for the resident. The pills she administered were [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release 24 hour 240 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Medication was given on 9/12/21 at 8:16 AM by LPN #4. She stated she should have not given the resident the pills. She stated she was not aware the other nurse had given the pills to Resident #5 already. She stated she did not know the resident's medication cards had been pulled and put on the other cart. She stated she asked the nurse about Resident #5's medications after she had given Resident #5 the medication and the nurse told her she had already given them. She stated her actions could have caused the resident to go downhill. She stated the resident's BP could have bottomed out and pulse could have dropped low. She stated the Physician gave an order to check Resident #5's vital signs every 2 hours. She stated the DON told her to count the cart down and leave the facility. On 9/21/21 at 12:55 PM, in an interview with LPN #2, stated on 9/11/21 she pulled up medication and put it in a cup for LPN #3 to give on 9/12/21. She stated that was against policy. She stated she was trying to help LPN #3 out since she was doing her a favor by working her shift. She stated by doing that LPN #3 did not know what she was giving the residents. She stated the medications could have spilled in the medication cart. She stated Resident #5's BP and heart rate could have dropped and she could have been sent to the hospital. She stated that it could have caused harm to the resident. She stated the DON wrote her up. She stated the DON did a medication pass with her. She stated the error could have been avoided if LPN #3 had checked to see if Resident #5 had received her medications. She stated LPN #4 gave Resident #5's medications the first time. On 9/21/21 at 1:11 PM, in an interview with LPN #4 stated she had the 100 and 300 halls on 9/12/21 and she gave Resident #5 her morning medications around 8 AM and she held the resident's BP medication because it was low. She stated she always signs the MAR as she goes and she signed the MAR right after giving Resident #5 her medications. She stated she has never pre pulled medication and placed them in the cup for another nurse to give. She stated that is against policy. She stated when a nurse gives BP medication and does not check the BP, that could cause the resident's BP to bottom out. She stated LPN #3 called the MD, DON, and family. She stated LPN #3 asked her if she had given Resident #5 her medication after LPN #3 had given the second dose. On 9/22/21 at 12:03 PM, in an interview with LPN #2 she stated she pre pulled 10- 15 residents' medication on 9/11/21 for LPN #3 to give on 9/12/21. Record review of the Admission Record for Resident #5 revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS with an ARD dated 8/4/21 does not reveal a BIMS score. Record review of Resident #5 Order Summary report dated, September 2021, revealed [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release by mouth daily, [MEDICATION(S)] tablet 150 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Review of Resident #5 Medication Administration Record (MAR) September 2021 revealed [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release 24 hour 240 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Medication was given on 9/12/21 at 8:16 AM by LPN #4. Record review of Resident #5's current Comprehensive Care Plans revealed she has history of [CONDITION(S)] and a history of joint replacement surgery, decreased mobility, mood problem related to altered mental status, diuretic therapy related to hypertension, anticoagulant therapy related to [CONDITION(S)], antibiotic therapy, history of [CONDITION(S)] Avium-Intracellular Complex of the right wrist, alteration in hematological status related to history of Malignant Neoplasm of breast, Diabetes Mellitus, [CONDITION(S)], Heart failure, and abnormal bleeding and bruising of skin related to use of aspirin daily. The intervention for all the above diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 9/22/21 at 12:42 PM, in an interview with Administrator stated she is aware of the medication incidents. She stated they have had in-services with the nurses. She stated she has told the nurses do not do anything untill they check it. She stated LPN #2 should never place medications in a cup for another nurse to give. She stated each nurse should pull their own medications and give to the resident. She stated they did a Quality Assurance and Performance Improvement (QAPI) on medication after the first incident on 9/3/21. We have had meetings and in-service on medications. She stated they have had in-services on staff never to give medications from another nurse. She stated they have observed medication pass. She stated she has checked the medication carts to make sure nurse are not pre-pulling medications. She stated the Medical Director is planning to do an in-service with staff. On 9/22/21 at 4:13 PM, in an interview with LPN #6 Care Plan nurse stated the Comprehensive Care Plan is developed to let nursing staff know the plan of care. The staff should follow care plan when giving care. She stated if care plan is not followed the Resident would not be getting the right care. Medications should be administered per Physician orders. She stated that is on the care plan.

Based on observation, staff interviews, resident interview, resident resident representative interview, record review, and facility policy review, the facility failed to ensure Residents were free from significant medication errors which resulted in two (2) resident which became hypotensive requiring intravenous fluid administration and one resident requiring transport to the emergency department for two (2) of seven (7) sampled residents. Residents #1 and #5. Findings Include: Review of the facility's policy, Medication Administration-General Guidelines, dated November 1, 2008, revealed, Policy: Medications are administered as prescribed with good principles and practices .B. Administration .2) Medications are administered in accordance with written orders of the attending physician .4) Medications are administered when they are prepared. Medications are not pre-poured. 5) Medications are administered without unnecessary interruptions. 6) The person who prepares the dose for administration is the person who administrators the dose. 7) Residents are identified before medication is administered. Methods of identification include a. checking identification band b. checking photograph attached to the medical record c. calling resident by name . Resident #1 Record review of an incident dated 9/3/21, LPN#1 Nursing Description: On the hall doing med pass at 0759. Pulled the meds for resident (Formal Name Resident #2). Went into the Pt room and she would not take them at the time. I decided to continue with my med pass and go on to the next resident. To try again in a couple of minutes. I pulled (Formal Name Resident #1's) medicine at this time. (Formal Name Resident #2) medicine was still on the cart at the time. Instead of picking up(Formal Name Resident #1's) medicine and putting it in the cart and locking it. I picked up (Formal Name Resident #2's) medication. I realize the incident once I made it back to the cart and opened it. I checked for any drug reactions and reviewed the medications he received. I immediately reported it to the Nurse Practitioner (NP) who was in the building at the time. Pt (patient) was checked every 30 to see if there was a change in level of consciousness (LOC). Pt remained the same. His still oriented and alert. Resident Description: Resident Unable to give Description. Immediate Action Taken: Description: I reported it to the Nurse Practitioner (Formal Name) that was present in the building at the time. She advised that I retake the Pt blood pressure and recheck the Pt every 2 hours for the next 4 hours. The first set of vitals that were taken at 0700 read as follows: 97.2 117/86 70 18 96. I continued to monitor the Pt for any changes for LOC and behaviors but the Pt remained the same. I rechecked Pt BP at 0920 it was 142/67 HR 78. I advised the Certified Nursing Assistant (CNA) to push fluids. At 1130 his BP was 101/60 HR 73. I told the NP she ordered for the Pt to be sent out for fluids and further evaluation related to the drop in BP.I called (Formal Name of Local Hospital) and gave them report.(Formal Name of Ambulance Company) was called and family was called but it went straight to voicemail. Pt is still alert and oriented x 4. Pt is aware of the situation. No c/o (complaints) of distress noted . On 9/20/21 at 3:44 PM, in an interview with Licensed Practical Nurse (LPN) #1 stated Resident #2 was asleep and would not take her medication. She stated she placed Resident #2's medication in the top drawer of the medication cart. She stated she pulled Resident #1 ' s medications. She stated a Certified Nursing Assistant (CNA) came and asked her to help pull up a resident up in bed. She stated she placed Resident #1 ' s medication in the top drawer and locked the cart. She stated when she returned to the cart, she picked up the wrong medication cup by accident and gave Resident #1, Resident # 2's medication. She stated all of Resident #2's morning medications were given to Resident #1. She stated the Regional Nurse Consultant (RNC) was in the building and filled out an incident report. She went to the NP who was in the facility, and told her what had happened. She stated the NP gave her an order to check blood pressure (BP) every 30 minutes and compare for the next two hours. She stated when she checked Resident #1's BP the 2nd time it was dropping and she phoned the NP and got an order to send the resident to the hospital and called an ambulance. She stated the NP gave her an order to start intravenous (IV) fluids and Registered Nurse (RN) #1 started the IV. She stated Resident #1 left by ambulance at 1500 (3PM). She stated Resident #1 was seen at a local hospital. She stated Resident #1 could have had mood changes but the resident did not have any changes in mood. She stated her actions could have caused a problem. She stated the [MEDICATION(S)] could cause a change in his [CONDITION(S)] level. She stated the medications could cause the resident to have a change in his heart rhythm. She stated she checked all Resident #1's vital signs and they were all within normal range but she did not document the oxygen level and respirations. She stated she tried to call the family but RR#1 did not answer the phone and she did not leave a voice message. She stated she did not know to call the other family listed in the chart. She stated she tried to call the RR the entire day but she did not document each time she tried to call family. She stated she told the oncoming nurse, LPN #5, that she did not reach the family and the oncoming nurse was supposed to continue to try calling the family. She stated it is very important that family is contacted. She stated the family should know everything that is going on with the resident. She stated she identifies a resident by room number, name, birthday and verbally calls the resident by name before she gives them their medications. She stated she did all the above, but that day she just had the wrong cup of medications in her hand. On 9/21/21 at 10:30 AM, in an interview with the Regional Nurse Consultant (RNC) she stated LPN #1 told her what had happened. She stated she told she her to tell the NP. She stated she went and talked to Resident #1. Resident #1 denied any side effects of the medication. She stated she got an order to start intravenous (IV) fluids and that she and RN #1 started the IV fluids. She stated the NP gave them an order to send the resident to the hospital. She stated she told LPN #1 to check vital signs and call 911. She stated LPN #1 should have done all vital signs and documented them. She stated LPN #1 was not sent home nor was she suspended. She stated she did a 1:1 in-service with LPN #1 on medication and wrote her up. She stated by LPN #1 giving Resident #1 the wrong medications, it caused his BP to drop. She stated it could have caused him to have mental changes as well, from the medication error. On 9/21/21 at 11:05 AM, in an interview with Resident #1's Resident Representative (RR) stated the staff told her Resident #1 had been sent to the hospital. She stated the staff told her he was given the wrong medication. She stated Resident #1 told her they gave him the wrong medication and his BP went up. She stated she was told by the nurse that the resident was given the wrong medication and his BP dropped. On 9/21/21 at 11:24 AM, in an interview with the Director of Nursing (DON) stated LPN #1 should have done all vital signs, including respirations and oxygen level. She stated if the nurse did not document it then she did not do it. She stated LPN #1's actions could have caused the Resident to have an allergic reaction to the medication. She stated the resident could have had a drop in BP and pulse. She stated the resident could have had a decrease in level of consciousness, nausea, vomiting and diarrhea. She stated there is no excuse for the medication error. She stated a nurse should always check right route, date, time, and dosage on all medication passes. She stated LPN #1 should have given report to the oncoming nurse to contact the family. On 9/21/21 at 12:55 PM, in an interview with Administrator in Training stated we had a Quality Assurance and Performance Improvement (QAPI) meeting scheduled for 9/21/21, but we canceled due to the Medical Director (MD) not being able to attend meeting. He stated the QAPI has been rescheduled for 9/24/21. He stated they did a PIP in reference to Resident #1. Review of the Performance Improvement Plan (PIP) revealed it was completed on 9/10/21, related to medication errors. On 9/22/21 at 11:11 AM, in an interview with Resident #1 stated he had been sent to the hospital one time. Resident #1 stated they gave him the wrong medication and his blood pressure dropped from the medication. On 9/23/21 at 12:13 PM, during a phone interview with the NP revealed she was in the facility when LPN #1 gave Resident #1 the wrong mediations. She stated she gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated that LPN #1 came back to her and she gave an order to send Resident #1 out to the local hospital. She gave an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She assessed resident and no distress was noted. She stated the resident's BP dropped. She stated the resident's heart rate could have slowed down. On 9/24/21 at 2:23 PM, in a phone interview with the Pharmacist, he stated Resident #1 was given three (3) anti-hypertensive medications. He stated the medications could cause the resident's BP to drop. He stated the risk factors are limited due to the fact the resident only received one dose of the medications. He stated the medication could cause the resident not to feel good. He stated the [MEDICATION(S)] could rarely cause any type of physical harm. He stated the resident would probably become less engaging and lethargic. He stated the resident would have to be given the medications over a long period of time to have an effect. He stated the resident would have to be given [MEDICATION(S)] for 10 days to have an effect. He stated [MEDICATION(S)] takes two hours to get in the blood stream and it would not have a long-term effect on the resident. He stated for [MEDICATION(S)] to cause liver failure the resident would have to be given it for 6 months. He stated the nurse realized she made a mistake and got an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . He stated the biggest risk is the resident had potential for falls. Resident #1's risk factors was low based on medications she received. Record review of Resident #1's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 8/12/21, Section C, revealed a Brief Interview for Mental Status (BIMS) score of nine (9), which indicated Resident #1 had moderate cognitive impairment. Record review of the Health Status Note by LPN #1 dated 9/3/21 at 13:08 (1:08 PM), revealed Resident #1's blood pressure was 87/54 at 12:30 PM. NP gave orders to start Intravenous (IV) normal saline. The IV was started by RN #1 at 12:50 PM. BP was rechecked at 12:56 it was 93/56 and heart rate was 61. Will continue to monitor. Record review of the Health Status Note dated 9/3/21 at 17:05 (5:05 PM) revealed BP 86/53 heart rate 65 at 13:39 (1:39 PM), BP 85/60 HR 65 at 1400 (2:00 PM) and BP 76/50 and HR 61 at 14:27 (2:27 PM). Record review of the Health Status Note revealed Resident #1 was discharged from the hospital on 9/3/21 at 21:30. Record review of an in-service, titled Medication Pass and Reordering Medication completed by the pharmacist revealed the inservice was completed on 9/16/21. LPN #1's signature was included on the sign-in sheet. Record review of the Admission Record for Resident #1 revealed he was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Order Summary Reported dated, September 22, 2021, for Resident #1 revealed Aspirin tablet chewable 81 milligrams (MG) by mouth give one tablet one time a day, [MEDICATION(S)] 1 MG by mouth one time a day, Klor-Con 10 Extended Release 10 milliequiveliants (MEQ) ([MEDICATION(S)] ER) give 10 meq one time a day by mouth, Vitamin B1 tablet ([MEDICATION(S)] HCI) Give 200 mg by mouth one time a day, and [MEDICATION(S)] tablet 20 MG by mouth two times a day. Record review of Resident #1's September 2021 Medication Administration Record revealed Aspirin tablet chewable 81 milligrams (MG )by mouth give one tablet one time a day, [MEDICATION(S)] 1 MG by mouth one time a day, Klor-Con 10 Extended Release 10 milliequiveliants (MEQ) ([MEDICATION(S)] ER) give 10 meq one time a day by mouth, Vitamin B1 tablet ([MEDICATION(S)] HCI) Give 200 mg by mouth one time a day, and [MEDICATION(S)] tablet 20 MG by mouth two times a day was documented as given on 9/3/21 by LPN #1. Record review of Resident #2's Order Summary Report dated 9/13/21 revealed Resident # 2 had orders for the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the hospital Discharge Summary revealed no new orders, resident was discharged (D/C) same day resident went to the hospital. Resident #1 was diagnosed with [CONDITION(S)] -drug related. Resident #5 Record review of the incident report dated 9/12/21, prepared by the DON, revealed LPN #4 gave morning medication at 8:16 AM and two (2) hours later LPN #3 gave same medication at 10:55 AM to Resident #5. Record review of LPN #2's handwritten investigation statement dated 9/13/21 revealed LPN #2 pre pulled the medication for Resident #5 on 9/11/21 and placed the cup in medication cart with Resident #5's name on it for LPN #3 to give to the resident on 9/12/21. Record review of a progress note dated 9/12/21 at 10:50 AM, written by the DON revealed, I received a phone call from (Formal name of LPN #3).She states that she accidentally gave resident a second dose of her medication and was not aware that resident had already received meds from another nurse. I instructed nurse to do vital signs on pt immediately and call MD and RP to notify. I notified Administrator, (Formal Name). Record review of a progress note dated 9/12/21 at 14:30 (2:30 PM), written by the DON, revealed, Received call from nurse (Formal name LPN#3) stating that resident's BP is now 89/53. Instructed that I would call (Formal name of Physician) to notify of BP. Called (Formal name of Physician) and received order to give resident 1000 cc's (Cubic centimeters) of .45 Normal Saline at 125cc/hr (hour) and to continue to monitor. Order obtained and RN on duty notified of order. Record review of a progress noted dated 9/13/21, at 8:00 AM revealed Resident #5 had been at the nursing station all morning with her head on the desk and had only eaten only a few bites of her breakfast and stated that she was not hungry. Her BP was 85/51 and her AM BP meds were held. Record review of a progress noted dated 9/13/21, at 12:13 PM revealed Resident #5 remained at the nursing station and had only eaten only a few bites of her lunch. Record review of a progress noted dated 9/14/21, at 8:01 AM revealed Resident #5 was found in the dining room vomiting. Record review of a document on facility letterhead dated 9/28/21 revealed LPN#3 was sent home at approx 4:40 PM on 9/12/21 and was terminated from the nursing department at (Formal Name of Facility). The document was signed by the DON. On 9/21/21 at 11:49 AM, in an interview with the DON stated LPN #2 asked LPN #3 to work for her on 9/12/21. LPN #3 agreed to work for LPN #2. LPN #2 was trying to help LPN #3 out by pre pulling medications and placing them in a cup, which is against facility policy. She stated the resident could have had adverse effects from receiving a double dose of medications. She stated it could have affected the residents BP, respiration, pulse and oxygen (O2) issues. [CONDITION(S)] medications can cause a decrease in level of consciousness, dizziness, and weakness. She stated LPN #3 should have never given medications she did not prepare. She stated LPN #3 did not know what was in the cup, since she did not prepare it. She stated Resident #5 was on the 400 hall and was moved to the 300 hall. She stated the nurse on the 300 hall had already given Resident #5's medication and signed the Medication Administration Record (MAR). She stated LPN #3 did not check the MAR or check with nurse on the 300 hall before giving medications. She stated, I don't know what kind of nurse would do that. She stated when a resident is moved to another hall the nurse on the that hall gives the medication. She stated LPN #3 did not check the MAR, compare the drugs in the cup with the MAR, or check to see if the MAR was signed nor did she ask the nurse on the 300 hall before giving the resident medication. She stated she has tried to contact LPN #3 by text message and phone call and has not been able to reach her. She stated she has tried three times to reach LPN #3. She stated LPN #3 text her and asked if she was on the schedule or not. She stated she text LPN #3 back and said no. On 9/21/21 at 12:11 PM, in a phone interview with LPN #3 she stated LPN #2 asked me to work for her. She put the medication in the cup for me to give to the residents. She stated she thought Resident #5 was still on the hall. She stated she watched LPN #2 put the pills in the cup the day before. She stated she did not know the facility policy. She stated moving residents to other halls happens all the time. She stated the nurse on the hall was supposed to go down the hall where the resident has been moved to give the resident medications. She stated she checked the MAR, and it was not signed. She stated she thought the resident was still her resident. She stated she looked at the MAR and compared it to the medication in the cup. She stated she knows the pills and what they look like. She stated she knows the pills in the cup were correct pills for the resident. The pills she administered were [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release 24 hour 240 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Medication was given on 9/12/21 at 8:16 AM by LPN #4. She stated she should have not given the resident the pills. She stated she was not aware the other nurse had given the pills to Resident #5 already. She stated she did not know the resident's medication cards had been pulled and put on the other cart. She stated she asked the nurse about Resident #5's medications after she had given Resident #5 the medication and the nurse told her she had already given them. She stated her actions could have caused the resident to go downhill. She stated the resident's BP could have bottomed out and pulse could have dropped low. She stated the Physician gave an order to check Resident #5's vital signs every 2 hours. She stated the DON told her to count the cart down and leave the facility. On 9/21/21 at 12:55 PM, in an interview with LPN #2, stated on 9/11/21 she pulled up medication and put it in a cup for LPN #3 to give on 9/12/21. She stated that was against policy. She stated she was trying to help LPN #3 out since she was doing her a favor by working her shift. She stated by doing that LPN #3 did not know what she was giving the residents. She stated the medications could have spilled in the medication cart. She stated Resident #5's BP could have dropped and she could have been sent to the hospital. She stated that it could have caused harmed the resident. She stated the DON wrote her up. She stated the DON did a medication pass with her. She stated the error could have been avoided if LPN #3 had checked to see if Resident #5 had received her medications. She stated LPN #4 gave Resident #5's medications the first time. On 9/21/21 at 1:11 PM, in an interview with LPN #4 stated she had the 100 and 300 halls on 9/12/21 and she gave Resident #5 her morning medications around 8 AM and she held the resident's BP medication because it was low. She stated she always signs the MAR as she goes and she signed the MAR right after giving Resident #5 her medications. She stated she has never pre pulled medication and placed them in the cup for another nurse to give. She stated that is against policy. She stated when a nurse gives BP medication and does not check the BP, that could cause the resident's BP to bottom out. She stated LPN #3 called the MD, DON, and family. She stated LPN #3 asked her if she had given Resident #5 her medication after LPN #3 had given the second dose. On 9/22/21 at 12:03 PM, in an interview with LPN #2 she stated she pre pulled 10- 15 residents' medication on 9/11/21 for LPN #3 to give on 9/12/21. On 9/22/21 at 12:42 PM, in an interview with the Administrator revealed she is aware of the medication incidents. She stated they have had in-services with the nurses. She stated she has told the nurses do not do anything till they check it. She stated LPN #2 should never place medications in a cup for another nurse to give. She stated each nurse should pull their own medications and give to the resident. She stated they did a Quality Assurance and Performance Improvement (QAPI) on medication after the first incident on 9/3/21. We have had meetings and in-service on medications. She stated they have had in-services on staff never to give medications from another nurse. She stated they have observed medication pass. She stated she has checked the medication carts to make sure nurses are not pre-pulling medications. She stated the Medical Director is planning to do an in-service with staff. Record review of the Admission Record for Resident #5 revealed Resident #5 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission MDS with an ARD dated 8/4/21 does not reveal a BIMS score. Record review of Resident #5 Order Summary report dated, September 2021, revealed [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release by mouth daily, [MEDICATION(S)] tablet 150 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Review of Resident #5 Medication Administration Record (MAR) September 2021 revealed [MEDICATION(S)] tablet 1 MG by mouth daily, Aspirin tablet 81 MG by mouth daily, [MEDICATION(S)] tablet 500 MG by mouth daily, [MEDICATION(S)] tablet Extended Release 24 hour 240 MG by mouth daily, [MEDICATION(S)] 0.125 MG by mouth daily, [MEDICATION(S)] HCI tablet 400 MG three tablets by mouth daily, Losartan Potassium HCTZ 100-25 by mouth daily, [MEDICATION(S)] capsule 300 MG by mouth daily, [MEDICATION(S)] tablet 88 MCG by mouth daily, [MEDICATION(S)] HCI tablet 4 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 5 MG by mouth one tablet two times a day, [MEDICATION(S)] tablet 50 MG one tablet by mouth two times a day. Medication was given on 9/12/21 at 8:16 AM by LPN #4.

Based on observations, resident interviews, staff interviews, and record review, the facility failed to have sufficient nursing staff to meet the needs of the facility residents as evidenced by failure to protect residents from abuse (Residents #1, #6, #9), worsening pressure ulcers (Residents #3, #5, #12, #17), failure to administer medications timely (Residents #1, #5, #8, #10, #11, #12,#15 and #17), delay in incontinent care (Resident #8), failure to use lift for transfer Residents #2, #14), for 13 of 24 sampled residents out of a total of 65 residents in the building. The failure to have sufficient nursing staff placed residents in the facility at risk for serious harm, injury, impairment or death. F725 was determined to be an Immediate Jeopardy (IJ) on 05/21/2021 and was determined to exist on 3/17/2021 when a resident with known aggressive behaviors was admitted to the facility without an increase in staffing to ensure other residents were not physically and verbally abused. The IJ was not removed prior to exit on 05/26/2021 and is considered ongoing. Findings Include: : Record review of the facility's, Staffing policy, dated 6/1/00, noted it is the policy of the facility to provide adequate staffing to meet the needs of the resident population. On 05/04/2021 at 1:14 PM, the State Agency (SA) observed Resident #1 pacing up and down the facility's hallway screaming and cursing loudly with his fist balled up and going in and out of other resident's room unsupervised. At the time of this observation, the facility had two (2) Licensed Practical Nurses (LPN) and six (6) Certified Nurse Aids (CNAs) working the Long-Term Care Unit where the resident lived. In a separate secured area of the facility, there was (1) LPN and 2 CNAs working the Alzheimers Dementia (AD) Unit. A Review of the POS [MEDICAL RECORD OR PHYSICIAN ORDER] . On 05/06/21 at 10:45 AM in an interview with Certified Nursing Assistant (CNA) #7, revealed he had been a CNA at the facility for two years. CNA #7 explained that he has had to work overtime frequently lately due to needing staff. He explained he usually works 7-3 shift but has also work 7 AM to 11 PM shifts when needed. On 05/06/21 at 3:30 PM, an interview with CNA #12, revealed she was working a 12-hour shift today instead of the usual 8 hour shift scheduled. She further explained there is always problems with enough staffing and the CNAs work short. She explained working short is hard on residents and the staff. On 05/05/2021 at 10:00 AM in an interview with Resident #8, she explained she must wait for long periods of time for CNAs to answer call lights, approximately 30 minutes. On 05/10/21 at 3:15 AM in an interview with Resident #12, revealed he uses a urinal but needs to have a brief changed occasionally due to bowel incontinence. He explained he must wait long periods of times to have the call light answered and cleaned up. On 05/11/2021 at 12:00 PM in an interview with Resident #15, the resident explained sometimes it takes up to three (3) hours to get pain medications after he request medications and up to 30 minutes or longer to have a new brief changed . He reported he knows other residents are in need to, but he knows he needs to be taken care of and is tired of fighting with the facility. On 05/11/21 at 4:45 PM in an interview with LPN #14 revealed on 05/09/21 on the 3-11 shift, it was just her and a CNA until after dinner. The nurse said she had to choose between giving medications and changing the resident's briefs. On 05/12/21 at 10:00 AM in an interview with CNA #9, revealed she has been a CNA for [AGE] years and all this time has been at the current facility. She reported that she works the Dementia Unit 12 hours a day and usually there are 2 CNA working the unit but lately has only had one. She explained most of the time she works by herself with 14-16 Dementia residents since February 2020. She reported a nurse is always on the unit and sometimes it is a Registered Nurse (RN) but usually a Licensed Practical Nurse (LPN). She reported the nurse has never helped with resident care, but sometimes will help pass out a tray. She reported that as of right now there is one resident with total care and cannot walk but the other residents walk. She stated that in the past, the Alzheimers Dementia (AD) Unit has had up to 5 residents for total care and 4 residents in a wheelchair. She explained Resident #20 requires a sit to stand lift daily. She further explained another resident, Resident #30 requires assist with a sit to stand frequently due to resident is inconsistent with standing on her own. She reported she has used the sit to stand lift by herself due to not having enough staff on the unit. She reported that she has reported short staffing to Director of Nursing (DON) and Assistant Director of Nursing (ADON) but nothing has been done about the staffing. She explained when using a sit to stand lift alone, a resident could be dropped, and reports she is not able to care for residents as needed due to short staffing. She stated also she felt that there has been a couple of falls on the Dementia Unit due to low staffing. She stated a resident's light was going off for at least 10 minutes, but she was assisting another resident with a shower and by the time she went to answer the light resident was on the floor, she reported another resident fell in the TV room while she was assisting another resident. She explained if there would be 2 CNAs on the unit one CNA could answer call lights while the other CNA is providing showers. She explained she has not been able to follow care plans due to not having enough staff and this could be a hazard to all residents on the unit. Interview on 5/13/21 at 12:32 PM with CNA # 9 said she has had to work the AD unit without another CNA more than one occasion and has had to transfer residents via sit to stand and full body lifts without assistance due to the nurse cannot assist because she could not leave the residents with behaviors. The CNA said on one occasion she was in the room with a nurse transferring a resident via Hoyer and one of the behavior residents started acting out and they had to run out in the hall to stop the resident from hitting another resident. She stated that using a stand with one (1) person instead of two (2) could get residents hurt and maybe even dropped from a lift. Interview on 5/13/21 at 12:32 PM with CNA #8 confirmed she has been on the Alzheimer's unit without another CNA more than once and voices concerns for the residents and herself. She explained that it is hard to watch the elders with behaviors and to provide care for other residents. The CNA said she had to transfer residents via Hoyer lift without assistance because the nurse had to monitor the other residents with behaviors. The CNA said she was in-serviced about the care plans and know the staff should follow the plan of care but some of the residents cannot transfer themselves according to the care plans. The staff must do whatever it takes to transfer the resident. On 5/20/21 at 09:15 AM, the DON revealed she has never read the Federal regulations for nursing homes and is not aware of what each regulation means. The DON revealed because of the facility's budget, her hands were tied regarding staff, and she was not allowed to bring in contract workers anymore. She explained the facility did use agency staffing in December after being cited for staffing concerns, but not since then. The DON reported the facility had 4 residents on the Alzheimer's unit that could not transfer independently. The DON confirmed if there's not enough staff to take care of the resident's this could cause a negative outcome. The DON explained she was told by the Administrator the facility does not have the money or the numbers to get the staff. On 5/20/21 at 10:00 AM with Regional Director of Operations Manager, revealed the current facility assessment does not guide the facility on staffing and how to meet the needs of the residents. The administrator is responsible for having an appropriate facility assessment including staffing needs. The Operations manager said the deficient practice started from the COVID pandemic prior to the DON because the facility did not have enough staff. On 05/20/21 at 12:30 AM interview with Physician #2 said the facility does not have enough staff to meet the needs of the residents. The physician said she takes care of all the residents' medical needs along with her nurse practitioner but also relies on the nursing staff to informed of any issues related to resident's care. The physician also explained she reported several issues to the State Agency in December about low staffing problems. Review of the December 2020 survey by the state agency revealed the facility received a citation due to low staffing numbers that failed to meet the residents' needs. On 05/20/21 at 1:00 PM interview with the Medical Director revealed he is on a month-to-month contract with the facility. The Medical Director revealed he is part of the QAPI team he attends the meetings monthly. The physician said he was aware of the low staffing problems but thought the facility was working on the problem and had corrected the problem. The physician explained he did not report this to the SA or the AG's Office, but he did talk to the corporate people about the problem. He further explained he thought the Administrator said the facility was going to bring in Agency staff. On 05/20/21 at 2:00 PM interview with the Administrator revealed the administrator is responsible for writing the Facility Assessment, but it is not sufficient to assist the facility in meeting the needs for staffing in order to meet the care needs of the residents in this building. The Administrator also confirmed the Facility Assessment does not give guidance on competent staffing. The Administrator confirmed the facility should have known they did not have sufficient/competent staff to take care of the needs of the residents. The Administrator confirmed the facility have system failures with staffing.

MS CI # , # , # , # Based on interviews, record review, job description review, and plan of correction review from 12/04/20, the facility's Administration failed to (1) ensure the facility used its resources effectively, to sustain compliance for staffing to ensure adequate care of residents' needs; (2) implement abuse policies and procedures by recognizing escalating behaviors for prevention of resident to resident abuse and protection of residents; (3) report potential and actual abuse to State Survey Agency and local authorities; (4) ensure care of resident needs to prevent development and worsening of pressure ulcers; (5) ensure medications were available and administered to residents routinely and timely for 24 of 24 residents out of a total of 65 residents. The facility's failure to have effective Administrative oversight, implementation, and monitoring of its resources resulted in a situation that is likely to cause serious injury, impairment, harm, or death to residents. This situation resulted in an Immediate Jeopardy, and the State Agency identified the Immediate Jeopardy (IJ) on 5/21/21. The IJ was determined to exist on 11/17/21, when medications were not available as ordered, and the IJ was not removed prior to exit on 05/26/21 and is considered ongoing. Findings Include: A review of the job description entitled Nursing Home Administrator (NHA) documented, As Nursing Home Administrator, you will be responsible for the overall operations, leadership' management, and success of the facility in accordance with resident/employee needs, government, regulations, and company policy. Responsible for financial management, quality assurance, regulatory management, business development goals and maximization of revenue, family relations, and resident care. In addition, responsible for attracting and retaining top performing talented team members as well as the supervision and career coaching team members on staff. Essential duties of the Administrator include: direct and coordinate medical, nursing, and administrative staffs and services; implements and coordinates policies and procedures for various departments, conducts regular rounds to monitor delivery of nursing care and operation of support departments; ensures consultants and other support resources are appropriately utilized; direct hiring and training of personnel, oversees Quality Assurance and Performance Improvement (QAPI) standards; maintains working knowledge of governmental regulations. Review of the Administrator's license revealed the licensure was issued on April 1, 2021. The previous Administrator had resigned. On 05/20/21 at 2:00 PM, an interview with the Administrator revealed he reports to the Regional Corporate Operations Manager who develops policies. The Administrator stated it is the responsibility of the Administrator to make sure the policies are followed. The Administrator stated he is responsible for writing the Facility Assessment; however, the Administrator confirmed the facility's current assessment is not sufficient to meet the needs of the residents in this building. The Administrator confirmed the assessment does not give guidance on staffing, wound care and lifts. The Administrator stated that he would need to make some corrections to the Facility Assessment. The Administrator explained the Department heads meet every morning to discuss issues, concerns, and deficient practice in the facility and the QAPI team meets monthly to discuss high risk issues. He confirmed that he should have known the facility did not have sufficient/competent staff to take care of the needs of the residents. The Administrator said that during the last QAPI meeting in April the team discussed that some medications were not given as ordered. The plan from QAPI was for the DON to call the pharmacy when a medication was not available. The Administrator also said the QAPI team discussed the wound care assessment documentation not being done. The plan again was for the DON to assess all the wounds and put documentation in the resident's charts. The Administrator confirmed the facility has system failures with the wound care, staffing and medication administration. The Administrator also confirmed he failed to report the resident-to-resident abuse incidents. The Administrator said he previously worked in Louisiana and was told that in Louisiana it was not required to report verbal abuse. He denied being aware a resident was hit, and hair was pulled until the State Agency investigated the complaint. The Administrator confirmed he did not talk to the resident until after the SA interviewed the resident. The Administrator also confirmed he did not report a suspicious fracture. The Administrator said he put it on his calendar to remember to send in the investigation, but he forgot. The administrator said he received a copy of the resident X-ray reports and noted he had a fracture to the tibia. In the interview continued on 05/20/21 at 2:00 PM, the Administrator confirmed the facility should have known they did not have sufficient/competent staff to take care of the needs of the residents. The Administrator said he thought it was okay to piece the schedule together. He said he let some Certified Nurse Aides work 2 or 3 hour shifts to make up for the shortage. The Regional Director of Operations (RDO) stated the Administrator is responsible for having an appropriate facility assessment. The RDO confirmed the facility was aware of the problem with getting the resident's medications but the facility has a back-up pharmacy. The RDO stated deficient practice started from the COVID-19 pandemic with the prior DON because the facility did not have enough staf An interview on 05/20/21 at 12:30 PM with a facility physician said she had met with the Administrator and Director of Nursing (DON) about her concerns several times and reported several issues in December about low staffing and medication problems. The Physician stated the Administrator stated that the facility had a contract with the local pharmacy to receive three to seven days' worth of medication until the routine medication came in. The Administrator said the facility was going to bring in agency staff. Review of the 2567 and Plan of correction from survey on 12/04/20 with a completion date of 01/26/21 revealed the facility had failed to follow the plan of correction related to cited staffing deficiencies. The plan of correction read: 1. State Agency entered building on 12/2/2020, facility was notified on 12/04/2020 that there was not sufficient staff for 12/02/2020. When next notified of possible staffing shortage on December 11th, 12th and 13th, Director of Nursing (DON) called Administrator who called Regional Director of Operations. All employees on call sheet were called. Staffing agency was called on December 11th to provide coverage. Staffing agency was able to provide coverage and facility agreed to guarantee two nurses and two certified nursing assistants (C.N.A.) slots for the next two weeks and pay hazard pay. Agency was able to provide needed employees. 2. All residents have the potential to be affected by this deficient practice. 3. Nurses were in-serviced on staffing on December 14,2020 by Administrator, Quality Assurance and Performance Improvement plan was completed December 14, 2020 by the Administrator. System changes put into place to ensure the problem does not recur include computerized schedules, proper use of daily staffing sheets, and review of staffing in department head meeting. Charge nurses for each shift will notify DON via facility cell phone if sufficient staffing is not in place or call-ins or no-shows occur. Charge nurse for each shift will text DON number of nurses and C.N.A.s so that we may ensure adequate staffing, DON will log calls on call log sheet. 4. Staffing schedules have been placed into Smartlinx on December 23. Assistant Director of Nursing (ADON) started completing daily staffing sheets on December 14 and went back to December 5, ADON will turn in staffing sheets to Administrator. ADON will spot check staffing 3 times per week for 6 weeks then as needed and will document on Staffing Reconciliation Sheet. Administrator will confirm staffing and sign off on sheets. Facility will monitor its performance to ensure solutions are sustained by computing daily required nursing hours to ensure above standard of 2.8. Finding will be presented to Quality Assurance Committee (QA) who will review and make recommendations regarding staffing. QA committee will review monthly for 3 months then as needed. Interview on 05/25/21 at 12:32 PM with the Assistant Director of Nursing (ADON) revealed as soon as the facility achieved compliance from the 12/04/20 survey deficiency, the facility pulled out the agency staff. She stated the facility has been short ever since.

CI , CI , CI , CI Based on an interview the governing body failed to act on information reported by the facility's management regarding operation of the facility. The governing body failed to provide oversight for the facility's Quality Assurance Performance Improvement (QAPI) program and related facility concerns. The governing body failed to hold the Administrator accountable for the safe daily operations of the facility. This had the potential to affect 65 of 65 residents in the facility. The facility's failure to act on reported information by the facility's management regarding operation of the facility and failure to be accountable, engaged, and involved for the implementation of facility policies and management of the facility, put all residents residing in the facility at risk for serious harm, serious injury, serious impairment, or possible death. This failure resulted in worsening pressure ulcers, missed significant medications, abuse and failure to provide sufficient and competent staff, failure to provide behavioral health services and competent staff for behavioral health needs, and failed to have an effective QAPI program. The situation was determined to be an Immediate Jeopardy (IJ) which began on 11/17/2020 after the SA entered the facility and identified the failure of the facility's governing body to act on reported information by the facility's management regarding operation of the facility to decrease the likelihood of serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 5/21/21 and was determined to exist on 11/17/2020. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. Findings include: On 5/20/21 at 10:00 AM, an interview with the Regional Director of Operations (RDO) revealed the owner of the facility would be considered the Governing Body. The RDO stated the facility does not have a policy that addresses the Governing Body. On 05/20/21 at 2:00 PM, an interview with the Administrator revealed the owner is the governing body. The Administrator stated that he reports to the Regional Corporate Operations Manager. The Administrator stated the facility's policies are developed by the corporate department. The Administrator stated it is his responsibility to make sure the policies are followed. On 5/20/21 at 2:30 PM, an interview with the owner confirmed he is the governing body. The owner stated he appoints the Administrator, and that the Administrator reports directly to him. The owner stated he is a part of the Quality Assurance Performance Improvement (QAPI) program and that any QAPI issues are brought to him through emails, phone calls or fax by the Administrator. He stated he does not have a particular process to receive the QAPI information. The owner stated the pharmacy was changed during the summer last year. The owner stated he was aware of the issues with the medications, staffing, residents being admitted with behaviors and wound issues. He stated he did not know how severe it was and that all this was an eye opener to him. The owner confirmed his QAPI program failed but he did not know where the failure began and with whom.

CI , CI , CI , CI Based on staff interview and record review the facility failed to develop a facility assessment to determine resources needed to competently care for the residents who resided in the facility. This failure resulted in non-compliance related to wounds not being assessed, medications not available for administration, not providing behavioral health services, failure to protect residents from abuse and neglect, and sufficient staff not available to care for residents. This had the potential to affect 65 of 65 residents in the facility. The facility failed to provide a policy or procedure on the development and implementation and utilization of the facility assessment. The facility's failure to evaluate the Resident population and identify the resources needed to provide the necessary care and services was likely to cause all residents residing in the facility serious harm, serious injury, serious impairment, or possible death. Serious outcomes related to the failure included worsening wounds, missed medications, unidentified and treated behaviors, and abuse and neglect. The situation was determined to be an Immediate Jeopardy (IJ) which began on 11/17/2020 after the SA entered the facility and identified the failure of the facility to develop a facility assessment to determine resources needed to competently care for the residents who resided in the facility to decrease the likelihood of serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 5/21/21 and was determined to exist on 11/17/2020. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. Findings Include: Review of the facility assessment dated [DATE] revealed the facility failed to address the overall staffing needed, staff competencies needed and services necessary to provide care to residents in the facility. On 5/20/21 at 09:15 AM, during an interview with the Director of Nursing (DON) stated she had never seen the facility assessment and does not understand what it does. The DON stated she depended on the Administrator to explain and make sure the facility was following the facility assessment. On 5/20/21 at 10:00 AM, an interview with the Regional Director of Operations confirmed the facility assessment does not guide the facility on staffing and how to meet the needs of the residents. The administrator is responsible for having an appropriate facility assessment. On 05/20/21 at 2:00 PM, an interview with the Administrator revealed he is responsible for the facility assessment. The Administrator confirmed the facility assessment is not sufficient to meet the needs of the residents in this building. The Administrator also confirmed the assessment does not give guidance on wound care/lifts or competent staff. The Administrator stated he needed to correct the assessment.

CI , CI , CI , CI Based on interview, record review, and facility policy review, the facility failed to have an effective Medical Director to act on reported deficient practices for resident care policies, for current professional standards of practice related to abuse/neglect, remain free from avoidable accidents, wound care, behavioral health care, missed significant medications, competent and sufficient staffing, complete and accurate documentation of the medical records and following and revising resident care plans and to oversee the facility's policies and Quality Assurance Performance Improvement (QAPI) program prior to the State Agency (SA) entering the facility on 5/4/21, for the Complaint Investigation survey. This had the potential to affect 65 of 65 residents in the facility. The failure of the facility to have a Medical Director to evaluate and act on reported deficient practices for resident care policies, for current professional standards of practice related to wound care, abuse/neglect, behavioral health care, missed significant medications, pharmacy services, have competent and sufficient staffing, have complete and accurate documentation of the medical records, reviewing polices and the Quality Assessment and Performance Improvement (QAPI) program concerns was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 11/17/20. The SA identified the failure of the facility's Medical Director to act on reported deficient practices for resident care policies, for current professional standards of practice related to abuse/neglect, behavioral health care, missed significant medications, pharmacy services, have competent and sufficient staffing, have complete and accurate documentation of the medical records, reviewing polices and the Quality Assessment and Performance Improvement (QAPI) program concerns, had the likelihood of serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 5/24/21 and was determined to exist on 11/17/20. The facility Administrator was notified of the IJ on 5/24/21 at 3:01 PM and was presented with the IJ template. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. Findings include: The facility's, Medical Director policy, dated 6/1/2020, noted, it is the policy of this facility that physician services are under the supervision of the Medical Director. This policy noted the Medical Director is a licensed physician in the state and is responsible for the standards, coordination, surveillance, and planning for improvement of medical care in the facility. This policy noted the Medical Director also acts as a liaison between administration and attending physicians, acts as a consultant to the Director of Nursing services in relating to resident care services, assures the residents receives adequate services appropriate to meet their needs, assures the medical regimen is incorporated with the resident care plan, participates in staff meetings concerning, but not limited to infection control, quality assurance, pharmaceutical services, resident care policies. The Medical Director is also responsible for reviewing employee pre-employment and physical examination reports and is responsible for assuring physician services are in compliance with current rules, regulations, and guidelines concerning long-term care. On 05/20/21 at 1:00 PM, in an interview with the Medical Director, he stated he is working on a month-to-month basis at this time. He confirmed he is part of the QAPI program and attends the monthly meetings. He confirmed he was aware the facility had concerns with staffing and medications not being available but stated he thought the concerns had been corrected. The Medical Director stated he had not reported any facility concerns to the State Agency (SA) or the Attorney General's (AG's) office. He confirmed he had talked to the corporate people (governing body and Regional Director of Operations) about the problems but stated the Administrator stated the facility has a contract with the local pharmacy to receive three (3) to seven (7) days of medications until the routine medication come in from the routine pharmacy. The Medical Director stated he was told by the Administrator the facility was going to bring in agency to cover for the shortage in staffing. The Medical Director stated he was not aware of residents being admitted with behaviors and abuse of other residents. He stated he did not know the Psychiatric Nurse Practitioner was not seeing the residents on the Alzheimer's/Dementia (A/D) unit. The Doctor confirmed he should have followed up on the deficient practice and he should have known about the deficient issues in the facility through QAPI. On 05/20/21 at 12:30 AM, in an interview with local Medical Doctor (MD) stated the facility does not have enough staff to meet the needs of the residents. The MD stated she is the resident's Medical Doctor and works at the facility with the Nurse Practitioner (NP). The MD stated she has talked to the Administrator about her concerns at the facility. She stated she has concerns related to the residents not receiving medications in a timely manner and are always unavailable or on order. She stated the resident's go for days without medications. The MD stated she is not notified for several days that a resident did not receive their medications. She stated she also has concerns related to the facility does not complete appropriate wound assessments. The wound assessments are not done for several weeks at a time. The MD stated the Director of Nursing (DON) changes the wound care orders without permission because of the cost of the medication. The MD stated she has not been invited to the QAPI meetings because (proper name) is still the Medical Director. The MD stated she has met with the Administrator and DON about her concerns. The local MD also stated she reported several issues to the SA in December about low staffing and medication problems. The MD stated she has the NP to check the Medication Administration Records (MARS) to see if the residents are getting their medication because of the concerns.

CI , CI , CI , CI Based on interview, record review, and facility policy review, the facility failed to provide documented evidence that it has, through its Quality Assurance and Performance Improvement (QAPI) Program, reviewed and analyzed data for concerns related to Abuse/Neglect, Reporting Abuse and Neglect, Developing a Baseline Care Plan, failure to implement and follow the resident's Care Plan, failure to revise the resident's Care Plan, Monitor treatments and care for Pressure Ulcers, remain free from avoidable accidents, have sufficient Nursing Staff, have competent Nursing Staff, provide Behavioral Health Services, have sufficient/competent staff for Behavior Health Needs, monitor Pharmacy Services, failed to monitor for Significant Medication Errors, failed to monitor facility Administration, failed to monitor the Governing Body for effectiveness, failed to develop a Facility Assessment, failed to monitor for accurate and complete resident records, and failed to call meetings to review and analyze data regarding these concerns prior to the State Agency (SA) entering the facility on 5/4/21, for the Complaint Investigation survey. This had the potential to affect 65 of 65 residents in the facility. The failure of the facility to utilize the QAPI program to determine the root cause of Abuse/Neglect, failure to report Abuse and Neglect, failure to develop a Baseline Care Plan, failure to implement and follow the resident's Care Plan, failure to revise the resident's Care Plan, monitor treatments and care for Pressure Ulcers, remain free from avoidable accidents, have sufficient Nursing Staff, have competent Nursing Staff, provide Behavioral Health Services, have sufficient/competent staff for Behavior Health needs, monitor Pharmacy Services, failed to monitor for Significant Medication Errors, failed to monitor facility Administration, failed to monitor the Governing Body for effectiveness, failed to develop a Facility Assessment, failed to monitor for accurate and complete resident records and identify deficient practices was likely to cause serious injury, harm, impairment, or death. The situation was determined to be an Immediate Jeopardy (IJ) which began on 11/17/20, when the SA entered the facility and identified the failure of the facility's QAPI Committee to meet, review, and analyze data to develop corrective actions to prevent Abuse/Neglect, prevent failure to report Abuse and Neglect, prevent the failure to develop a Baseline Care Plan, prevent the failure to implement and follow the resident's Care Plan, prevent the failure to revise the resident's Care Plan, failed to monitor treatments and care for Pressure Ulcers, prevent injury to prevent avoidable accidents, have sufficient Nursing Staff, have competent Nursing Staff, provide Behavioral Health Services, have sufficient/competent staff for Behavior Health Needs, monitor Pharmacy Services, failed to monitor for Significant Medication Errors, failed to monitor facility Administration, failed to monitor the Governing Body for effectiveness, failed to develop a Facility Assessment, failed to monitor for accurate and complete resident records to decrease the likelihood of serious injury, harm, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 5/21/21 and was determined to exist on 11/17/20. The facility Administrator was notified of the IJ on 5/21/21 at 3:30 PM and was presented with the IJ template. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. Findings include: The facility's, Quality Assessment and Performance Improvement policy, undated, noted the facility will implement and maintain a Quality Assessment and Performance Improvement program. This policy overview noted, The QAPI committee will implement a process that is ongoing, multi-level, and facility wide that encompasses managerial, administrative, clinical, ancillary, and environmental services as well as contracted services and suppliers. The program should address all systems of care and management practices while emphasizing safety, quality of life, and resident choice. This policy noted, the primary purpose of the committee is to identify and analyze actual or potential quality issues, develop, and implement appropriate plans to improve performance, to address identified quality issues, and monitor the effectiveness of implemented changes. The committee will make any needed revisions to performance improvement plans. Other purposes of the QAPI committee are to maintain satisfactory, consistent functioning of systems, to prevent deviations from care process (to the extent possible), to discern issues and concerns with facility systems, and to correct said systems as needed. The committee will ensure that information about the QAPI committee activity is provided to consultants and other who are not members of the committee but have responsibility of the Governing Body oversight. The QAPI committee will be responsible for reviewing the Quality Assessment and Performance Improvement plan at least annually for necessary revisions or changes. Records of annual reviews or amendments will become a part of the QAPI committee's permanent records. On 5/17/21 at 12:00 PM, in an interview with the Administrator (ADM) and the Director of Nursing (DON) revealed the facility has QAPI meetings monthly. The Administrator stated the facility discusses high risk issues and other problems that arise in the other departments. The Administrator stated he conducts the QAPI meetings, and each department head discusses issues in their departments. The QAPI interdisciplinary team monitors these issues to ensure the corrective action has been implemented and the correction is being sustained. The Administrator and the DON stated the facility discussed wounds in the April 2021 (4/22/21) meeting. The meeting revealed the DON needed wound care training. The recommendation of the QAPI team was for the DON to follow the Medical Nurse Practitioner (MNP) for training and to send the residents with large wounds to wound care. The DON is responsible for assessing and measuring the wounds weekly. The DON will do the weekly wound reports and notify the doctor and the Responsible Party (RP) of the residents wound status. The DON said she never got the chance to receive the training from the MNP. The DON said she has not had any training since nursing school. She has done some wound care, but it was with hospice for palliative care. She has not done curative care. The ADM said the QAPI facility was asked, how does the QAPI committee know when an issue arises in any department? The Administrator stated the Committee meets monthly with all department heads and all high risk and problematic concerns are discussed. The SA asked, how does the QAPI committee know when a deviation from performance or a negative trend is occurring? Administrator revealed the department heads discuss whether the things put in place is working are not. The team meets every morning. The SA asked, is there a mechanism for staff to report quality concerns to the QAPI committee? The Administrator and DON stated they have an open-door policy. The SA asked, how does the QAPI committee decide which issues to work on? The Administrator stated they discuss all high-risk issues with the team every morning to decide what is more urgent. The SA asked how does the QAPI committee know that corrective action has been implemented? They stated the department heads follow up and reports daily in stand up. The SA asked, how does the QAPI committee know when improvement is occurring? They stated through the department heads daily at stand up. The SA asked, how long will the QAPI committee monitors an issue that it has corrected? The Administrator stated they will track and trend for a couple of months and make a decision whether to continue or change to something else. The SA asked, how is this decided? He answered, through the interdisciplinary team. In an interview on 5/1//21 at 12:30 PM with the Assistant Director of Nursing (ADON) confirmed the facility meets monthly for a QAPI meeting. The ADON said the facility discussed high risk issues from all departments. The QAPI committee discusses ways to resolve the problems and put things in place. The committee follows up in the stand up and at the monthly meetings. On 5/20/21 at 09:15 AM, in a interview with the DON, she stated the QAPI meeting is conducted monthly. The team reviews high risk issues. The DON stated at the last meeting, the team discussed wound care. The QAPI committee determined the DON will continue to assess and monitor wound care and the DON would complete the weekly wound assessments and measurements. The team also discussed residents with behaviors and the team did not have any recommendations. Social Services brings grievances to the QAPI meeting. The DON stated they discussed weight loss, Urinary Tract Infections, and residents with behaviors. On 5/20/21 at 10:00 AM, in an interview with the Regional Director of Operations (RDO) stated the facility uses a software company to audit the facilities weekly cooperate audio calls and does questionnaires. This information is pulled from the Minimum Data Set (MDS) system. This system helps to tell the problems the facility is having. The RDO stated the QAPI is done from the Administration level. The QAPI team discusses incidents reports and reportable events. The RDO confirmed she expected the QAPI program to discuss all programs. The RDO confirmed the QAPI program is ineffective. The RDO stated the staff needs more education on medications, handling behaviors, and providing wound care. The RDO confirmed the facility assessment does not guide the facility on staffing and how to meet the needs of the residents. The RDO stated the Administrator is responsible for having an appropriate facility assessment. The RDO confirmed the facility was aware of the problem with getting the resident's medications. The RDO stated the facility has a back-up pharmacy. The RDO stated the nursing consultant reported several times the DON is not efficient and competent in her role. The RDO stated the deficient practice started from the COVID-19 pandemic with the prior DON because the facility did not have enough staff. The RDO and the Clinical Nurse Consultant identified the medication problem in October. The RDO stated they were unaware if it was discussed in the QAPI meeting. The RDO confirmed the staff is not competent to take care of residents with psychiatric behaviors. On 05/20/21 at 1:00 PM, in an interview with the Medical Director, he stated at this time he is on a month-to-month contract with the facility. The doctor revealed he is part of the QAPI team and attends the monthly meetings. The doctor stated he was aware of the concerns with low staffing and medications not being available. The doctor stated he did not report this to the State Agency (SA) or the Attorney Generals (AG's) Office. The Medical Director stated he thought the facility had corrected the problems and he talked to the corporate people about the problems. The Medical Director stated he was told by the Administrator the facility has a contract with the local pharmacy to receive three (3) to seven (7) days of medication until the routine medication comes in. The Medical Director stated the Administrator told him the facility was going to bring in Agency staff to help cover the low staffing and said he was not aware of the residents that were admitted with behaviors. He also stated he was not aware the Psychiatric Nurse Practitioner (NP) was not seeing the residents on the Alzheimer's Dementia (A/D) Unit. The Medical Director confirmed he should have followed up on the deficient practice and he should have known about the deficient issues in the facility through the QAPI program. A record review of the facility's QAPI committee meeting, dated 1/19/21, revealed that the meeting was held with no information the topic of the meeting. All required disciplines were present, either in person or by phone. A record review of the facility's QAPI committee meeting, dated 3/18/21, revealed that the meeting was held with no information the topic of the meeting. No signature for the required Medical Director was noted on the sign in sheet and no documentation of him being notified by phone. A record review of the facility's most recent QAPI committee meeting, dated 4/22/21, revealed that the meeting was held with no information the topic of the meeting listed and only a signature sheet was provided. All required disciplines were present.

Based on observation, staff and resident interviews, facility policy review, and hospital discharge recommendations, the facility failed to ensure residents were protected from abuse as evidenced by: 1) Resident #1 yelling at residents, hitting residents, and pulling the hair of Resident #6, and physical contact with Resident #9. 2) The facility staff failed to follow the no manual lift policy.The facility staff also failed to follow the mechanical lift policy requiring a two (2) persons assist with transfer which resulted in major injuries for Resident #2 and Resident #14. The facility failed to ensure residents were protected from abuse and neglect for five (5) of 24 residents reviewed for abuse and neglect. The facility's failure to ensure resident's rights to be free from abuse and neglect. The faciliy's actions placed these and other vulnerable residents in a situation that would likely cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 5/20/21 and determined to be effective on 3/17/21 when Resident #1 was admitted to the facility and physical/verbal abuse of other residents occurred. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. Findings include: The facility's, Behavioral Health Services policy, undated, stated it is the policy of the facility to provide all residents the necessary behavioral health care and services to assist him or her to reach and maintain the highest practicable level of physical, mental, and psychosocial functioning in accordance with the comprehensive assessment and plan of care. This policy stated behavioral health care plans will be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. The facility's, Freedom from Abuse, Neglect, and/or Exploitation Prevention Plan Education policy, revised on 11/14/17, noted the resident has the right to be free from abuse, neglect, misappropriations of resident property and exploitation by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardian, friends, or other individuals Abuse-The willful inflection of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. a. Physical abuse-Includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. b. Mental abuse-Includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. c. Psychosocial harm-Include but are not limited to extreme embarrassment, ongoing humiliation, degradation as a human being. d. Neglect-Failure of the facility, it is employees or service providers to provide goods and services to a resident necessary to avoid physical harm, mental anguish, or emotional distress. 1. Any employee who witnesses or has cause to suspect abuse/neglect/misappropriation of property/or exploitation of a resident must report it immediately to the Administrator/Director of Nursing of the facility. Record review of the facility's last Dementia training dated January 21 ,2020, revealed the facility had a Virtual Dementia training with the facility staff. A review of Resident #1 Pre-Admission Screening (PAS) dated 3/30/21, revealed Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . The PAS revealed Resident #1 takes, and has a history of taking, [CONDITION(S)] medication. A review of the facility's Comprehensive Care Plan dated 4/15/21, revealed Resident #1 has impaired cognitive function/dementia or impaired thought process related to Dementia and has difficulty making decisions. Resident #1 also experiences Short- and long-term memory loss. The intervention was to engage the resident in simple, structured activities that avoid overly demanding tasks. Resident #1 also has an Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior and confusion. Resident #1 has the potential to be aggressive with staff and other residents related to anger, dementia, and poor impulse control. Resident #1's interventions included (1) administering medications (2) analyzing time of day, places, circumstances (3) assessing and anticipating the resident's needs, triggers and what de-escalates behavior. Resident #1 has communication problems related to cognitive communication deficiencies. The facility intervention is to cue, reorient and supervise as needed. Resident #1 has a mood problem related to known physiological condition with manic features. A review of the facility's Physicians' orders dated May 7, 2021 revealed Resident #1 [MEDICATION(S)] (mg) 0.5 milligrams orally daily for anxiety, [MEDICATION(S)] 10 mg orally at bedtime for dementia, [MEDICATION(S)] 10 mg orally twice a day for anxiety, [MEDICATION(S)] 5 mg orally twice a day for dementia, [MEDICATION(S)] 10 mg orally three times a day for [CONDITION(S)] and [MEDICATION(S)] 300 mg orally at bedtime for [CONDITION(S)]. A review of the facility's Nurses' Notes dated 4/20/21 at 11:06 AM, revealed Registered Nurse (RN) #2 overheard Resident #6 say don't touch my hair. The note revealed RN #2 got up from the nurse's station to see what was going on. RN #2 heard Resident #1 say I'm going to kill your God D**n A**. Resident #1 repeated the statement two more times. Observation 5/4/21 at 1:14 PM of Resident #1 pacing up and down the facility hallway speaking in a loud tone and cursing with balled fists. Resident #1 was not wearing shoes or a mask. The facility Administrator attempted to redirect the resident and was unsuccessful. Resident #1 approached the State Agency (SA) pushing her in the chest with his pointer finger. The resident was redirected by facility staff. On 05/5/2021 at 2:00 PM, in an interview with Resident #6, revealed she is afraid of Resident #1. Resident #6 said Resident #1 hit her and pulled her hair. Resident #6 said Resident #1 continued to yell and scream at her and the other residents. Resident #6 also said if Resident #1 comes up to her again she is going to punch him before he can get to her because she is afraid of him. During an interview on 05/5/21 at 1:15 pm, with the Director of Nurses (DON) revealed the DON did not talk to resident #6 about Resident #1 hitting her. The DON said she was not part of the admission process when Resident #1 was admitted to the facility. The DON said she told the Administrator that this facility cannot meet the needs of the resident. The DON said Resident #1 is a danger to himself and others. The DON said the staff told her Resident #1 pulled Resident #6's hair and verbally threatened her. The Doctor wrote orders to send him to a local Behavioral Unit. A review of the local Behavioral Health notes dated 4/20/21, revealed Resident #1 was admitted [DATE] due to aggressive behaviors. Resident #1 presented with [CONDITION(S)], hallucinations, and aggressive behaviors toward other Residents at the nursing home. Resident #1 continues to pace in the hallways at the nursing home. Resident continued to present with aggression/threatening behavior, medication was given to stabilize him. A Review of the local Behavioral Health Discharge Summary dated 4/29/21, revealed Resident #1 was discharged with a new prescription to give [MEDICATION(S)] 25 mg by mouth (po) twice a day for [CONDITION(S)]. The order also states to continue [MEDICATION(S)] 10 mg po twice a day for mood disorder, [MEDICATION(S)] 10 mg every eight hours as needed for [CONDITION(S)], [MEDICATION(S)] 300 mg po at bedtime for [CONDITION(S)], [MEDICATION(S)] 250 mg po twice a day for seizures and [MEDICATION(S)] 0.5 mg for anxiety. A review of the facility's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the facility's Medical Doctor on 5/20/21 at 12:30 PM, revealed she discontinued the [MEDICATION(S)] 25 mg orally twice a day because of the black box warning. On 05/5/21 at 10:00 AM, interview with the Social Services Director (SSD) states Resident #1's behavior was discussed in a meeting with the Administrator, DON, Assistant Director of Nursing (ADON) and Admissions Director. The SSD said the facility cannot meet Resident #1's needs. The SSD said this resident has too many behaviors and cannot be redirected. The SSD also said she suggested to send Resident #1 to the behavior unit prior to him hitting Resident #6. The SSD confirmed Resident #1's PAS is not correct. On 5/5/22 at 10:15 AM, with RN #3 said she was sitting at the nurse station on the Alzheimer's Unit (AD) and heard Resident #6 say do not touch my hair again. The nurse said she did not see Resident #1 hit Resident #6. The nurse said by the time she got down the hall Resident #1 was yelling and threatening Resident #6. Resident #1 said I am going to kill you, B***h. The nurse said she separated the residents. RN #3 said she has asked the DON and the Administrator several times to send Resident #1 out. The nurse said Resident #1 is dangerous and she is afraid he is going to hurt one of the residents or the staff. RN #3 said Resident #1 is hard to redirect. On 5/5/21/21 at 10:30AM, in an interview with RN #4, she said she works on the AD unit from 7PM-7AM. RN #4 said Resident #1 was hard to redirect. RN #4 also said Resident #1 curses and yells at the residents constantly. RN #4 said she told the MD that she was concerned Resident #1 might hurt one of the vulnerable residents on the unit. RN #4 said the other residents are scared to death of him. On 5/5/21 at 10:45 AM, in an interview with The Activity Coordinator (AC) for the AD unit said she was responsible for doing Dementia training with the staff. The AC said the staff was trained on hire and annually. The AC said the staff has not been trained in over a year since the pandemic began. The facility has hired several new staff that has not been trained on Dementia care. The AC said when Resident #1 was on the AD unit she had to do one on one activities with him because his attention span was short. The AC coordinator said he was hard to redirect. He would yell and scream at the other residents. On 5/5/21 at 11:15AM, in an interview with The Business Office/Admissions Manager (BOM) said she is responsible for accepting referrals to the facility. The BOM said she does not have any assessment training. The BOM said she has worked in a nursing home for several years. The BOM said the Administrator sent her to a local nursing home to look at Resident #1, to determine if this facility could meet the needs of the resident. The BOM said the resident was quiet and was not acting out. The DON of that nursing facility said Resident #1 needs to be on a locked unit because he likes to wander and their facility does not have a locked unit. On 5/5/21 at 11:30 AM, in an Interview with CNA #7 states he works the 7-3 shift. CNA #7 said Resident #1 is hard to redirect. CNA #7 said the resident fights the staff when they attempt to provide care. CNA #7 said the resident continues to curse at the staff and residents. CNA #7 said Resident #1 is impulsive and he walks up to the other residents' face and shake his fist at them. Resident #1 pushes other residents in the facility. CNA #7 said all the residents are afraid of Resident #1. On 5/5/21 at 12:00 PM, in an Interview with CNA # 5, said she works the 3-11 shift. CNA #5 said she has not had any in-services on Dementia care since she has been working at the facility. CNA #5 said she tries to avoid Resident #1. On 5/5/21 at 1:00 PM, in an interview with CNA #6, said she works the 7-3 shift. CNA #6 said she has not had any Dementia Care training. On 5/5/21 at 1:15 PM, in an interview with the DON, she confirmed the facility has not completed Dementia training since the COVID-19 pandemic. The staff has not had any psychiatric (psych) training. The DON said she was not involved in the admission process. The Corporate office, and the Administrator decides which residents are admitted to the facility. The DON said she did not approve Resident #1's admission. The DON said after the resident was admitted she told the Administrator Resident #1 is difficult to redirect and the facility cannot meet his needs. The DON said Resident #1 has a lot of psychiatric problems. The DON said the staff and the residents are afraid of this resident. She was told they will have to keep the resident and find a way to meet his needs. On 5/5/21 at 1:30 PM, in an interview with the PNP said she has not been in the facility since March 2020. The PNP said the facility refused to allow her to come in the facility due to Covid-19. The facility called her and asked her to come back to the facility on [DATE]. The PNP said she assessed and monitored the residents on the AD and the residents that have behaviors. The PNP said she monitors the residents' medications. The PNP said she will be visiting the residents twice a week. The PNP said she will review all Residents that are on [CONDITION(S)] medications at that time. On 5/11/21 at 4:35 PM, in an interview with License Practical Nurse (LPN) #14, revealed she worked the AD unit with Resident #1. LPN #4 said Resident #1 cursed the staff and other residents all the time. LPN #14 said Resident #1 continued to call them b*****s and M****r F*****s the whole shift. LPN #14 also said Resident #1 is hard to redirect and is impulsive. He runs up to the other resident's faces and draws his fist, yells, and curses at them. LPN #14 confirmed she has not had any behavior or dementia training. LPN #14 said she did not know what to do for Resident #1. LPN #14 said she reported to the DON and the Administrator that the staff did not know what to do to take care of Resident #1 and that he was a danger to himself and the other residents. LPN #14 said she was told to call the doctor and report his behavior. LPN #14 said she was calling the doctor every hour and the doctor finally said do not call her again, call the Administrator because he refuses to send the resident to a behavioral health unit. LPN #14 said the Administrator said he could not send the resident out because his census was low, and he had to keep every resident he could in the building. LPN #14 said she told the Administrator that it is not right that the facility will not get this man some help and causes the other residents to be feaful in their home. LPN #14 said this is the most horrible place, I've ever worked. Record review of the Admission Record revealed the facility admitted Resident #1 on 3/17/2021, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 00 that indicated Resident #1 is cognitively impaired. Record review of the Admission Record revealed Resident # 6 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 02/26/21, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) of 13 that indicated Resident #6 is cognitively intact. A review of the facility's Progress Notes dated 5/4/21 at 1:03 PM revealed Resident #1 rushed up to Resident #9's chest. Resident #1 tried to push his chest into Resident #9's chest. Resident #9 raised his hands up to keep him off him. Resident #1 was in and out of other resident's rooms cursing and hollering and taking items off the nurse's station. Resident #1 was sent out to the local behavior unit on 05/4/21. On 05/6/2021 at 11:00 AM, in an interview with Resident #9 said Resident #1 ran up to him and rammed his chest into his chest. Resident #9 said Resident #1 also hit him. Resident #9 said if Resident #1 comes at him again he is going to knock him out because that man is crazy. Resident #9 said he told the staff Resident #1 needs to go to a psychiatric hospital because he is going to hurt somebody. Resident #9 said Resident #1 fights the staff all the time and yells and scream at the residents and everybody fears him. I'm going to hit him before he hit me. Record review of the Admission Record revealed Resident #9 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident # 9's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/18/21, revealed Resident #9 had a Brief interview for Mental Status (BIMS) of 15 that indicated Resident #9 is cognitively intact. On 05/5/2021 at 2:30 PM, in an interview with Resident #22 said Resident #1 paces up and down the hall screaming and cursing at the staff. Resident #22 said the staff cannot manage Resident #1. Resident #22 said she stays in her room because she does not want Resident #1 running up to her and hitting her. Resident #22 said she's afraid Resident #1 will come in room because her door does not lock. Record review of the Admission Record revealed Resident #22 was admitted to the facility on [DATE]with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #22's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/21, revealed Resident #9 had a Brief Interview for Mental Status (BIMS) of 12 that indicated Resident #22 is cognitively intact. On 05/5/2021 at 3:00 PM, in an interview with Unsampled Resident C said she is afraid of Resident #1. Unsampled Resident C said Resident #1 pushed her and almost caused her to fall. Unsampled Resident C also said she did not like going in the day room on the AD unit because Resident #1 would yell, scream, and curse at her and the staff. Unsampled Resident C said she was afraid he would hit her with his fist because he would ball it up at her and the staff. Record review of the Admission Record revealed Unsampled Resident C was admitted to the facility on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Unsampled Resident C's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/13/21 revealed Unsampled Resident C had a Brief Interview of Mental Status (BIMS) of 9 that indicated Resident #9 is mildly cognitively impaired. 5/6/2021 at 3:00PM, in an interview with Resident #1's brother he said Resident #1 got in trouble all his life. The brother said they lived together for the last [AGE] years. Resident #1's brother said Resident #1's behavior continued to get worse. Resident #1 would fight him. He could not handle him. Resident #1's brother said Resident #1 urinated and had a bowel movement on the floor. The brother also said Resident #1 cut him with a knife like a dog. The brother said he could not do anything with him. He placed him in the local nursing home because he could not handle him. Record review of the facility's Mechanical Lifts policy, dated April 18, 2008, revealed, Policy: In order to facilitate a safe lifting environment for staff and residents, mechanical lifts are to be utilized for lifting and transferring residents whenever possible. The mechanical lift program will include the following components: *Resident assessment * Staff training for safety and operation of mechanical lifting devices . Resident Assessment Residents will be assessed upon admission, quarterly, and with any significant change in condition for lifting and transferring needs and to determine the appropriate method and equipment needed to lift/transfer the resident. This assessment is to be completed by the Registered Nurse or Licensed Physical Therapist. This assessment will identify the type of equipment needed, sling type and size, and number of staff needed to complete the lift or transfer. The assessment will become part of the resident's medical record. The lifting/transferring needs and type of equipment needed will be added to the resident's plan of care and this information made available to unlicensed personnel . Staff Training Any staff member responsible for lifting and/or transferring residents will receive training on the operation of mechanical devices, application of slings, and safety measures based on the equipment manufactures recommendations. The training must be completed, and competency demonstrated prior to lifting and/or transferring residents . The manufacturer's, User Instruction Manual, for the Hoyer HPL700, revealed 2. Safety Precautions .WARNING DO NOT lift a patient unless you are trained and competent to do so .6. Operating Instructions .CAUTION Have someone assist you when attempting to transfer a patient. The User Manual for the Stand-Up Patient Lift, RPS350-1-I from the manufacture revealed staff should observe a trained team of experts perform the lifting procedures and then perform the entire lift procedure several times with proper supervision and a capable individual acting as a patient. The stand-up lift may be operated by one healthcare professional for all lifting preparations, transferring from and transferring to procedures with a cooperative, partial weight-bearing patient. However, since medical conditions vary, Invacare recommends that the healthcare professional evaluate the need for assistance and determine whether more than one assistant is appropriate in each case to safely perform the transfer. The use of the patient lift by one assistant should be based on the evaluation of the healthcare professional for each individual case. The facility's, Lifting Policy, revealed an acknowledgment This is to certify that I am not to lift any resident without first obtaining assistance. I hereby agree not to lift any resident by my efforts alone . Resident #2 A record review of the facility's investigation related to Resident #2, revealed a statement from CNA #3 stated, she did not notice any concerns while providing care to Resident #2 on 4/22/21. A review of a statement by CNA #2 revealed she entered Resident #2's room, CNA #3 picked up the resident and placed him in the bed. CNA #2's statement revealed she heard a pop sound and asked CNA #3 was that the resident's leg? CNA #2's statement revealed that CNA #3 thought it was the bed that made the popping sound. CNA #2's statement revealed that CNA #3 stated, Ain't nothing wrong with him, and then walked out of the room. On 5/6/21 at 3:00 PM, in an interview with the DON revealed the ADON took the statements from all the nurses of what happened the day the resident was injured. The DON said the Administrator finished the investigation and reported it to the SA. The DON said CNA #2 told her that CNA #3 transferred Resident #2 without a lift. Both CNAs were in the room. CNA #2 said she heard a pop and asked CNA #3 if that was the resident's leg. CNA #3 said no that was the bed. CNA #2 stated ok and left the room. The DON stated CNA #2 did not report the incident to the nurse or anybody in the facility until she was asked for a statement. The DON said after she received a statement from CNA #2 the facility determined the fracture was caused by the CNA #3 during transfer. CNA #3 has not been back ever since the incident occurred. The DON stated the Administrator reported the incident to the SA. On 5/4/2021 at 10:30 AM, in an interview with Resident #2's daughter stated she received a call from a friend letting her know Resident #2's left leg was swollen and twisted. Resident #2's, daughter said she called the facility and was told they do not know what happened to Resident #2's leg. The daughter said she talked to the Medical Nurse Practitioner (MNP) who said this resident has a fracture to his left leg, but she did not know how it happened. On 5/4/21 at 2:00 PM, in an interview with the MNP, she stated she was informed on 4/25/21 by the nurse that Resident #2 had a bad skin tear to the left lower leg. The MNP said the resident's leg was really swollen and she was unable to palpate a pulse in the resident's leg. The MNP said she came back on 4/27/21 to re-evaluate Resident #2's, leg and noted it was flaccid and twisted. The MNP said she called the Medical Director and said the resident needed to go to the hospital for an X-ray to the left leg. The X-ray revealed an acute oblique fracture involving the distal 3rd of the left tibial diaphysis with slight lateral displacement of the distal fracture fragment. The MNP said she talk to the Administrator and the Director of Nursing (DON) saying an investigation needs to be done because Resident #2 could not have received a fracture like this from a bump on the bed. The MNP said she told the Administrator that she would have to report this to the State Agency (SA). The MNP said she called it in to the SA on the hotline as an anonymous complaint. On 5/4/21 at 2:15 PM, in an interview with Certified Nursing Assistant #1 (CNA), she stated she worked the 11-7 shift on 4/22/21. CNA #1 said she did not receive report from any of the other CNA's. CNA #1 said the resident was in the bed when she came in that night and she checked the resident every two (2) hours to see if he had a bowel movement or had urinated. CNA #1 said she pulled the cover down just to his knee and noted he did not need care. CNA #1 said around 4:30 AM she noted the resident had a large amount of blood on the sheet and said she notified the nurse. CNA#1 said she did not get the resident up that morning. CNA #1 said the resident is care planned to get up with a Hoyer lift with 2 people during transfer. On 5/4/21 at 2:30 PM, in an interview, Licensed Practical Nurse #1 (LPN) stated CNA #1 came to her and reported the resident had dried blood on his sheet around 4:45 AM or 5:00 AM. The nurse said she noted dried blood on the left shin and a thin layer of skin was pulled back on his left leg. The measurements were 6 centimeter (cm)x2.5 cm x0.1cm. The nurse said she cleansed the wound with normal saline, applied topical antibiotic ointment and dry dressing. The nurse said she covered it with a bordered gauze. Tylenol was given for pain. The Physician, DON and Resident Representative (RR) was notified. The nurse said the resident was unable to say what happen to his leg due to confusion. On 5/4/21 at 2:45 PM, in an interview with the Assistant Director of Nurses (ADON), she stated that on 4/27/21, she received a text from the Physician saying that Resident #2 had a large skin tear on his left leg. The ADON stated that she is off work and will check on it when she comes in. An X-ray was ordered by the doctor because they noted increased swelling and limited range of motion. The results came back, and they saw it was a fracture. The ADON started the investigation and interviews with the staff that was providing care to the resident, on the 3-11 shift. The ADON turned all that information over to Administrator. On 5/4/21 at 3:00 PM, in an interview with CNA #2 she stated she works the 3-11 shift. CNA #2 stated she works as needed and has worked at this facility for six (6) or seven (7) months. CNA #2 said she went to Resident #2's room on 4/22/21 to see if CNA #3 needed help with transferring the resident back to bed because he is transferred via Hoyer. CNA #2 said when she came in the Resident #2's room, she asked CNA #3 if she wanted her to get the Hoyer lift. CNA #2 stated that CNA #3 stated, No I always transfer him without assistance. CNA #2 stated when CNA #3 transferred the resident, by lifting him in her arms. CNA #2 stated she heard a loud pop. She asked CNA#3 was that his leg? CNA #3 said no that was the bed. CNA #2 said the facility is a no manual lift facility and the resident is care planned for a Hoyer lift with transfers. CNA #2 said the care plan is under the task bar where the CNA's chart the residents' care. CNA #2 stated she was in-serviced in February on how to use lifts. The CNA #2 stated she has not been in-serviced on reporting. However, she should have told the nurse, but she was concerned with taking care of her residents. On 5/4/21 at 3:15 PM, in an interview with CNA #3, stated she works the 3-11 shift. CNA #3 said she used the sit-to stand lift to transfer the resident on 4/22/21. CNA #3 said it depends on how the resident is acting that day determines what is used for transfers. CNA #3 said the resident does not have any problems bearing weight. She transfers him all the time with the sit-to stand lift. CNA #3 confirmed she transferred the resident without assistance. CNA #3 stated she did not know about the care plan. CNA #3 stated she did not know the resident was care planned for a Hoyer lift. CNA #3 also revealed she has not had an in-service on reporting. On 5/4/21 at 3:30 PM, in an interview with Lead CNA #4 revealed she did an Inservice in February on the lifts. CNA #4 said the CNA's task is in the computer. The Comprehensive Care Plan is in the computer stating how the resident is transferred. This facility is a no manual lift facility. CNA #4 stated the facility requires two (2) people with all lifts. CNA #4 stated it has been over a year since the facility has done any training on abuse/neglect and reporting. CNA #4 stated the new staff has not been in-serviced on abuse/neglect and reporting. On 5/13/21 at 12:32 PM, in an interview with CNA #8 stated she has had to work the Alzheimer's and Dementia unit without another CNA and has had to transfer residents via sit to stand and Hoyer without assistance. The CNA said the nurse cannot assist because she cannot leave the residents with behaviors. The CNA said on one occasion she was in the room with a nurse transferring a resident via Hoyer and one of the behavior residents started acting out and they had to run out in the hall to stop the resident from hitting another resident. The staff must do whatever it takes to transfer the resident. A record review of Resident #2's Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD)dated 3/9/21 revealed a Brief Interview for Mental Status score of 7, indicating severe cognitive impairment. A record review of the Resident #2's Admission Record revealed he was admitted on [DATE]. A record review of Resident #2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Comprehensive Care Plan revealed, Resident #2 has an Activities of Daily Living self-care performance deficit related to limited mobility, limited range of motion. The intervention stated use total lift to maximize independence with transferring. A record review of the progress notes dated 4/23/21, by LPN #1, revealed she examined Resident #2's leg and observed dried blood on his left shin with bruising around the area. Documentation revealed LPN #1 cleansed the area with normal saline, patted dry and smoothed out the skin and applied triple antibiotic ointment. She then covered with bordered gauze. Measurements at that time was 6 cm x 2.5cm x 0.1cm. LPN #1 contacted Medical Doctor (MD) and the DON. A record review of the progress notes dated 4/25/21, by LPN #2, revealed skin tear to left leg, area covered with a bordered gauze and dated 4/24/21. LPN #2 removed dressing and observed two sheer appearing tears. The lower tear measured 4 cm and the upper tear measured 2&3/4-3cm. LPN #2 notified MD. A record review of the progress notes dated 4/27/21 at 18:00 by LPN #3, revealed an order per MD to send Res [TRUNCATED]

Based on staff and resident interviews, facility policy reviews, and record reviews, the facility failed to report to the State Agency (SA) within two (2) hours, an incident of resident-to-resident abuse and failed to report to the SA within five days a finding of neglect after completion of an investigation of a major injury to a resident for two (2) of four (4) residents reviewed for abuse/neglect. Resident #6 and Resident #2. The facility's failure to report resident to resident abuse, when Resident #1 hit, pulled the hair of, and yelled at Resident #6 and the facility's failure to report within five days a finding of neglect after completion of an investigation of a fracture for Resident #2, placed all residents in a situation that caused or was likely to cause serious harm, serious injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) which began on 4/20/2021, when the facility failed to report the incident of Resident #1 hitting, pulling the hair of, and yelling at Resident #6. The facility Administrator was notified of the IJ on 05/06/2021 and the IJ template was given to the administrator at 3:15 PM. The IJ was not removed prior to the SA exit on 05/26/2021 and is considered ongoing. The IJ and Substandard Quality of Care (SQC) existed at: CFR(s)483.12(c)(1) - Reporting of Alleged Violations Findings Include: A review of the facility's policy, Incident Report Checklist, undated, revealed . if the incident is reportable (i.e. resident on resident, inappropriate touching or sexual conduct, fall with significant injury, or nwitnessed/unexplainable injury) you must notify the Director of Nursing (DON) or the Administrator immediately as this has to be reported to the State Agency within one (1) hour of occurrence. A review of the facility's policy, Accidents and Incidents undated revealed . The Director of Nursing (DON) and or Administrator are notified of allegations of abuse or neglect and any injury of unknown origin at the time it is discovered . Regardless of how minor an accident or incident may seem; it should be reported and an incident report form completed . Completed incident reports are forwarded to the Administrator or Director of Nurses for further review. The policy further revealed Appropriate staff should be educated upon on hire and periodically thereafter regarding completing incident reports correctly and documenting in the medical records. A record review of the Quarterly MDS with and ARD of 4/8/21 for Resident #9, revealed A BIMS score of 15. Resident #6 An interview on 05/02/2021 at 11:00 AM with Resident #6's daughter revealed she voiced her concern that her mother had been assaulted by another resident in the facility. On 05/5/2021 at 2:00 PM interview with Resident #6 revealed she is afraid of Resident #1. Resident #6 stated that Resident #1 hit her and pulled her hair on 4/20/21. Resident #6 stated Resident #1 continued to yell and scream at her and the other residents. Resident #6 stated if Resident #1 comes up to her again she is going to punch him before he can get to her because she is afraid of Resident #1. A record review of the progress notes dated 4/20/21 by Registered Nurse(RN) #3, revealed RN #3 was at the nurses station and heard Resident #6 say ,do not touch my hair, She stated when she got up to see what was going on she saw Resident #1 by Resident #6 screaming, I am going to kill your God D**n A**, Resident #1 repeated that statement several times to Resident #6 , then he walked down the hall. Resident #2 A review of anonymous Complaint # , received on 4/28/2021 by the SA, revealed Resident #2 was found to have a skin tear but no one had reported an accident. The report also stated later assessment done revealed bruising and [CONDITION(S)]. An x ray was completed and the resident had a fracture of his left leg. An interview on 05/04/2021 with Resident #2's daughter revealed she had received a call from the Nurse Practitioner (NP) of the facility and was notified her father had a fracture and she was unsure what happened but thought the facility was investigating it. Record review of a statement by CNA #2 revealed when she entered Resident #2's room, she observed, CNA #3 picking up the resident out of his wheelchair and placed him in the bed. During this time CNA #2 stated she heard a popping sound and question CNA #3 was that the resident's leg? CNA #2 stated that CNA #3 thought it was the bed that made the popping sound. CNA #2's statement revealed that CNA #3 stated, Ain't nothing wrong with him, and then left the room. During the interview with the Medical Nurse Practitioner (MNP) on 5/4/21 at 2:00 PM, revealed she was informed on 4/25/21 by the nurse that Resident #2 had a bad skin tear to the left lower leg. The MNP stated she called the Physician. She stated the Physician informed her to send the resident out for evaluation. The X-ray revealed an acute oblique fracture involving the distal 3rd of the left tibial diaphysis with slight lateral displacement of the distal fracture fragment. The MNP stated she talked to the Administrator and the Director of Nursing (DON) saying an investigation needed to be done. The MNP said she told the Administrator that she would have to report this to the State Agency (SA). The MNP said she called it in to the SA on the hotline as an anonymous complaint. An interview on 5/6/21 at 3:00 PM with the Director of Nursing (DON) revealed the Assistant Director of Nursing (ADON) documented all the staff interviews regarding what happened the day the resident was injured. The DON said the Administrator finished the investigation and told her he reported it to the State Agency (SA). The DON said CNA #2 told her that CNA #3 transferred Resident #2 without a lift. Both CNAs were in the room. CNA #2 said she heard a popping sound and asked CNA #3 if that was the resident's leg. CNA #3 said no that was the bed. The DON stated CNA #2 did not tell anyone what happened. The DON said after she received a statement from CNA #2 the facility determined the fracture was caused by CNA #3 transferring the resident from the wheelchair to the bed without a lift. The DON stated it was her understanding the Administrator was supposed to report the incident to the SA. A record review of Resident #2's Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the local hospital discharge summary dated 4/27/21, revealed left tibia and fibula fracture. A record review of the X-ray report from local hospital dated 4/27/21, revealed acute oblique fracture involving the distal 3rd of the left tibia diaphysis with slight lateral displacement of the distal fracture fragment. The joints are not involved. On 5/20/21 at 2:00 PM, in an interview with the Administrator regarding reporting the incidents involving Resident #1 and Resident #6, he stated he had been an administrator in Louisiana and there he was told he did not have to report verbal abuse. The Administrator stated he was not aware Resident #1 had hit Resident #6 or that her hair was pulled until the SA investigated the complaint. The Administrator confirmed he had not reported Resident on Resident verbal abuse. Regarding the incident involving Resident #2, the Administrator stated he received a copy of Resident #2's X-ray reports and the completed investigation of the incident and was aware the resident sustained [MEDICAL RECORD OR PHYSICIAN ORDER] . The Administrator stated he did not report the final outcome of the investigation within 5 days of the incident. The Administrator stated he put a reminder on his calendar to send the final investigation of the incident but forgot to send it.

Based on observation, staff interview, record review and facility policy review, the facility failed to develop and implement a comprehensive care plan for residents with behaviors, residents who received therapeutic medications, residents who used lifts for transfers, and residents who had pressure ulcers for 17 of 24 residents reviewed for care plans. Residents # #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13 #14#15, #16 and #17. The facility's failure to develop and implement resident care plans caused or was likely to cause serious injury, serious impairment, or death of the residents. This situation was determined to be an Immediate Jeopardy (IJ), which began on 3/17/21 when an aggressive resident was admitted to the facility and subsequently assaulted another resident, and a comprehensive care plan was not implemented until 4/15/21 and the IJ determined to exist on 4/20/21. The IJ was not removed prior to exit on 5/26/21 and is considered ongoing. The IJ existed at §483.21(b) Comprehensive Care Plans §483.21(b)(1) Findings include: The facility's, Using the Care Plan undated, read, it is the policy of this facility that the care plan be used in developing the resident's daily care routines. Daily care and documentation should be consistent with the resident's care plan. Resident #1 A review of the facility's Progress Notes dated 4/20/21 at 15:30, revealed Resident #1 was transferred to the local Behavior facility because of increased confusion/agitation. Resident #1 constantly pacing in hallway, cursing, yelling at staff and residents. Threatening to kill peers and is difficult to redirect. A review of the facility's Progress Notes dated 4/30/32 at 15:21 revealed Resident #1 returned to the facility with new orders for [MEDICATION(S)] (mg) 0.5 milligrams orally daily for anxiety, [MEDICATION(S)] 10 mg orally at bedtime for dementia, [MEDICATION(S)] 10 mg orally twice a day for anxiety, [MEDICATION(S)] 5 mg orally twice a day for dementia, [MEDICATION(S)] 10 mg orally three times a day for [CONDITION(S)] and [MEDICATION(S)] 300 mg orally at bedtime for [CONDITION(S)], [MEDICATION(S)] 25 mg po twice a day, [MEDICATION(S)] 10 mg every 8 hours, [MEDICATION(S)] 250 mg orally twice a day. On 5/4/21 at 1:14 PM Resident #1 was observed running up and down the hallway in the facility yelling, screaming, cursing, and threatening staff and other residents. Resident #1 approached the State Agency (SA) and poked her in the chest while screaming and cursing. Resident #1 was redirected by the facility Administrator. A review of the facility's Comprehensive Care Plan dated 4/15/21, revealed Resident #1 has impaired cognitive function/dementia or impaired thought process related to Dementia or impaired thought processes r/t Dementia, difficulty making decisions. Short- and long-term memory loss. The intervention was to engage the resident in simple, structured activities that avoid overly demanding tasks. Resident #1 also has an Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior and confusion. Resident #1 has the potential to be aggressive with staff and other residents related to anger, dementia, and poor impulse control. Resident #1's interventions used in the facility was to administer medications, analyze time of day, places, circumstances, assess, anticipate the resident's needs, triggers and what de-escalates behavior. Resident #1 has communication problems related to cognitive communication deficiency. The facility intervention is to cue, reorient and supervise as needed. Resident #1 has a mood problem related to known physiological condition with manic features. On 5/7/2021, at3:15 PM, in an interview with Registered Nurse (RN) #1 confirmed the facility failed to develop a behavior care plan to meet the individualized needs of Resident #1. RN #1 said she did not know what else to do with Resident #1. The local Behavioral health facility did not give recommendations except for the medication. RN #1 said the DON and Administrator said the facility did not have enough staff to do a one on one. RN #1 revealed she has not had behavioral health training. RN #1 said all residents are assess for transfers. Sometimes the staff transfer the residents with lifts without recommendations from Therapy or without it being on the care plan. This is not the facility policy. The nurse confirmed Resident #1 care plan was not developed to meet Resident #1 individualized needs after his stay at the behavioral facility. Resident #2 On 5/6/21 at 3:00 PM, in an interview with the Director of Nursing (DON), revealed the Assistant Director of Nursing (ADON) took the statements from all the nurses of what happened the day the Resident #2 was injured. The DON said CNA #2 told her that CNA #3 transferred Resident #2 without a lift. Both CNAs were in the room. CNA #2 said she heard a pop and asked CNA #3 if that was the resident's leg. CNA #3 said no that was the bed. The DON said after she received a statement from CNA #2 the facility determined the fracture was caused by the CNA #3 during transfer. A record review of the facility's investigation related to Resident #2, revealed a statement from Certified Nursing Assistant (CNA) #3 stated, she did not notice any concerns while providing care to Resident #2 on 4/22/21. A review of a statement by CNA #2 revealed she entered Resident #2's room, CNA #3 picked up the resident and placed him in the bed. CNA #2's statement revealed she heard a pop sound and asked CNA #3 was that the resident's leg? CNA #2's statement revealed that CNA #3 thought it was the bed that made the popping sound. A record review of Resident #2 Admission Record revealed an admitted [DATE]. A record review of Resident #2 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the Comprehensive Care Plan revealed, Resident #2 has an Activities of Daily Living self-care performance deficit related to limited mobility, limited range of motion. The intervention stated use total lift to maximize independence with transferring. A record review of the local hospital discharge summary dated 4/27/21, revealed left tibia and fibula fracture. A record review of the X-ray report from local hospital dated 4/27/21, revealed acute oblique fracture involving the distal 3rd of the left tibia diaphysis with slight lateral displacement of the distal fracture fragment. The joints are not involved. Resident #3 05/06/21 at 1:15 PM in an interview with Resident #3's daughter revealed her mother acquired the wound in the facility. The daughter said she hired a sitter to assist the resident because the staff was not turning her and assisting with meals. 0n 5/05/21 at 1:00 PM interview with LPN #5 she reported Resident #3 acquired the wound to her sacrum in the facility. The nurse said the resident acquired the wound before she started working at the facility. Record review for Resident #3's Admission Record revealed the facility initially admitted Resident #3 on 02/24/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Quarterly Minimum Data Set with Assessment Reference Date (ARD) dated for 2/15/21 Section H revealed Resident #3 was always incontinent of bowel and bladder. Section M revealed Resident #3 had a Stage 3 pressure ulcer. Record review of Resident #3's care plans revealed the wound care plans do not include Wound Care Clinic appointments or new updated wound care orders for sacrum wound. Record review of new updated care plans for Resident #3 on 05/14/2021 at 10:00 AM from RN #1 revealed the new updated care plans revealed no changes in care plan for Stage 3 wound and not a new care plan for new Stage 2 wound. Resident #5 On 05/06/2021 at 9:00 AM in an interview with LPN #10, she explained she helped take care of Resident #5 while she was at the facility. She reported Resident #5 did have some wounds on admission, but she did develop other wounds while at the facility. She further reported the resident had her left leg contracted and was hard to have resident straighten leg out. She explained the resident would not wear heel protectors much, but staff would try and reapply. Record review of Resident #5's Admission Record revealed, the facility admitted Resident on 05/19/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 had one (1) Stage 2 and one (1) unstageable wound. The latest Discharge MDS with ARD of 1/21/2021 revealed the same findings as the quarterly MDS. Record review of Resident #5's Initial Weekly Wound Pressure report dated 05/20/2020 revealed resident #5 was admitted with wound left heel inner aspect unstageable with measurements 2 cm x 1.4 cm x 0.2 cm and wound to wound to right buttock and a Stage two (2) with measurements 1 cm x 1 cm x 0.2 cm. Review of Resident #5's nurse progress notes dated 05/25/2020 revealed a new area to left gluteal fold with partial thickness measurements of 1.5 cm x 0.5 cm x0.1 cm. Record review of Resident #5's care plans revealed care plans for potential for impairment to skin integrity after it was identified Resident #5 had a left heel wound and a Stage II to her right buttock. The care plan was initiated on 06/04/2020 with interventions treatments as ordered, assess/record/monitor wound healing weekly measure length, width, and depth, type of tissue and exudate, and a care plan Resident #5 has pressure ulcer with not specified location or type of pressure ulcer with initiated date 09/17/2020 assess/record/monitor wound healing with missing specify frequency. The record reviews of Resident #5's weekly wound audits and care plans revealed the facility failed to develop care plans to correlate with Resident #5's wounds. Resident #6 Record review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Annual MDS with ARD date 2/26/2021 Section M revealed Resident #6 had a Pressure ulcer of 1 or greater or a scar over a bony prominence. Section M had no other areas flagged for skin conditions. Record review of Resident #6's weekly body audit dated for dated 03/03/2021, revealed right and left ankles with both wounds measuring 1.0 cm x 1.0 cm with callous like wound on ankles. A record review of Resident #6's care plans revealed resident had pressure ulcers to bilateral outer ankles that was initiated on 04/29/2021 with interventions to administer treatments as ordered and assess/record/monitor wound healing weekly measure length, width, and depth. Care plans for Resident #6's wound was not developed when the wounds were initially identified. Resident #7 Record review of Resident #7's Face Sheet revealed the Facility initially admitted on [DATE] and readmitted on [DATE] with the following Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) dated [DATE] Section M of the MDS revealed Resident #7 had only one Stage 3 wound. Review of weekly body audit for Resident #7 revealed a sacrum wound Stage 3 with measurements 3 cm x 7 cm x 0.2 cm with bright red granulation tissue. The next body audit dated for 12/17/2020 with sacrum wound and no measurements. A weekly body audit noted for 03/16/2021 with sacrum wound measuring 3.5 cm x 1.8 cm x 0.2 cm. A weekly body audit noted for 04/13/2021 revealed new pressure ulcer to right buttock with no measurements. Record review of weekly skin reports provided by the DON revealed wound measurements for Resident #7 on 03/15/21 facility acquired Stage 2 sacrum 1.8 cm x 3.5 cm and 0.1 cm and on 05/08/2021 stage 3 sacrum with 1.5 cm x 1 cm x 0.1 cm stage 3. Record review of Resident #7's care plans printed on 05/07/2021 revealed a care plan initiated on 09/06/2018 and revised on 04/26/2021 resident has a potential for altered skin integrity related to immobility and incontinent episodes of bowel with goal to have no complications related to Stage 3 ulcer and interventions for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. These records are inconsistence with wound measurements observed by the DON and SA. Resident #12 Record review of Face Sheet revealed the facility initially admitted Resident #12 on 10/24/2021 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], Section M of the MDS revealed Resident #12 had one Stage 2 ulcer. Record review of Resident #12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . and a new order on 05/10/2021 for [MEDICATION(S)] apply to buttocks. An order with start date 01/01/2021 noted clean bilateral knees with normal saline, pat dry apply [MEDICATION(S)] to wound beds, secure with border gauze and changer every 48 hours, and another order with start date 04/20/2021 cleanse wound to left and right anterior knee with normal saline, pat dry, apply [MEDICATION(S)] to wound bed and cover with a border dressing one time a day for wound care. On 5/6/21 at 2:55 PM, the SA observed the DON do a full body audit on Resident #12. The full body audit with the DON revealed one ulcer to both anterior knees and left lower lateral leg above the ankle and an ulcer to left lateral lower leg. An assessment of the buttocks revealed three (3) open areas to right buttock and one (1) open area to left buttock. On 5-13-21 at 9:30 AM in an interview with Wound Care Clinic Nurse, RN #2, She explained Resident #12 was seen at the wound care clinic She explained Resident #12 was readmitted to the wound care clinic on 12/21/2020 from the facility. She reported Resident #12 was treated on 01/07/2021 for a pressure ulcer to right buttock which was acquired at the facility and the resident had reported to her the wound had been there for about two (2) weeks. Record review of Resident #12's care plans revealed a start date of 04/14/2021 resident has a Stage 2 ulcer of the heel with interventions to assess/record/monitor wound healing two times weekly measure length, width, and depth. Records review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 never had a wound documented to his heels. Record review of Resident #12's care plans revealed no care plans were developed for Resident #12's actual wounds to his heels, knees, lower leg or buttocks. Resident #13 Observation on 05/06/21 at 10:00 AM, revealed LPN #6 provide wound care to Resident #13's left heel. The nurse cleansed the left heel with wound cleanser, applied Santyl and covered with kerlix. The wound was open and pink in the middle of the wound bed. Record review for Resident #13's Admission Record revealed the facility admitted Resident #13 initially on 04/04/2018 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] .An order to inspect resident feet daily was started on 04/14/2021. Record review of Resident #13's Quarterly MDS with ARD date 04/28/2021 revealed Section M revealed Resident #13 had one Stage 2 pressure ulcer. Record review of Resident #13's care plans printed 05/14/2021 revealed a care plan for resident refusing heel protectors and floating heels on pillows with date initiated 05/11/2021 and resident has a Stage 2 left heel pressure ulcer related to immobility and noncompliance with heel protectors with wound care orders and assess/record/monitor healing weekly, measure length, width, and depth. Care plans were not developed for Resident #13's wound with interventions to inspect resident feet daily when the wound was identified. Resident #14 Record review of Resident #14's Admission Record revealed the facility initially admitted Resident #14 on 05/20/2015 and readmitted on [DATE] with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's Quarterly MDS with ARD date of March 1, 2021, Section M of the MDS revealed Resident #14 had no pressure, venous, or arterial ulcers, but did have moisture associated skin damage. Record review of Resident #14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #14's care plans revealed a care plan was initiated on 01/07/2021 for resident has ulcer to coccyx and left and right great toes but did not include a care plan for a Stag 2 to the buttocks. Resident #17 Record review of Resident #17's Admission Record revealed the Facility originally admitted Resident #17 on 3/4/2021 and readmitted on [DATE] with the Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's 5-day Minimum Data Set (MDS) with ARD of March 12, 2021, revealed Section M of the MDS revealed Resident #17 had one unstageable wound due to non-removable dressing/device and one unstageable wound due to slough or eschar diabetic foot ulcer and other open [CONDITION(S)] on the foot. Record review of Resident #17's nurse progress notes revealed on admission 03/04/2021 Resident #17 had a wound present to sacrum, three incision scars near umbilical area, wound to left heel, and black scar tissue visible to toes. Record review of a Baseline care plans dated 03/04/2021 revealed the Baseline care plan was incomplete. Record review of Resident #17's care plans printed 05/17/2021 revealed a care plan for resident has infection of the sacrum related to Stage 4 pressure ulcer of the sacrum/refuses diaper change and care. The care plan was initiated on 05/08/2021 with interventions administer antibiotic as ordered, maintain peripherally inserted central catheter (PICC) dressing changes and flush before and after IV antibiotics, monitor PICC site for signs and symptoms of infection, monitor/document/ report to physician sign and symptoms of [CONDITION(S)]. Resident #17 had only one care plan for wound care initiated on 05/05/2021. The care plan explained resident has potential for impairment to skin integrity of all pressure points related to contact [CONDITION(S)], fragile skin, and infection of sacral wound with interventions encourage good nutrition, follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] .

Based on observation, staff interview, record review and facility policy review, the facility failed to revise comprehensive care plans to meet individual needs for residents with pressure ulcers, residents receiving therapeutic medications and for a resident who returned from Behavioral Health for (14) of (24) care plans reviewed. Resident #1, #2, #3, #4, #5, #7, #8, #9, #10, #11, #12, #15, #16 and #17. The facility's failure to revise care plans caused or was likely to cause serious injury, serious impairment, or death of the residents. This situation was determined to be an Immediate Jeopardy (IJ) on [DATE] and was determined to exist on [DATE] when a resident with COVID-19's plan of care was not reviewed or revised for ordered medications for COVID-19. The IJ was not removed prior to exit on [DATE] and is considered ongoing. The IJ existed at 483.21(b) Comprehensive Care Plans §483.21(b)(2) Findings include: The facility's, Care Plan Comprehensive Policy Statement undated, read, the facility will develop the comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing, and psychological needs. Care plans are revised as changes in the resident's condition dictates. Reviews are made at least quarterly. The Care Planning Committee/Team is responsible for maintaining care plans in a current status. Resident # 1 Record review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility on [DATE]. Record review of Resident #1 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating that Resident #1 has severe impairment in cognition. Record Review revealed that Resident #1 had a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 1's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for the [CONDITION(S)] diagnosis, including medications ([MEDICATION(S)]) and labs. Record review of the facility's Progress Notes dated [DATE] at 15:30, revealed Resident #1 was transferred to the local Behavior facility because of increased confusion/agitation. Resident #1 constantly pacing in hallway, cursing, yelling at staff and residents. Threatening to kill peers and is difficult to redirect. Record review of the facility's Progress Notes dated [DATE] at 15:21, revealed Resident #1 returned to the facility with new orders for [MEDICATION(S)] (mg) 0.5 milligrams orally daily for anxiety, [MEDICATION(S)] 10 mg orally at bedtime for dementia, [MEDICATION(S)] 10 mg orally twice a day for anxiety, [MEDICATION(S)] 5 mg orally twice a day for dementia, [MEDICATION(S)] 10 mg orally three times a day for [CONDITION(S)] and [MEDICATION(S)] 300 mg orally at bedtime for [CONDITION(S)], [MEDICATION(S)] 25 mg po twice a day, [MEDICATION(S)] 10 mg every 8 hours, [MEDICATION(S)] 250 mg orally twice a day. On ,d+[DATE] at 1:14 PM Resident #1 was observed running up and down the hallway in the facility yelling, screaming, cursing, and threatening staff and other residents. Resident #1 approached the State Agency (SA) and poked her in the chest while screaming and cursing. Resident #1 was redirected by the facility Administrator. A review of the facility's Comprehensive Care Plan dated [DATE], revealed Resident #1 has impaired cognitive function/dementia or impaired thought process related to Dementia or impaired thought processes r/t Dementia, difficulty making decisions. Short- and long-term memory loss. The intervention was to engage the resident in simple, structured activities that avoid overly demanding tasks. Resident #1 also has an Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior and confusion. Resident #1 has the potential to be aggressive with staff and other residents related to anger, dementia, and poor impulse control. Resident #1's interventions used in the facility was to administer medications, analyze time of day, places, circumstances, assess, anticipate the resident's needs, triggers and what de-escalates behavior. Resident #1 has communication problems related to cognitive communication deficiency. The facility intervention is to cue, reorient and supervise as needed. Resident #1 has a mood problem related to known physiological condition with manic features. Resident #2 Record review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE]. Record review of Resident #2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 5 MG Give 5 mg by mouth two (2) times a day for anticoagulant (Ordered [DATE]) 2. [MEDICATION(S)] Hcl 500 mg Give by mouth one (1) tablet two (2) times a day for Type 2 diabetes (Ordered [DATE]) Record review of Resident # 2's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for the Chronic Embolism with [CONDITION(S)] diagnosis, including medications ([MEDICATION(S)]) and labs or no care plan (focus, goals, or interventions) in place for Type 2 diabetes diagnosis, including medications ([MEDICATION(S)]) and labs. Resident #3 [DATE] at 1:15 PM in an interview with Resident #3's daughter revealed her mother acquired the wound in the facility. The daughter said she hired a sitter to assist the resident because the staff was not turning her and assisting with meals. 0n [DATE] at 1:00 PM interview with LPN #5 she reported Resident #3 acquired the wound to her sacrum in the facility. The nurse said the resident acquired the wound before she started working at the facility. Record review for Resident #3's Admission Record revealed the facility initially admitted Resident #3 on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Quarterly Minimum Data Set with Assessment Reference Date (ARD) dated for [DATE] Section H revealed Resident #3 was always incontinent of bowel and bladder. Section M revealed Resident #3 had a Stage 3 pressure ulcer. Record review of Resident #3's care plans the wound care plans do not include Wound Care Clinic appointments or new updated wound care orders for sacrum wound. Record review of new updated care plans for Resident #3 on [DATE] at 10:00 AM from RN #1 revealed the new updated care plans revealed no changes in care plan for Stage 3 wound and not a new care plan for new Stage 2 wound. Resident #4 Record review of the Admission Record revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], Resident #4 tested positive for COVID-19 and the Physician ordered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet 250 Give 500 milligrams (MG) by mouth one time a day for infection for one (1) day 2. [MEDICATION(S)] Tablet 6 MG Give 1 tablet by mouth one time a day for COVID-19 for 10 days 3. [MEDICATION(S)] Capsule 20 Mg Give 1 capsule by mouth two times a day for COVID-19 4. [MEDICATION(S)] Tablet 40 MG Give 2 tablets by mouth three times a day for COVID-19 for 30 days Resident #4 was transferred to the hospital emergency room for evaluation on [DATE] and subsequently died . Record review of Resident # 4's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Covid-19 diagnosis, including medications ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]). Resident #5 On [DATE] at 9:00 AM in an interview with LPN #10, she explained she helped take care of Resident #5 while she was at the facility. She reported Resident #5 did have some wounds on admission, but she did develop other wounds while at the facility. She further reported the resident had her left leg contracted and was hard to have resident straighten leg out. She explained the resident would not wear heel protectors much, but staff would try and reapply. Record review of Resident #5's Admission Record revealed, the facility admitted Resident on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], revealed Section M of the MDS revealed Resident #5 had one (1) Stage 2 and one (1) unstageable wound. The latest Discharge MDS with ARD of [DATE] revealed the same findings as the quarterly MDS. Record review of Resident #5's care plans revealed care plans for potential for impairment to skin integrity with an initiation date of [DATE]. Resident #5 has a Stage II to her right buttock and an unstageable wound to left heel with an initiation date of [DATE] with interventions treatments as ordered, assess/record/monitor wound healing weekly measure length, width, and depth, type of tissue and exudate, and a care plan Resident #5 has pressure ulcer with not specified location or type of pressure ulcer with an initiation date of [DATE] assess/record/monitor wound healing with missing specify frequency. The record reviews of Resident #5's Physician Orders, body audits, and care plans revealed the facility failed to revise and update care plans while Resident #5 was at the facility. Resident #7 Record review of the Admission Record revealed Resident #7 was initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day for [CONDITION(S)] with supper (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 300 mg Give one (1) tablet by mouth one time a day for Gout (Ordered [DATE]) Review of Resident #7's Admission Record revealed that the resident has [CONDITION(S)] (a h Record review of Resident # 7's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for [CONDITION(S)] diagnosis, including medications ([MEDICATION(S)]) and labs. Also revealed there was no care plan in place for Gout diagnosis, including medications ([MEDICATION(S)]) and labs. Observation on [DATE] at 2:30 PM, observed Resident #7 had two bandages intact, one to the sacrum and one to the right hip. The SA observed the DON remove the edges of the bandages and measure each wound for Resident #7's wound to right hip 1.5 cm x 7.0 cm x 0.25 cm, new wound noted to right gluteal fold 0.5 cmx 1.25 cm x 0.1 cm, and wound to sacrum 10 cm x 7 cm. The DON did not measure the depth of the sacrum wound. Moderate amount of purulent drainage with odor noted. Record review of Resident #7's care plans printed on [DATE] revealed a care plan initiated on [DATE] and revised on [DATE] resident has a potential for altered skin integrity related to immobility and incontinent episodes of bowel with goal to have no complications related to Stage 3 ulcer and interventions for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. These records are inconsistence with wound measurements observed by the DON and SA on [DATE] at 2:30 PM. Resident #8 Record review the Admission Record revealed Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 25 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 2. [MEDICATION(S)] Solution 100 unit/mL 30 units subcutaneously one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 3. [MEDICATION(S)] HCL Extended Release give 500 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 4. [MEDICATION(S)] Inject per sliding scale related to Type 2 Diabetes (Ordered [DATE]) Record review of Resident # 8's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Type 2 Diabetes Mellitus [CONDITION(S)] diagnosis, including medications ([MEDICATION(S)], [MEDICATION(S)], [MEDICATION(S)], and Insulin) and labs. Resident #9 Record review of the Admission Record revealed Resident #9 was originally admitted on [DATE] and readmitted on [DATE]. Record review of Resident #9's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #9's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet to MG Give 1 tablet by mouth one time a day for Essential Hypertension (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 50 MG Give 50 mg by mouth in the morning for Hypertension (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth in the morning for Hypertension/[CONDITION(S)] related to Essential Hypertension (Ordered [DATE]) Record review of Resident # 9's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Hypertension diagnosis, including medications ([MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]). Resident #10 Record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE]. Record review of Resident #10's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #10's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Solution 100 mg/milliliter (ML) by mouth two times a day related to seizures (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 75 mg by mouth one (1) time a day related to cerebral infarction, unspecified (Ordered [DATE]) Record review of Resident # 10's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for [CONDITION(S)] Disorder diagnosis, including medications ([MEDICATION(S)] Solution) and labs. Also, there is no care plan in place for cerebral infarction diagnosis, including medications ([MEDICATION(S)]) and labs. Resident #11 Record review of the Admission Record revealed Resident #11 was admitted to the facility on [DATE]. Record review of Resident #11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Delayed Release two (2) capsules by mouth before meals for Chronic Pancreatitis (Ordered [DATE]) 2. [MEDICATION(S)] Sodium Delayed Release 500 mg by mouth two (2) times a day for convulsive disorder (Ordered [DATE]) 3. [MEDICATION(S)] HCL 1000 mg by mouth two (2) days a day for Diabetes (Ordered [DATE]) 4. [MEDICATION(S)] Table 25 MG Give one (1) tablet by mouth in the morning related to Essential (Primary) Hypertension. Record review of Resident # 11's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Diabetes Mellites diagnosis, including medications ([MEDICATION(S)]) and labs. Also, there are no care plans in place for Chronic Pancreatitis diagnosis, including medications ([MEDICATION(S)] Delayed Release). There are no care plans in place for convulsive disorder diagnosis, including medications ([MEDICATION(S)] Sodium) and labs. Also, there is no care plan in place for Hypertension diagnosis, including medications ([MEDICATION(S)]). Resident #12 Record review of the Admission Record revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 5 mg by mouth two times a day for Deep Vein [CONDITION(S)] (Ordered [DATE]) Resident #12 was found unresponsive on [DATE]. Resident #12 expired at the facility. Record review of Resident # 12's comprehensive care plan revealed a care plan focus for the resident that states the resident has altered cardiovascular status r/t arrhythmia (A-Fib) and implanted pacemaker device (Medtronic). There are no interventions in place for medications ([MEDICATION(S)]) and labs. On [DATE] at 2:55 PM, the SA observed the DON do a full body audit on Resident #12. The last weekly wound assessment given by the DON done on [DATE] with only a wound to left anterior kneecap noted. The full body audit with the DON revealed one ulcer to both anterior knees and left lower lateral leg above the ankle. The right anterior knee wound had scant amount serous drainage, no odor, and red granulation tissue noted. The left anterior knee wound had moderate amount of serous drainage, no odor, and red/pink granulation tissue. The ulcer to left lateral lower leg had no drainage, no odor, and pink granulation tissue. An assessment of the buttocks revealed three (3) open areas to right buttock and one (1) open area to left buttock. All the three (3) open pressure areas to the right buttock and the one (1) pressure area to the left buttock had minimal bloody drainage and no odor with red granulation tissue noted. Record review of Resident #12's care plans revealed a start date of [DATE] resident has a Stage 2 ulcer of the heel with interventions to assess/record/monitor wound healing two times weekly measure length, width, and depth. Records review of Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #12 never had a wound documented to his heels. Record review of Resident #12's care plans revealed no care plans for resident's actual wounds. On [DATE] at 9:30 AM, in an interview with Wound Care Clinic Nurse, RN #2, she explained Resident #12 was seen at the wound care clinic before he went into the nursing facility. She reported he was being treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . She explained Resident #12 was readmitted to the wound care clinic on [DATE] from the facility. She reported Resident #12 was treated on [DATE] for a pressure ulcer to right buttock which was acquired at the facility and the resident had reported to her the wound had been there for about t Resident #15 Record review of the Admission Record revealed Resident #15 was admitted to the facility on [DATE]. Record review of Resident #15's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #15's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident # 15's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Diabetes Mellites diagnosis, including medications ([MEDICATION(S)]) and labs. Resident #16 Record review the Admission Record reveals Resident #16 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time a day related to Essential Hypertension 2. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time day related to Essential Hypertension (Ordered [DATE]) 3. [MEDICATION(S)] 250 MG give 1 tablet by mouth one time a day related Seizures (Ordered [DATE]) 4. [MEDICATION(S)] 50 MG give 1 tablet by mouth two times a day related to Essential Hypertension (Ordered [DATE]) 5. [MEDICATION(S)] Sodium Tablet Delayed Release 500 MG Give 1 tablet by mouth one time a day related to Seizures (Ordered [DATE]) Record review of Resident # 16's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Hypertension diagnosis, including medications ([MEDICATION(S)], [MEDICATION(S)], and [MEDICATION(S)]). Also, there is no care plan in place for [CONDITION(S)] diagnosis, including medications ([MEDICATION(S)] Sodium and [MEDICATION(S)]) and labs. Resident #17 Record review the Admission Record revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #17's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record Review of Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth two times a day related to Essential Hypertension ([DATE]) 2. [MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 60 MG Give 1 tablet by mouth one time a day related to [CONDITION(S)] (Ordered [DATE]) Record review of Resident # 17's comprehensive care plan revealed there was no care plan (focus, goals, or interventions) in place for Hypertension diagnosis, including medications ([MEDICATION(S)] and [MEDICATION(S)]). Also, there is no care plan in place for Congestive Heart Failure, including medications ([MEDICATION(S)]). On [DATE] at 10:45 AM, in an interview with CNA #7, he explained he has been a CNA and worked at the facility for two years. When ask CNA #7 regarding how he knows the care each resident requires he explained that you can look at the computer at the Resident's plan of care and ask the nurse. He further explained sometimes he does rounds with the off going CNA and get an update on each resident but sometimes the CNAs are already gone. On [DATE] at 9:45AM, in an interview with CNA #6, she explained she has been a CNA for [AGE] years, and 1 year at the facility. When ask how she is aware of individual resident's needs, she explained look the care plans on the computer. She reported the CNAs used to have pocket guides but now everything is on the computer. When ask if she noticed a change in a resident what would she do, she explained she would notify the Resident's nurse, ADON and DON. On [DATE] at3:15 PM, in an interview with Registered Nurse (RN) #1, she said she is responsible for updating the care plans. The nurse said If the resident has a decline with transfers, the CNA notifies the nurse, the nurse notifies therapy and therapy gives her their recommendations. All lifts are place on the resident's care plans. RN #1 said she did not know what else do with Resident #1. The local Behavioral health did not give recommendations except for the medication. RN #1 said the DON and Administrator said the facility did not have enough staff to do a one on one. RN #1 revealed she has not had Behavioral health training. RN #1 said all residents are assess for transfers. Sometimes the staff transfer the residents with lifts without recommendations from Therapy or without it being on the care plan. This is not the facility policy. The nurse confirmed Resident #1's care plan was not updated after his stay at the Behavioral facility. RN #1 said she thought it was updated but realized she had not done it when the SA came into the building. RN #1 said it is her responsibility to update the care plans and to provide interventions along with the nursing departments help. RN #1 said she has started updating the care plans daily by printing off all new orders and placing them on the care plan. RN #1 also said all high-risk medications should be added to the care plan. RN #1 confirmed she does not have any behavioral health training. On [DATE] at 11:00 AM, in an interview with the Minimum Data Set (MDS) nurse, RN #1, she explained since she took over the MDS job she has been trying to update all care plans as Resident concerns come up. She explained the DON and her are the nurses who mostly do the care plans, but she has noticed that some of the nurses on night shift has tried to update care plans as needed. On [DATE] at 11:30 AM, in an interview with LPN #5, she explained she does not do any updates on the care plans for residents. She further explained she thought the DON and the MDS nurse was responsible for resident's care plans. On [DATE] at 1:30 PM, in an interview with the DON, she explained she did work in MDS prior to becoming DON and did care plans as the MDS nurse. She explained since becoming the DON, she has not been able to keep up with the Resident's care plans as she should. She further explained she is still learning all the roles of the DON and trying to learn as she goes. She reported prior to becoming DON, she worked in the MDS department and tried to update care plans frequently but reported during COVID-19 and lately she has had to work the medication carts and not be able to do her jobs. When asked what the purpose of the Resident's care plan, she explained the care plans are to ensure that the resident is taken care of the right way. When asked if a care plan is not updated could that cause any problems for the resident, she explained yes, the resident may not get all the care they require and could cause accidents.

Based on observations of staff and residents, staff and resident interviews, record review, and facility policy review, the facility failed to ensure residents received care, consistent to prevent pressure ulcers, to promote the healing of pressure ulcers, prevent an infection, and prevent new ulcers from developing for eight (8) of nine (9) residents sampled. Residents #3, #5, #6, #7, #12, #13, #14, and #17. The State Agency (SA) identified an Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) which began on 04/06/2021 when the facility failed to ensure Resident #7's wound was free from infection as evidenced by the wound developed a fowl odor and increased drainage. This wound was cultured and revealed an infection present in the wound bed. The facility's failure to ensure residents received care, consistent to prevent pressure ulcers, to promote the healing of pressure ulcers, prevent an infection, and prevent new ulcers from developing placed the residents in a situation that caused or is likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 05/05/2021 and was determined to exist on 04/06/2021. The IJ was not removed prior to exit on 05/26/2021 and is considered ongoing. Findings Include: The facility's, Skin Care Process policy, revealed a date of January 17, 2018. It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet professional standards to treat the loss of skin integrity should it occur .Process: The skin care process has 6 components: 1. Evaluation of the resident's skin condition 2. Determining risk for altered skin integrity. 3. Developing and implementing an individualized plan of care. 4. Evaluating the effectiveness of the plan of care and revising approaches as needed. 5. QAPI system for overall effectiveness of the skin care process. 6. Staff education related to the skin care process. Process Guidelines: 1. Evaluation of the resident's skin condition on admission as as needed. 2. Determining the risk for altered skin integrity: a. The Admit/Readmit Physical Evaluation should be completed on admission and readmission. b. The Braden Scale should be completed upon admission, readmission, quarterly and as needed to determine pressure ulcer risk. c. The Malnutrition Risk Assessment should be completed on admission, readmission, quarterly and as needed. 3. See care plan process. 4. If a wound is not showing signs of improvement within 2 weeks of treatment, a re-evaluation of the wound and change in treatment should be considered. 5. QAPI system for evaluating the overall effectiveness of the skin care process. 6. Staff education: Nursing staff should receive training regarding skin and skin care as appropriate upon hire and periodically thereafter. Nurses may need further training in evaluation, assessment, staging and measuring wounds prior to being responsible for wound care . Pressure Wounds: The goal of this facility in regard to pressure wounds is to promote the prevention of the healing of pressure wounds that are present and to minimize the potential for development of new pressure wounds using the Skin Care Process. Resident #3 On 05/05/21 at 1:15 PM in an observation of wound care on Resident #3 with Licensed Practical Nurse (LPN) #5 revealed the nurse cleansed a large, opened wound to sacrum with wound cleanser, there were no odors are drainage. The wound bed is pink with maceration around the edges. The nurse cleansed with wound cleanser and packed with Santyl, gauze, covered with dry dressing. On 05/06/21 at 1:15 PM in an interview with the Resident #3's daughter revealed Resident #3 acquired the wound in the facility. The daughter said she hired a sitter several months ago to assist the resident because the staff was not turning her and assisting with meals. 0n 5/05/21 at 1:30 PM interview with LPN #5, said explained Resident #3 acquired the wound in the facility. She further explained Resident #3 acquired the wound before she started working at the facility. She reported she does the treatments, but she does not measure the wounds and the DON is responsible for keeping up with the measurements. Record review of Resident #3's Weekly Pressure Injury record dated 09/30/2020, revealed the Stage 3 wound to the sacrum measured 1 centimeter (cm) x 4.0 cm x 0.5 cm with granulation tissue. The next Weekly Pressure Injury Record was dated 1/11/2021 and was blank with no information entered. The most recent weekly Pressure Injury Record was completed on 5/07/2021 and revealed Resident #3 had a Stage 3 pressure ulcer to the sacrum measuring length 4 cm, width 5 cm, depth 0.75 cm and tunneling of 2 cm at 6 o'clock and a Stage 2 pressure wound to the right gluteal fold measuring 1 cm X 1.5 cm X 0.1 cm. Record review of Resident #3's first 03/04/2021 with Wound Care revealed measurement for sacrum Stage 3 pressure injury length 6.0 cm, width 5.0 cm, and depth 0.6 cm. The report revealed large amount of serosanguineous exudate with no tunneling, but wound did have slough noted. On 5-13-21 at 9:30 AM, in an interview with (Proper Name) Wound Clinic Wound Care Nurse, Registered Nurse (RN) #2, she explained the facility has three (3) residents that come for wound care. She explained the residents come once every three (3) weeks and the facility does a rotation schedule for the three (3) residents. When asked regarding Resident #3, she explained the resident was referred to wound care on 03-04-21 for a stage 3 decubitus ulcer. She further explained that was all the Resident #3's referral said. She explained she has no start date of the decubitus and not sure exactly when the wound began. She reported Resident #3 was seen years ago for the same wound but in August 2017 the facility stopped sending residents due to the facility wanted to do the wounds in house. Record review for Resident #3's Face Sheet revealed the facility initially admitted Resident #3 on 02/24/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Quarterly Minimum Data Set with Assessment Reference Date (ARD) dated for 2/15/21 Section C revealed Resident #3 had a Brief Interview of Mental Status (BIMS) score of 05, which indicates severe cognitive impaired. Section G revealed Resident # 3 required two (2) plus person assistance with bed mobility and transfers. Section H revealed Resident #3 was always incontinent of bowel and bladder. Section M revealed Resident #3 had a Stage 3 pressure ulcer. Record review of Dietician Progress notes revealed Resident #3 has been seen monthly since 12/16/2020. The progress notes revealed Resident #3 was seen 4/28/2021 regarding wound review and hospital return with a weight gain of 6.4 percent (%) in the past 30 days with supplements Boost three times a day, Juven twice a day, and Promod twice a day. Record Review of Resident #3 Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . An additional order dated 10/30/2019 states to visually check dressing to Stage 3 ulcer every shift and the order was discontinued on 03/19/2021. A record review of Resident #3's last Braden Scale with a date of 09/30/2020 revealed Resident # 3 is moderate risk for pressure ulcer with a score of 13. Record review of Nursing Progress Notes revealed a Patient at Risk (PAR) dated for 3/12/2021 with a care plan meeting with Resident #3's daughter and concerns regarding Resident #3's care. The noted revealed a staff member will go with resident to wound care, frequent visual observations to ensure wound care being carried out, and having nurse initial, date, and time the bandages were changed. The note revealed no measurements of the wound. The record revealed the previous PAR note was dated for 07/22/2020 with Stage 3 sacral area measurements 2.5 cm x 2 cm x 0.3 cm with bright pink granulation tissue with white edges related to maceration with no odor and scant amount of serous drainage. Record review of Nursing Progress Notes revealed a Patient at Risk (PAR) note dated for 3/12/2021 with a care plan meeting with Resident #3's daughter and concerns regarding Resident #3's care. The noted revealed a staff member will go with resident to wound care, frequent visual observations to ensure wound care being carried out, and having nurse initial, date, and time the bandages were changed. Record review of Resident #3's Treatment Administration Record (TAR) for January 2021 revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the TAR for March 2021 revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of April 2021 TAR revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of lab results for Resident #3 revealed [MEDICATION(S)] level low at 1.9 dated for 03/24/2021. Resident #5 SA phoned son of Resident #5 on 05/04/21 at 11:00 AM. SA asked him regarding his mom's care while a resident at Liberty Nursing Home, and he explained the first concern was his mother got bedsores while at the facility. Record review of Resident #5's Admission Record revealed the facility admitted Resident on 05/19/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 was discharged to another facility on 1/21/2020. Record review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of November 16, 2020, Section C revealed Resident #5 had a BIMS score of 06, which indicated Resident #5 had severe cognitive impairment. Section G of the MDS revealed Resident #5 required extensive assistance with two plus persons. Section H of the MDS revealed Resident #5 had an indwelling catheter and always incontinent of bowel. Section M of the MDS revealed Resident #5 had one (1) Stage 2 and one (1) unstageable wound. The latest Discharge MDS with ARD of 1/21/2021 revealed the same findings as the quarterly MDS. Record review of Resident #5's Initial Weekly Wound Pressure report dated 05/20/2020 revealed resident #5 was admitted with a wound on the left heel, inner aspect, unstageable, with measurements of 2 cm x 1.4 cm x 0.2 cm and wound to right buttock Stage two with measurements 1 cm x 1 cm x 0.2 cm. Review of Resident #5's Nurse Progress Notes dated 05/25/2020 revealed a new area to left gluteal fold with partial thickness measurements of 1.5 cm x 0.5 cm x0.1 cm with cleansed area with wound cleanser pat dry, [MEDICATION(S)] applied to area. There was no weekly body audit with the new wound to left gluteal fold with measurements. Review of Resident #5's weekly body audit dated 06/17/2020 revealed no measurements and continue treatment to coccyx and right foot. Further record review of Resident #5's weekly body audits dated 09/02/20, 09/28/20, 10/14/20 revealed body audits with wounds right and left buttock with no measurements recorded. Record review of physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #5's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order dated 06/12/2020 for denuded area to left buttock cleanse area with wound cleanser and pat dry apply [MEDICATION(S)] cover area with silicone dressing daily and Stage 2 to right buttock to cleanse with wound cleanser and pat dry, apply [MEDICATION(S)] 20% to area and cover with silicone dressing daily. A new order dated for 08/03/2020 states unstageable ulceration to left heel (inner aspect) cleanse with wound cleanser and pat dry, apply sure prep to wound bed only, cover with 4x4 and foam heel dressing and wrap with [MEDICATION(S)] and secure with tape every two days. Record review of Resident #5's only lab value record dated 06/03/2020 with an [MEDICATION(S)] level 2.8, which indicated a low level. Record review of Resident #5's only Braden Scale dated 09/30/2020 for predicting pressure sores revealed Resident #5 is at high risk for developing pressure sores. Record review of Resident #5's Treatment Administration Record (TAR) revealed when resident first arrived at the facility in May 2020, Resident #5 had missing documentation for treatment to left heel were missed on 05/21/2020, 05/22/2020, 05/23/2020, 05/27/2020, 05/28/2020, and 05/29/2020 and missing documentation for treatment to Stage 2 to right buttock on 05/21/2020, 05/22/2020, 05/27/2020, 05/28/2020, and 05/29/2020. On 5/5/2021 at 3:00 PM, in an interview with the DON, when asked if a treatment is not initialed what does that mean, she reported if it is not documented than it is not done. She further explained the treatments on the Treatment Administration Record should be initialed after the treatment is done. Resident #6 Interview on 5/2/2021 at 11:00 am with Resident #6's daughter revealed her mother is not cognitively impaired. She reported her mother developed a sore on her ankle while at the facility and still has the sore. She reported the staff does not do the treatments regularly. Observation and interview on 5/6/21 at 3:30 PM, revealed LPN #10 performed a skin assessment on Resident #6. LPN #10 explained Resident#6 has had the wounds for a long time and reports the wound will get better and then open back up. No dressing observed to wounds. Observed LPN #10 measure wounds with a paper ruler for each wound, wounds measurements were documented by LPN #10 to be left ankle 1.5 cm x 1.0 cm and right ankle measurement 1.5 cm x 1.5 cm x 0.2 cm. Both wounds to ankle were covered with blue dye, wound tissue dyed blue with some darker tissue to the center of the wounds, and wounds edges both irregular. The wounds had no drainage. Record review of Resident #6's weekly body audit dated for 01/08/2021 only reports no new skin alterations. Body audits dated 03/02/2021, 04/27/2021, 05/06/2021 revealed no measurements of wound to ankles and no weekly pressure injury records available. A weekly body audit dated 03/03/2021 revealed right and left ankles with both wounds measuring 1.0 cm x 1.0 cm with callous like wound on ankles. Three weekly skin reports provided by the DON revealed on 01/28/2021 Resident #5 had bilateral ankle abrasions with one measurement of 2.0 cm x 2.0 cm; on 03/15/2021 resident had non-pressure wounds to bilateral ankles, the wounds were facility acquired and a measurement of 2.0 cm x 2.0 cm one set of measurements for bilateral ankles; and on 04/13/2021 facility acquired non-pressure wounds to bilateral outer ankles and a measurement of 1.5 cm x 1.5 cm. A Pressure Report dated 05/08/2021 revealed Resident # 6 with pressure wounds to bilateral ankles with measurements left ankle 1.5 cm x 1.2 cm and right ankle 1.5 cm x 1.5 cm with Stage 2 noted with eschar tissue per DON skin assessment. 05-10-21 at 3:45 PM In an interview with Resident #6 she explained she got the wounds to her ankles years ago and at first the facility did not do anything about them for a long time. She reported that she keeps hitting her ankles on the wheelchair. She reported the facility does paint the wounds with something blue but still does not do it every day. She explained that the areas still hurt with any pressure on the ankles. Record review of Resident #6's Face Sheet revealed the facility initially admitted Resident #6 on 07/31/2017 and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Face Sheet revealed Resident #6 had an added diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Annual MDS with ARD date 2/26/2021 Section C revealed Resident #6 had a BIMS score of 13, which indicated Resident #6 is cognitively intact. Section M revealed Resident #6 had a Pressure ulcer of 1 or greater or a scar over a bony prominence. Section M had no other areas flagged for skin conditions. Resident #6's Quarterly MDS with ARD date 12/08/2020 Section M had no areas flagged for skin conditions. Record review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's only Braden Scale report available dated 06/23/2020 revealed Resident #6 was a low risk for predicting pressure sores. Record reveal of Resident #6's most recent lab results dated 05/05/2021 revealed an [MEDICATION(S)] level of 3.1. Resident #7 On 05/05/2021 at 7:30 AM, in an interview with LPN #5 during medication administration to Resident #7, the resident received [MEDICATION(S)] 500 milligram (mg). When asked LPN #5 why resident was receiving antibiotics, she explained Resident #7 has an infection. When asked what type of infection, LPN #5 explained Resident #7 has a wound infection. She explained she will be doing his wound care later today. On 5/6/21 at 10:30 AM, during an observation of wound care by LPN #5 for Resident #7's sacral wound and right gluteal fold, the sacral wound was observed with a moderate amount of brown, purulent drainage with a foul odor noted. The wound bed tissue was brown and necrotic with some slough noted to the sacral wound. The right gluteal fold wound had 75 % slough with a scant amount of purulent drainage. LPN #5 explained Resident #7 has had the wound to his sacrum for a long time. She further explained the wound had gotten worse since the resident was in the hospital last month. She reported that he used to go to wound care, but not sure when and no longer does. She reported the wound to resident's right gluteal fold was new after his last hospital stay. LPN #5 and SA only observed two (2) open pressure wounds for Resident #7, one to the sacrum and one to the right gluteal fold. On 05/06/21 at 10:45 AM, in an interview with CNA #7, he explained has been a CNA and at the facility for two years. He reported that the Resident #7 has had the wound to his sacrum for a long time and that it would heal and then be bad again. On 05/11/21 at 2:20 PM, in an interview with the DON prior to wound measurements on Resident #7, the DON asked the SA if she could just pull-down bandage and measure the resident's wounds. While measuring Resident #7's wound, she explained she does not know where she got only one wound measurement for Resident #7 on 05/08/21. She further explained the area to Resident #7's right gluteal fold is new. While measuring the sacral wound, she reported the wound stinks. Observation on 5-11-21 at 2:30 PM, Resident #7 had two bandages intact, one to the sacrum and one to the right hip. The SA observed the DON remove the edges of the bandages and measure each wound for Resident #7 with wound to right buttock 1.5 cm x 7.0 cm x 0.25 cm, new wound noted to right gluteal fold 0.5 cmx 1.25 cm x 0.1 cm, and wound to sacrum 10 cm x 7 cm. The DON did not measure the depth of the sacrum wound. Moderate amount of purulent drainage with odor noted. DON measured the wounds with a 4 x 4 gauze package and just pulled back the bandages and measured, she did not remove the dressings, just pulled the edges back. On 5/17/2021 at 12:30 PM, in an interview with the emergency contact for Resident #7, she explained she is the resident's Responsible Party now. When asked if the facility has notified her of his wounds, she reported she was called about 2-3 weeks ago and notified of his wounds and that the resident needed wound care. She explained the Resident will start going to wound care at (Proper Name) Hospital. When asked does she know how long resident has had the wounds, she reported she not sure how long because the family has not able to come see the resident due to COVID-19 isolations and the resident has been out to the hospital. She denies any concerns with the facility other than it is hard to get in touch with the facility at times because no one will answer the phone. Record review of a weekly body audit dated 07/07/2020 for Resident #7 revealed a sacrum wound Stage 3 with measurements 3 cm x 7 cm x 0.2 cm with bright red granulation tissue. The next body audit was dated for 12/17/2020 with sacrum wound and no measurements. A weekly body audit was done 02/06/2021 and 03/13/2021 revealed no measurements of wounds and treatments continue to coccyx and testicles as ordered. A weekly body audit dated 03/16/2021 revealed a sacrum wound with no staging of the wound, but wound measuring 3.5 cm x 1.8 cm x 0.2 cm completed by LPN #1. A weekly body audit dated 04/13/2021 revealed a new pressure ulcer to right buttock with no measurements. Record review of weekly skin reports provided by the DON revealed wound measurements for Resident #7 on 03/15/21 facility acquired Stage 2 sacrum 1.8 cm x 3.5 cm x 0.1 cm and on 05/08/2021 stage 3 sacrum with 1.5 cm x 1 cm x 0.1 cm stage 3. Record review of a Physicians Order dated 4/6/2021 revealed wound culture of Stage 3 sacral decubitus one time only for wound care. Record review of a Physicians Order dated 07/07/2020 revealed Stage 3 to sacral/gluteal cleft cleanse with wound cleanser and pat dry, apply puracol to wound bed, cover with Opti foam dressing daily. This order was discontinued 04/06/2021 and a new order started on 04/06/2021 for Hydrogel apply to Stage 3 sacral decubitus topically one time cleanse area with wound cleanser and pat dry, cover with Opti foam dressing daily and as needed for dislodging/soiling. The wound care order started on 04/06/2021 was discontinued on 05/04/2021 and a new order was started cleanse Stage 3 sacral wound decubitus with ¼ strength Dakin's solution, apply calcium alginate to wound bed and cover with bandage one time a day. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Nurse Progress notes dated for 04/08/2021 for Resident #7 revealed resident was sent out to the local hospital on 4/08/2021 with the hospital diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Lab reports 04/08/2021 revealed abnormal complete blood count (CBC) with elevated white blood cell counts 19.2 and on 04/09/2021 CBC elevated level of 23.5, urinalysis with positive nitrites, large leukocytes, and urine culture with Escherichia coli, and wound culture collection date of 04/08/2021 with heavy growth of pseudomonas aeruginosa. Resident #7 returned to the facility on [DATE] with a new order of order to start on 04/14/2021 cleanse sacral and hip wound with wound cleanser, pat dry, apply [MEDICATION(S)] Alginate foam pad apply to sacral and hip wound topically one time a day, [MEDICATION(S)] 875-125 milligrams give one tablet by mouth two times a day for infection for 7 days started on 04/13/21 and end 04/20/2021. Record review of nurse progress notes dated 04/15/2021 revealed Resident #7 was sent back to local hospital for altered mental status but returned the same day. Record review of nurse progress notes dated 04/18/2021 revealed Resident #7 was sent back out to the local hospital on 04/18/2021 and admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A new Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] #7 returned from the hospital and order end date 04/28/2021. Record review of wound culture of Resident #7's sacral wound collected on 04/22/2021 revealed heavy growth of pseudomonas aeruginosa with sensitivity report. Record review of nurse progress notes on 04/26/2021 revealed Resident #7 was unresponsive and sent back to local hospital and resident returned to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of a Physicians Order dated 05/04/2021 revealed cleanse Stage 3 sacral decubitus with ¼ strength Dakin's Solution, apply calcium alginate to wound bed and cover with bandage one time a day for sacral wound. Record review of Resident #7's Face Sheet revealed the Facility initially admitted on [DATE] and readmitted on [DATE] with the following Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) dated [DATE], Section C revealed Resident #7 had a Brief Interview for Mental Status (BIMS) score of 05, which means Resident #7 is severely cognitively impaired. Section G of the MDS revealed Resident #7 required extensive assistance with one (1) person for bed mobility and toileting, and extensive assistance with two (2) persons assist for transfers. Section H of the MDS revealed Resident #7 was always incontinent of bowel and bladder. Section M of the MDS revealed Resident #7 had only one Stage 3 wound. Record review of Antibiotic Usage Surveillance Tool revealed Resident #7 was on three (3) different antibiotics related to wound infections. Review of Braden scale for Resident #7 dated 09/30/2020 revealed a score of 16 which indicated low risk for developing pressure sores. Record review of Resident #7's care plans printed on 05/07/2021 revealed a care plan initiated on 09/06/2018 and revised on 04/26/2021 resident has a potential for altered skin integrity related to immobility and incontinent episodes of bowel with goal to have no complications related to Stage 3 ulcer and interventions for weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue, and exudate. These records are inconsistence with wound measurements observed by the DON and SA. Resident #12 On 5/6/21 at 2:55 PM, the SA observed the DON do a full body audit on Resident #12. The last weekly wound assessment given by the DON done on 5/3/21 with only a wound to left anterior kneecap noted. The full body audit with the DON revealed abrasions to both the left and right anterior knees and one left lower lateral leg venous ulcer above the ankle. The right anterior knee wound had scant amount serous drainage, no odor, and red granulation tissue noted. The left anterior knee wound had moderate amount of serous drainage, no odor, and red/pink granulation tissue. The venous ulcer to left lateral lower leg had no drainage, no odor, and pink granulation tissue. An assessment of the buttocks revealed three (3) open areas to right buttock and one (1) open area to left buttock. All the three (3) open pressure areas to the right buttock and the one (1) pressure area to the left buttock had minimal bloody drainage and no odor with red granulation tissue noted. The SA observed the DON measure the wounds to the right and left buttocks with her index finger and thumb and recorded measurements of right buttock site #1 measured 0.5 cm x 0.5 cm x 0.1 cm, site #2 measured 1.0 cm x 1.0 cm x 0.1 cm, and site #3 measured 1.5 cm x 1.5 cm x 0.1 cm. The SA observed the DON measure the wound to the left buttock with her index finger and thumb and document measurements of 1.0 cm x 1.5 cm x 0.1 cm. The measurements for the right knee were 1.0 cm x 2.0 cm and the DON did not record a depth. The left knee measurements were 3.5 cm x 3.0 cm, and the DON did not record a depth measurement. The left lateral lower leg ulcer was not measured by the DON for measurements. She did not use any type of measuring instrument. On 05/07/21 at 1:00 PM in an interview with Medical Records LPN #10, she explained there is no Braden Scales on file for Resident #12. 05-10-21 at 3:15 PM in an interview with Resident #12 when asked how and when he got his wounds, Resident #12 explained that he fell at home and got wounds to his legs. He reported he cannot walk and does not want to get up out of bed. He explained he goes to wound care he thinks every 2 weeks. He further explained the wounds on his buttocks come and go. He reported he can move freely in the bed and tries to move to relieve pressure. He reported that he gives himself bathes from the waist up. On 5/11/21 at 1:55 PM, an observation of the DON performing a body audit and wound measurements on buttock wounds for Resident #12 revealed three (3) wounds to Resident #12's right buttock and one wound to the left buttock with the DON. The DON explained 2 of the wounds to Resident #12's right buttock was healed on the body audit done 5/8/21. DON measured wounds with a Q-tip applicator package and documented the measurements as right buttock wound #1 as 2.0 cm x 1.5 cm x 0.1 cm, right buttock wound #2 as 0.5cm x 0.5 cm, and 0.1 cm, and wound right buttock #3 as 1.0 cm x 2.0 cm x 0.1 cm. The left buttock had one wound with a measurement of 0.5 cm x 0.5 cm x 0.1 cm. The DON did n

Complaint # MS Based on staff, resident, Nurse Consultant, Nurse Practitioner and Medical Doctor interviews, Owner of the facility, observations of staff and residents, and record review the facility failed to ensure residents received care from competent staff to promote wound healing during wound care and while using a wound vacuum (vac for four (4) of eight (8) Residents. Residents #7, #12, #14 and #17. The failure to ensure residents received competent care, with wound vac usage, to promote wound healing placed the residents in a situation that caused or is likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) on 05/05/2021 and was determined to exist on 3/17/21, when Resident #1 was admitted with severe mental illnesses, with staff had insufficient training in severe mental illnesses training. The IJ was not removed prior to exit on 05/26/2021 and is considered ongoing. Findings Include: The facility's policy, Skin Care Process dated 01/17/2018, It is the policy of this facility to provide care and services with the goal of maintaining the resident's skin integrity and to provide care and services that meet the need professional standards to treat the loss of skin integrity should it occur .6. Nursing staff should receive training regarding skin and skin care as appropriate upon on hire and periodically thereafter. Nurses may need further training in evaluation, assessments, staging and measuring wounds prior to being responsible for wound care. An observation on 5/6/21 at 2:30 PM, with the Director of Nursing (DON) was observed measuring wounds with her index finger and thumb and charted 1 centimeter (cm) length and 2.5 cm width. She did not use any type of measuring instrument. State Agency (SA) observed DON measured Resident #14 wound area with her fingers and recorded measurements 2 cm length and 1 cm width. On 5/6/21 at 2:55 PM, an observation of the DON doing a full body audit on Resident #12. An assessment of the buttocks revealed three (3) open areas to right buttock and one (1) open area to left buttock. Observed DON measure wounds to buttocks with index and thumb and recorded measurement of Right buttock site #1) 0.5 x 0.5 x 0.1 cm, site #2) 1 x 1 x 0.1 cm, and site #3) 1.5 x1.5 x 0.1 cm. Observed DON measure wound to left buttock with index fingers and thumb and document measurements of 1 x 1.5 x 0.1 cm. She did not use any type of instrument to measure the wound. An observation on 5/11/21 at 2:30 PM, revealed wound care on Resident #7 the DON did not measure the depth of the sacrum wound. On 5/05/21 at 1:30 PM, in an interview with LPN #5, reported she does the treatments, but she does not measure the wounds and the DON is responsible for keeping up with the measurements. On 5/5/2021 at 3:00 PM, in an interview with the DON, when asked if a treatment is not initialed what does that mean, she stated, if it is not documented than it is not done. She further explained the treatments should be initialed after the treatment is done. On 05/06/21 at 10:50 AM, in an interview with the DON, she explained she just started doing weekly wound care reports. She explained that she has not been consistent with doing wound reports. She explained the nurses on the med carts do the treatments and the measurements for the wounds. DON stated there is no specific days to measure wounds. She reported there has not been any in services or special training regarding wound care. She reported the only wound care training the nurses have had including her, are from school and she did wounds for Hospice before, but no wound care treatments were done in Hospice, she just kept the resident comfortable. She further explained that the nurse on the floor was to measure Resident #6's and Resident #3's wound today. SA explained the wound was not measured during wound care. In an interview with LPN #5, on 5/6/21 at 1: 00PM, she stated she has never measured any wounds including Resident #7. She stated that the DON asked her to measure wounds. She stated she feels that the DON needs to look at the resident's wounds at least weekly. She explained the DON asked for our measurements for her report, but the DON does not look at wounds weekly and does not measure wounds. On 5/6/21 at 5:30 PM, in an interview with the Nurse Consultant, she explained the DON has not been consistent with wound care reports for months. She explained she has gone over the wound care with the DON and explained to the DON that she would need to assess the wounds weekly and would discuss the wounds weekly. She explained she has not been able to do patient at risk (PAR) notes due to no wound reports not being turned in. She further reported that about one (1) or two (2) months ago she asks the DON to do complete 100% body audits in the building but never received the audits. The SA explained to the nurse consultant that the SA has asked for weekly wound reports but received one report with the date of 5-3-21 and other notes from the DON with names and measurements listed but no dates. The nurse consultant reported that the wounds are to be assessed on admission and weekly. On 5/7/21 at 10:00 AM, in an interview with DON, asked her how she measured the wounds yesterday with the body audits, she demonstrated with her thumb and index finger. She reported she measured with her fingers. She further explained that she has looked at wounds so much that she knows the measurements. When ask the appropriate way to measure wounds, she explained with a ruler. She further explained she needs a little measuring tape and that never knew how to measure with the circle measuring tool. She reported she likes to use a gauze with the wrapper to measure the wounds. She explained that she must send reports to formal Technology name, the facility Nurse Consultant, and the dietician but again she explained she has been overwhelmed with the DON position and has not been consistent with would care reports. On 5/7/21 at 10:10 AM in an interview with the Assistant Director of Nurses (ADON), she explained she has nothing to do with the wounds and DON is the individual who does wound reports and monitors wounds. On 05/07/21 at 1:00 PM, in an interview with Medical Records LPN #10, she explained there is no Braden Scales on file for Resident #12. On 5/7/21 at 2:00 PM, in a phone interview with Medical Nurse Practitioner, she explained she ordered a wound vac for Resident #17. She reported that resident goes to wound care at a local wound care clinic every 2 weeks. She explained she trained three nurses, Assistant Director of Nursing (ADON), LPN #5, and LPN # 10 today for the wound vac and all three know how to work the wound vac for the resident. On 5/7/21 at 2:30 PM, in an interview with DON, the DON gave the SA wound care reports with dates for 1-28-21, 3-15-21, 3-17-21, 3-24-21, 3-26-21, 3-29-21, 4-1-21, 4-5-21, ad 4-13-21. She explained she knew she had some more wound reports somewhere and explained she found them in the floorboard of her car. She explained that she must take her work home with her sometimes. She further explained she again she has not been consistent with wound care, but she had no wound care training except for working Hospice and school. She again explained the nurses on the floor has only had the wound training from nursing school. She explained there has not been any set days for the wounds measuring wounds or her doing the wound reports, but each resident is scheduled for weekly body audits. She reported that she hopes to schedule wound measuring for Monday because she must have the weekly wound reports turned in to the nurse consultant on Thursday. On 5/7/21 at 3:00 PM, in an interview with DON, when asked who the nurses were trained for wound vac and she explained she is not exactly sure who was trained on the wound vac, but she was not. When ask has she had any experience with wound vac, she explained no. When asked what the plan was with the wound vac if the wound vac malfunctions and the three nurses are not in the building, she explained she does not know that answer will find out. On 5/7/21 at 3:15 PM, in an interview with Nurse Consultant she explained the DON is responsible for weekly skin wound reports and the weekly body audits are done weekly by the resident's nurse. She reported that in the facility policy an LPN can measure wounds, but LPN cannot stage wounds and the DON should see wounds weekly and do a wound assessment including measurements. When ask what the facility measures wounds with, she reports the facility has paper rulers and measures width side to side, height with head to toes, and use a Q-tip for measuring depth. On 5/10/21 at 10:20 AM, in an interview and record review, with the DON, to review body audits with DON which was completed last week and over the weekend by the DON. she explained she included all findings on the individual body audit sheets, and she measured all wounds and printed a non-pressure and pressure wound report. She explained wounds on Resident #14's coccyx wound, scab was gone and healed. She explained that Resident #12's wounds on his left buttock are healed and one on the right buttock is healed but she assessed the wounds as shear tears. DON questioned Corporate Consultant and Nurse Consultant if a gluteal fold wound is pressure, both replied it would depend on what it looked like and where it is. DON reported that she does not think it is a pressure wound. Reviewed report for Resident #7 with DON and Resident #7 only having one wound listed, she explained she is not sure maybe the wound on the right hip was healed. Explained to DON, she will need to do another body audit with SA. DON explained she will come get SA for the body audits. On 5/10/21 at 3:30 PM, in an interview with Resident #17, he stated that his choices were to go to a nursing facility or go home with hospice. He reports he is starting to feel better now. While in Resident #17's room the wound vac started to beep. SA went and got DON regarding the machine beeping she went into the room and explained the machine's battery is low and she will plug it up. On 5/10/21 in an interview with DON at 4:00 PM, asked the DON regarding wounds on Resident #17, she explained resident did have some blackened areas on one of his heels and his toes but thinks they blackened areas all fell off. On 5/11/21 at 8:00 AM, in an interview with the DON, she explained during the night Resident #17's wound vac lost suction and he refused to have the dressing changed and the provider was notified. On 5/11/21 at 10:00 AM, in an interview with Medical Nurse Practitioner, she stated she felt like the facility did not have enough staff or education for taking care of Resident #17 wounds. She explained Resident #17 was a train wreck when he came in and has been sent out to hospital several times for evaluation and treatment and continue antibiotics for wound infection. On 05/11/21 at 2:20 PM, in an interview with DON prior to doing wound measurements on Resident #7, DON asked SA if she could just pull-down bandage and measure resident's wounds. While doing Resident #7's wound measurements, she explained she does not know where she got only one wound measurement for Resident #7 on 05/08/21. She further explained the area to Resident #7's right gluteal fold is new. While measuring the sacral wound, she reported the wound stinks. On 5/13/21 at 11:45 AM, in an interview with Medical Nurse Practitioner regarding wound care, she explained that wound care is not consistent in the building and that has become a problem with wounds. She explained the wounds will look good and then go bad. She explained the nurses do most of the wound care and DON very seldom looks even at the wounds. Resident #17 required a lot of wound care with a wound like his and the facility is not capable to care for him. She reported he was admitted with [CONDITION(S)] to his spine and requires more care. On 05/17/2021 at 11:00 AM, in a phone interview with Resident #17's Resident Representative (RR), when asked had she be notified of any wounds to resident, she explained no she had not. On 5/17/21 at 3:00 PM, in an interview with the Administrator, he stated that he discussed in the Quality Assurance (QA) meeting with the DON. He stated the facility discussed wounds in the April 2021 QA meeting. The DON needed wound care training. The recommendation was for the DON to follow the NP for training and to send the residents with large wounds to wound care. The DON is responsible for assessing and measuring the wounds weekly. The DON will do the weekly reports and notify the doctor and RR of the residents wound status. The DON said she never got the chance to receive the training from the NP. The DON said she has not had any training since nursing school. On 5/20/21 at 9:15 AM, in an interview with the DON confirmed she did not have training to care for residents with wound Vac's. The DON also confirmed the residents admitted in the last three (3) months should not have been admitted because the staff was not competent to meet their needs. The DON said most of the nurses are new grads and have not been educated on wound care, medications, and behaviors. On 5/20/21 at 10:00 AM, in an interview with Regional Director of Operations (RDO) stated the staff needs more education on wound care. On 05/20/21 at 12:30 AM, in an interview with local Medical Doctor (MD) she reported she has concerns related to the facility does not complete appropriate wound assessments. The wound assessments are not done for several weeks at a time. The MD stated the Director of Nursing (DON) changes the wound care orders without permission because of the cost of the medication. On 5/20/21 at 2:30 PM in an interview with the owner, stated he was aware of the staffing issues. He stated he was not aware of the severity of it. On 5/20/21 at 3:00 PM, in an interview with the Administrator, he confirmed the facility should have known they did not have sufficient/competent staff to take care of the needs of the residents. A record review of weekly body audit for Resident #7 revealed a sacrum wound Stage 3 with measurements 3 cm x 7 cm x 0.2 cm with bright red granulation tissue. The next body audit dated for 12/17/2020 with sacrum wound and no measurements. A weekly body audit noted for 03/16/2021 with sacrum wound measuring 3.5 cm x 1.8 cm x 0.2 cm. A weekly body audit noted for 04/13/2021 revealed new pressure ulcer to right buttock with no measurements. A record review of weekly skin reports provided by the DON revealed wound measurements for Resident #7 on 03/15/21 facility acquired Stage 2 sacrum 1.8 cm x 3.5 cm and 0.1 cm and on 05/08/2021 stage 3 sacrum with 1.5 cm x 1 cm x 0.1 cm stage 3. A record review of body audits revealed weekly body audit on 10/31/2020 with wounds to right and left knee and left lower leg, body audit on 11/23/2020 with wounds right buttock with 2 open areas, and no other weekly body audits completed. A weekly pressure injury record dated 04/19/2021 revealed a wound to right buttock with measurements 0.3 cm x 0.3 cm x 0 cm. A weekly body audit done on 05/08/2021 by DON did not list sites of wounds. Record review of the local hospital wound report revealed date 04/08/2021 wound to right buttock Stage 2 pressure ulcer with measurements of 0.3 cm x 0.3 cm x 0.01 cm. A record review of Resident #14's weekly body audits revealed only 3 body audits prior to 05/07/2021. Weekly body audit dated 09/19/2020 revealed Resident #14 had redness to buttocks and treatment to left breast. Resident #14 had one weekly pressure injury record dated 01/11/2021 but report was incomplete, blank, no areas entered. A weekly body audit completed on 05/06/2021 completed by the DON with area to left great toe measuring 1 cm x 2.5 cm eschar and area to left buttock measuring 2 cm x 1 cm scab. 05/07/2021 revealed Resident #14 had black area on left big toe, no measurements documented. A record review of the Braden scale on Resident #17 revealed it was incomplete. A record review of body audits and weekly pressure injury reports from DON on 05/11/2021 at 10:00 AM for Resident #17 revealed a body audit dated 05/06/2021 and could not determine measurements or exact locations for Resident #17. Another weekly body audit dated 05/08/2021 with three wounds listed and only one measurement for sacrum wound 12 cm x 10.4 cm x 4 cm with serosanguinous drainage, muscle and bones exposed, and undermining at 9 and 12 o'clock, with notes indicating new debridement to sacrum wound, resident refused measurements of groin denuded area, and resident refuses to turn to right and lays on back. Received weekly pressure injury reports for Resident #17 on 05/11/2021 with dates 3/4/2021, 3/15/2021, 4/7/21, and two reports for 5/8/21. The reports were all for Resident #17's sacrum wound and revealed wound measured 10 cm x 8 cm x 0.1 cm on 03/04/2021 and measured 12 cm x 10 cm x 4 cm on 05/08/2021. A record review of the latest in-service on Skin Care Process dated 1/7/21 revealed the signatures of LPN #5, LPN #6 and ADON. A record review of all the in-services revealed no training or sign in sheet for Wound Vac training.

CI Based on observation, staff and resident interview and record review, the facility failed to provide sufficient/competent staff for Behavioral Health needs when Resident #6 was assaulted and hair pulled by Resident #1 and Resident #9 had his chest rammed by Resident #1, for one (1) of five (5) Residents reviewed for behaviors. Resident #1. The facility's failure to provide sufficient /competent staff for Behavioral Health needs and address known behaviors put Resident #6, Resident #9 and all the residents who reside in the facility at risk for serious harm, serious injury, serious impairment, or possible death. This situation was determined to be an Immediate Jeopardy (IJ), which began on 3/17/21 and determined to exist on 4/20/21 when Resident #1 assaulted Resident #6, rammed his chest into Resident #9's chest and caused other residents to be afraid to live in the facility. The IJ was not removed prior to exit on 05/26/21 and is considered ongoing. Findings include: Record review of the facility's, Behavioral Health Services policy, undated revealed, It is the policy of the facility to provide all residents the necessary behavioral health care and services to assist him or her to reach and maintain the highest practicable level of physical, mental, and psychosocial functioning in accordance with the comprehensive assessment and plan of care . behavioral health care plans will be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition . The facility's, Staffing policy, dated 6/1/00, noted it is the policy of the facility to provide adequate staffing to meet the needs of the resident population. On 5/4/21 at 1:14 PM, observed Resident #1 pacing up and down the facility hallway screaming and cursing loud with his balled fist. Resident #1 did not have on shoes or a mask. The facility Administrator attempted to redirect Resident #1 and was unsuccessful. Resident #1 approached the State Agency (SA) poking her in the chest. The resident was redirected by the staff down hallway. On 5/5/21 at 10:45 AM, in an interview with The Activity Coordinator (AC) for the AD unit said she was responsible for doing Dementia training with the staff. The (AC) said the staff is trained on hire and annually. The AC said the staff has not been trained in over a year since the pandemic began. The facility has hired several new staff that has not been trained on Dementia care. On 5/5/21 at 11:30 AM, an interview with CNA # #7 said he works the 7-3 shift. CNA #7 confirmed he has not had any behavior training on how to take care of residents with those type of behaviors. The resident is frightening and intimidates the other residents. On 5/5/21 at 11:45AM, an interview with the Social Services Director (SSD), the SSD said that after Resident #1 was admitted the resident immediately started yelling, cursing, and swinging at the residents. The SSD said she told the Administrator and the DON that Resident #1 is dangerous and can cause harm to the vulnerable residents and the resident refuses to be re-directed. The SSD said she told the Administrator the resident needs to be sent out before he hurts somebody. The SSD confirmed the staff does not have behavioral training. During an interview on 05/5/21 at 1:15 PM, with the Director of Nursing (DON), revealed she did not talk to Resident #6 about Resident #1 hitting her. The DON confirmed the staff is not trained to take care of residents with behaviors. The DON said she told the Administrator that this facility cannot meet the needs of Resident #1. The DON also stated Resident #1 is a danger to himself and others. During an interview on 05/5/21 at 1:30 PM, with the Administrator revealed he knew Resident #1 had behaviors. The Administrator also confirmed the staff has not been trained in behavioral health. The Administrator said the facility had a Psychiatric Nurse Practitioner (NP) that monitors and adjusts the medications for residents with behaviors. The Psychiatric (NP) has not seen the residents since March 2020. The Administrator said the psychiatric (NP) will start back working for this facility 5/5/21 to educate staff, monitor and adjust the residents' medications with behaviors. The Administrator also confirmed the Facility Assessment is not sufficient to guide the staff to meet the needs of the Residents. On 05/5/2021 at 2:00 PM, in an interview with Resident #6 revealed she is afraid of Resident #1. Resident #6 said Resident #1 hit her and pulled her hair. Resident #6 said Resident #1 continues to yell and scream at her and the other residents. Resident #6 said if Resident #1 comes up to her again she is going to punch him before he can get to her because she is afraid of him. Record review of the Annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 2/26/21, revealed Resident #6 had a Brief Interview for Mental Status (BIMS) score of 13, that indicated that Resident #6 is cognitively intact. On 05/6/2021 at 11:00 AM, interview with Resident #9 said Resident #1 ran up to him and rammed his chest into his chest. Resident #9 said Resident #1 also hit him. Resident #9 said if Resident #1 comes at him again he is going to knock him out because that man is crazy. Resident #9 said he told the staff Resident #1 needs to go to a psychiatric hospital because he is going to hurt somebody. Resident #9 said Resident #1 fights the staff all the time and yells and scream at the residents. everybody is afraid of him. I'm going to hit him before he hit me. Record review of the Quarterly MDS with an ARD of 4/18/21, revealed Resident #9 had a BIMS score of 15 indicating cognitively intact. On 5/11/21 at 4:35 PM, in an interview with (LPN) #14 revealed LPN #14 said the staff has not had any behavior or dementia training. LPN #14 also said she does not know what to do for this resident. LPN #14 said she reported to the DON and the Administrator that the staff did not know what to do to take care of Resident #1 and that he was a danger to himself and the other residents. LPN #14 said she told the Administrator that this is not right. The facility should get Resident #1 some help because the other residents are in fear in their home. Record review of the facility's last Dementia training dated 1/21/20 revealed the facility had a virtual dementia training with the facility staff.

MS # MS # MS # Based on observation, staff and resident interview, facility policy review and record review the facility failed to ensure that routine medications were acquired and administered to meet the needs of the residents. Facility documentation indicated that 12 of the 17 residents had missed 393 doses of significant medications. (Resident #1, #2, #4, #7, #8, #9, #10, #11, #12, #15, #16, and #17) The Facility's failure to provide routine medications placed residents at risk, and in a situation that resulted in hospitalization of Resident #4 and likely resulted in the death of Resident #12 who expired in the facility after missing 37 doses of significant medications. Missing significant medications is likely to cause serious harm, injury, impairment of death to all residents residing in the Facility. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE], when Resident #4 missed 26 doses of medications ordered for COVID-19, was hospitalized on [DATE] and subsequently died at home. There were also eleven (11) other residents who missed significant medication doses. The facility Administrator was notified of the IJ on [DATE] and the IJ template was given to the Administrator at 3:30 PM. The IJ was not removed prior to the State Agency (SA) exit on [DATE] and is considered ongoing. The IJ and Substandard Quality of Care (SQC) existed at CFR(S): 483.55(a)- Pharmaceutical Procedures. Findings include: Review of the Facility's policy entitled Pharmaceutical Services, dated February 26, 2003, reveals that it is the policy of the Facility to provide all drugs and biologicals an approved pharmaceutical services and such services are under the supervision of a Registered Pharmacist. The Procedure states: 1. Pharmaceutical services are available to ensure that our resident's drugs and biologicals are provided as ordered by the attending physician . 3. Our pharmaceutical services provide appropriate methods and procedures for the procurement, dispensing and administration of drugs and biologicals. 4. Pharmacy service, including the availability of obtaining prescription drugs, is provided on a twenty-four (24) hour basis. 5. Pharmacy services are monitored to assure that our drug distribution system, to include the ordering, labeling, and administering of drugs and biologicals, is in compliance with out established policies and procedures . Review of the facility's policy entitled AmPharm Backup Information, undated, revealed: . 2. The facility can get up to 3 days of medications to cover until our shipment reached the facility. Getting more than a 3 day supply is not authorized. 3. If medications are needed for a patient during our hours of operation, the facility is to contact AmPharm, and we will take care of the backup process. 4. If medications are needed for a patient during hours that AmPharm is closed, the facility is to contact the after-hours pharmacy and they will take care of getting the medications filled and delivered to the facility. The facilities are not authorized to contact backup directly for medication fills. They are to contact AmPharm or the after-hours pharmacy. This is to keep costs down and to have a record of medications we need to send without duplicating items. On [DATE] at 9:10 AM, in an observation and interview of medication pass with Licensed Practical Nurse (LPN) #6, two (2) medications were unavailable for administration. Resident #8 did not receive [MEDICATION(S)] 25 MG ordered for Diabetes and [MEDICATION(S)] 25 milligrams (MG) ordered for the prevention of headaches. LPN #6 entered a number 9 in the signature box and stated the nurses record that number in the resident's record to identify that the medications were not administered because they are unavailable. She further stated that there is no back up pharmacy and that the facility has an emergency kit for medications, but it contains mostly antibiotics. On [DATE] at 8:10 AM, an interview with LPN #5, she stated that medications are not always available on the medication cart, as they are on order. On [DATE] at 10:45 AM, in an interview with the Director of Nurses (DON), she explained that the Facility uses a Local Pharmacy (LP) for back up. She stated that if medications are needed, the nurses must contact the Facility's Pharmacy (FP) and they contact the back-up pharmacy. She stated that Human Resources provides orientation to newly hired nurses on ordering medications. On [DATE] at 2:30 PM, an interview with LPN #9, she stated that she has worked at the facility for three (3) months. She stated the facility only uses the FP, but they used to use the LP for back-up meds. On [DATE] at 3:55 PM, in an interview with the Medical Nurse Practitioner (MNP), she stated that residents have told her they have not been receiving their medications. When residents have complained, she would question the nurses about the medications, and they would tell her that the medications were on order. On [DATE] at 12:20 PM, in an interview with LPN #7, she stated that she has worked at the facility for two (2) months. LPN #7 revealed that back up pharmacy has not been used by the facility since [DATE]. She further stated that [MEDICATION(S)] is not a cycle medication and must be reordered every time, causing a problem with getting that medication in a timely manner. On [DATE] at 1:20 PM, in an interview with LPN #8, she revealed that she has worked at the facility for five (5) years. She stated during this time, there has not been any training on ordering or reordering medications. On [DATE] at 9:15 AM, in an interview with the (DON) she stated that she was aware that the nurses were unable to get medications. The DON said she had told the nurses to document everything in the resident charts, because she had told the Administrator that the medications were not coming in and she did not know what else to do. On [DATE] at 10:15 AM, in an interview with the Nurse Consultant, she stated she had spoken to the DON and had recommended the DON to do in-services for the nurses on the appropriate way to obtain medications. She stated that the DON did not follow up with the in-services. On [DATE] at 12:30 PM, in an interview with the Medical Doctor #2 (MD #2), she stated that she is aware that residents do not get their medications in a timely manner and there are times when residents have been without medications for days. She stated most of the time she is not notified for several days of residents not receiving their medications. The MD explained that when she has questioned the nurses regarding medications not being given, they would tell her the medications are on order. The MD said that she has met with the Administrator and DON regarding her concerns. On [DATE] at 1:00 PM, in a telephone interview with the Medical Director, he revealed that he was aware of medications not being available, but he thought the problem had been corrected. The Medical Director stated that he should have known about the deficient issues within the Facility and followed up. He stated that the Quality Assurance and Performance Improvement (QAPI) Committee should have kept him informed. On [DATE] at 2:00 PM, in an interview with the Administrator, he confirmed that he is aware that the Facility has a system failure with medication administration. He stated in April's QAPI meeting they discussed medications not being given. He further stated that the DON is supposed to call the pharmacy when a medication is not available. On [DATE] at 2:30 PM, in a telephone interview with the Owner of the Facility, he stated that he was aware of the medication issues within the Facility. He said, but I did not know how severe it was. He stated that the QAPI program had failed. Resident #4 Record review Resident #4's Admission Record revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #4's Diagnosis Information included COVID-19, Heart Failure, Type 2 Diabetes Mellitus, Recurrent Major Depressive Disorder, Acute Kidney Failure, [CONDITION(S)], and Anxiety Disorder. Record review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #4 was cognitively intact. On [DATE], Resident #4 tested positive for COVID-19 and the Physician ordered the following medications: 1. [MEDICATION(S)] Tablet 250 Give 500 milligrams (MG) by mouth one time a day for infection for one (1) day 2. [MEDICATION(S)] Tablet 6 MG Give 1 tablet by mouth one time a day for COVID-19 for 10 days 3. [MEDICATION(S)] Capsule 20 Mg Give 1 capsule by mouth two times a day for COVID-19 4. [MEDICATION(S)] Tablet 40 MG Give 2 tablets by mouth three times a day for COVID-19 for 30 days Review of Resident #4's Medication Administration Record (MAR) revealed that the resident did not receive the following dose(s) of medications because they were unavailable: -[MEDICATION(S)] 500 mg - [DATE] (1 of 1 dose missed) -[MEDICATION(S)] - [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Nine (9) missed doses) -[MEDICATION(S)] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] (13 missed doses) Resident #4 missed a total of 26 doses of significant medication ordered for COVID-19 from [DATE] to [DATE]. Resident #4 was transferred to the hospital emergency room for evaluation on [DATE] and subsequently died . On [DATE] at 01:00 PM, in a telephone interview with Resident #4's mother, she revealed Resident #4 contracted COVID-19 at the facility and was transferred to the hospital. She stated she went to the hospital and her daughter's doctor told her there was nothing more that could be done for her daughter. She stated the doctor said that he did not know what had happened, but maybe she had missed medications. The resident's mother decided to take her daughter home rather than her being discharged back to the facility. She said her daughter expired on [DATE]. Resident #12 Record review of the Admission Record revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #12's Diagnosis Information included Unspecified [CONDITION(S)], Peripheral Vascular Disease, Chronic Embolism and [CONDITION(S)] of Unspecified Deep Veins of Unspecified Lower Extremity, Chronic Kidney Disease, and Essential Hypertension. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #12 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates that Resident #12 is cognitively intact. Record review of Resident #12's Physician Orders revealed that the physician ordered the following medications: 1. [MEDICATION(S)] Capsule 100 Grams (GM) Give 1 capsule by mouth three times a day for [CONDITION(S)] (Ordered on [DATE]) 2. [MEDICATION(S)] 5 mg by mouth two times a day for Deep Vein [CONDITION(S)] (Ordered [DATE]) Review of Resident #12's MAR reveals that the resident did not receive the following dose(s) of medications because they were unavailable: -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (24 missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (13 missed doses) The total number of doses of significant medications that Resident #12 missed from [DATE] to [DATE], totaled 37. Resident #12 was found unresponsive on [DATE]. Resident #12 expired at the facility. Resident #17 Record review the Admission Record revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #17's Diagnosis Information revealed, [CONDITION(S)] of Vertebra, Sacral and Sacrococcygeal Region, Unstageable Pressure Ulcer of Sacral Region, Gram Negative [CONDITION(S)], Congestive Heart Failure, [CONDITION(S)] Heart Disease, Diabetes Mellitus due to Underlying Condition with Foot Ulcer, [CONDITION(S)], Chronic Peripheral [CONDITION(S)] and Essential Hypertension. Record review of the 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident has a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #17 is cognitively intact. Record Review of Resident #17's Physician Orders revealed the following Physician Orders: 1. [MEDICATION(S)] Solution Inject 60 units subcutaneously at bedtime related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 2. Insulin [MEDICATION(S)] Solution Inject 5 units subcutaneously three times a day related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth two times a day related to Essential Hypertension ([DATE]) 4. [MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 5. [MEDICATION(S)] Tablet 60 MG Give 1 tablet by mouth one time a day related to [CONDITION(S)] Heart Disease (Ordered [DATE]) 6. [MEDICATION(S)] Solution Inject 60 units subcutaneously in the evening related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 7. [MEDICATION(S)] Solution 100 Init/ML Inject 15 units subcutaneously in the morning for Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 8. Insulin [MEDICATION(S)] Solution Inject 5 units subcutaneously three times a day related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 9. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 10. [MEDICATION(S)] HCL Capsule 300 MG Give 1 capsule by mouth every dayshift for infection related -Gram-Negative [CONDITION(S)] (Ordered [DATE]) 11. [MEDICATION(S)] Tablet 750 MG Give 1 tablet by mouth one time a day related to Gram Negative [CONDITION(S)] for 14 days (Ordered [DATE]) 12. [MEDICATION(S)] Tablet 500 MG Give 1 tablet by mouth every 24 hours for [CONDITION(S)] for 56 days (Ordered on [DATE]) 13. [MEDICATION(S)] in D5W Solution 750 MG/150 ML Use 750 MG intravenously every 24 hours for [CONDITION(S)] for 42 days infuse @100 ML/HR to PICC (Ordered [DATE]) 14. [MEDICATION(S)] Solution Reconstituted 1 GM intravenously one time a day for sacral wound infection for 14 days (Ordered [DATE]) Review of Resident #17's MAR reveals that the resident did not receive the following dose(s) of ordered medications because they were unavailable: -[MEDICATION(S)] Solution 60 units on [DATE] (One (1) missed dose) -Insulin [MEDICATION(S)] Solution 5 units on [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] 25 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] Tablet 40 MG on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (Five (5) missed doses) -[MEDICATION(S)] Tablet 60 MG on [DATE] (One (1) missed dose) -[MEDICATION(S)] Solution Inject 60 units on [DATE] (One (1) missed dose) -[MEDICATION(S)] Solution 15 units on [DATE] (One (1) missed dose) -Insulin [MEDICATION(S)] Solution 5 units on [DATE] (One (1) missed dose) -[MEDICATION(S)] Tablet 20 MG on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] HCL Capsule 300 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] Tablet 750 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] in D5W 750 MG/ML on [DATE] (One (1) missed dose) -[MEDICATION(S)] Tablet 500 MG on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] Solution 1 GM on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #17 missed from [DATE], to [DATE], totaled 27. Record review revealed that Resident #17 did not receive his insulin and antibiotic therapy as ordered and likely contributed to worsening of the resident's wounds. Resident #7 Record review of the Admission Record revealed Resident #7 was initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #7's Diagnosis Information included Type 2 Diabetes Mellitus, Heart Failure, Cardiomegaly, Cerebral Infarction, and Essential Hypertension. Record review of the Discharge Minimum Data Set (MDS) dated [DATE], revealed that the Resident #7 has a Brief Interview for Mental Status (BIMS) score of 05, which indicates that Resident #7 is severely cognitively impaired. Record Review of Resident #7's Physician Orders revealed the following Physician Orders: 1. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day for [CONDITION(S)] with supper (Ordered [DATE]) 2. [MEDICATION(S)] Tablet ,d+[DATE] MG Give 1 tablet by mouth two times a day for infection for 7 days. (Ordered [DATE]) Review of Resident #7's MAR reveals that the resident did not receive the following dose(s) of ordered medication because it was unavailable: -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Eight (8) missed doses) -[MEDICATION(S)] on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #7 missed from [DATE] to [DATE], totaled 9. Review of Resident #7's Admission Record revealed that the resident has [CONDITION(S)] (a heart condition that can cause stroke or death). Resident #10 Record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE]. Record review of Resident #10's Diagnosis Information included Alcohol Dependence, Seizures, Stroke, Alcohol Abuse with Withdrawal, and Dementia. Record review of the Admission Minimum Data Set (MDS) dated [DATE], reveals Resident #10 has a Brief Interview for Mental Status (BIMS) score of 03, which indicates that Resident #10 is severely cognitively impaired. Review of Resident #10's Physician orders revealed the following Physician orders: 1. [MEDICATION(S)] 75 mg by mouth one time a day related to stroke (Ordered [DATE]) 2. [MEDICATION(S)] Solution 100 mg/milliliter (ML) by mouth two times a day related to seizures (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 1000 MCG give 1 tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) 4. [MEDICATION(S)] Tablet 1 MG Give 1 Tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) 5. [MEDICATION(S)] Capsule 100 MG Give 1 capsule by mouth three times a day for [CONDITION(S)] (Ordered [DATE]) 6. [MEDICATION(S)] HCL Tablet 100 MG Give 1 tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) Review of Resident #10's MAR reveals that the resident did not receive the following dose (s) of medications because they were unavailable: -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (13 missed doses) -[MEDICATION(S)] Solution one dose of the ordered medication on [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Nine (9) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Ten (10) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (41 missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (2 missed doses) The total number of doses of significant medications that Resident #10 missed from [DATE] to [DATE], totaled 79. Resident #11 Record review of the Admission Record revealed Resident #11 was admitted to the facility on [DATE]. Record review of Resident #11's Diagnosis Information included Type 2 Diabetes Mellitus, Seizures, Chronic Pancreatitis, Essential Hypertension, Vitamin B12 Deficiency [CONDITION(S)], Recurrent Depressive Disorders, [CONDITION(S)] Type [CONDITION(S)] Disorder, and Chronic Obstructive Pulmonary Disorder. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], reveals that the Resident #11 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #11 is cognitively intact. Record Review of the Physician orders revealed that Resident #11 had the following Physician Orders: 1. [MEDICATION(S)] HCL 100 mg by mouth two (2) times a day for Extrapyramidal Side Effects (Ordered [DATE]) 2. [MEDICATION(S)] Delayed Release two (2) capsules by mouth before meals for Chronic Pancreatitis (Ordered [DATE]) 3. [MEDICATION(S)] Sodium Delayed Release 500 mg by mouth two (2) times a day for convulsive disorder (Ordered [DATE]) 4. [MEDICATION(S)] 20 mg by mouth a day for Depression ([DATE]) 5. [MEDICATION(S)] 25 mg by mouth in the morning related to Essential (Primary) Hypertension (Ordered [DATE]) 6. [MEDICATION(S)] HCL 1000 mg by mouth two (2) days a day for Diabetes (Ordered [DATE]) 7. [MEDICATION(S)] 2 mg by mouth two (2) times a day related to [CONDITION(S)] Disorder ([DATE]) Review of Resident #11's MAR reveals that the resident did not receive the ordered medications on the following dates, as medication was unavailable: -[MEDICATION(S)] HCL on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE] and [DATE] (Five (5) doses) -[MEDICATION(S)] Sodium on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE] (Nine (9) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (Nine (9) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (13 doses) The total number of missed doses of significant medications that Resident #11 missed from [DATE] to [DATE], totaled 57. On [DATE] at 9:40 AM, in an interview with Resident #11, she revealed the resident that her medications are not always available. She was able to recall not getting [MEDICATION(S)] for three (3) consecutive days. She said that if there was a time that she did not take her medications, she did not refuse them, it was because the Facility ran out of her medications. She further stated that this happens almost monthly. Resident #8 Record review the Admission Record revealed Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #8 has a Brief Interview for Mental Status (BIMS) score of 13, which indicates that Resident #8 is cognitively intact. Record review of Resident #8's Diagnosis Information included, Type 2 Diabetes Mellitus, Congestive Heart Failure, Cerebral Vascular Accident, [CONDITION(S)], Local Infection of the Skin and Subcutaneous Tissue, and Recurrent Major Depression Disorder. Physician orders reveals that Resident #8 had the following Physician Orders: 1. Chewable Aspirin Tablet 81 mg by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 6.25 mg by mouth two (2) times a day related to Essential Hypertension (Ordered [DATE]) 3. [MEDICATION(S)] 75 mg by mouth one (1) time a day for blood clot prevention (Ordered [DATE]) 4. [MEDICATION(S)] 20 mg by mouth one time a day for Depression (Ordered [DATE]) 5. [MEDICATION(S)] 25 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 6. [MEDICATION(S)] Solution 100 unit/mL 30 units subcutaneously one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 7. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth one time day related to Essential Hypertension (Ordered [DATE]) 8. [MEDICATION(S)] HCL Extended Release give 500 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 9. [MEDICATION(S)] ,d+[DATE] mg by mouth two times a day for infection to left great toe for ten (10) days (Ordered [DATE]) Review of Resident #8's MAR reveals that the resident did not receive the ordered medications on the following dates, as the medication was unavailable: -Aspirin on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], and [DATE] (Four (4) missed doses) -[MEDICATION(S)] Sulfate on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) missed doses) The total number of doses of significant medications that Resident #8 missed from [DATE] to [DATE], totaled 49. Resident #16 Record review the Admission Record reveals Resident #16 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #16's Diagnosis Information include [CONDITION(S)], Seizures, Essential Hypertension, and [CONDITION(S)] of Left Lower Limb. Record review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed Resident #16 had a Brief Interview of Mental Status score of 14 indicating that the resident was cognitively intact. Record Review of the Physician orders reveals that Resident #16 had the following Physician Orders: 1. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time a day related to Essential Hypertension (Ordered [DATE]) 2. [MEDICATION(S)] 20 MG give 1 tablet by mouth one time a day related to [CONDITION(S)] (Ordered [DATE]) 3. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time day related to Essential Hypertension (Ordered [DATE]) 4. [MEDICATION(S)] 250 MG give 1 tablet by mouth one time a day related Seizures (Ordered [DATE]) 5. [MEDICATION(S)] 50 MG give 1 tablet by mouth two times a day related to Essential Hypertension (Ordered [DATE]) 6. [MEDICATION(S)] Solution 5 MG/ML Inject 5 m intramuscularly every 6 hours related to Restlessness and agitation (Ordered [DATE]) 7. [MEDICATION(S)] 100 MG give 2 tablets by mouth two times a day related to [CONDITION(S)] (Ordered [DATE]) 8. [MEDICATION(S)] HCL 10 MG give 1 tablet by mouth one time a day related to [CONDITION(S)] (Ordered [DATE]) 9. [MEDICATION(S)] Sodium Tablet Delayed Release 500 MG Give 1 tablet by mouth one time a day related to Seizures (Ordered [DATE]) 10. [MEDICATION(S)] ,d+[DATE] MG give 1 tablet by mouth two times a day for [CONDITION(S)] (Ordered [DATE]) 11. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth two times a day for Agitation Review of Resident #16's MAR reveals that the resident did not receive the ordered medications on the following dates, as the medication was unavailable: -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (three (3) missed doses) -[MEDICATION(S)] on [DATE], [DATE], and [DATE] (Three (3) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE] and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE] (One (1) missed dose) -[MEDICATION(S)] Sodium on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE]/1 and [DATE] (Three (3) missed doses) -[MEDICATION(S)] Solution on [DATE], [DATE], [DATE], [DATE] and [DATE] (15 missed doses) -[MEDICATION(S)] Tablet on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #16 missed from [DATE] to [DATE], totaled 45. Resident # 1 Record review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility on [DATE]. Record review of Resident #1 Diagnosis Information included Unspecified Dementia with Behavioral Disturbance, [CONDITION(S)], Cognitive Communication Deficit, Generalized Anxiety Disorder, Mood Disorder with Known Physiological Condition with Manic Features, [CONDITION(S)], and [CONDITION(S)] Pectoris. Record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating that Resident #1 has severe impairment in cognition. Record Review revealed that Resident #1 had the following Physician Orders: 1. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth at bedtime for Dementia (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth at bedtime for Dementia (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 300 MG Give 300 mg by mouth at bedtime for Dementia with Behavioral problems related to Mood Disorder due to known physiological condition with manic features. (Ordered [DATE]) 4. [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth two times a day for Agitation and Anxiety (Ordered [DATE]) 5. [MEDICATION(S)] Solution Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [CONDITION(S)] (Ordered [DATE]) 6. [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth two times a day related to unspecified Dementia with Behavioral Disturbance (Ordered [DATE]) 8. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth three times a day related to Mood Disorder due to known physiological condition with Manic Features (Ordered [DATE]) 9. [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet by mouth one time a day related to Generalized Anxiety Disorder (Ordered [DATE]) 10. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth one time a day for right foot pain for 5 days (Ordered [DATE]) Review of Resident #1's MAR reveals that the resident did not receive the ordered medications on the following dates, as the medication was unavailable: -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) doses missed) -[MEDICATION(S)] on [DATE] ((One (1) dosed missed) -[MEDICATION(S)] on [DATE] (One (1) dose missed) -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] on [DATE] (One (1) dose missed) -[MEDICATION(S)] on [DATE] and [DATE] (Four (4) doses missed) -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) doses missed) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) doses missed) The total number of doses of significant medications that Resident #1 missed from [DATE] to [DATE], totaled 19. Resident #2 Record review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE]. Record review of Resident #2's Diagnosis Information included Type 2 Diabetes Mellitus, Chronic Embolism with [CONDITION(S)], Unspecified Fracture of Shaft of Left Fibula, [CONDITION(S)

MS # MS # MS # Based on observation, staff and resident interview, facility policy review and record review the facility failed to ensure significant medications (e.g., anticoagulants, anti-[CONDITION(S)], heart, antidiabetic, steroids, COVID-19 regimen medications, [CONDITION(S)] and antibiotics) were administered to prevent discomfort or complications for 12 of 17 sampled residents reviewed for medication administration. (Resident #1, #2, #4, #7, #8, #9, #10, #11, #12, #15, #16, and #17) The Facility's failure to ensure residents received medications per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . This placed other residents in a situation that is likely to cause serious harm, injury, impairment, or death. This situation was determined to be an Immediate Jeopardy (IJ) which began on [DATE], when Resident #4 missed 26 doses of medications ordered for COVID-19 and was hospitalized on [DATE]. Resident #4 subsequently expired at home. Eleven (11) other residents also missed significant medication doses. The facility Administrator was notified of the IJ on [DATE] and the IJ template was given to the Administrator at 3:30 PM. The IJ and Substandard Quality of Care (SQC) existed at CFR(S): 483.45(f)(2)- Residents are free of any significant medication errors. The IJ was not removed prior to the State Agency (SA) exit on [DATE] and is considered ongoing. Findings include: Review of the facility's policy entitled Administration of Drugs, dated [DATE], revealed: It is the policy of this facility that residents receive their medications on a timely basis and in accordance with our established policies 4. Medications must be charted immediately following the administration by the person administering the drugs. The date, time administered, dosage, etc., must be entered in the medical record and signed by the person entering the data. Review of the facility's policy entitled AmPharm Backup Information, undated, revealed: . 2. The facility can get up to 3 days of medications to cover until our shipment reaches the facility. Getting more than a 3 day supply is not authorized. 3. If medications are needed for a patient during our hours of operation, the facility is to contact AmPharm, and we will take care of the backup process. 4. If medications are needed for a patient during hours that AmPharm is closed, the facility is to contact the after-hours pharmacy and they will take care of getting the medications filled and delivered to the facility. The facilities are not authorized to contact backup directly for medication fills. They are to contact the AmPharm or the after-hours pharmacy. This is to keep costs down and to have a record of medications we need to send without duplicating items. On [DATE] at 9:10 AM, in an observation and interview of medication pass with Licensed Practical Nurse (LPN) #6, two (2) medications were unavailable for administration. Resident #8 did not receive [MEDICATION(S)] 25 milligrams (MG) ordered for headache prevention and [MEDICATION(S)] 25 MG ordered for Diabetes. LPN #6 stated that there is no back up pharmacy and that the facility has an emergency kit for medications, but it contains mostly antibiotics. She further stated when medications are not given, the nurse records the number 9 in the signature box and that prompts the nurse to enter a note in the Progress Notes to explain the issue with the medication. On [DATE] at 8:10 AM, an interview with LPN #5, revealed that medications are not always available on the medication cart and medications are on order. On [DATE] at 10:45 AM, in an interview with the Director of Nurses (DON), regarding back up pharmacy, she explained that the facility uses the Local Pharmacy (LP) for back up. She stated that if medications are needed, the nurses must contact the Facility's Pharmacy (FP) and they contact the back-up pharmacy. She explained that the nurses are not trained on ordering medications but when they are hired, they receive orientation on facility policies from Human Resource. On [DATE] at 2:30 PM, an interview with LPN #9 revealed that she has worked at the facility for three (3) months. She explained that the nurses used to use LP Pharmacy for back-up meds, but now the facility only uses the FP. On [DATE] at 3:55 PM, in an interview with the Medical Nurse Practitioner (MNP), she revealed that the residents have told her they have not been receiving their medications. She stated that when residents have complained, she would ask the nurses about the medications and they would tell her that the medications were on order. On [DATE] at 12:20 PM, in an interview with LPN #7, she revealed that she has worked at the facility for two (2) months. LPN #7 stated that the facility has not used back up pharmacy since [DATE]. She further explained that [MEDICATION(S)] is not a cycle medication and there is a problem with getting that medication in a timely manner. On [DATE] at 1:20 PM, in an interview with LPN #8, she revealed that she has worked at the facility for five (5) years and that there has not been any training on ordering or reordering medications. On [DATE] at 9:15 AM, in an interview with the (DON) she stated that most of the nurses are new graduates and have not been educated on medications. The DON stated that she was aware that the nurses were unable to get medications and that she had told the nurses to document everything because she had told the Administrator that the medications were not coming in and she did not know what else to do. On [DATE] at 10:15 AM, in an interview with the Nurse Consultant, she stated she had spoken to the DON and that she had recommended that the DON in-service the staff on the appropriate way to get medications. However, she stated that the DON did not follow up and present the in-services to the nurses. The Nurse Consultant further stated that she has had trouble getting responses from the DON. On [DATE] at 12:30 PM, in an interview with the Medical Doctor #2 (MD #2), she stated that she is aware that residents do not get their medications in a timely manner and there are times that residents go for days without medication. She stated that most of the time she is not notified for several days of residents not receiving their medications. The MD said that when she has questioned the nurses regarding medications not being given, she is told that the medications are on order. The MD said that she has met with the Administrator and DON about her concerns. On [DATE] at 1:00 PM, in a telephone interview with the Medical Director, he stated that he was aware of medication not being available, but he had thought the facility had corrected the problem. The Medical Director stated that he should have followed up on the deficient practice and should have known about the deficient issues within the Facility through Quality Assurance and Performance Improvement (QAPI). On [DATE] at 2:00 PM, in an interview with the Administrator, he confirmed that he is aware that the Facility has a system failure with medication administration. He stated that during the QAPI meeting in April it was discussed that there are medications that are not being given. He further stated that the Director of Nursing is supposed to call the pharmacy when a medication is not available. On [DATE] at 2:30 PM, in a telephone interview with the Owner of the Facility, he said that he was aware of the medication issues, but I did not know how severe it was. He stated that the QAPI program failed. Resident #4 Record review of the Admission Record revealed Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #4's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) dated [DATE] revealed that Resident #4 had a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #4 was cognitively intact. On [DATE], Resident #4 tested positive for COVID-19 and the Physician ordered the following medications: [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet 250 Give 500 milligrams (MG) by mouth one time a day for infection for one (1) day 2. [MEDICATION(S)] Tablet 6 MG Give 1 tablet by mouth one time a day for COVID-19 for 10 days 3. [MEDICATION(S)] Capsule 20 Mg Give 1 capsule by mouth two times a day for COVID-19 4. [MEDICATION(S)] Tablet 40 MG Give 2 tablets by mouth three times a day for COVID-19 for 30 days Review of Resident #4's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] 500 mg - [DATE] (1 of 1 dose missed) -[MEDICATION(S)] - [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Nine (9) missed doses) -[MEDICATION(S)] - [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] (13 missed doses) Resident #4 missed a total of 26 doses of significant medication ordered for COVID-19 from [DATE] to [DATE]. Resident #4 was transferred to the hospital emergency room for evaluation on [DATE] and subsequently died . A telephone interview on [DATE] at 01:00 PM, with Resident #4's mother revealed Resident #4 contracted COVID-19 at the facility and was transferred to the hospital. The resident's mother stated when the facility called to inform her of Resident #4's transfer to the hospital, she went to the hospital and doctors told her there was nothing more that could be done for her daughter. She stated that the doctor at the hospital said that he did not know what had happened, but maybe she had missed medications. The resident's mother decided to take her home rather than her being discharged back to the facility and her daughter expired at home on [DATE]. Resident #12 Record review of the Admission Record revealed Resident #12 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #12's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], revealed that Resident #12 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates that Resident #12 is cognitively intact. Record review of Resident #12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Capsule 100 Grams (GM) Give 1 capsule by mouth three times a day for [CONDITION(S)] (Ordered on [DATE]) 2. [MEDICATION(S)] 5 mg by mouth two times a day for Deep Vein [CONDITION(S)] (Ordered [DATE]) Review of Resident #12's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (24 missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (13 missed doses) The total number of doses of significant medications that Resident #12 missed from [DATE] to [DATE], totaled 37. Resident #12 was found unresponsive on [DATE]. Resident #12 expired at the facility. Resident #17 Record review the Admission Record revealed Resident #17 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #17's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the 5-Day Minimum Data Set (MDS) dated [DATE] revealed that the resident has a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #17 is cognitively intact. Record Review of Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Solution Inject 60 units subcutaneously at bedtime related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 2. Insulin [MEDICATION(S)] Solution Inject 5 units subcutaneously three times a day related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth two times a day related to Essential Hypertension ([DATE]) 4. [MEDICATION(S)] Tablet 40 MG Give 1 tablet by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 5. [MEDICATION(S)] Tablet 60 MG Give 1 tablet by mouth one time a day related to [CONDITION(S)] Heart Disease (Ordered [DATE]) 6. [MEDICATION(S)] Solution Inject 60 units subcutaneously in the evening related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 7. [MEDICATION(S)] Solution 100 Init/ML Inject 15 units subcutaneously in the morning for Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 8. Insulin [MEDICATION(S)] Solution Inject 5 units subcutaneously three times a day related to Diabetes Mellitus due to underlying condition with foot ulcer (Ordered [DATE]) 9. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 10. [MEDICATION(S)] HCL Capsule 300 MG Give 1 capsule by mouth every dayshift for infection related -Gram-Negative [CONDITION(S)] (Ordered [DATE]) 11. [MEDICATION(S)] Tablet 750 MG Give 1 tablet by mouth one time a day related to Gram Negative [CONDITION(S)] for 14 days (Ordered [DATE]) 12. [MEDICATION(S)] Tablet 500 MG Give 1 tablet by mouth every 24 hours for [CONDITION(S)] for 56 days (Ordered on [DATE]) 13. [MEDICATION(S)] in D5W Solution 750 MG/150 ML Use 750 MG intravenously every 24 hours for [CONDITION(S)] for 42 days infuse @100 ML/HR to PICC (Ordered [DATE]) 14. [MEDICATION(S)] Solution Reconstituted 1 GM intravenously one time a day for sacral wound infection for 14 days (Ordered [DATE]) Review of Resident #17's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] Solution 60 units on [DATE] (One (1) missed dose) -Insulin [MEDICATION(S)] Solution 5 units on [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] 25 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] Tablet 40 MG on [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (Five (5) missed doses) -[MEDICATION(S)] Tablet 60 MG on [DATE] (One (1) missed dose) -[MEDICATION(S)] Solution Inject 60 units on [DATE] (One (1) missed dose) -[MEDICATION(S)] Solution 15 units on [DATE] (One (1) missed dose) -Insulin [MEDICATION(S)] Solution 5 units on [DATE] (One (1) missed dose) -[MEDICATION(S)] Tablet 20 MG on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] HCL Capsule 300 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] Tablet 750 MG on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] in D5W 750 MG/ML on [DATE] (One (1) missed dose) -[MEDICATION(S)] Tablet 500 MG on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] Solution 1 GM on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #17 missed from [DATE], to [DATE], totaled 27. Record review revealed that Resident #17 did not receive his insulin and antibiotic therapy as ordered and likely contributed to worsening of the resident's wounds. Resident #7 Record review of the Admission Record revealed Resident #7 was initially admitted on [DATE] and readmitted on [DATE]. Record review of Resident #7's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Discharge Minimum Data Set (MDS) dated [DATE], reveals that the Resident #7 has a Brief Interview for Mental Status (BIMS) score of 05, which indicates that Resident #7 is severely cognitively impaired. Record Review of Resident #7's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] Tablet 20 MG Give 1 tablet by mouth one time a day for [CONDITION(S)] with supper (Ordered [DATE]) 2. [MEDICATION(S)] Tablet ,d+[DATE] MG Give 1 tablet by mouth two times a day for infection for 7 days. (Ordered [DATE]) Review of Resident #7's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Eight (8) missed doses) -[MEDICATION(S)] on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #7 missed from [DATE] to [DATE], totaled 9. Review of Resident #7's Admission Record revealed that the resident has [CONDITION(S)] (a heart condition that can cause stroke or death). Resident #10 Record review of the Admission Record revealed Resident #10 was admitted to the facility on [DATE]. Record review of Resident #10's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) dated [DATE] reveals Resident #10 has a Brief Interview for Mental Status (BIMS) score of 03, which indicates that Resident #10 is severely cognitively impaired. Review of Resident #10's Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 75 mg by mouth one time a day related to stroke (Ordered [DATE]) 2. [MEDICATION(S)] Solution 100 mg/milliliter (ML) by mouth two times a day related to seizures (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 1000 MCG give 1 tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) 4. [MEDICATION(S)] Tablet 1 MG Give 1 Tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) 5. [MEDICATION(S)] Capsule 100 MG Give 1 capsule by mouth three times a day for [CONDITION(S)] (Ordered [DATE]) 6. [MEDICATION(S)] HCL Tablet 100 MG Give 1 tablet by mouth one time a day related to Alcohol Dependence (Ordered [DATE]) Review of Resident #10's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (13 missed doses) -[MEDICATION(S)] Solution one dose of the ordered medication on [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Nine (9) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Ten (10) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (41 missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (2 missed doses) The total number of doses of significant medications that Resident #10 missed from [DATE] to [DATE], totaled 79. Resident #11 Record review of the Admission Record revealed Resident #11 was admitted to the facility on [DATE]. Record review of Resident #11's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] reveals that the Resident #11 has a Brief Interview for Mental Status (BIMS) score of 15, which indicates that Resident #11 is cognitively intact. Record Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] HCL 100 mg by mouth two (2) times a day for Extrapyramidal Side Effects (Ordered [DATE]) 2. [MEDICATION(S)] Delayed Release two (2) capsules by mouth before meals for Chronic Pancreatitis (Ordered [DATE]) 3. [MEDICATION(S)] Sodium Delayed Release 500 mg by mouth two (2) times a day for convulsive disorder (Ordered [DATE]) 4. [MEDICATION(S)] 20 mg by mouth a day for Depression ([DATE]) 5. [MEDICATION(S)] 25 mg by mouth in the morning related to Essential (Primary) Hypertension (Ordered [DATE]) 6. [MEDICATION(S)] HCL 1000 mg by mouth two (2) days a day for Diabetes (Ordered [DATE]) 7. [MEDICATION(S)] 2 mg by mouth two (2) times a day related to [CONDITION(S)] Disorder ([DATE]) Review of Resident #11's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] HCL on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE] and [DATE] (Five (5) doses) -[MEDICATION(S)] Sodium on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] [DATE] (Nine (9) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (Nine (9) doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE] and [DATE] (13 doses) The total number of missed doses of significant medications that Resident #11 missed from [DATE] to [DATE], totaled 57. On [DATE] at 9:40 AM, an interview with Resident #11, revealed that the resident states that her medications are not always available. She stated that this happens almost monthly and that she remembers not getting her [MEDICATION(S)] for three (3) consecutive days. Resident #8 Record review the Admission Record revealed Resident #8 was initially admitted to the facility on [DATE] and readmitted on [DATE]. Record review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed that Resident #8 has a Brief Interview for Mental Status (BIMS) score of 13, which indicates that Resident #8 is cognitively intact. Record review of Resident #8's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. Chewable Aspirin Tablet 81 mg by mouth one time a day related to Congestive Heart Failure (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 6.25 mg by mouth two (2) times a day related to Essential Hypertension (Ordered [DATE]) 3. [MEDICATION(S)] 75 mg by mouth one (1) time a day for blood clot prevention (Ordered [DATE]) 4. [MEDICATION(S)] 20 mg by mouth one time a day for Depression (Ordered [DATE]) 5. [MEDICATION(S)] 25 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 6. [MEDICATION(S)] Solution 100 unit/mL 30 units subcutaneously one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 7. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth one time day related to Essential Hypertension (Ordered [DATE]) 8. [MEDICATION(S)] HCL Extended Release give 500 mg by mouth one (1) time a day related to Type 2 Diabetes Mellitus (Ordered [DATE]) 9. [MEDICATION(S)] ,d+[DATE] mg by mouth two times a day for infection to left great toe for ten (10) days (Ordered [DATE]) Review of Resident #8's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -Aspirin on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], and [DATE] (Four (4) missed doses) -[MEDICATION(S)] Sulfate on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Six (6) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) missed doses) The total number of doses of significant medications that Resident #8 missed from [DATE] to [DATE], totaled 49. Resident #16 Record review the Admission Record reveals Resident #16 was admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Record review of Resident #16's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the admission Minimum Data Set with an assessment reference date of [DATE] revealed Resident #16 had a Brief Interview of Mental Status score of 14 indicating that the resident was cognitively intact. Record Review of the Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 1. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time a day related to Essential Hypertension (Ordered [DATE]) 2. [MEDICATION(S)] 20 MG give 1 tablet by mouth one time a day related to [CONDITION(S)] (Ordered [DATE]) 3. [MEDICATION(S)] 10 MG give 1 tablet by mouth one time day related to Essential Hypertension (Ordered [DATE]) 4. [MEDICATION(S)] 250 MG give 1 tablet by mouth one time a day related Seizures (Ordered [DATE]) 5. [MEDICATION(S)] 50 MG give 1 tablet by mouth two times a day related to Essential Hypertension (Ordered [DATE]) 6. [MEDICATION(S)] Solution 5 MG/ML Inject 5 m intramuscularly every 6 hours related to Restlessness and agitation (Ordered [DATE]) 7. [MEDICATION(S)] 100 MG give 2 tablets by mouth two times a day related to [CONDITION(S)] (Ordered [DATE]) 8. [MEDICATION(S)] HCL 10 MG give 1 tablet by mouth one time a day related to [CONDITION(S)] (Ordered [DATE]) 9. [MEDICATION(S)] Sodium Tablet Delayed Release 500 MG Give 1 tablet by mouth one time a day related to Seizures (Ordered [DATE]) 10. [MEDICATION(S)] ,d+[DATE] MG give 1 tablet by mouth two times a day for [CONDITION(S)] (Ordered [DATE]) 11. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth two times a day for Agitation Review of Resident #16's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (three (3) missed doses) -[MEDICATION(S)] on [DATE], [DATE], and [DATE] (Three (3) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE] and [DATE] (Seven (7) missed doses) -[MEDICATION(S)] on [DATE], [DATE], [DATE], [DATE] and [DATE] (Four (4) missed doses) -[MEDICATION(S)] on [DATE] (One (1) missed dose) -[MEDICATION(S)] Sodium on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE]/1 and [DATE] (Three (3) missed doses) -[MEDICATION(S)] Solution on [DATE], [DATE], [DATE], [DATE] and [DATE] (15 missed doses) -[MEDICATION(S)] Tablet on [DATE] (One (1) missed dose) The total number of doses of significant medications that Resident #16 missed from [DATE] to [DATE], totaled 45. Resident # 1 Record review of Resident #1's Admission Record revealed Resident #1 was admitted to the facility on [DATE]. Record review of Resident #1 diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Admission Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 00, indicating that Resident #1 has severe impairment in cognition. Record Review revealed that Resident #1 had the following Physician Orders: 1. [MEDICATION(S)] Tablet 25 MG Give 1 tablet by mouth at bedtime for Dementia (Ordered [DATE]) 2. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth at bedtime for Dementia (Ordered [DATE]) 3. [MEDICATION(S)] Tablet 300 MG Give 300 mg by mouth at bedtime for Dementia with Behavioral problems related to Mood Disorder due to known physiological condition with manic features. (Ordered [DATE]) 4. [MEDICATION(S)] Tablet 1 MG Give 1 tablet by mouth two times a day for Agitation and Anxiety (Ordered [DATE]) 5. [MEDICATION(S)] Solution Tablet Delayed Release 250 MG Give 1 tablet by mouth two times a day related to [CONDITION(S)] (Ordered [DATE]) 6. [MEDICATION(S)] Tablet 5 MG Give 1 tablet by mouth two times a day related to unspecified Dementia with Behavioral Disturbance (Ordered [DATE]) 8. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth three times a day related to Mood Disorder due to known physiological condition with Manic Features (Ordered [DATE]) 9. [MEDICATION(S)] Tablet 0.5 MG Give 1 tablet by mouth one time a day related to Generalized Anxiety Disorder (Ordered [DATE]) 10. [MEDICATION(S)] Tablet 10 MG Give 1 tablet by mouth one time a day for right foot pain for 5 days (Ordered [DATE]) Review of Resident #1's MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) doses missed) -[MEDICATION(S)] on [DATE] ((One (1) dosed missed) -[MEDICATION(S)] on [DATE] (One (1) dose missed) -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) missed doses) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) missed doses) -[MEDICATION(S)] on [DATE] (One (1) dose missed) -[MEDICATION(S)] on [DATE] and [DATE] (Four (4) doses missed) -[MEDICATION(S)] on [DATE] and [DATE] (Two (2) doses missed) -[MEDICATION(S)] on [DATE], [DATE] and [DATE] (Three (3) doses missed) The total number of doses of significant medications that Resident #1 missed from [DATE] to [DATE], totaled 19. Resident #2 Record review of the Admission Record revealed Resident #2 was admitted to the facility on [DATE]. Record review of Resident #2's diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #2's Quarterly Minimum Data Set (MDS) dated [DATE], reveals a Brief Interview for Mental Status (BIMS) score of 07. A BIMS score of 07 indicate

Based on observations, resident interviews, staff interviews, and record review the facility failed to completely and accurately document in the clinical records for eight (8) of nine (9) residents reviewed for wounds. Residents #3, #5, #6, #7, #12, #13, #14, and #17. The Facility's failure to accurately document in the clinical records puts 8 of 9 residents at risk for the likelihood of serious harm, serious injury, serious impairment or death. This situation was determined to be an Immediate Jeopardy (IJ) on 05/21/2021 and was determined to exist on 04/06/2021 when the facility failed to assess wounds accurately and document findings in medical records. The IJ was not removed prior to exit on 05/26/2021 and is considered ongoing. The IJ existed at §483.70(i) Medical records. Findings Include: Resident #3 Record review for Resident #3's Admission Record revealed the facility initially admitted Resident #3 on 02/24/2019 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) dated for 2/15/21, Section M revealed Resident #3 had a Stage 3 pressure ulcer. Record review of Resident #3's Treatment Administration Record (TAR) for January 2021 revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the TAR for March 2021 revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of April 2021 TAR revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Weekly Pressure Injury Record for Resident #3 revealed one record dated 1/11/2021 which was incomplete. There are no other records indicating evaluation or assessment of wounds for January 1, 2021 through May 8, 2021. Resident #5 Record review of Resident #5's Admission Record revealed the facility admitted Resident #5 on 05/19/2020 with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #5 was discharged to another facility on 1/21/2021. Record review of Resident #5's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of November 16, 2020, Section M of the MDS revealed Resident #5 had one (1) Stage 2 and one (1) unstageable wound. The latest Discharge MDS with ARD of 1/21/2021 revealed the same findings as the quarterly MDS. Record review of Resident #5's Initial Weekly Wound Pressure report dated 05/20/2020, revealed Resident #5 was admitted with a wound on the left heel, inner aspect, unstageable, with measurements of 2 cm x 1.4 cm x 0.2 cm and wound to right buttock Stage two with measurements 1 cm x 1 cm x 0.2 cm. Review of Resident #5's Nurse Progress Notes dated 05/25/2020 revealed a new area to left gluteal fold with partial thickness measurements of 1.5 cm x 0.5 cm x0.1 cm with cleansed area with wound cleanser pat dry, [MEDICATION(S)] applied to area. There was no weekly body audit with the new wound to left gluteal fold with measurements. Review of Resident #5's weekly body audit dated 06/17/2020 revealed no measurements and continue treatment to coccyx and right foot. Further record review of Resident #5's weekly body audits dated 09/02/20, 09/28/20, 10/14/20 revealed body audits with wounds right and left buttock with no measurements recorded. A record review of Resident #5's TAR revealed an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . A record review of the TAR for Stage 2 Right Buttock wound care on 5/21/20 , 5/22/20, 5/27/20, 5/28/20 and 5/29/20 revealed no nurse initials for those dates. The unstageable ulceration to left heel inner aspect wound care for Hydrogel had missing documentation for 5/28/20 thru 5/29/20. Resident #6 Record review of Resident #6's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review reveals that there are no records indicating consistent assessment or measurement of ankle wounds from January 28 through May 8, 2021. A Pressure Report dated 05/08/2021 revealed Resident # 6 with pressure wounds to bilateral ankles with measurements left ankle 1.5 cm x 1.2 cm and right ankle 1.5 cm x 1.5 cm with Stage 2 noted with eschar tissue per DON skin assessment. Record review of Resident #6's weekly body audit dated for 01/08/2021 only reports no new skin alterations. Body audits dated 03/02/2021, 04/27/2021, 05/06/2021 revealed no measurements of wound to ankles and no weekly pressure injury records available. A weekly body audit dated 03/03/2021 revealed right and left ankles with both wounds measuring 1.0 cm x 1.0 cm with callous like wound on ankles. Three weekly skin reports provided by the DON revealed on 01/28/2021 Resident #5 had bilateral ankle abrasions with one measurement of 2.0 cm x 2.0 cm; on 03/15/2021 resident had non-pressure wounds to bilateral ankles, the wounds were facility acquired and a measurement of 2.0 cm x 2.0 cm one set of measurements for bilateral ankles; and on 04/13/2021 facility acquired non-pressure wounds to bilateral outer ankles and a measurement of 1.5 cm x 1.5 cm. Record review of Resident #6's Admission Record revealed the facility initially admitted Resident #6 on 07/31/2017 and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record revealed Resident #6 had an added diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #6's Annual MDS with ARD date 2/26/2021 Section M revealed Resident #6 had a Pressure ulcer of 1 or greater or a scar over a bony prominence. Section M had no other areas flagged for skin conditions. Resident #6's Quarterly MDS with ARD date 12/08/2020 Section M had no areas flagged for skin conditions. Resident #7 Record review of the Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #7's Weekly Pressure Injury Records revealed one record dated 5/8/2021. There are no other records indicating evaluation or assessment of wounds for January 1, 2021, through May 8, 2021. Record review of Resident #7's Admission Record revealed the Facility initially admitted on [DATE] and readmitted on [DATE] with the following Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record also revealed Resident #7 was diagnosed with Pseudomonas and Urinary Tract Infection 04/14/2021 and [CONDITION(S)] on 04/13/2021. Record review of the Discharge Minimum Data Set (MDS) dated [DATE], Section M of the MDS revealed Resident #7 had only one Stage 3 wound. Resident #12 Record review of Resident #12's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident also had order to send to the local wound care clinic every 2 weeks with start date 03/16/2021. An order with start date 01/01/2021 noted clean bilateral knees with normal saline, pat dry apply [MEDICATION(S)] to wound beds, secure with border gauze and changer every 48 hours, and another order with start date 04/20/2021 cleanse wound to left and right anterior knee with normal saline, pat dry, apply [MEDICATION(S)] to wound bed and cover with a border dressing one time a day for wound care. Record review of Resident's #12's TAR for April 2021 revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the May TAR revealed omitted documentation for the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Weekly Pressure Injury Record for Resident #12 revealed one record dated 4/19/2021 for area to right buttock. There are no other records indicating evaluation or assessment of wounds for January 1, 2021, through May 8, 2021. Record review of Admission Record revealed the facility initially admitted Resident #12 on 10/24/2021 and readmitted on [DATE] with Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of the Quarterly Minimum Data Set (MDS) dated [DATE], Section M of the MDS revealed Resident #12 had one Stage 2 ulcer. Resident #13 Record review of Resident #13's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A new order for Santyl Ointment apply to left heel and cover with gauze dressing one time a day for wound care start on 03/03/2021. Another order to inspect resident feet daily started on 04/14/2021. Record review of Resident #13's medical records revealed the facility had no weekly pressure injury records for Resident #13 and there are no other records indicating evaluation of wounds from 01/01/2021 through 05/08/2021. Record review for Resident #13's Admission Record revealed the facility admitted Resident #13 initially on 04/04/2018 and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record revealed Resident #13 was diagnosed with Pressure ulcer of left heel Stage 2 on 04/16/2021. Record review of Resident #13's Quarterly MDS with ARD date 04/28/2021, Section M revealed Resident #13 had one Stage 2 pressure ulcer. Resident #14 Record review of Resident #14's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The order was started on 01/10/2021 and discontinued on 03/15/2021 related to coccyx wound healed. An order was started on 03/16/2021 for ensure [MEDICATION(S)] dressings are applied to left and right great toes as ordered, change dressings every 3 days and when visibility soiled as ordered date, initial, and time every dressing and document every dressing change in progress notes, and inspect resident's feet daily every shift, an order was started on 12/13/2021 for Hydrocol pad apply to left and right 1st toes ulcers topically every 72 hours, change dressings every 3 days and when visibility soiled and order discontinued on 04/09/2021 resolved. Record review revealed that there are no records indicating assessment or measurement of wounds from January 1 through May 8, 2021. The Treatment Administration Record (TAR) Lacks documentation of application of Hydrogel and covering of Hydrocol Pad to left and right first toe ulcers on 3/13/21, 3/22/21 and 4/3/21. Record review of Resident #14's Admission Record revealed the facility initially admitted Resident #14 on 05/20/2015 and readmitted on [DATE] with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Record also revealed Resident #14 was diagnosed with Stage 2 pressure ulcer unspecified buttock 01/29/2021. Record review of Resident #14's Quarterly MDS with ARD date of March 1, 2021, Section M of the MDS revealed Resident #14 had no pressure, venous, or arterial ulcers, but did have moisture associated skin damage. Resident #17 Record review of Resident #17's Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] ¼ strength Dakin's Solution, apply [MEDICATION(S)] powder to wound bed, pack wound with silver alginate, cut sponge to fit within wound bed, place wound vac at 125 pressure continuous suction change on Tuesday and Friday or sooner if there is suction malfunction, in case of wound vac malfunction, cleanse sacral decubitus with ¼ strength Dakin's solution, apply [MEDICATION(S)] powder to wound bed, pack wound with silver alginate and cover with bandage and notify provider. Stage 2 ulceration at site of urinary catheter insertion wound caused from pressure from the catheter, cleanse area with soap and water, dry, apply mixture of A and D ointment, [MEDICATION(S)] ointment, and [MEDICATION(S)] cream daily, and wound care follow up at Field on 05/20/2021. Resident #17 had an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review revealed missing documentation of wound care on the TAR for Hydrocel Gel to sacral wound on 03/28/2021, 04/03/2021, 04/11/2021; Providone-Iodine Solution to wounds to toes on 04/10/2021, 04/22/2021; Dakin's ¼ strength and hydrogel to sacral wound on 4/03/2021, 04/10/2021, 04/11/2021, 04/24/2021, and 04/29/2021. Record review of weekly pressure injury records for Resident #17 revealed only four (4) weekly pressure reports for sacral wound dated 03/04/2021, 03/15/2021, 04/07/21, and 05/08/2021 in Resident #17's medical records. There were no other weekly pressure injury records provided by the facility. Record review of Resident #17's Admission Record revealed the facility originally admitted Resident #17 on 3/4/2021 and readmitted on [DATE] with the Medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Record review of Resident #17's 5-day Minimum Data Set (MDS) with ARD of March 12, 2021, revealed Section M of the MDS revealed Resident #17 had one unstageable wound due to non-removable dressing/device and one unstageable wound due to slough or eschar, diabetic foot ulcer and other open [CONDITION(S)] on the foot. On 5/5/2021 at 3:00 PM, in an interview with the DON, when asked if a treatment is not initialed what does that mean, she reported if it is not documented than it is not done. She further explained the treatments on the Treatment Administration Record should be initialed after the treatment is done. On 05/06/21 at 10:50 am interview with the DON, she explained she just started doing weekly wound care reports. She explained that she has not been consistent with doing wound reports. She explained the nurses on the med carts do the treatments and the measurements for each wound. 5-6-21 at 5:30 PM in an interview with the Nurse Consultant, she explained the DON has not been consistent with wound care reports for months.

CI Based on observation, interviews, record review, facility policy review, hospital discharge recommendations, the facility failed to provide Behavioral Health services when a resident was assaulted, and hair pulled by Resident #1 for one (1) of five (5) residents reviewed for behaviors, Resident #1. The failure to provide Behavioral Health Services and address known behaviors put Resident #6 and all other residents who reside in the facility at risk for serious harm, serious injury, serious impairment, or death. Resident #1 was witnessed with aggressive behaviors including yelling, cursing, threatening, and physically touching other residents. This situation was determined to be an Immediate Jeopardy (IJ), which began on 3/17/21 and determined to exist on 4/20/21. The IJ as not removed prior to exit on 5/26/21 and is considered ongoing. Findings include: The facility's, Behavioral Health Services policy, undated, noted, it is the policy of the facility to provide all residents the necessary behavioral health care and services to assist him or her to reach and maintain the highest practicable level of physical, mental, and psychosocial functioning in accordance with the comprehensive assessment and plan of care. This policy noted behavioral health care plans will be reviewed and revised as needed, such as when interventions are not effective or when the resident experiences a change in condition. A review of the facility's last Dementia training, dated January 21, 2020, revealed the facility had conducted a virtual training with the facility staff. Resident #1 A review of Resident #1 Pre-Admission Screening (PASSR) dated 3/30/21, revealed Resident #1 has a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . A review of the facility's Comprehensive Care Plan dated 4/15/21, revealed Resident #1's care plan listed the resident has the potential to be aggressive with staff and other residents related to anger, dementia, and poor impulse control due to impaired cognitive function/dementia or impaired thought process related to Dementia or impaired thought processes r/t Dementia. The interventions included to engage the resident in simple, structured activities that avoid overly demanding tasks, to administer medications, analyze time of day, places, circumstances, assess, anticipate the resident's needs, triggers and what de-escalates behavior, to cue, reorient and supervise as needed. Resident #1 also has Activities of Daily Living (ADL) self-care performance deficit related to aggressive behavior and confusion. A review of the previous facility's progress notes dated 3/8/21 revealed Resident #1 exhibited behaviors prior to admission. Resident #1 continues to wander, requires constant monitoring and redirection by staff, sometimes resident is verbally aggressive with staff and residents, spits on the floor and going in and out of other residents' rooms. A review of the facility's Nurses' Notes dated 4/20/21 at 11:06 AM, revealed Registered Nurse (RN) #2 over heard Resident #6 say don't touch my hair. The note revealed RN #2 got up from the nurse's station to see what was going on. RN #2 heard Resident #1 say I'm going to kill your God D**n A**. Resident #1 repeated that two more times. Observation 5/4/21 at 1:14 PM, revealed Resident #1 pacing up and down the facility hallway screaming and cursing loud with balled fist. Resident #1 did not have on shoes or mask. The facility Administrator attempted to redirect the resident and was unsuccessful. Resident #1 approached the State Agency (SA) and poked her in the chest. The resident was redirected by the staff down hallway. On 05/5/2021 at 2:00 PM, in an interview with Resident #6, revealed she is afraid of Resident #1. Resident #6 said Resident #1 pulled her hair and hit her. Resident #6 said Resident #1 yells and screams at the other residents and staff all day. During an interview on 05/5/21 at 1:15 pm, with the Director of Nurses (DON) revealed she do not have any behavioral health training. The DON said she was not part of the admission process when Resident #1 was admitted to the facility. The DON said the residents and the staff are afraid of Resident #1. The DON confirmed the staff has not had any behavioral health training. The DON said Resident #1 is a danger to himself and others. The DON said the staff told her Resident #1 pulled Resident #6's hair and verbally threatened her. The Doctor wrote orders to send him to the local Behavioral Unit. A review of the local Behavioral Health notes dated 4/20/21, revealed Resident #1 was admitted [DATE] due to aggressive behaviors. Resident #1 presented with [CONDITION(S)], hallucinations, and aggressive behaviors toward other Residents at the nursing home. Resident #1 continues to pace in the hallways at the nursing home. Resident continued to present with aggression/threatening behavior, medication was given to stabilize him. A Review of the local Behavioral Health Discharge Summary dated 4/29/21, revealed Resident #1 was discharged with a new prescription to give [MEDICATION(S)] 25 mg by mouth (po) twice a day for [CONDITION(S)]. The order also states to continue [MEDICATION(S)] 10 mg po twice a day for mood disorder, [MEDICATION(S)] 10 mg every eight hours as needed for [CONDITION(S)], [MEDICATION(S)] 300 mg po at bedtime for [CONDITION(S)], [MEDICATION(S)] SOD DR 250 mg po twice a day for seizures and [MEDICATION(S)] 0.5 mg for anxiety. A review of the facility's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Interview with the facility's Medical Doctor on 5/20/21 at 12:30 PM, revealed she discontinued the [MEDICATION(S)] 25 mg orally twice a day because of the black box warning. On 05/5/21 at 10:00 AM, interview with the Social Services Director (SSD) said in a meeting with the Administrator, Assistant Director of Nursing (ADON) and Admissions Director discussed Resident #1's behavior. The SSD said the facility cannot meet Resident #1's needs. She stated Resident #1 has too many behaviors and cannot be redirected. The SSD also suggested to send Resident #1 to the behavior unit prior to him hitting Resident #6. The SSD confirmed Resident #1's PASSR is not correct. On 5/5/22 at 10:15 AM, with (RN) #3 said she was sitting at the nurse station on the Alzheimer's Unit (AD) and heard Resident #6 say do not touch my hair again. The nurse said she did not see Resident #1 hit Resident #6. The nurse said by the time she got down the hall Resident #1 was yelling and threatening Resident #6. Resident #1 said I am going to kill you, B****. The nurse said she separated the residents. RN #3 said she has asked the DON and the Administrator several times to send Resident #1 out. The nurse said Resident #1 is dangerous and she is afraid he is going to hurt one of the residents or the staff. RN #3 said Resident #1 is hard to redirect. On 5/5/21/21 at 10:30AM, in an interview with RN #4, she said she works on the AD unit from 7PM-7AM. RN #4 said Resident #1 was hard to redirect. RN #4 also said Resident #4 curses and yells at the residents constantly. RN #4 said she told the MD that she was concerned Resident #1 might hurt one of the vulnerable residents on the unit. RN #4 said the other residents are scared to death of him. On 5/5/21 at 10:45 AM, in an interview with The Activity Coordinator (AC) for the AD unit said she was responsible for doing Dementia training with the staff. The (AC) said the staff is trained on hire and annually. The AC said the staff has not been trained in over a year since the pandemic began. The facility has hired several new staff that has not been trained on Dementia care. The AC said when Resident #1 was on the AD unit she had to do one on one activities with him because his attention span was short. The AC coordinator said he was hard to redirect. He would yell and scream at the other residents. An interview on 5/5/21 at 11:30 AM, with CNA # #7 said he works the 7-3 shift. CNA #7 said Resident #1 is hard to redirect. CNA #7 said Resident #1 fights the staff when they attempt to provide care. CNA #7 confirmed he has not had any behavior training on how to take care of residents with those type of behaviors. The resident is frightening and intimidates the other residents. During an interview on 5/5/21 at 1:30 PM, with the Psych Nurse Practitioner (NP) revealed she has not been in the facility since March 2020. The Psych (NP) said the facility refused to allow her to come in the facility due to Covid-19. The facility called her and asked her to come back to the facility on [DATE]. The Psych (NP) said she will assess and monitor the residents on the AD and the residents that have behaviors. The Psych (NP) said she monitors the residents' medications. The Psych (NP) said she will be visiting the residents twice a week. The Psych (NP) said she will review all Residents that is on [CONDITION(S)] medications at that time. On 5/11/21 at 4:35 PM, in an interview with License Practical Nurse (LPN) #14, revealed she worked the AD unit with Resident #1. LPN #4 said Resident #1 cursed the staff and other residents all the time. LPN #14 said Resident #1 continued to call them B*****s and M****r F*****s the whole shift. LPN #14 also said Resident #1 is hard to redirect and is impulsive. He runs up to the other resident's faces and draws his fist, yells, and curses at them. LPN #14 confirmed she has not had any behavior or dementia training. LPN #14 said she did not know what to do for Resident #1. LPN #14 said she reported to the DON and the Administrator that the staff did not know what to do to take care of Resident #1 and that he was a danger to himself and the other residents. LPN #14 said she was told to call the doctor and report his behavior. LPN #14 said she was calling the doctor every hour and the doctor finally said do not call her again, call the Administrator because he refuses to send the resident to a behavioral health unit. LPN #14 said the Administrator said he could not send the resident out because his census was low, and he had to keep every resident he could in the building. LPN #14 said she told the Administrator that it is not right that the facility will not get this man some help and cause the other residents to be in fear in their home. LPN #14 said this is the most horrible place, I've ever worked. Record review of the Face Sheet revealed the facility admitted Resident #1 on 3/17/2021, per the face sheet, with the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/26/21, revealed Resident #1 had a Brief Interview for Mental Status (BIMS) of 00 indicating Resident #1 is cognitively severely impaired. 0